Body Contouring: Art, Science, and Clinical Practice

Body Contouring Melvin A. Shiffman Alberto Di Giuseppe (Eds.) Body Contouring Art, Science, and Clinical Practice ...

Author: Melvin A. Shiffman | Alberto Di Giuseppe

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Body Contouring

Melvin A. Shiffman Alberto Di Giuseppe (Eds.)

Body Contouring Art, Science, and Clinical Practice

Melvin A. Shiffman, MD, JD 17501 Chatham Drive Tustin, CA 92780-2302 USA [email protected]

Alberto Di Giuseppe, MD Department of Plastic and Reconstructive Surgery, School of Medicine University of Ancona 1, Pizza Cappelli 60121 Ancona Italy [email protected]

ISBN: 978-3-642-02638-6

e-ISBN: 978-3-642-02639-3

DOI: 10.1007/978-3-642-02639-3 Springer Heidelberg Dordrecht London New York Library of Congress Control Number: 2009942715 © Springer-Verlag Berlin Heidelberg 2010 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfi lm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer. Violations are liable to prosecution under the German Copyright Law. The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Cover design: eStudio Calamar, Figueres/Berlin Printed on acid-free paper Springer Science+Business Media (www.springer.com)

Dedication

This book is dedicated to the women of my life, to my mother, Sara, who died at the age of 82 in December 2008, who was the dearest angel of my young age and to my wife, Isabella, married for 20 years, who was my unique love and who has been patient and helpful in sustaining all my work and dedication. I wish the new generation of nephews, Diana, Federico, and Saverio, to continue our work following the same principles that have imprinted our lives. Special thanks to my dearest friend, Melvin, a man of special talent and humanity, sensible, and creative, who has made the greatest effort to realize this book. Dr. Alberto Di Giuseppe

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Foreword

As plastic surgeons, we seek to combine art and science to improve the results we see in clinical practice. Through our artistic sensibilities, we try to understand and obtain aesthetic results. Scientific analysis provides the data to predict which approaches will be successful and safe. Both art and science connote a high level of skill or mastery. At the present time, our literature is replete with descriptions of specific procedures for body contouring. However, there remains a need for a definitive reference describing the basic principles to address the complete scope of body contouring including the postbariatric patient and their plastic surgery deformities. Dr. Shiffman and Dr. Di Giuseppe saw this need and sought to address the needs of plastic surgeons faced with the complexities of body contouring surgery. This is a comprehensive text aimed at providing multiple perspectives. The numerous sections, which include adiposity and lipolysis, the breast, abdomen, chest, and buttocks, the extremities, and liposuction, offer various approaches from the foremost authors. Indeed it is with a tremendous amount of skill and mastery that Dr. Shiffman and Dr. Di Giuseppe have successfully edited and collated the numerous contributions to this work. In addition, they have authored individually or, in collaboration, over a dozen of the 87 total chapters. Their combined work as editors and authors are evident throughout their text. The final result is a comprehensive contribution that will benefit all plastic surgeons seeking to improve their approach to body contouring. Division of Plastic Surgery The University of Alabama at Birmingham Birmingham, USA

Jorge I. de la Torre

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Preface

Contouring of the body includes shaping of the neck, torso, breasts, hip, abdomen, and extremities. The types of procedures performed to shape the body involve surgical excisions, liposuction, implantation, injection of fillers, and in rare instances other modalities. Since the advent of bariatric surgery with extreme weight loss and sagging of tissues, body contouring has become more extensive and consequently with more possible complications. Clothes have been used to accentuate the body contour in certain areas and minimize in other areas. However, clothes that expose more of the body contour will accentuate the body’s defects. Therefore, patients are requesting improvement in the shape of their bodies in order to accommodate the clothes that are fashionable. There are limits as to what surgery will accomplish but certainly the procedures that are available can improve the shape but rarely can make it perfect. Patients should be made to understand the limits of the procedures, the limits of correction that can be obtained, and the possibility of complications that may permanently mar the patient’s appearance. The cosmetic surgery patient usually expects perfection without complications even when the possible risks and complications are thoroughly discussed. These are elective procedures on patients who are usually in good health although this is not necessarily true for the post bariatric surgery patient. Obesity increases the risks of surgery and the patient who is overweight should be specifically informed of this problem. This book is an attempt to bring to the student and practicing plastic and cosmetic surgeon, or any specialty where body contouring may be performed, the types of procedures available, the techniques of performing these procedures, and their possible risks and complications. Special attention is paid to the procedures and problems of the post bariatric patient since this is a separate specialty of body contouring. Many international specialists have been selected to contribute to this book in order to expand the knowledge of those performing body contouring surgery. Knowledge is international and should not be restricted to local or national ideas only. The reader will be introduced to old and new techniques and variations in techniques in order to better understand what is available to the aesthetic surgeon. Students and experienced surgeons of body contouring surgery will greatly benefit by the extensive information available that is not otherwise to be found in one book but mainly in a variety of papers in the medical literature. Tustin, California, USA Ancona, Italy

Melvin A. Shiffman Alberto Di Giuseppe

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Contents

Part I Anatomy, Classification of Adiposities, Body Contouring, Injection Lipolysis 1 Mammary Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Michael R. Davis

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2 Gluteal Contouring Surgery: Aesthetics and Anatomy . . . . . . . . . . . . . Robert F. Centeno

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3 Anatomy and Topography of the Anterior Abdominal Wall . . . . . . . . . Michael R. Davis and Matthew R. Talarczyk

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4 History of Classifications of Adiposity Excess . . . . . . . . . . . . . . . . . . . . . Melvin A. Shiffman

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5 Body Contour: A 50 Year Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ivo Pitanguy and Henrique N. Radwanski

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6 Injection Lipolysis for Body Contouring . . . . . . . . . . . . . . . . . . . . . . . . . Diane Duncan

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Part II Breast 7 History of Breast Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Melvin A. Shiffman

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8 Inframammary Approach to Subglandular Breast Augmentation . . . . Anthony Erian and Amal Dass

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9 Hydrodissection Axillary Approach Breast Augmentation . . . . . . . . . . . Sid J. Mirrafati and Melvin A. Shiffman

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10 Complications of Breast Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . Anthony Erian and Melvin A. Shiffman

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11 Regnault B Mastopexy: A Versatile Approach to Breast Lifting and Reduction . . . . . . . . . . . . . . . . . . . . . . . 119 Howard A. Tobin xi

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12 Mastopexy/Reduction and Augmentation Without Vertical Scar . . . . . 125 Sid J. Mirrafati 13 Breast Reduction and Mastopexy with Vaser in Male Breast Hypertrophy . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Alberto Di Giuseppe 14 Gynecomastia Repair Using Power-Assisted Superficial Liposuction and Endoscopic Assisted Pull-Through Excision . . . . . . . . 139 Yitzchak Ramon and Yehuda Ullmann 15 Mastopexy Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Melvin A. Shiffman 16 History of Breast Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Melvin A. Shiffman 17 Strombeck Breast Reduction Technique . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Pierre F. Fournier 18 Inverted Keel Resection Breast Reduction . . . . . . . . . . . . . . . . . . . . . . . . 169 Ivo Pitanguy and Henrique N. Radwanski 19 Vaser-Assisted Breast Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Alberto Di Giuseppe 20 Complications of Breast Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Melvin A. Shiffman Part III Abdomen, Chest, Buttocks 21 History of Abdominoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207 Giovanni Di Benedetto and William Forlini 22 Abdominoplasty Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217 Melvin A. Shiffman 23 Liposculpture of the Abdomen in an Office-Based Practice . . . . . . . . . . 219 Peter M. Prendergast 24 “Anchor-Line” Abdominoplasty: A Comprehensive Approach to Abdominal Wall Reconstruction and Body Contouring . . . . . . . . . . . 239 Paolo Persichetti, Pierfranco Simone, Annalisa Cogliandro, and Nicolò Scuderi 25 Circular Lipectomy with Lateral T high–Buttock Lift . . . . . . . . . . . . . . 249 Héctor J. Morales Gracia 26 Prevention and Management of Abdominoplasty Complications . . . . . 267 Melvin A. Shiffman

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27 Mastopexy with Extended Chest Wall-Based Flap After Massive Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277 Luiz Haroldo Pereira and Aris Sterodimas Part IV Extremities 28 Brachioplasty: How to Choose the Correct Procedure . . . . . . . . . . . . . . 287 A. Chasby Sacks 29 Brachioplasty: A Body-Contouring Challenge . . . . . . . . . . . . . . . . . . . . 293 James G. Hoehn, Sumeet N. Makhijani, and Jerome D. Chao 30 “Fish-Incision” Brachioplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307 Rajiv Y. Chandawarkar 31 Brachioplasty Technique with Molds Combined to Vaser Assisted Lipomyosculpture . . . . . . . . . . . . . . . . . . . . 313 Ewaldo Bolivar de Souza Pinto and Pablo S. Frizzera Delboni 32 Limited Incision Medial Brachioplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . 321 Andrew P. Trussler and Rod J. Rohrich 33 Augmentation Brachioplasty with Cohesive Silicone Gel Implants . . . . 327 Gal Moreira Dini and Lydia Massako Ferreria 34 Long-Term Outcomes and Complications After Brachioplasty . . . . . . . 331 James Knoetgen III 35 Lymphoscintigraphy: Evaluation of the Lymphatic System . . . . . . . . . . 337 Cristina Hachul Moreno, Aline Rodrigues Bragatto,Américo Helene, Carlos Alberto Malheiros, and Henrique Jorge Guedes Neto 36 Medial Thigh Lift and Declive: Inner Thigh Lift Without Using Colle’s Fascia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347 Daniele Spirito 37 Spiral Lift: Medial and Lateral Thigh Lift with Buttock Lift and Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355 Sadri O. Sozer, Francisco J. Agullo, and Humberto Palladino 38 A Novel Treatment Option for Thigh Lymphoceles Complicating Medial Thigh Lifting Procedures . . . . . . . . . . . . . . . . . . . 365 Wayne K. Stadelmann 39 Fat Augmentation of Buttocks and Legs . . . . . . . . . . . . . . . . . . . . . . . . . . 373 Lina Valero de Pedroza 40 Lower Leg Augmentation with Combined Calf-Tibial Implant . . . . . . . 381 Afshin Farzadmehr and Robert A. Gutstein

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Part V Liposuction 41 Ultrasound-Assisted Lipoplasty: Basic Physics, Tissue Interactions, and Related Results/Complications . . . . . . . . . . . . 389 William W. Cimino 42 History of Ultrasound-Assisted Lipoplasty . . . . . . . . . . . . . . . . . . . . . . . 399 William W. Cimino 43 Face and Neck Remodelling with Ultrasound-Assisted Lipoplasty (Vaser) . . . . . . . . . . . . . . . . . . . . . . 405 Alberto Di Giuseppe 44 High Definition Liposculpting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419 Alfredo Hoyos 45 Vaser-Assisted Liposculpture for Body Contouring . . . . . . . . . . . . . . . . 425 Alberto Di Giuseppe 46 Circumferential Para-Axillary Superficial Tumescent (CAST) Liposuction for Upper Arm Contouring . . . . . . . . . . . . . . . . . . 459 Andrew T. Lyos 47 Body Contouring with Focused Ultrasound . . . . . . . . . . . . . . . . . . . . . . . 473 Javier Moreno-Moraga and Josefina Royo de la Torre 48 Focus Ultrasound on Limited Lipodystrophies . . . . . . . . . . . . . . . . . . . . 485 Michele Cataldo, Luca Grassetti, and David E. Talevi 49 Aesthetic Body Contouring of the Posterior Trunk and Buttocks Using Third Generation Pulsed Solid Probe Internal Ultrasound-Assisted Lipoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493 Onelio Garcia Jr. 50 Treatment Options in Benign Symmetric Lipomatosis . . . . . . . . . . . . . . 505 Anthony P. Sclafani, Kenneth Rosenstein, and Joseph J. Rousso 51 Liposuction for Madelung’s Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 513 Robert Yoho 52 Body Contouring of the Thigh: The Third Dimension by Leonardo Da Vinci . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517 Alberto Di Giuseppe 53 Liposuction of the Calves and Ankles Associated with Calf Implant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 539 Adrien E. Aiache 54 Management of HIV-Associated Lipodystrophy: Medical and Surgical Options for Lipoatrophy and Lipohypertrophy . . . . . . . . . . . . . . . 545 C. Scott Hultman and Anne Keen

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55 Prevention and Treatment of Liposuction Complications . . . . . . . . . . . 553 Melvin A. Shiffman 56 Comparison of Blood Loss in Suction-Assisted Lipoplasty and Third-Generation Ultrasound-Assisted Lipoplasty . . . . . . . . . . . . . 565 Onelio Garcia Part VI Fat Transfer 57 Fat Transfer Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 577 Melvin A. Shiffman 58 Enhancing Muscle Appearance with Extensive Liposuction and Fat Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 587 Alfredo Hoyos 59 Remodelling Breast and Torso with Liposuction and Fat Grafts . . . . . . 595 Alfredo Hoyos and David Broadway 60 Buttock Remodeling with Fat Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . 599 William L. Murillo 61 Complications of Fat Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 617 Hassan Abbas Khawaja, Melvin A. Shiffman, Enrique Hernandez-Perez, José Enrique Hernández-Pérez, and Mauricio Hernandez-Perez Part VII Body Contouring After Severe Weight Loss 62 History of Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 629 Melvin A. Shiffman 63 Psychosocial Aspects of Body Contouring Surgery After Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 633 Troy W. Ertelt, Joanna M. Marino, and James E. Mitchell 64 Psychosocial Issues in Body Contouring . . . . . . . . . . . . . . . . . . . . . . . . . . 641 David B. Sarwer 65 Nutrition Issues After Bariatric Surgery for Weight Loss . . . . . . . . . . . 651 George John Bitar and Sally Myers 66 The Body’s Aesthetic Units for Body Contouring Surgery in Massive Weight Loss Patients . . . . . . . . . . . . . . . . . . . . . . . . . 661 Héctor J. Morales Gracia and Alberto Javier Coutté Mayora 67 Classification of Contour Deformities After Massive Weight Loss: Clinical Applications of the Pittsburgh Rating Scale . . . . . . . . . . . . . . . 675 Angela S. Landfair, Dennis J. Hurwitz, Madelyn H. Fernstrom, Raymond Jean, and J. Peter Rubin

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68 Facial Contouring in the Postbariatric Surgery Patient . . . . . . . . . . . . . 687 Anthony P. Sclafani and Vikas Mehta 69 Total Body Lift After Massive Weight Loss . . . . . . . . . . . . . . . . . . . . . . . 695 Nestor Veitia and Dennis J. Hurwitz 70 Transaxillary Breast Augmentation/Wise-Pattern Mastopexy in the Massive Weight Loss Patient . . . . . . . . . . . . . . . . . . . . 709 George John Bitar 71 Mastopexy with Extended Chest Wall-Based Flap After Massive Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 719 Ruth Maria Graf, Daniele Pace, and Alexandre Mansur 72 Medial Thigh Lift Free Flap for Breast Augmentation After Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . 725 Thomas Schoeller and Georg M. Huemer 73 Rotation-Advancement Superomedial Pedicle Mastopexy Following Massive Weight Loss . . . . . . . . . . . . . . . . . . . . . . . 735 Albert Losken 74 Flank Reshaping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 743 Keith Robertson and Bilal Gondal 75 Perforator Sparing Abdominoplasty: Indications and Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . 757 Ulrich M. Rieger and Martin Haug 76 Abdominal Lipectomy and Mesh Repair of Midline Periumbilical Hernia After Bariatric Surgery Sparing the Umbilicus . . . . . . . . . . . . . 763 Antonio Iannelli 77 Combined Abdominoplasty and Medial Vertical Thigh Reduction Following Severe Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . 769 Mohammed G. Ellabban and Nicholas B. Hart 78 Complications in Abdominoplasty Patients After Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 775 Mikko Larsen and Peter W. Plaisier 79 Quality of Life After Abdominoplasty Following Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 783 Wilson Cintra, Miguel Luiz Antonio Modolin, Joel Faintuch, Rolf Gemperli, and Marcus Castro Ferreira 80 Algorithm for Surgical Plane in Brachioplasty After Massive Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 789 Claudio Cannistra

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81 L Brachioplasty Following Massive Weight Loss . . . . . . . . . . . . . . . . . . . 795 Daron Geldwert and Dennis J. Hurwitz 82 Brachioplasty After Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . 803 Franco Migliori 83 Brachioplasty and Axillary Restoration with Treatment Algorithm for Brachioplasty . . . . . . . . . . . . . . . . . . . . . . 809 Charles K. Herman and Berish Strauch 84 Current Techniques in Medial Thighplasty . . . . . . . . . . . . . . . . . . . . . . . 815 David W. Mathes 85 Thighplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 827 Cristina Hachul Moreno, Aline Rodrigues Bragatto, Américo Helene Jr, Carlos Alberto Malheiros, and Henrique Jorge Guedes Neto 86 Combined Thigh and Buttock Lift After Massive Weight Loss . . . . . . . 837 Claudio Cannistrà 87 Venous Thromboembolism in Bariatric Body Contouring Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 847 Maura Reinblatt and Michele A. Shermak Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 865

Contributors

Francisco J. Agullo, MD Mayo Clinic, Division of Plastic Surgery, 200 First Street SW, Rochester, MN 55905, USA and Department of Surgery, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso, TX 79905, USA [email protected] Adrien E. Aiache, MD 9884 Little Santa Monica Blvd, Beverly Hills, CA 90212, USA [email protected] George J. Bitar, MD Bitar Cosmetic Surgery Institute, 8650 Sudley Road 203, Manassas, VA 20110, USA [email protected] Aline Rodrigues Bragatto, Jr, MD Rua Vergueiro, 1353 cj 407, Paraiso CEP 04101-000, São Paulo, Brazil [email protected] David Broadway, MD 9777 S Yosemite Street, Suite 200, Lone Tree, CO 80124, USA [email protected] Claudio Cannistrà, MD Department of Surgery, Plastic Surgery Unit, Bichat C. B. University Hospital, 71 rue de Rome, 75008 Paris, France [email protected] or [email protected] Michele Cataldo, MD via Turati 4, 20060 Trezzano Rosa, Milano, Italy [email protected] or [email protected] Robert F. Centeno, MD P.O. Box 24330, Christian Sted, VI 00824–0330, USA [email protected] Rajiv Y. Chandawarkar, MD Department of Surgery, Division of Plastic Surgery, University of Connecticut, School of Medicine, Farmington, CT 06030, USA [email protected]

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Jerome D. Chao, MD Division of Plastic Surgery , Albany Medical College, 25 Hackett Blvd, MC133, Albany, NY 12208, USA [email protected] William W. Cimino, PhD Sound Surgical Technologies, 1300 Plaza Court North, Suite 103, Lafayette, CO 80026, USA and 578 W. Sagebrush Ct., Louisville, CO 80027, USA [email protected] or [email protected] Wilson Cintra, JR, MD Plastic Surgery Service, Hospital das Clínicas, Av. San Gabriel, 201 conj. 704/5, São Paulo, SP 01435001, Brazil [email protected] Annalisa Cogliandro, MD Division of Plastic and Reconstructive Surgery, Campus Bio-Medico University, Via Fontanellato, 49, 00142 Rome, Italy [email protected] Alberto Javier Coutté Mayora, MD Belisario Domínguez No. 2501, Colonia Obispado, Monterrey, Nuevo León C.P 64060, México [email protected] Amal Dass, MD Advanced Aesthetics & Surgery, 1, Grange Rd, Orchard Bldg, #06-06 Singapore 239693 [email protected] Michael R. Davis, MD Division of Plastic Surgery, University of Alabama, Birmingham School of Medicine, 510 20th Street South, 1164 Faculty Office Tower, Birmingham, AL 35294-3411, USA [email protected] Jorge I. De La Torre, MD Division of Plastic Surgery, The University of Alabama at Birmingham, 510 20th Street South, 1164 South Faculty Office Tower, Birmingham, AL 35294-3411, USA [email protected] Josefina Royo de la Torre, MD Instituto Medico Laser, General Martinez-Campos 33, 28010 Madrid, Spain [email protected] Pablo Silva Frizzera Delboni, MD Plastic Surgery Department, Santa Cecilia University – UNISANTA, São Paulo, Brazil [email protected] or [email protected] Lina Valero de Pedrosa, MD Carrera 16 No 82-95-Cons: 301, Bogota, DC, Colombia [email protected] Ewaldo Bolivar de Souza Pinto, MD, PhD Plastic Surgery Department, Santa Cecilia University – UNISANTA, Alameda Santos, 455 – cj. 306, São Paulo, Brazil [email protected] or dePedrosa [email protected] Giovanni Di Benedetto, MD, PhD Marche Polytechnic University Medical School, Via Tronto, 20, Ancona, Italy [email protected]

Contributors

Contributors

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Alberto Di Giuseppe, MD Department of Plastic and Reconstructive Surgery, School of Medicine, University of Ancona, 1, Piazza Cappelli, 60121 Ancona, Italy [email protected] Gal Moreira Dini, MD Department of Plastic Surgery, Universidade Federale de São Paulo, Escola Paulista de Medicina, R. Vicencia faria Versage 400 ap. 113-14, Sorocaba Sao Paulo 18031-080, Brazil [email protected] Diane Duncan, MD FACS, 1701 East Prospect Road, Fort Collins, CO 80525, USA [email protected] Mohammed G. Ellabban, MD Plastic and Reconstructive Surgery Unit, Royal Preston Hospital, Sharoe Green Lane North, Fulwood, Preston PR2 9HT, UK [email protected] Anthony Erian, MD Division of Plastic Surgery, Orwell Grange, 43 Cambridge Road, Wimpole, Cambridge, UK [email protected] Troy W. Ertelt, MD Department of Psychology, University of North Dakota, Grand Forks, and Neuropsychiatric Research Institute, 120, 8th Street South, Fargo, ND 58102, USA [email protected] Joel Faintuch, MD Plastic Surgery Service, Hospital das Clínicas, São Paulo, SP, Brazil and Division of Nutrology Residence Program, Plastic Surgery Service, Hospital das Clínicas, São Paulo, SP, Brazil [email protected] Afshin Farzadmehr, MD Plastic Surgery Center of Beverly Hills, 1125 South Beverly Drive, Suite 600, Los Angeles, CA 90035, USA [email protected] or [email protected] Madelyn H. Fernstrom, PhD 3811 O’Hara Street, Suite 1617, Pittsburgh, PA 15213, USA [email protected] Marcus Castro Ferreira, MD Plastic Surgery Service, Hospital das Clínicas, São Paulo, SP, Brazil [email protected] Lydia Massako Ferreria, MD, PhD Department of Plastic Surgery, Universidade Federale de São Paulo, Escola Paulista de Medicina, São Paulo, Brazil [email protected] William Forlini, MD, PhD Marche Polytechnic University Medical School, Via Tronto, 20, Ancona, Italy [email protected]

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Pierre F. Fournier, MD 55 Boulevard de Strasbourg, 75 010 Paris, France [email protected] Onelio Garcia, Jr. MD Division of Plastic Surgery, University of Miami, Miller School of Medicine, 3850 Bird Road, Suite 102, Miami, FL 33146, USA [email protected] Daron Geldwert, MD Hurwitz Center for Plastic Surgery, 3109 Forbes Avenue, Suite 500, Pittsburgh, PA 15213, USA [email protected] Rolf Gemperli, MD Plastic Surgery Service, Hospital das Clínicas, Rua Pedrosa Alvarenga, 120, São Paulo, SP 04531-004, Brazil [email protected] Bilal Gondal, MB BCh, BAO Dubl, BSc, BA King Fahd Uni of Petroleum and Minerals, KFUPM, PO Box 372, Dhahran 31261, Saudi Arabia [email protected] Ruth Maria Graf, MD, PhD Division of Plastic and Reconstructive Surgery, Department of Hospital de Clínicas, Federal University of Paraná (UFPR), Curitiba-PR, Brazil [email protected] or [email protected] Luca Grassetti, MD Department of Plastic and Reconstructive Surgery, Marche Polytechnic University Medical School, Ancona, Italy [email protected] Robert A. Gutstein, MD† Plastic Surgery Center of Beverly Hills, 1125 South Beverly Drive, Suite 600, Los Angeles, CA 90035, USA Nicholas B. Hart, MD, FRCS Plastic Surgery Unit, Castle Hill Hospital, Cottingham Hull, East Yorkshire, HU16 5JQ, UK [email protected] Martin Haug, MD Department of Plastic and Reconstructive Surgery, Basel University Hospital, Spitalstrasse 21, 4056 Basel, Switzerland Américo Helene, Jr. MD Av Itacira, 577 Planalto Paulista, CEP 04064-000, Sao Paulo, Brazil [email protected] Charles K. Herman, MD Department of Plastic Surgery, Albert Einstein College of Medicine, New York, NY, USA and Plastic and Reconstructive Surgery, Pocono Health Systems, 100 Plaza Court, East Stroudsburg, PA 18301, USA [email protected] Enrique Hernandez-Perez, MD 7801 NW 37th St., Club VIP, Suite 369, Miami, FL 33166-6503, USA [email protected]

Contributors

Contributors

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José Enrique Hernández-Pérez, MD Center for Dermatology and Cosmetic Surgery, Plaza Villavicencio 3er Nivel Local 3-1, Col. Escalón, San Salvador, CP 01-177 [email protected] Mauricio Hernandez-Perez, MD Center for Dermatology and Cosmetic Surgery, Plaza Villavicencio 3er Nivel Local 3-1, Col. Escalón, San Salvador, CP 01-177 [email protected] James G. Hoehn, MD Division of Plastic Surgery, Albany Medical College, 25 Hackett Blvd, MC133, Albany, NY 12208, USA [email protected] Alfredo Hoyos, MD Evolution Medical Center, Calle 119, 11D-30 (nueva), Bogota, Colombia [email protected] Georg M. Huemer, MD General Hospital Linz, Krankenhausstrasse 9, 4021 Linz, Austria [email protected] C. Scott Hultman, MD, MBA Division of Plastic and Reconstructive Surgery, University of North Carolina, Suite 7040, Burnett-Womack Building, CB 7195, Chapel Hill, NC 27599-7195, USA [email protected] Dennis J. Hurwitz, MD Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA and Department of Surgery, New York-Presbyterian Hospital, 3109 Forbes Avenue, Suite 500, Pittsburgh, PA 15213, USA [email protected] Antonio Iannelli, MD Chirurgie Digestive et Centre de Transplantation Hépatique, Hôpital L’Archet 2, University of Nice Sophia Antipolis, 151 Route Saint Antoine de Ginestière, BP 3079, Nice, Cedex 3, France [email protected] Raymond Jean, MD Department of Plastic Surgery, Loma Linda University, 11175 Campus Street, Suite 21126, Loma Linda, CA 92354, USA [email protected] Anne Keen, RN Division of Plastic and Reconstructive Surgery, University of North Carolina, Suite 7040, Burnett-Womack Building, CB#7195, Chapel Hill, NC 27599-7195, USA [email protected] Hassan Abbas Khawaja, MD Cosmetic Surgery and Skin Center, 53 A, Block B II, Gulberg III, Lahore, 54660, Pakistan [email protected] or [email protected] James Knoetgen III, MD Private Practice, 20296, Bakersfield, CA 93390-0296, USA [email protected]

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Angela S. Landfair, MD, MPH Division of Plastic Surgery, University of Pittsburgh, 3553 Terrace Street, Suite 6B, Pittsburgh, PA 15213, USA [email protected] Mikko Larsen, MD Department of Plastic and Reconstructive Surgery, Free University Medical Center, Amsterdam, The Netherlands; Department of General Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands and Van der Helmstraat 341, 3067HH Rotterdam, The Netherlands [email protected] Albert Losken, MD Division of Plastic Surgery, Emory University School of Medicine, 550 Peachtree Street, Suite 84300, Atlanta, GA 30308, USA [email protected] or [email protected] Andrew T. Lyos, MD Division of Plastic Surgery, Bobby R. Alford Department of Otorhinolaryngology and Communicative Sciences, Baylor College of Medicine, Houston, TX, USA [email protected] Sumeet N. Makhijani, MD Division of Plastic Surgery, Albany Medical College, 25 Hackett Blvd, MC133, Albany, NY 12208, USA [email protected] Carlos Alberto Malheiros, MD Rua Vergueiro,1353 cj 407, Paraiso CEP 04101-000, São Paulo, Brazil [email protected] Alexandre Mansur, MD Rua Alberto Foloni, 575 – ap 23A, Centro Cívico Curitiba, Paraná, CEP 80540-000, Sao Paulo, Brazil [email protected] Joanna M. Marino, MD Department of Psychology, University of North Dakota, Grand Forks, Neuropsychiatric Research Institute, 120 8th Street South, Fargo, ND 58102, USA [email protected] David W. Mathes, MD Department of Surgery, Division of Plastic Surgery, University of Washington, School of Medicine, 98195, Seattle, WA, USA [email protected] Vikas Mehta, MD The NY Eye and Ear Infirmary, 310 East 14th Street, New York, NY 10003, USA [email protected] Franco Carlo Migliori, MD Plastic Surgery Unit, “San Martino” University Hospital, Largo Rosanna Benzi, 10, Monoblocco 8A Piano Levante, Genoa 16132, Italy [email protected]

Contributors

Contributors

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Sid J. Mirrafati, MD 3140 Redhill Avenue, Costa Mesa, CA 92626, USA [email protected] James E. Mitchell, MD Department of Clinical Neuroscience, University of North Dakota School of Medicine and Health Sciences, Neuropsychiatric Research Institute, 120 South 8th Street, Fargo, ND, USA [email protected] Miguel Luiz Antonio Modolin, MD Plastic Surgery Service, Hospital das Clínicas, São Paulo, SP 01486-000, Brazil [email protected] Héctor J. Morales Gracia, MD Belisario Domínguez 2501, Colonia Obispado, Monterrey, Nuevo León, CP 64060, México [email protected] Cristina Hachul Moreno, MD Rua Vergueiro,1353 cj 407, Paraiso CEP 04101-000, São Paulo, Brazil [email protected] Javier Moreno-Moraga, MD Instituto Medico Laser, General Martinez-Campos 33, 28010 Madrid, Spain [email protected] William L. Murillo, MD Division of Plastic and Reconstructive Surgery, Louisiana State University Medical Center, 1542 Tulane Avenue, New Orleans, LA 70112, USA and Division of Plastic and Reconstructive Surgery, Universidad del Valle, Cali, Colombia [email protected] Sally Myers, RD Bitar Cosmetic Surgery Institute, Northern Virginia, 8501 Arlington Blvd. Suite 500, Fairfax, VA 22031, USA [email protected] Henrique Jorge Guedes Neto, MD Rua Vergueiro,1353 cj 407, Paraiso CEP 04101-000, São Paulo, SP, Brazil [email protected] Daniele Pace, MD, MSc Rua Solimões, 1175, Mercês Curitiba, Paraná, CEP 80810-070, Brazil [email protected] Humberto Palladino, MD Department of Surgery, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso, TX 79905, USA [email protected] Luiz Haroldo Pereira, MD Luiz Haroldo Clinic, 45/206 Rua Xavier da Silveira, Rio de Janeiro, 22061-010, Brazil [email protected] Paolo Persichetti, MD, PhD Division of Plastic Surgery, University Campus Bio-Medico of Rome, Via Bertoloni 19, 00197 Rome, Italy [email protected]

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Ivo Pitanguy, MD Ivo Pitanguy Clinic, Rua Dona Mariana, 65, Rio de Janeiro, 22280-020, Brazil [email protected] Peter W. Plaisier, MD Department of General Surgery, Albert Schweitzer Hospital, PO Box 444, 3300 AK, Dordrecht, The Netherlands [email protected] Peter M. Prendergast, MD Venus Medical Beauty, Heritage House, Dundrum Office Park, Dundrum, Dublin 14, Ireland [email protected] Henrique N. Radwanski, MD Ivo Pitanguy Clinic, Rua Dona Mariana, 65, Rio de Janeiro, 22280-020 Brazil [email protected] Yitzchak Ramon, MD Elisha and Rambam Medical Centers, Haifa, Israel [email protected] Maura Reinblatt, MD Department of Plastic Surgery, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Suite A-513, Baltimore, MD 21224, USA [email protected] Ulrich M. Rieger, MD Department of Plastic Reconstructive Surgery, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria [email protected] or [email protected] Keith M. Robertson, MD Whitfield Clinic, Waterford, Ireland [email protected] Rod J. Rohrich, MD 1801 Inwood Road, WA4.238, Dallas, TX 75390, USA [email protected] Kenneth Rosenstein, MD Department of Otolaryngology, Division of Facial Plastic Surgery, The New York Eye and Ear Infirmary, 310 East 14th Street, North Building, New York, NY 10003, USA [email protected] Joseph J. Rousso, MD Department of Otolaryngology, Division of Facial Plastic Surgery, The New York Eye and Ear Infirmary, 310 East 14th Street, North Building, New York, NY 10003, USA [email protected] J. Peter Rubin, MD Division of Plastic and Reconstructive Surgery, 3380 Blvd of the Allies, Suite 180, Pittsburgh, PA 15238, USA [email protected] or [email protected] A. Chasby Sacks, MD Arizona Cosmetic Surgery, 4202 North 32nd Street, Suite F, Phoenix, AZ 85018, USA [email protected]

Contributors

Contributors

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David B. Sarwer, PhD University of Pennsylvania School of Medicine, Penn Behavioral Health, 3535 Market Street, Philadelphia, PA 19104, USA [email protected] Thomas Schoeller, MD, MSc Department for Handsurgery, Microsurgery, and Reconstructive Breast Surgery, Marienhospital Stuttgart, Böheimstraße 37, 70199 Stuttgart, Germany [email protected] Anthony P. Sclafani, MD Department of Otolaryngology, Division of Facial Plastic Surgery, The New York Eye and Ear Infirmary, 310 East 14th Street, North Building, New York, NY 10003, USA [email protected] Nicolò Scuderi, MD Department of Plastic and Reconstructive Surgery, La Sapienza University, Rome, Italy [email protected] Michele A. Shermak, MD Johns Hopkins University School of Medicine, Division of Plastic Surgery, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Suite A-518, Baltimore, MD 21224, USA [email protected] Melvin A. Shiffman, MD, JD 17501 Chatham Drive, Tustin, CA 92780-2302, USA [email protected] Pierfranco Simone, MD Division of Plastic and Reconstructive Surgery, Campus Bio-Medico University, Rome, Italy [email protected] Sadri Ozan Sozer, MD El Paso Plastic Surgery, 1600 Medical Center Drive, Suite 400, El Paso, TX 79902, USA Department of Surgery, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso, TX 79905, USA [email protected] or [email protected] Daniele Spirito, MD Via delle Baleniere 107/b, 00121, Rome-Ostia, Italy [email protected] Wayne K. Stadelmann, MD Pillsbury Medical Office Building, 48 Pleasant Street, Suite 201, Concord, NH 03301, USA [email protected] Aris Sterodimas, MD, MSc Department of Plastic Surgery, Ivo Pitanguy Institute, Pontifical Catholic University of Rio de Janeiro, Rua Dona Mariana 65, Rio de Janeiro 22280-020, Brazil [email protected] Berish Strauch, MD Department of Plastic Surgery, Albert Einstein College of Medicine, Bronx, NY 10467, USA [email protected] or [email protected]

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Matthew R. Talarczyk, MD Plastic and Reconstructive Surgery, Wright-Patterson Medical Center, 88 SGOS/SGCQP, 2881 Sugar Maple, Wright-Patterson AFB, OH, USA [email protected] David E. Talevi, MD Department of Plastic and Reconstructive Surgery, Marche Polytechnic University Medical School, Ancona, Italy [email protected] Howard A. Tobin, MD Facial Plastic and Cosmetic Surgery Center, 6300 Regional Plaza, Suite 475, Abilene, TX 79606, USA [email protected] Andrew P. Trussler, MD Department of Plastic Surgery, University of Texas Southwestern, 1801 Inwood Road, WA4.238, Dallas, TX 75390, USA [email protected] Yehuda Ullmann, MD Department of Plastic and Reconstructive Surgery, Rambam Medical Center, 8 Ha’Aliya Street, Haifa 31096, Israel [email protected] Nestor Veitia, MD 3109 Forbes Avenue, Suite 500, Pittsburgh, PA 15213, USA [email protected] Robert Yoho, MD 797 South Arroyo Parkway, Pasadena, CA 91105, USA [email protected]

Contributors

Part Anatomy, Classification of Adiposities, Body Contouring, Injection Lipolysis

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Mammary Anatomy Michael R. Davis

1.1 Introduction A thorough understanding of breast development and anatomy is a requirement for modern plastic surgeons. Advanced techniques of reduction mammaplasty, mastopexy, augmentation, and reconstruction demand a comprehensive knowledge of the current detailed descriptions of breast architecture. As a complicated physiologic and aesthetic structure, the form and function of the breast weighs heavily on a woman’s psyche. Significant improvements or complications can impact greatly on the self image for better or worse. Optimizing results and avoidance of complications takes root in the knowledge of breast anatomy. Only then can a plastic surgeon engage his full creativity in sculpting the breast form.

1.2 Development (Fig. 1.1) As a cutaneous appendage, the breast takes its origin from the ectoderm. The breast bud begins differentiation during weeks 8–10 along the milk ridge. The normal human breast develops over the fourth intercostal space of the anterolateral chest wall. Supernumerary nipples and breasts can occur anywhere along the milk ridge

M. R. Davis Division of Plastic Surgery, University of Alabama, Birmingham School of Medicine, 510 20th Street South, 1164 Faculty Office Tower, Birmingham, AL 35294-3411, USA e-mail: [email protected]

from the axilla to the groin. Statistically, they are most common near the left inframmary crease. Following a brief period of activity shortly after birth in response to maternal hormones, breast development becomes dormant until the onset of puberty. Pubertal onset is becoming ever earlier in modern society but currently occurs at approximately 9 years of age. Typically, by the age of 14, parenchymal growth has extended to its mature borders. These include the sternum medially, the anterior border of the latissimus dorsi laterally, the clavicle superiorly, and the inframammary crease inferiorly. These represent approximate anatomic landmarks and are not rigidly defined borders. Breast tissue can extend across the midline and beyond the inframammary crease. An extension of the breast tissue normally penetrates the axillary fascia into the axillary fat pad and is termed the “Tail of Spence.” Mature breast morphology projects off the chest wall in a conical fashion with its apex deep to the nipple–areola complex. Development of overall breast shape is multifactorial. Breast form is dependent on fat content and location, muscular and skeletal chest wall contour, and skin quality. These structures display complex attachments and interactions to result in the final form. Breast shape and size is unique to each individual and is determined largely by heredity.

1.3 Parenchyma (Fig. 1.2) Embedded within the fibrofatty stroma lays the glandular portion of the breast. Glandular structure consists

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_1, © Springer-Verlag Berlin Heidelberg 2010

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Fig. 1.1 The breast overlies the anterolateral chest wall containing primarily glandular tissue and fibrofatty stroma

of millions of lobules clustered to comprise approximately 20–25 lobes. Interlobular ducts come together to form approximately 20 main lactiferous ducts. Lactiferous sinuses collect milk, and specialized ducts within the nipple transmit milk to the surface. Glandular size remains relatively constant from individual to individual. The bulk of the breast consists of fat. Subcutaneous as well as interlobular fat content determine the texture, contour, and density. The breast parenchyma is encompassed and supported by an intricate fascial system. The superficial fascial system is variable and sometimes indistinct from the overlying dermis anteriorly. Fat content of the subcutaneous tissue between the dermis and superficial fascia determines the clarity of these structures. Continuous with the superficial fascia is a deep component that separates the parenchyma from the pectoral fascia as well as the fascia overlying the adjacent muscles. Interposed between the superficial and deep components of the superficial fascial system are fascial extensions termed Cooper’s ligaments. Anchored to the muscular fascia, these ligaments act to suspend the parenchyma. Attenuation of these tissues is largely responsible for ptosis.

Fig. 1.2 Glandular breast tissue is lobular in structure with 20–25 lobes each drained by a lactiferous duct. Milk then enters the collecting ducts followed by lactiferous sinuses prior to exiting the nipple

1 Mammary Anatomy

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1.4 Musculature At its foundation, the breast sits on a prominent musculature that also impacts form and physiology. The five primary muscle groups that lie deep into the breast are pectoralis major and minor, serratus anterior, upper external oblique, and upper rectus abdominis. Perfo rating these structures are the breast’s primary arterial, venous, nerves, and lymphatic supply.

1.5 Skeletal Support Breast symmetry and form is also dependent on normal skeletal support. The breast overlies the antero lateral thorax principally over ribs 2–6. Conditions which manifest chest wall abnormalities such as pectus excavatum and carinatum, Marfan’s syndrome, and Poland’s syndrome can present a challenge in optimizing breast aesthetics. It is also important to take note of the changes in the chest wall contour induced by plastic surgical intervention such as breast augmentation.

1.6 Arterial Supply (Fig. 1.3) Breast tissue possesses a rich blood supply from multiple arterial sources. These sources collateralize within the breast to make a redundant system with significant clinical implications. Division of parenchyma is safe provided one of the several primary axes is preserved. Entering the superomedial portion of the breast over intercostal spaces 2–6 are perforators from the internal mammary artery. These vessels supply the medial pectoralis muscle prior to entering the breast tissue and overlying skin. The dominant perforators emanate from the second and third intercostal spaces. These should be spared during reduction mammoplasty utilizing the superomedial pedicle. Of note, they are occasionally of adequate caliber for use as recipient vessels for free flap breast reconstruction. Supplying the breast superolaterally is the lateral thoracic artery, also termed the external mammary artery. This vessel originates from the axillary artery and enters the breast from the inferior axilla. It distributes its main branches in the upper outer quadrant of the breast.

Fig. 1.3 Blood supply: The arterial supply to the breast is predominantly by perforators from the internal mammary artery followed by the lateral thoracic and anterolateral intercostals arteries

Intercostal vessels represent an additional important blood supply to the breast. The lateral breast receives anterior intercostal arteries from the third through sixth interspaces. These perforate the serratus anterior just lateral to the pectoral border. Lateral intercostal vessels enter the breast at the anterior margin of the latissimus dorsi to supply the lateral breast and overlying skin. Medial intercostal perforators are responsible for directly supplying the inferomedial and central parenchyma inferior to the nipple. These perforators course upward through the breast tissue to supply the gland and are one source for nipple–areola complex perfusion.

1.7 Venous Drainage Two systems of veins drain the breast. The subdermal venous plexus above the superficial fascia is quite variable and represents the superficial system. These veins arise from the periareolar venous plexus. Within the parenchyma, the superficial system anastomoses with the deep system. Deep venous drainage of the breast corresponds with the arterial supply. Venous perforators following internal mammary perforators drain via

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the internal mammary vein to the innominate vein. Lateral thoracic veins or external mammary veins drain into the axillary vein. Intercostal veins drain via the azygos vein into the superior vena cava.

1.8 Innervation (Fig. 1.4) Mammary innervation is dense and has considerable redundancy. In addition to the abundant general cutaneous sensitivity, the central portion of the breast including the nipple–areola complex serves as an erogenous zone and therefore is supplied by fibers contributing to a sensual character. Just as with the perfusion of the breast, innervation of the skin comes from all directions. Superiorly the cervical plexus contributes fibers that course beneath the platysma to innervate the upper portion of the breast. These fibers course in the subcutaneous tissue and can be elevated and preserved with skin flaps of proper thickness. Intercostal segmental nerves contribute the remainder of breast sensation and should be viewed as the

Fig. 1.4 Innervation: Branches of the cervical plexus supply the superior breast. The anteromedial and anterolateral intercostal nerves supply the mass of the breast inferiorly from their respective directions

M. R. Davis

primary sensory nerves. Through the interdigitations of the serratus anterior emanate the third through sixth anterolateral intercostal nerves. They enter the lateral breast at the lateral pectoral margin. Entering the medial breast along with the internal mammary perforators are contributions from the second through sixth anteromedial intercostal nerves. As with the anterolateral intercostal nerves, they contribute sensation to the nipple–areola complex.

1.9 Lymphatics (Fig. 1.5) Lymphatic drainage of the breast has been extensively studied for its oncologic implications. Breast surgeons of all disciplines should have an intimate knowledge of the lymphatic anatomy within the breast. The predominance of lymph from the mammary gland passes along the interlobular lymphatic vessels to the subareolar plexus. Lymph is then directed primarily toward the axillary lymph nodes (75%) coursing along the venous drainage. Lateral lymphatics course around the edge of the pectoralis major to enter

Fig. 1.5 Lymphatic drainage: Lymphatic flow from the parenchyma coalesces first in the subareolar plexus and is then directed predominantly to the axilla. Medial lymphatics are directed to the internal mammary nodes or to the contralateral breast. Inferior lymphatics may enter the subperitoneal plexus

1 Mammary Anatomy

the pectoral nodal group. Additional lymphatics route through the pectoral muscles leading to the apical nodal group. From the axilla, the lymph drains into the subclavian and supraclavicular nodes. The medial portion of the breast contributes lymphatic vessels which drain via the parasternal or internal mammary nodes. They follow internal mammary perforators. There are occasional lymphatic contributions to the contralateral breast. Inferior lymphatics may enter the rectus sheath and drain into subperitoneal plexus.

1.10 Nipple–Areola Complex As mentioned previously, the nipple–areola complex deserves special attention for its unique aesthetic, sensual, and lactational function. It is an area of dense perfusion and innervation. Every attempt should be made to preserve these meaningful functions. Secondary to its physiologic redundancy, the nipple–areola complex can be reliably preserved with attention to anatomic principles.

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Importantly, the blood supply to the nipple–areola complex is both parenchymal and subdermal. The varied dermoglandular pedicles used in reduction mammaplasty and mastopexy thus preserve potential lactation and perpetuate redundant perfusion. The subdermal plexus encompassing the nipple–areola complex serves to directly perfuse the skin of the nipple and areola. The nipple itself represents the apex of the mammary gland. Specialized contractile lactiferous ducts within the nipple facilitate lactation. Montgomery’s glands, which reside in the areola, lubricate the nipple–areola complex functioning primarily during lactation. Clinically, they appear as small nodules distributed throughout the areola and should be preserved. The nipple serves as a port of entry for bacteria into the mammary gland. Bacteria can be cultured from throughout the glandular portion of the breast. Thus, the division of the gland as in most breast surgery can elaborate bacteria (typically Staphylococcus epidermidis). Bacterial prophylaxis should be strongly considered in any breast surgery, but especially with implant placement.

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Gluteal Contouring Surgery: Aesthetics and Anatomy Robert F. Centeno

2.1 Introduction Most plastic surgeons are probably more familiar with the anatomy of the face, abdomen, or breasts than with the anatomy of the gluteal region. Because only a small percentage of plastic surgery procedures involve the buttocks, retaining knowledge of its clinical anatomy is not a high priority for most surgeons. This picture, however, is changing as increasing number of patients request body contouring and are increasingly aware of the numerous techniques now available for enhancing the gluteal region. These include the use of implants, autologous fat transfer, autologous gluteal augmentation with tissue flaps, excisional procedures (lifts), and liposuction. Combinations of more than one of these techniques often produce superior aesthetic results. Unfortunately, these procedures can produce gluteal deformities as well as serious complications if the anatomical structures of the buttocks are not well understood. Obviously, the buttocks are subjected to a great amount of pressure, especially when sitting or bending. Any wound complication that develops will require a prolonged healing time and keep patients from resuming their daily activities. Even more serious is a surgery that interferes with gluteal muscle function or alters nerve activity in the legs. A well-developed and aesthetically-pleasing gluteal region is a trait unique to primates, which was likely an evolutionary adaptation to erect posture and bipedal locomotion. Buttock projection is largely formed by

R. F. Centeno P.O. Box 24330, Christian Sted, VI 00824-0330, USA e-mail: [email protected]

the gluteus maximus muscle and fat deposits in the superficial fascia. In addition, our erect posture contributed to the lumbosacral curve, which is also unique to primates. Evolutionary biology suggests that an hourglass figure, with a small waist and full buttocks, has historically been associated with female reproductive potential and physical health across cultures, generations, and ethnicities [1]. A waist-to-hip ratio of 0.7 in women remains the ideal of beauty even as different ethnic groups prefer different gluteal shapes and curvatures. As women age and fertility declines, skin laxity increases and the shape of the gluteal region usually changes as the content and distribution of fat and muscle change [2, 3]. The hourglass shape fades and the waist-to-hip ratio approaches 1.0, similar to men. An aesthetic outcome of gluteal contouring relies on the knowledge of clinical anatomy, both superficial and deep, in and around this region. Such knowledge also reduces the incidence of complications and improves patient satisfaction. Anatomical knowledge is essential for procedures that augment, reduce, or recontour the buttocks in this still evolving area of plastic surgery.

2.2 Codifying the Gluteal Aesthetic To determine the appropriate surgical plan for a patient inquiring about gluteal enhancement or body contouring surgery, the characteristics of ideal gluteal aesthetics must be carefully considered. In 2004, Cuenca-Guerra and colleagues first reported their analysis of more than 2,400 images of the gluteal area taken from various media sources [4, 5]. This study helped to codify four

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_2, © Springer-Verlag Berlin Heidelberg 2010

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Fig. 2.1 Well-defined sacral dimples and sacral triangle, lateral depressions, and a short infragluteal crease are important aesthetic characteristics of the gluteal region

of the most recognizable characteristics of an aesthetically-pleasing gluteal region (Fig. 2.1). The following landmarks are discussed in detail later in this chapter. 1. Two well-defined dimples on each side of the medial sacral crest that correspond to the posterior-superior iliac spines (PSIS). 2. A V-shaped crease (or sacral triangle) that arises from the proximal end of the gluteal crease with each line of the “V” extending toward the sacral dimples. 3. Short infragluteal folds that do not extend beyond the medial two-thirds of the posterior thigh. 4. Two mild lateral depressions that correspond to the greater trochanter of the femur. Most of these characteristics are universally accepted by a variety of cultures. However, Roberts has described specific variations in aesthetic ideals between ethnic groups in the U.S. [2]. Of the four landmarks just described, numbers 1 through 3 are generally constant features of attractive buttocks regardless of ethnicity. Number 4 (mild lateral depressions) is not preferred by Hispanic-Americans or African-Americans. Other aesthetic differences among ethnic groups have also been identified by Roberts. A short buttock with a high point of maximum projection is popular among AsianAmericans because this shape creates the illusion of

R. F. Centeno

longer legs and a balanced proportion between the torso and extremities. In Roberts’ analysis, HispanicAmericans and African-Americans seem to prefer more projection than either Asians or Caucasians, with a higher point of maximum projection and more severe lumbosacral depression. Caucasians in the U.S. trend toward a more athletic ideal with greater definition of the muscular and bony anatomy or a rounded appearance, with either shape having less anterior-posterior projection. Another way of evaluating the buttocks to help plan body contouring procedures and then assess their outcomes is to view the gluteal region as having eight aesthetic units (Fig. 2.2) [6]. From the posterior-anterior view, the gluteal region consists of two symmetrical “flank” units, a “sacral triangle” unit, two symmetrical gluteal units, two symmetrical thigh units, and one “infragluteal diamond” unit. All eight gluteal aesthetic units play a role in improving the aesthetic outcome of body contouring in the gluteal region, and all should be considered during the surgical planning process. Particular units may benefit from being augmented, reduced, preserved, or better defined. To enhance overall gluteal appearance, the junctions between these aesthetic units should guide incision placement during excisional procedures. Procedures performed on the torso, gluteal region, and lower extremities may have an important impact on the aesthetic perception of the buttocks. As an example, patients who have significant intraabdominal fat may have a widened, squared appearance if only abdominoplasty is performed. The same procedure in a patient without significant intraabdominal fat can better define the waist and improve gluteal aesthetics. Gluteal aesthetics can be greatly enhanced by judicious liposuction of the abdomen, anterior thigh, medial thigh, lateral thigh, flanks, and lumbosacral region. However, overly aggressive liposuction of the buttock, infragluteal fold, or hips often produces suboptimal aesthetic results. Poorly placed incisions also detract from the gluteal aesthetic. For example, a circumferential body lift (CBL) incision that runs straight across the back will make the buttock appear too long and rectangular or too square, depending on whether the incision is too high or too low, respectively. An incision that curves into a V shape along the lateral and inferior borders of the sacral triangle can greatly help define this aesthetic unit (Fig. 2.3). This “inverted dart” incision has been previously described [6–8].

2 Gluteal Contouring Surgery: Aesthetics and Anatomy Fig. 2.2 The eight gluteal aesthetic units are: 2 symmetrical “flank” units (1 and 2); 1 “sacral triangle” unit (3); 2 symmetrical buttock units (4 and 5); 1 infragluteal “diamond” unit (6); and 2 symmetrical thigh units (7 and 8)

Fig. 2.3 Preoperative markings and postoperative position of the “inverted dart” modification to the posterior circumferential body lift incision

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A patient’s existing anatomy plays an important role in Mendieta’s gluteal evaluation system, which is helpful for determining the best way to augment or recontour the buttocks [9, 10]. Because of space limitations, only portions of his system can be mentioned here, but it involves analysis of the underlying bony framework of the buttocks, the skin, and the subcutaneous fat distribution, in addition to the musculature that overlies the bony frame. Mendieta suggests that surgeons begin by evaluating the frame, including the height of the pelvis, and the shape of the frame (round, square, A- or V-shaped). The gluteus maximus muscle should be evaluated to determine whether the muscle is tall, intermediate, or short compared with its width. This information can guide the surgeon in selecting the most appropriate procedure for a patient. Also, they should determine where volume is needed by analyzing whether volume should be added or removed from the upper inner, lower inner, upper outer, and lower outer quadrants of the gluteus maximus. Useful information for determining the procedure that would produce a superior aesthetic result additionally requires an evaluation of the four points at which the gluteal maximus muscle and frame join: the upper inner gluteal/ sacral junction, the intergluteal crease/leg junction, the lower lateral gluteal/leg junction, and the lateral midgluteal/hip junction. Finally, from the lateral view, they should determine the degree of ptosis, which is assessed much like breast ptosis, but identifies the degree to which skin droops over the infragluteal fold [9, 11]. Improvement of severe (grade III) ptosis usually requires an excisional procedure such as a buttock lift, and Gonzalez has recently described several techniques: an upper buttocks lift, a lower DTA (dermotuberal anchorage) lift, a lateral buttocks lift, and a medial buttocks lift [12]. Some of these lifts may be incorporated with gluteal implant or autologous tissue augmentation. Patients who have lost a massive amount of weight typically have an excess of lax skin throughout the gluteal region in addition to buttocks ptosis. They may be best served with a CBL and autologous tissue augmentation for additional volume [8]. Although some massive weight loss patients may not need additional volume, they may benefit from moving the volume to another part of the buttocks to produce better gluteal projection at the level of the mons pubis. In these cases, fat transfer provides a good option. Gluteal implants are not a good choice for MWL patients

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because the poor quality of their subcutaneous tissue and skin may increase the risk of complications.

2.3 Topical Anatomical Landmarks The superficial features shown in Fig. 2.1 are clinically relevant to gluteal augmentation with Alloplastic implants or autologous tissue, either a flap or transferred fat [2, 13–20]. The definition of these features also can be greatly improved with liposuction and transferred fat [2, 21]. As mentioned earlier, the sacral dimples, sacral triangle, lateral depressions, and infragluteal folds that are well defined and proportioned are judged to be appealing across many cultures [2, 4, 7]. Several bony landmarks important to gluteal procedures are easy to identify in most patients. The palpable and often visible iliac crest forms the superior border of the buttocks and is important for guiding incision placement in a buttock lift or CBL with or without augmentation. The incision can be placed more superiorly or inferiorly with respect to the iliac crest depending on the postoperative result desired. Unfortunately, the incision location requires a trade-off between waist definition and buttock elongation. A higher incision can better maintain a pleasing waist-to-hip ratio, but it violates the sacral triangle aesthetic unit, elongates the buttocks, and limits autologous flap placement so that maximum projection is higher than ideal. A lower incision diminishes waist definition, but preserves the sacral triangle aesthetic unit, shortens the buttocks, and permits the point of maximum projection at the level of the mons pubis. Good waist definition is nearly impossible to achieve in MWL patients with a long history of obesity no matter where the incision is placed because many years of an expanded rib cage have left them with a “barrel chest” deformity that cannot be corrected. The PSIS, which are typically easy to palpate, form two distinct depressions called the sacral dimples produced by the confluence of the PSIS, the multifidus muscles, the lumbosacral aponeurosis, and the insertion of the gluteus maximus. Because the sacral dimples are characteristic of attractive buttocks, attempts should be made to create, enhance, or unmask this anatomical feature [6]. The sacral dimples are also good reference points for aesthetic analysis of the buttocks.

2 Gluteal Contouring Surgery: Aesthetics and Anatomy

Another reason for the sacral dimples being important is that they serve as the superior corners of the sacral triangle, which is defined by the two PSIS with the coccyx as the inferior border of the triangle. Liposuction and/or the “inverted dart” modification of the posterior CBL incision mentioned earlier are useful for enhancing the sacral triangle during body contouring procedures [6]. In all gluteal contouring procedures the location of the sacral triangle feature should be respected and marked prior to surgery. If implants are to be used for augmentation, regardless of their position, the sacral triangle serves as the medial borders of the dissection (Fig. 2.4). Another important topical landmark is the lateral trochanteric depression formed by the greater trochanter and insertions of thigh and buttocks muscles, including the gluteus medius, vastus lateralis, quadratus femoris, and gluteus maximus. This depression is important in the aesthetics of an athletically-toned buttock preferred by many Caucasians, but some ethnic groups – such as

a

c

Fig. 2.4 Implant augmentation locations for (a) submuscular, (b) intramuscular, and (c) subfascial procedures. IC iliac crest; PSIS posterior-superior iliac spine; GT greater trochanter; IGF infragluteal fold

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African-Americans and U.S. Hispanics – request that the trochanteric depressions not be emphasized or even filled in if they are prominent [2]. The infragluteal fold is a fixed and well-defined structure that serves as the inferior border of the buttock proper and is formed by subcutaneous fat and thick fascial insertions from the femur and pelvis through the intermuscular fascia to the skin [22]. The length and definition of the infragluteal fold play important roles in aesthetically-pleasing buttocks. In his study of ideal buttock aesthetics, Cuenca-Guerra determined that an infragluteal fold that does not extend beyond the medial two-thirds of the posterior thigh contributes to a full, taught, and youthful-looking buttock. A longer infragluteal fold typically suggests an aged, ptotic, and deflated-looking buttock with skin and fascial excess [4, 23]. Although not a part of the buttock proper, the ischial tuberosities are the bony prominences upon which people sit.

b

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2.4 Gluteal Aesthetics and Subcutaneous Fat Distribution The amount and distribution of subcutaneous fat content accounts for the round shape and projection of the buttocks. Subcutaneous fat content in the gluteal region is usually greater in women vs. men, infants vs. adults, and in some ethnic groups. Some evolutionary biologists believe that subcutaneous gluteal fat is important for padding the buttock region when sleeping in the supine position and evolved as an adaptive mechanism for heat dissipation while maintaining sufficient adipose stores critical to normal physiology [24]. The distribution of gluteal fat, as well as its volume, also plays an important role in gluteal aesthetics. Cuenca-Guerra and Lugo-Beltran have analyzed gluteal aesthetics from the lateral view that incorporates the buttock, surrounding torso, and lower extremities. Ideally, the ratio of the anterior-superior iliac spine (ASIS) to the greater trochanter and the greater trochanter to the lateral point of maximum projection of the buttock should not exceed 1:2 [5]. The author has found this analytical system based on the lateral view to be very useful and clinically relevant in determining which surgical procedure(s) should best achieve desired results. In addition to attaining the ratio of 1:2 when viewed from the side, attractive buttocks have other characteristics that relate to the distribution of subcutaneous fat. • A visible lumbosacral depression should help to distinguish the back from the buttocks. • There should be no excess fat either in the lumbosacral area or in subgluteal region. Excess fat in areas commonly referred to as the “love handles,” “saddle-bags,” and “banana roll” also detract from gluteal aesthetics. • The point of maximum projection of the buttocks should correspond to the level of the mons pubis. Attaining these characteristics may require the use of combined procedures. Impressive recontouring can be achieved with liposuction alone, especially to better define the lumbosacral depression, the sacral triangle, and the subgluteal area. However, liposuction must not be too aggressive in the area of the “banana roll,” just inferior to the infragluteal fold. Too much liposuction in the most superior portion of the posterior thigh can exacerbate buttock ptosis and cause deformities in the infragluteal fold, a structure that is very difficult to

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replicate surgically [22]. A good understanding of gluteal anatomy reduces the risk of these outcomes. Anthropometric and radiological studies have determined that both aging and weight gain cause the distribution of fat in the buttocks to change. One investigation of 115 randomly selected women ranging in age from 17 to 48 found statistically significant changes in several measurement parameters [23]. Weight gain produces an overall increase in buttock height and width, lengthens the intergluteal crease, and shortens the infragluteal fold. Aging, independent of weight gain, also increases buttock height and lengthens the intergluteal crease, but makes the infragluteal fold longer. Both aging and weight gain are associated with drooping of the infragluteal fold. Although weight gain alone increases buttock width, this measurement decreases with age regardless of weight. Changes in subcutaneous fat content and distribution, in addition to skin and fascial laxity, are believed to explain these findings. Fat distribution has been studied in both men and women, and generalized body types have been described. These include the android, gynoid, and intermediate body types. An individual’s body type may change according to weight loss, aging, or gender. For example, as women age and reach menopause, they tend to develop a more centralized fat distribution (both intraabdominal and subcutaneous fat), and the gynoid body type of youth develops more android characteristics. The most visible differences in the distribution of subcutaneous fat when comparing young and older women occur at the waist and mid-trochanter level. In addition, obesity increases the android tendency or centralized fat distribution of both sexes. This helps explain why body type and overall fat distribution patterns are relatively consistent among people with rapid and significant weight loss [24]. Massive weight loss patients are greatly affected by platypygia, partly because weight loss, whether through diet or surgery, often occurs in an uneven manner. Studies have suggested that adipose tissues in certain body regions are more resistant to weight loss than others [25]. The genetic programming of the resistant adipocytes seems to differ from adipocytes in areas that are more responsive to weight loss, which may mean that genetics influence different somatotypes. Within the android, gynoid, and intermediate body types are subgroups of somatotypes. Following weight loss, the “Apple” somatotype seems to have less adipose tissue in the gluteal region than the “Pear.” Regardless of somatotype, however, many MWL patients tend to lose gluteal

2 Gluteal Contouring Surgery: Aesthetics and Anatomy

volume and projection and want to have this deformity specifically addressed along with the skin laxity. Skeletal changes in massive weight loss patients: In addition to redistribution of subcutaneous fat following massive weight loss, anatomical changes in several areas of the skeleton are common, especially in patients who were morbidly obese before losing weight. Many of these changes relate to posture and permanently affect the morphology of the skeleton, which may limit the effectiveness of gluteal contouring efforts. Spinal column lordosis, vertebral compression, and pelvic rotation all negatively affect gluteal projection [26]. In obese individuals, restrictive pulmonary disease is often associated with a postural obstructive component that produces pulmonary hyperinflation [27], which often leads to permanent expansion of the thoracic cage. This “barrel-chested” appearance cannot be corrected and has a deleterious impact on gluteal aesthetics. Massive weight loss does not improve these skeletal abnormalities, which may be magnified or even worsened as the body mass index is lowered. A worsening of skeletal changes after surgical weight loss procedures may relate to poorly managed chronic hypocalcemia, vitamin D deficiency, and serum telopeptides that lead to osteopenia [28]. Although they cannot be corrected, some of the problematic skeletal changes can be disguised, at least

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partially, with gluteal procedures, especially autologous gluteal augmentation with a tissue flap or fat transfer. Knowledge of the anatomical abnormalities common in MWL patients can help surgeons understand why the buttocks appear flattened after the posterior portion of a CBL or buttock lift. In many patients, a CBL magnifies preexisting gluteal hypoplasia. Understanding where and why more volume is needed to recreate gluteal projection comes from familiarity with the anatomy of the gluteal and hip region.

2.5 The Importance of Fascial Anatomy The aesthetics of the aging buttocks are greatly affected by the fascial anatomy of the gluteal region. In addition to volume loss and skin laxity, which also affect MWL patients, relaxation of the fascial “apron” contributes to gluteal ptosis. This superficial fascial apron and the deep gluteal fascia fuse, become tightly adherent, and form the infragluteal fold, which is an important feature of aesthetically-pleasing buttocks [22, 29, 30]. The fascial apron (Fig. 2.5) is analogous to the superficial fascial system (SFS) described by Lockwood [31]. Liposuction in the infragluteal fold area (for correction of a “banana roll”) must be done carefully and

a

b

Fig. 2.5 Gluteal and SFS fascial anatomy. (a) The structure of the SFS “fascial apron.” (b) The lumbosacral and gluteal fascia

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prudently because this feature is extremely difficult to surgically recreate. Resection and tightening of the skin and this superficial fascial apron are major components of the CBL procedure or buttock lift – with or without autologous gluteal augmentation – and play an important role in improving gluteal ptosis. The deep gluteal fascia, or investing fascia of the gluteus maximus muscles, is critically important as a fixation point in many types of gluteal procedures (e.g., autologous augmentation and/or lifts). It also serves as a strong retaining fascia in the subfascial approach to augmentation with implants.

2.6 Superficial Neurovascular Anatomy Perfusion to musculocutaneous structures in the gluteal region is supplied by perforating branches of the superior and inferior gluteal arteries, both of which are terminal branches of the internal iliac artery and ultimately pass through the greater sciatic foramen into the thigh (Fig. 2.6). As described by Ahmadzadeh and colleagues, the superior gluteal artery can usually be found by envisioning a line between the posterior-superior iliac spine and the greater trochanter [32]. Several perforators from

Fig. 2.6 Superior and inferior gluteal arteries and lumbo-sacral perforator arteries

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this artery should lie 5–10 cm adjacent to the medial two-thirds of this line. Before it enters the gluteus maximus muscle to supply perforators to the superior portion of this muscle and overlying skin, the superior gluteal artery passes superior to the piriformis muscle [32, 33]. The inferior gluteal artery passes inferior to the piriformis muscle and supplies the lower half of the gluteus maximus muscle and overlying structures. All perforators from the inferior gluteal artery pass through the gluteus maximus, as do half the perforators from the superior gluteal artery; the other half pass through the gluteus medius muscle. The superior gluteal artery typically has 5 ± 2 cutaneous perforators, with the inferior gluteal artery typically having 8 ± 4 [32]. Some of these perforating vessels must be sacrificed during the posterior portion of a CBL, an autologous gluteal augmentation, or a buttock lift. Even with this loss, however, the rich and reliable vascular supply in the gluteal region provides robust perfusion [32–35]. Many other arteries also supply the region, including the deep circumflex iliac, lumbar, lateral sacral, obturator, and internal pudendal arteries. Sensation to the gluteal region and lateral trunk comes from several sources: the dorsal rami of sacral nerve roots 3 and 4, the cutaneous branches of the iliohypogastric nerve arising from the L1 root (Fig. 2.7), and the superior cluneal nerves that originate from the L1, L2, and L3 roots and then pass over the iliac crest (Fig. 2.8). A lower body or buttock lift with or without autoaugmentation temporarily disrupts protective cutaneous sensation transmitted by these nerves. Consequently, patients should be counseled about the need for frequent positional changes and avoidance of heating pads and blankets to prevent pressure necrosis or burns. As branches of the L1 nerve root, the iliohypogastic and ilioinguinal nerves originate in the sacral plexus (Fig. 2.7). They then travel inferiomedially between the transversus abdominis and internal oblique muscles. The iliohypogastric nerve divides into lateral and anterior cutaneous branches to supply skin overlying the lateral gluteal region and the area above the pubis on the anterior surface. These nerves are put at risk when a CBL incision is made at or below the inguinal crease. The lateral cutaneous branch of the iliohypogastic and the intercostal nerves also can be entrapped laterally during surgery. This is most likely when aggressive lateral plication of the external oblique muscle is performed to enhance waist definition or if “3-point” or quilting sutures are used laterally to close “dead space.”

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Fig. 2.7 The ilioinguinal and iliohypogastric nerves, the latter of which extends around the body to supply the lateral and anterior aspects

Fig. 2.8 Posterior cutaneous nerves: (a) Dorsal rami of S3 and S4. (b) The superior cluneal nerves

While contouring the lateral and anterior trunk and thighs during body contouring procedures, surgeons must be aware of clinically significant anatomic variations of the ilioinguinal, iliohypogastric, and lateral femoral cutaneous nerves. In a fresh cadaveric study, Whiteside and colleagues determined that, on average, the ilioinguinal nerve enters

the abdominal wall 3.1 cm medial and 3.7 cm inferior to the ASIS and terminates 2.7 cm lateral to the midline and 1.7 cm above the pubic symphysis [36]. The iliohypogastric nerve enters the abdominal wall musculature 2.1 cm medial and 0.9 cm below the ASIS and ends 3.7 cm lateral to the linea alba and 5.2 cm above the pubic tubercle.

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However, another study of human cadavers found that the position of the iliohypogastric nerve in relation to the ASIS can vary by as much as 1.5–8 cm on the right side and 2.3–3.6 cm on the left side. The ilioinguinal nerve and its relation to the ASIS vary by as much as 3–6.4 cm on the right and 2–5 cm on the left [37]. A study of 110 patients undergoing hernia repair determined that the course of both nerves was consistent with descriptions in anatomy texts in 41.8% of cases, but varied significantly in 58.2% of patients [38]. Most variations were related to “take-off” angles, bifurcations, aberrant origins, or accessory branches occurring at deeper layers of the abdominal wall. However, in 18 of 64 cases, the ilioinguinal nerve was superficial to the external oblique aponeurosis and the superficial inguinal ring. Injury to the lateral femoral cutaneous nerve (LFCN) was described as early as 1885. Meralgia parasthetica is the clinical syndrome caused by LFCN compression or injury and is characterized by anesthesia, causalgia, and hypesthesias in its dermatomal distribution. Typically, the nerve is described as coursing anterior to the ASIS and inferior to the inguinal ligament. Aszmann et al. showed that in 4% of cadavers dissected, the nerve exited posterior to the ASIS and across the iliac crest [39]. In another cadaveric study, Grothaus and colleagues demonstrated that the LFCN is susceptible to injury as far as 7.3 cm

Fig. 2.9 Gluteus maximus muscle and relationships to nearby neurovascular structures

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medial to the ASIS and 11.3 cm below the ASIS on the Sartorius muscle [40].

2.7 Deep Neuromuscular Anatomy The expansive gluteus maximus muscle (Fig. 2.9) originates in the fascia of the gluteus medius, the external ilium, the fascia of the erector spinae, the dorsum of the lower sacrum, the lateral coccyx, and the sacrotuberous ligament. It inserts on the iliotibial tract and proximal femur. Innervation of the gluteus maximus comes from the inferior gluteal nerve. This muscle is a powerful extensor of the flexed femur and provides lateral stabilization of the hip. Correct positioning of submuscular, intramuscular, and subfascial implants in relation to fascial structures and the gluteal maximus muscle are shown in Fig. 2.10. Originating on the external ilium and inserting on the lateral greater trochanters, the gluteus medius abducts the hip and thigh and helps stabilize the pelvis during standing and walking (Fig. 2.11). Nearby, the gluteus minimus muscle originates on the external surface of the ilium and inserts on the anterior-lateral greater trochanter (Fig. 2.12). This muscle abducts the femur at the hip joint and also serves as a pelvic stabilizer. Both the gluteus medius and gluteus minimus are innervated by

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a

c

Fig. 2.10 Implant position in relation to gluteal anatomy: (a) submuscular, (b) intramuscular, and (c) subfascial augmentation

Fig. 2.11 Gluteus medius muscle and relationships to nearby neurovascular structures

b

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Fig. 2.12 Gluteus minimus muscle and relationships to nearby neurovascular structures

Fig. 2.13 The location of the sciatic nerve in relation to the piriformis muscle

the superior gluteal nerve. The superior gluteal artery and nerve, which supply both muscles, exit the sciatic foramen above the piriformis muscle and travel through the plane between the gluteus medius and minimus. A lateral rotator and abductor of the femur, the piriformis muscle is innervated by branches of L5, S1, and S2. The small, triangular-shaped piriformis, which is obliquely oriented, originates at the anterior sacrum and inserts on the superior medial border of the greater trochanters. The piriformis muscle divides the greater sciatic foramen into inferior and superior portions. The

piriformis overlies the sciatic nerve and plays an important role as a landmark for the gluteal neurovascular structures, as well as the sciatic nerve (Fig. 2.13). For example, the piriformis marks the most inferior extent of an implant pocket for augmentation in the submuscular plane. Many other muscles are lateral rotators and abductors of the femur, including the superior gemellus, inferior gemellus, and obturator internus muscles, which all lie caudal to the piriformis. The most anterior of the gluteal muscles is the tensor fascia lata (Fig. 2.14). It

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Fig. 2.14 Tensor fascia lata with gluteal-lumbosacral fascia removed

originates on the lateral iliac crest and ASIS, passes superficial to the gluteus medius and minimus, and inserts on the iliotibial tract. It helps with flexion, abduction, and rotation of the thigh, and stabilizes the knee during extension. The terminal branch of the lateral femoral circumflex artery provides perfusion, with innervation supplied by the superior gluteal nerve. The sciatic nerve is the largest nerve of the body and originates in the sacral plexus – at the nerve roots of L4 through S3. Its only gluteal branch provides innervation to the hip joint. The sciatic nerve exits the gluteal region through the greater sciatic foramen below the piriformis muscle and above the superior gemellus muscle to enter the posterior compartment of the thigh (Fig. 2.15). Above the popliteal space, the sciatic nerve splits into the common peroneal nerve and the tibial nerve. Compression or injury of the sciatic nerve may cause loss of function of the posterior thigh compartment muscles, all muscles of the leg and foot, and loss of sensation in the lateral leg and foot, as well as the sole and dorsum of the foot [41]. Anatomical studies indicate that the sciatic nerve and its main branches – the tibial and common peroneal nerves – are subject to variability in relation to the piriformis muscle. The sciatic nerve leaves the pelvis through the infrapyriform foramen in 96% of cases. However, in 2.5% of cases, the common peroneal nerve may branch away from the sciatic nerve early and exit through the piriformis muscle while the tibial nerve exits below the piriformis. In another 1.5% of cases, the common peroneal nerve divides from the tibial nerve and exits the pelvis above the piriformis

Fig. 2.15 The sciatic nerve in relation to the superior and inferior gluteal arteries and veins

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muscle, while the tibial nerve exits below the muscle [42,43]. Although uncommon, these anatomic variations must be looked for during gluteal procedures because injury to these nerves could lead to clinical complications during submuscular and intramuscular implant augmentation. Although rare, gluteal compartment syndrome has been reported in the literature. Possible causes include trauma, alcoholism, drug-induced coma, EhlersDanlos syndrome, sickle cell disease, gluteal artery aneurysm rupture, abdominal aortic aneurysm repair, orthopedic surgery, bone marrow biopsy, intramuscular injections, rhabdomyolysis, extreme physical overexertion, and prolonged surgical positioning in the lateral decubitus or lithotomy positions. Even though gluteal surgery rarely causes gluteal compartment syndrome, surgeons need a thorough knowledge of the gluteal compartments and the potential impact different aesthetic procedures may have. A low index of suspicion and early intervention will reduce any permanent negative sequelae of this potentially devastating clinical problem. Three gluteal compartments have relatively inelastic boundaries: the gluteus maximus compartment, the gluteus medius-minimus compartment, and the tensor fascia lata compartment. The gluteus maximus compartment consists of the muscle plus its superficial and deep fibrous fascia, which is contiguous with the fascia lata of the thigh. This compartment attaches superiorly to the iliac crest and laterally to the iliotibial tract. Medially, the superficial and deep gluteal fascia join the sacral, coccygeal, and sacrotuberous ligaments. The gluteus medius-minimus compartment is defined superiorly by the deep gluteal fascia, the tensor compartment, and the iliotibial tract laterally. The ilium comprises the deep surface. The tensor fascia lata compartment is formed by the tensor fascia lata and the iliotibial tract. The gluteus medius-minimus compartment contains most of the critical neurovascular structures. Precise knowledge of their locations will help prevent operative injury and improve understanding of this rare compartment syndrome. The superior gluteal artery, vein, and nerve exit superior to the piriformis muscle. The inferior gluteal artery, vein, and nerve exit beneath the inferior edge of the piriformis and above the superior gemellus muscle to penetrate the gluteus maximus muscle. In addition, the sciatic nerve, posterior femoral cutaneous nerve, pudendal nerve, and nerves to the obturator internus and superior gemellus

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muscles exit in the same compartment, beneath the inferior border of the piriformis muscle. Increased compartment pressures with diminished perfusion to the gluteal muscles and tensor fascia lata can be caused by mass effect within these compartments. Damage to the vessels with bleeding and hematoma formation, or mass effect from a large implant, can theoretically increase compartment pressures beyond a safe limit. While still disputed in the literature, a compartment pressure higher than 30 mmHg may cause necrosis of muscle in as little as 4–6 h and Wallerian nerve degeneration in 8 h [44–46].

2.8 Surgical Injuries Many inadvertent opportunities for injuring patients are possible during gluteal procedures as the common prone and lateral decubitus positions carry risks, such as development of pressure sores, corneal abrasions, peripheral nerve compression, and traction injuries. Although the entire operative team is responsible for being vigilant and preventing these types of injuries, the surgeon possesses the most specialized knowledge of the impact that improper intraoperative positioning can have on a patient. Major peripheral nerve structures are especially at risk in the lateral decubitus position commonly used for a CBL or contouring liposuction of the flanks, back, and lateral thighs. An axillary roll can protect the brachial plexus from compression against the clavicle while in this position. The common peroneal nerve can be protected by using a gel mattress on the operative bed and avoiding compression against hard surfaces. Perioperatively, a gel mattress, “Roho,” or “egg-crate,” will provide extra padding to prevent nerve injury or irritation and also decrease the risk for development of stage 1 pressure sores that may occur during and after long surgical procedures. The prone position required for most gluteal procedures also puts the patient at risk in several ways. Moving a patient from the supine to the prone position should be a controlled process supervised by the surgeon to ensure that the airway is protected by anesthetists, the team is coordinated, and adequate personnel are available to make the turn effortless. The use of chest rolls to prevent hyperextension of the shoulder and compression of the brachial plexus is critical. Areas that include the ulnar

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nerves, knees, feet, and face should be padded to prevent pressure sores and/or nerve injuries. Protecting the eyes with goggles is more effective than taping the eyes closed because tape can easily be displaced with movement and moisture from lubricating ointment. If flexion of the hip is desired, a gel roll beneath the ASISs is a safe way of providing elevation [47–49]. Patients who are overweight or obese may develop hemodynamic and/or ventilatory problems when in the prone position. For example, the weight of the patient on the chest wall can decrease expansion of the chest and manifest as increased ventilatory pressures. Prone positioning also may decrease venous return, and therefore, affect preload and cardiac output. Careful vigilance and awareness will diminish the deleterious impact of these physiologic responses [50, 51].

2.9 Summary Selection of a gluteal contouring technique begins by evaluating the anatomy and existing distribution of subcutaneous fat in the buttocks and determining

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where gluteal aesthetics could be improved. The surrounding areas of the abdomen, flanks, back, hips, and lower extremities should be part of this analysis because they play a role in identifying the most appropriate procedure. The gluteal contouring algorithm (Fig. 2.16) illustrates the preferred choices for gluteal contouring under various conditions depending on the deformities present, and should help with determining which procedures are most appropriate for patients. If there is a loss of gluteal tissue volume, skin laxity, and buttock ptosis, a lower body or buttock lift with augmentation is the best option. Excisional procedures may also be needed to address the thighs and infragluteal area. Volume excess in areas surrounding the buttocks does not preclude the coexistence of gluteal hypoplasia, which is quite common in massive weight loss patients and effectively treated with autologous tissue. Contouring of the buttocks and surrounding areas is often best achieved with liposuction alone or as an adjunctive procedure. Results may be further refined with fat transfer to better define features common to attractive buttocks. This chapter has described some of the major anatomical issues that confront plastic surgeons when

Loss of volume Yes

No

Gluteal hypoplasia Yes

Volume excess

No Gluteal augment (tissue flap, implant, or fat transfer)

Yes

No

No

Yes Yes Abdomen only

Liposuction of lateral / medial thighs, buttocks or lumbosacrum

Skin laxity

Stop

Yes Yes

Medial thigh

Yes

Posterior thigh

Infragluteal fold ptosis

Posterior thigh lift

Lower buttocks lift

Abdominoplasty Medial thigh lift Extended thighplasty

Circumferential body lift or buttocks lift

Fig. 2.16 Decision-making algorithm for gluteal contouring procedures

Flanks, back and buttocks

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contouring and augmenting the gluteal region. Unless surgeons are very experienced in gluteal procedures, they are encouraged to refresh their anatomical knowledge and the many types of nerve and vascular variations that occur. A better understanding of gluteal anatomy and aesthetics will not only improve cosmetic results, but also reduce the risks of complications, some of which may be long-lasting.

References 1. Singh D. Universal allure of the hourglass figure: an evolutionary theory of female physical attractiveness. Clin Plast Surg. 2006;33(3):359–70. 2. Roberts TL III, Weinfeld AB, Bruner TW, Nguyen K. “Universal” and ethnic ideals of beautiful buttocks are best obtained by autologous micro fat grafting and liposuction. Clin Plast Surg. 2006;33(3):371–94. 3. Toth MJ, Tchernof A, Sites CK, Poehlman ET. Menopauserelated changes in body fat distribution. Ann NY Acad Sci. 2000;904:502–6. 4. Cuenca-Guerra R, Quezada J. What makes buttocks beautiful? A review and classification of the determinants of gluteal beauty and the surgical techniques to achieve them. Aesthetic Plast Surg. 2004;28(5):340–7. 5. Cuenca-Guerra R, Lugo-Beltran I. Beautiful buttocks: characteristics and surgical techniques. Clin Plast Surg. 2006;33(3):321–32. 6. Centeno RF. Gluteal Aesthetic Unit classification: a tool to improve outcomes in body contouring. Aesthetic Surg J. 2006;26(2):200–8. 7. Centeno RF, Young VL. Clinical anatomy in aesthetic gluteal body contouring surgery. Clin Plast Surg. 2006;33(3): 347–58. 8. Centeno RF. Autologous gluteal augmentation with circumferential body lift in the massive weight loss and aesthetic patient. Clin Plastic Surg. 2006;33(3):479–96. 9. Mendieta CG. Classification system for gluteal evaluation. Clin Plast Surg. 2006;33(3):333–46. 10. Centeno RF, Mendieta CG, Young VL. Gluteal contouring surgery in the massive weight loss patient. Clin Plast Surg. 2008;35(1):73–91. 11. Gonzalez R. Etiology, definition, and classification of gluteal ptosis. Aesthetic Plast Surg. 2006;30(3):320–6. 12. Gonzalez R. Buttocks lifting: how and when to use medial, lateral, lower, and upper lifting techniques. Clin Plast Surg. 2006;33(3):467–78. 13. de la Peña JA. Subfascial technique for gluteal augmentation. Aesthetic Surg J. 2004;24(4):265–73. 14. de la Peña JA, Rubio OV, Cano JP, Cedillo MC, Garcés MT. Subfascial gluteal augmentation. Clin Plast Surg. 2006;33(3):405–22. 15. Gonzalez-Ulloa M. Gluteoplasty: a ten-year report. Aesthetic Plast Surg. 1991;15(1):85–91. 16. Mendieta CG. Gluteoplasty. Aesthetic Surg J. 2003;23(6): 441–55.

R. F. Centeno 17. Vergara R, Amezcua H. Intramuscular gluteal implants: fifteen years’ experience. Aesthetic Surg J. 2003;23(2):86–91. 18. Mendieta CG. Intramuscular gluteal augmentation technique. Clin Plast Surg. 2006;33(3):423–34. 19. Cárdenas-Camarena L, Lacouture AM, Tobar-Losada A. Combined gluteoplasty: liposuction and lipoinjection. Plast Reconstr Surg. 1999;104(5):1524–31. 20. Pascal JF, Le Louarn C. Remodeling bodylift with high lateral tension. Aesthetic Plast Surg. 2002;26(3):223–30. 21. Valero de Pedroza L. Fat transplantation to the buttocks and legs for aesthetic enhancement or correction of deformities: long-term results of large volumes of fat transplant. Dermatol Surg. 2000;26(12):1145–9. 22. Da Rocha RP. Surgical anatomy of the gluteal region’s subcutaneous screen and its use in plastic surgery. Aesthetic Plast Surg. 2001;25(2):140–4. 23. Babuccu O, Gozil R, Ozmen S, Bahcelioglu M, Latifoglu O, Celebi MC. Gluteal region morphology: the effect of the weight gain and aging. Aesthetic Plast Surg. 2002;26(2):130–3. 24. Montagu A. The buttocks and natural selection. J Am Med Assoc. 1966;198(1):169. 25. Kopelman PG. The effects of weight loss treatments on upper and lower body fat. Int J Obes. 1997;21(8):619–25. 26. Fabris de Souza SA, Faintuch J, Valezi AC, Sant’ Anna AF, Gama-Rodrigues JJ, de Batista Fonseca IC, et al. Postural changes in morbidly obese patients. Obes Surg. 2005;15(7):1013–6. 27. Ferretti A, Giampiccolo P, Cavalli A, Milic-Emili J, Tantucci C. Expiratory flow limitation and orthopnea in massively obese subjects. Chest 2001;119(5):1401–8. 28. Giusti V, Gasteyger C, Suter M, Heraief E, Gaillard RC, Burckhardt P. Gastric banding induces negative remodeling in the absence of secondary hyperparathyroidism: potential role of serum C telopeptides for follow-up. Int J Obes (Lond). 2005;29(12):1429–35. 29. Lockwood TE. Transverse flank-thigh-buttock lift with superficial fascial suspension. Plast Reconstr Surg. 1991;87(6):1019–27. 30. Lockwood T. Lower body lift with superficial fascial system suspension. Plast Reconstr Surg. 1993;92(6):1112–22. 31. Lockwood TE. Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast Reconstr Surg. 1991;87(6):1009–18. 32. Ahmadzadeh R, Bergeron L, Tang M, Morris SF. The superior and inferior gluteal artery perforator flaps. Plast Reconstr Surg. 2007;120(6):1551–6. 33. Pan WR, Taylor GI. The angiosomes of the thigh and buttock. Plast Reconstr Surg. 2009;123(1):236–49. 34. Lui KW, Hu S, Ahmad N, Tang M. Three-dimensional angiography of the superior gluteal artery and lumbar artery perforator flap. Plast Reconstr Surg. 2009;123(1):79–86. 35. Taylor GI. The angiosomes of the body and their supply to perforator flaps. Clin Plast Surg. 2003;30(3):331–42. 36. Whiteside JL, Barber MD, Walters MD, Falcone T. Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and lower transverse incisions. Am J Obstet Gynecol. 2003;189(6):1574–8. 37. Avsar FM, Sahin M, Arikan BU, Avsar AF, Demirci S, Elhan A. The possibility of nervus ilioinguinalis and nervus iliohypogasticus injury in lower abdominal incisions and effects on hernia formation. J Surg Res. 2002;107(2):179–85.

2 Gluteal Contouring Surgery: Aesthetics and Anatomy 38. Al-dabbagh AK. Anatomical variations of the inguinal nerves and risks of injury in 110 hernia repairs. Surg Radiol Anat. 2002;24(2):102–7. 39. Aszmann OC, Dellon ES, Dellon AL. Anatomical course of the lateral femoral cutaneous nerve and its susceptibility to compression and injury. Plast Reconstr Surg. 1997;100(3): 600–4. 40. Grothaus MC, Holt M, Mekhail AO, Ebraheim NA, Yeasting RA. Lateral femoral cutaneous nerve: an anatomic study. Clin Orthop Relat Res. 2005;(437):164–8. 41. Drake RL, Wayne V, Mitchell AWM. Gray’s anatomy for students. Philadelphia: Elsevier, Churchill; 2005. 42. Babinski MA, Machado FA, Costa WS. A rare variation in the high division of the sciatic nerve surrounding the superior gemellus muscle. Eur J Morphol. 2003;41(1):41–2. 43. Ugrenovic S, Jovanovic I, Krstic V, Stojanovic V, Vasovic L, Antic S, et al. The level of the sciatic nerve division and its relations to the pyriform muscle. Vojnosanit Pregl. 2005; 62(1):45–9.

25 44. Prynn WL, Kates DE, Pollack CV Jr. Gluteal compartment syndrome. Ann Emerg Med. 1994;24(6):1180–3. 45. Hill SL, Bianchi J. The gluteal compartment syndrome. Am Surg. 1997;63(9):823–6. 46. Bleicher RJ, Sherman HF, Latenser BA. Bilateral gluteal compartment syndrome. J Trauma. 1997;42(1):118–22. 47. Kroll DA, Caplan RA, Posner K, Ward RJ, Cheney FW. Nerve injury associated with anesthesia. Anesthesiology 1990;73(2):202–7. 48. Lincoln JR, Sawyer HP Jr. Complications related to body positions during surgical procedures. Anesthesiology 1961; 22:800–9. 49. Parks BJ. Postoperative peripheral neuropathies. Surgery 1973;74(3):348–57. 50. Watson RA, Pride NB. Postural changes in lung volumes and respiratory resistance in subjects with obesity. J Appl Physiol. 2005;98(2):512–7. 51. Brodsky J. Positioning the morbidly obese patient for anesthesia. Obes Surg. 2002;12(6):751–8.

3

Anatomy and Topography of the Anterior Abdominal Wall Michael R. Davis and Matthew R. Talarczyk

3.1 Aesthetic Landmarks Abdominal beauty does not arise from a strictly defined form. There are varied appearances which are considered aesthetically pleasing. Surface landmarks contribute greatly to abdominal aesthetics, but the degree to which they are defined is not necessarily directly related to the level of feminine aesthetic beauty. As with most aesthetic features, proportion plays a significant role. Contour of the abdomen is dependent upon age, genetics, muscle mass, tone, obesity, intraabdominal pathology, parity, and posture. These factors may significantly alter topography. The anterolateral abdominal wall is bounded superiorly by the costal margins and the xiphoid, and below by the iliac crests, inguinal ligaments, pubic crest, and pubic symphysis. Its lateral margins are defined by conventional vertical lines dropped from the costal margins to the most elevated portion of the iliac crests. The linea alba extends in the midline from the xyphoid process to the symphysis pubis. It is divided by the umbilicus into supraumbilical and infraumbilical segments of nearly equal lengths. The rectus muscles produce elevated bands on each side of the linea alba. Transverse tendinous intersections create palpable depressions in muscular persons. There is usually one at the level of the xyphoid, one at the umbilicus, and one between. It is the combination of the linea alba and the linea transversae which form the abdominal “six-

M. R. Davis (*) Division of Plastic Surgery, University of Alabama, Birmingham School of Medicine, 510 20th Street South, 1164 Faculty Office Tower, Birmingham, AL, 35294-3411, USA e-mail: [email protected]

pack” sought by body builders. At the lateral margin of each rectus muscle, there is a depression called the linea semilunaris which is directed inferomedially toward the symphisis pubis. Visible grooves mark the lower limits of the inguinal ligament [1]. The abdominal wall form is created by the relationship between the osteomyofascial system, the subcutaneous fibroadipose tissue, and the skin. These relationships give the appearance of an aesthetic contour through light reflection variations from prominences and shadows from depressions. In the midline from the xiphoid to the navel, a shadow is formed by the depression of a medial sulcus corresponding to the linea alba. Lateral to this sulcus there are two vertical wide strip reflections produced by the prominence of the rectus abdominis muscles that join under the umbilicus. More lateral and slightly more posterior to these prominences there are two wide depressions called semilunar sulci. They produce a “lyre” form by the insertion of the skin at the condensation of the fascia of the oblique muscles into the external margin of the rectus muscles, the inguinal ligaments, and pubis. The silhouette of the abdomen is formed by the lower part of thoracic cage superiorly, the pelvis inferiorly, and the waist in the middle. The waist extends from 7 to 10 cm between the inferior costal margin and the iliac crest. The shape of the waist is dependent on the superior aperture of the pelvis. A wide pelvis produces a more accentuated waist. The waist can be absent when the pelvis is small, when the distance between the pelvis and the ribs is reduced, or when excess adiposity is present [2]. Umbilical position and appearance are important and prominent aesthetic features. The umbilicus represents residual scarring at the point of umbilical cord attachment. Typically, as the scar involutes and the abdominal wall matures, a depression forms. The central recession is a key aesthetic feature. In the inferior extreme of the

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shadow of the medial sulcus, a more accentuated shadow is formed by the triangular depression of the navel. Attractive navels are small and vertical in orientation, or have a T shape, which consists of a thin vertical hollow capped by a superior hood or shelf. Unaesthetic navels are horizontal, large, or protruding [3]. The umbilicus should be situated in the midline at or slightly above the superior iliac crests [4]. Aesthetic units of the abdomen have been defined for both men and women. There are six units (3 pairs) in men corresponding to the epigastrium, periumbilical, lower abdominal regions. Women have a seventh unit, the dorsal back roll region, which is also a consideration for treatment at the time of abdominal contour surgery. Men rarely complain of dorsal back rolls [5]. Modern aesthetically pleasing abdomens are varied in appearance and there are no strict criteria accepted as the standard of beauty. Though varied, they typically have in common a medial sulcus in the upper abdomen, two shadows of the semilunar lines that join over the pubis, and two protuberances between the shadows beginning in the thorax that join under the umbilicus, with a lyre shape. Under the umbilicus, the abdomen is typically not flat but slightly prominent [2]. The degree of adiposity represents the most striking and variable feature affecting abdominal wall appearance. Both intraabdominal and extraabdominal fat can act to efface surface landmarks and hip definition to the degree to render them unaesthetic. Modifications of the position and thickness of the tissues will alter the aesthetic appearance of the abdomen due to the changes of the light reflections and shadows. Therefore, the basic surgical principle today in abdominoplasty is to sculpture the tissues and reshape the light reflections and shadows by giving new tension in the musculoaponeurotic layer, sculpturing the overlaying fat under the cutaneous envelope, and by resecting excess skin and adipose when they are present.2

3.2 Skin and Subcutaneous Tissue Abdominal aesthetics are highly dependent on the properties and condition of the skin and subcutaneous tissues. They are the mortar from which improvement can be carved. Improper manipulation, however, can lead to complications. Many minor and major complications in abdominal plastic and reconstructive surgery occur with

M. R. Davis and M. R. Talarczyk

improper handling and violation of strict anatomic principles. Beneath the skin, there is the subcutaneous areolar tissue and superficial fascia. Over the lower thorax and epigastrium, the superficial fascia consists of one layer. This layer is thin and less organized than in the lower abdomen. In the lower abdomen it becomes more definitively bilaminar. Just superior to the inguinal ligament it can be divided into a superficial fatty stratum, termed Camper’s fascia, and a deeper, stronger, and more elastic membranous layer called Scarpa’s fascia [6]. The superficial layer is thick, areolar, and contains a variable amount of fat. This layer continues into the perineum, and in females, it continues over the labia majora. The deep layer is more membranous and contains elastic fibers. It is separated from the underlying deep fascia by a loose areolar layer. Inferiorly, it fuses with the deep fascia of the thigh, medial portion of the inguinal ligament, and pubic tubercle along the line of the fold of each groin [7].

3.3 Arterial Supply The lower anterolateral abdominal wall is perfused by three superficial branches of the femoral artery. From superior to inferior, these are the superficial circumflex iliac artery, the superficial epigastric artery, and the superficial external pudendal artery. These arteries are directed toward the umbilicus in the subcutaneous tissue. Each superficial epigastric artery anastomoses with the contralateral artery and all anastomose with deep epigastric arteries. Huger [8] defined three zones with respect to their corresponding primary blood supplies. Zone I overlying the rectus muscles is perfused by the superior– inferior epigastric system. Zone II lies in the lower abdominal region from a transverse line at the level of the anterior superior iliac spines to the pubis and inguinal creases and is supplied by the superficial epigastric, superficial external pudendal, and circumflex iliac system. Zone III is from the flare of the costal margin to the transverse line corresponding to the anterior superior iliac spines and is supplied by branches from the intercostal and lumbar arteries [8]. The deep arteries pass between the transversus abdominis and internal oblique muscles. They are the 10th and 11th posterior intercostal arteries, the anterior

3 Anatomy and Topography of the Anterior Abdominal Wall

branch of the subcostal artery, the anterior branches of the 4th lumbar arteries, and the deep circumflex iliac artery. The rectus sheath is supplied by the superior epigastric artery, which arises from the internal thoracic artery, as well as the inferior epigastric artery arising from the external iliac artery just above the inguinal ligament. The superior epigastric artery enters the upper end of rectus sheath deep to the rectus muscle. Typically, two vertical rows of musculocutaneous perforators pierce the anterior rectus sheath to supply overlying skin. The inferior epigastric artery lies first in the preperitoneal connective tissue and then enters the sheath above the level of the arcuate line to pass between the rectus muscle and the posterior layer of the sheath [9].

3.4 Venous Drainage The superficial epigastric, circumflex iliac, and pudendal veins converge in the groin to enter the greater saphenous vein. Above the umbilicus, the superficial veins empty into the superior vena cava via the internal mammary, intercostal, and long thoracic veins. Both groups join with one another through the thoracoepigastric vein, which ascends from the groin to the axilla. The two systemic groups of veins communicate indirectly at the umbilicus with the portal vein by means of a potential anastomosis with the paraumbilical vein, which passes from the left branch of the portal vein along the round ligament of the liver to the umbilicus [6].

3.5 Lymphatic Drainage The lymphatic drainage is divided into two general groups. The upper group, which lies in the supraumbilical region, drains into the pectoral and axillary nodes. The lower group in the infraumbilical region drains toward the superficial inguinal nodes. Lymphatics from the liver course along the ligamentum teres to the umbilicus, thereby communicating with the lymphatics of the anterior abdominal wall. Metastasis to the umbilicus from the liver can occur and may spread to the lymph nodes in the groin [1]. It should be noted that the deep inguinal lymph nodes receive most of the drainage from the lower extremity. Efferent vessels

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from the deep nodes drain into the external iliac, common iliac, and lumbar lymph nodes, eventually reaching the cisterna chyli and thoracic duct.

3.6 Innervation The cutaneous nerves are arranged segmentally in a similar manner to the intercostal nerves in the thorax. The lower six nerves sweep around obliquely to supply the abdominal circumference giving lateral cutaneous branches which course through the external oblique muscle. Each cutaneous branch divides into a lesser posterior nerve, extending back over the latissimus dorsi and a larger anterior nerve which supplies the external oblique muscle and overlying subcutaneous tissue and skin. The main stem of the intercostal nerve continues forward and reaches the midabdominal surface by passing through the rectus muscle, then emerging through the anterior rectus sheath approximately a centimeter from the midline. The most caudal nerves of the abdominal wall are derived from the first lumbar nerve. They are the iliohypogastric and ilioinguinal nerves [10].

3.7 Musculofascial Anatomy The abdominal wall contains multiple large, musculofascial units which serve several functional purposes. Laterally, from external to internal, there are two paired external oblique, internal oblique, and transversus abdominis muscles. There are two paired midline muscle groups which include the rectus abdominis muscle and the pyramidalis. All of these muscles contribute to increasing intraabdominal pressure and aid in micturition, defecation, and parturition [11]. The rectus abdominis muscle originates from the symphysis pubis and pubic crest and inserts onto the xiphoid process and costal cartilage five through seven. This muscle is innervated by the intercostal nerves T7–T11. Blood supply is from the same intercostal arteries, the superior epigastric artery, as well as the inferior epigastric artery. The rectus abdominis muscle is a large muscle group positioned on both sides of the midline and contained within the rectus sheath. The rectus sheath is a unique fibrous network with contributions from the internal and external abdominal

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oblique aponeurosis and the transversus abdominis aponeurosis fibers. The arcuate line of the rectus sheath defines where the internal abdominal oblique aponeurosis splits into two layers. One layer passes anterior to the rectus muscle while the other layer passes posterior to the rectus muscle. Therefore, above the arcuate line the anterior rectus sheath is comprised from the aponeuroses of both the external and internal abdominal oblique. The corresponding posterior rectus sheath arises from the internal oblique and transversus abdominis aponeuroses. The arcuate line anatomically defines the inferior limits of the posterior rectus sheath. Below the arcuate line, the internal abdominal oblique aponeurosis no longer bifurcates and the anterior rectus sheath is comprised of the internal and external abdominal oblique aponeuroses, as well as the transversus abdominis aponeurosis. The midline structure, the linea alba, is formed from the confluence of the transversus abdominis aponeurosis and the internal and external abdominal oblique aponeuroses. The external abdominal oblique originates from the lower eight ribs and inserts onto the anterior superior iliac spine as well as the pubic crest and tubercle. Like the rectus abdominis muscle, the external abdominal oblique is innervated by the intercostal nerves T7–T11. It also receives contributions from the iliohypogastric and the ilioinguinal nerves as well as the subcostal nerve (T12). Blood supply to this muscle is complex with perfusion from the intercostal arteries seven through eleven, the superficial and inferior epigastric arteries, the deep circumflex iliac arteries, the superficial circumflex iliac arteries, and the superficial external pudendal arteries. Fibers of this muscle group are directed inferomedially. The internal abdominal oblique muscle originates from the anterior two-thirds of the iliac crest, the lateral two-thirds of the inguinal ligament, as well as from the thoracolumbar fascia. This muscle inserts onto the lower four ribs and pubic crest. The blood supply and innervation to this muscle are similar to that of the external abdominal oblique muscle. Orientation of this muscle group is perpendicular to the fibers of the external abdominal oblique. The plane carrying the neurovascular supply to the anterior abdominal wall lies between the internal oblique and the transversus abdominis muscles. This plane is to be avoided anatomically during surgery to avoid bleeding and denervation of the abdominal wall.

M. R. Davis and M. R. Talarczyk

The anatomic plane between the external oblique and internal oblique muscles, however, is virtually bloodless when defined correctly and is used surgically by plastic surgeons in component separation during abdominal wall reconstruction [12]. The transversus abdominis muscle originates from the lower six ribs, the anterior iliac crests, the lateral inguinal ligament, as well as the thoracolumbar fascia. It inserts onto the pubic crest. The blood supply and innervation are also similar to that of the external and internal abdominal oblique muscle groups. The pyramidalis is an inferior midline structure and lies anterior to the lower third of the rectus muscles originating from the pubic crest and inserting onto the linea alba. It is innervated by the subcostal nerve and its blood supply comes from branches from the subcostal arteries, as well as the inferior epigastric arteries. The transversalis fascia comprises the entire connective tissue sheet lining the musculature of the abdominal cavity. The transversalis fascia extends from the rib cage to the pelvis. In some areas, this fascial layer is given a specific name such as “iliacus” or “psoas” fascia where it covers those muscles. The transversalis fascia varies in nature. It is thin and adherent deep to the transversus abdominis aponeurosis, yet thick and separate in the genitofemoral region. The peritoneum is the innermost layer of the abdominal wall and the inguinal area. It is loosely connected with the transversalis fascia in most areas, except at the internal ring, where the connection is stronger. Between the peritoneum and the transversalis fascia there is a loose layer of extraperitioneal fat used as an important landmark in many surgical operations [8].

3.8 Conclusions The abdominal wall contour is defined by the close relationships between the skeletal, musculofacial, and cutaneous systems. It can be safely manipulated into a more aesthetic form with a thorough understanding of the anatomy as well as pathophysiology. It contains a complex structural myofascial network that supports multifaceted functions of everyday life. Understanding the anatomic relationships of these units is paramount for clinicians in their ability to address and treat complex clinical scenarios.

3 Anatomy and Topography of the Anterior Abdominal Wall

References 1. McVay CB. Surgical Anatomy. 6th ed. Philadelphia: WB Saunders; 1989. p. 484–584. 2. Psillakis JM, Appiani E, de la Plaza R. Color atlas of aesthetic surgery of the abdomen. New York: Thieme; 1991. 3. Craig SB, Faller MS, Puckett CL. In search of the ideal female umbilicus. Plast Reconstr Surg. 2000;105:389. 4. Dubou R, Ousterhout D. Placement of the umbilicus in an abdominoplasty. Plast Reconstr Surg. 1978;61(2): 291–3. 5. Matarasso A. Abdominoplasty. Plast Surg Tech. 1995; 4:303.

31 6. Gray SW, Skandalakis JE, McClusky DA. Atlas of surgical anatomy for general surgeons. Baltimore: Williams and Wilkins; 1985. p. 342–9. 7. Peter LW, Roger W, Lawrence HB. Gray’s anatomy. 37th ed. UK: Churchhill Livingstone; 1989. p. 599–602. 8. Huger WE. The anatomic rationale for abdominal lipectomy. Am J Surg. 1979;45(9):612–7. 9. Skandalakis JE, Skandalakis PN, Skandalakis LJ. Surgical anatomy and technique. New York: Hamilton; 1999. p. 123–55. 10. Delvin B, Kingsnorth AN. The management of abdominal hernias. 2nd ed. London: Arnold; 1999. p. 211–30. 11. Grevious MA. Structural and functional anatomy of the abdominal wall. Clin Plast Surg. 2006;33(2):169–79. 12. Ahluwalia HS, Burger JP, Quinn TH. Operat Tech Gen Surg. 2004;6(3):147–55.

4

History of Classifications of Adiposity Excess Melvin A. Shiffman

4.1 Introduction Fat accumulation is classified in order to visualize areas of fat deformity that can be treated surgically. There are a variety of regions of the body that may accumulate excess amounts of fat, some of which are hereditary with a genetic defect. The gluteal, thigh, buttocks, and abdominal areas are the areas of frequent complaint from patients as areas of excess fat accumulation.

4.2 History Vague [1] measured circumferences (CFD) at the nape of the neck, sacrum, and the four proximal attachments of the extremities comparing male and female. An index of masculine differentiation (IMD) (Table 4.1) was established using the average fat in each area. Obesities were called gynoid and hypergynoid that consisted of localization of fat on the lower part of the body and android and hyperandroid that had localization of fat on the upper part of the body. The android obesity leads to metabolic disturbances. Ashwell et al. [2] used a photographic method for classifying female fat distribution (FD). The recommended measure, the FD score, was a simple ratio of waist and thigh diameters obtained from standard sideview somatype photographs. FD score = 26 log10 × waist diameter thigh diameter M. A. Shiffman 17501 Chatham Drive, Tustin, CA 92780-2302, USA e-mail: [email protected]

The photographic method requires special facilities and is therefore not available to all who wish to classify FD. Circumferential measurements have been successfully used to derive equations for the estimation of body fatness [3, 4]. Grazer and Klingbeil [5] classified fat accumulation taking into consideration major anatomic components in and around the hip and thigh areas that contribute to body configuration (Table 4.2) (Fig. 4.1). The method of correction of the deformity was also included. Ashwell et al. [6] used photographs to assess the patients as being either central, peripheral, or intermediate (Fig. 4.2) that was quicker and more reliable than the assessment of body outline drawings [7], X-rays [8], or skin fold thickness [9]. FD in women was classified by Kalkhoff et al. [10] on the basis of the ratio of the waist to hip circum ference. Shaer [11] produced a simplified classification of gluteal and thigh deformities (Fig. 4.3). This classification was used to plan surgical procedures. The lateral gluteal recess is a normal depression that may be visually aggravated by the accumulation of fat in the anterior superior iliac spine, iliac crest, and the trochanteric area. The deformities illustrated in Fig. 4.1 were treated by the author by augmentation of area one, fat removal in areas two, three, four, six, and seven, and skin excision in areas three, four, and six. At the present time, liposuction is the preferred method of fat removal and depressions can be treated with fat transfer. Skin excision is usually not necessary if superficial liposuction is performed that stimulates skin retraction. Ashwell et al. [12] classified the FD from anthropomorphic findings and could distinguish only those with

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M. A. Shiffman

Table 4.1 Classification of masculine differentiation on the basis of the index of masculine differentiation (IMD) scale IMD scale Group > + 15 +15

Hyperandroid

0

Android

−15 −45

Intermediate

60

Gynoid

−75 <−75

Hypergynoid

centralized distribution (“apples” or android) from those with peripheral distribution (“pears” or gynecoid). They performed computerized tomography and found that centralized FD tended to have more intraabdominal fat than those with peripheral distribution. Vague [1] noted that men are more likely than women to have centralized FD. He also found that android obesity was more closely associated with diabetes, gout, and atherosclerosis.

Song et al. [13] rated contour deformities after massive weight loss. Ten anatomic areas were analyzed including the arms, breasts, abdomen, flank, mons, back, buttocks, medial thighs, hips/lateral thighs, and lower thighs using a four point grading system. The scale was: 0 appearance in normal range. Needs no surgery. 1 mild deformity. Would require nonexcision or minimally invasive procedure. 2 moderate deformity. Would require an excisional procedure. 3 severe deformity. Would require combinations of excisional, lifting, and non invasive procedures, frequently involving large areas of undermining. Duggleby et al. [14] stated that the anthropometric indices of adiposity include BMI (body mass index), waist circumference, and waist:height ratio. The authors concluded that each index captures different aspects of size in terms of adiposity and there is a need to determine how the three indices relate to function and how they can be used in defining risk of ill health in women.

Table 4.2 Classification of thigh, hip, and gluteal contour deformity (Grazer and Klingbeil) [4] Type Characterization

Treatment

I (crural excess)

Includes medial thigh fullness, relaxation, and wrinkling. It is usually seen in the middle-aged patient and the deformity ismost often seen. Extreme examples of this deformity also occur in patients of advanced age or marked weight loss

Medial thighplasty

II (trochanteric or riding britches deformity)

Fullness of the trochanteric area. Frequently seen in younger age groups. This is the second most frequent deformity

Wedge plus (crural excess)

III (gluteal or supra-trochanteric recess)

Recess in the medial aspect of the buttocks on the lateral side. Seen primarily in the early middle-aged group

Tuck and roll (crural excess)

IV (composite of types II and III)

An aggravated example of type III recession with fullness over the trochanteric area

Tuck and roll (crural excess)

V (obesity)

Seen at almost any age. Cellulite dimpling most often seen

Simple wedge (crural excess)

VI (asymmetry)

Either traumatic or congenital. Seen at almost any age

Wedge plus roll and tuck

VII (aging or atrophy)

Usually occurs in older age groups. Involves generalized muscle atrophy and excessive skin with loss of adipose tissue. Seen with anorexia or other diet starvation syndromes

Tuck and pleat (atrophy)

4 History of Classifications of Adiposity Excess

I CRURAL EXCESS AGING

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II TROCHANTERIC DEFORMITY

IV II AND III

VI ASYMMETRY AND TRAUMATIC DEFORMITY

III GLUTEAL RECESS

V OBESITY

VII AGING OR ATROPHY

Fig. 4.1 Grazer and Klingbeil [4] classification of thigh, hip, and gluteal contour deformity. (a) I: crural excess: aging. (b) II: trochanteric deformity. (c) III: gluteal recess. (d) IV: II and III. (e) V: obesity. (f) VI: asymmetry and traumatic deformity. (g) VII: aging or atrophy

36

M. A. Shiffman

Fig. 4.2 Ashwell et al. [6] classification of obesity using photographs. (a) Central. (b) Peripheral. (c) Intermediate

References

Fig. 4.3 Shaer [11] simplified classification of gluteal and thigh deformities. 1: lateral gluteal recess. 2: anterior superior iliac spine crest collections. 3: trochanteric accumulation (“riding britches”) deformity. 4: ptotic or large buttocks. 5: diffuse lipomatous collection across sacrum and upper buttocks. 6: upper medial thigh ptosis or fat collection. 7: lower medial thigh fat collection

1. Vague J. The degree of masculine differentiation of obesities: a factor determining predisposition to diabetes, atherosclerosis, gout, and uric acid calculous disease. Am J Clin Nutr. 1956;4(1):20–34. 2. Ashwell M, Chinn S, Stalley S, Garrow JS. Female fat distribution – a photographic and cellularity study. Int J Obes. 1978;2(3):289–302. 3. Behnke AR. Anthropomometric evaluation of body composition throughout life. Ann NY Acad Sci. 1963;110:450–64. 4. Steinkamp RC, Cohen NL, Gaffey WR, McKey T, Bron G, Siri WE, Sargent TW, Isaacs E. Measures of body fat and related factors in normal adults-II: a simple clinical method to estimate body fat and lean body mass. J Chronic Dis. 1965;18(12):1291–307. 5. Grazer FM, Klingbeil JR. Body image. A surgical perspective. St. Louis: CV Mosby; 1980. p. 246–9. 6. Ashwell M, Chinn S, Stalley S, Garrow JS. Female fat distribution – a simple classification based on two circumferential measurements. Int J Obes. 1982;6(2):143–52. 7. Craig LS, Bayer LM. Androgynic phenotypes in obese women. Am J Phys Anthropol. 1967;26(1):23–34. 8. Garn SM. Fat weight and fat replacement in the female. Science. 1957;125(3257):1091–2. 9. Edwards DA. Observations on the distribution of subcutaneous fat. Clin Sci (Lond). 1950;9:259. 10. Kalkhoff RK, Hartz AH, Rupley D, Kissebah AH, Kelber S. Relationship of body fat distribution to blood pressure, carbohydrate tolerance, and plasma lipids in healthy obese women. J Lab Clin Med. 1983;102(4):621–7. 11. Shaer WD. Gluteal and thigh reduction: reclassification, critical review, and improved technique for primary correction. Aesthetic Plast Surg. 1984;8:165–72. 12. Ashwell M, Cole TJ, Dixon AK. Obesity: new insight into the anthropomorphic classification of fat distribution shown by computed tomography. Br Med J. 1985;290(6483): 1692–4.

4 History of Classifications of Adiposity Excess 13. Song AY, Jean RD, Hurwitz DJ Fernstrom MH, Scott JA, Rubin JP. A classification of contour deformities after bariatric weight loss: the Pittsburgh rating scale. Plast Reconstr Surg. 2005;116(5):1535–44. 14. Duggleby SL, Jackson AA, Godrey KM, Robinson SM, Inskip HM. The Southamptom Women’s Survey Study

37 Group: cut-off points for anthropometric indices of adiposity: differential classification in a large population of young women. Br J Nutr. 2008;18:1–7.

5

Body Contour: A 50 Year Perspective Ivo Pitanguy and Henrique N. Radwanski

5.1 Introduction Current sedentary lifestyle and dietary excesses, associated with factors such as genetic predisposition, pregnancy, and aging process, contribute to alterations of fat distribution and excess skin envelope that result in the loss of the individual’s body image. Until the second half of the twentieth century, body contour deformities were mostly hidden under heavy clothing or were reluctantly accepted. Localized fat deposits and skin flaccidity are sometimes resistant to the most sincere efforts in weight loss and sport activities. On the other hand, globalized fashion trends generally promote body-revealing attire, and this is especially true in warmer climates. All of these factors create a strong psychological motivation for surgical body contouring. This ever-increasing request for contour surgery has been favorably met by safe and efficient surgical techniques, resulting in a high degree of patient satisfaction. This chapter presents the authors’ approach to various body contour deformities, as it has evolved over more than three decades. These alterations may involve one single anatomical region, or may affect multiple body regions, and can require one or more than one combined procedures. In some cases, multiple or severe deformities will demand a multistage approach,

I. Pitanguy (*) Ivo Pitanguy Clinic, Rua Dona Mariana, 65, Rio de Janeiro 22280-020, Brazil e-mail: [email protected]

as in patients who have undergone dramatic weight loss. The concepts and principles that have been fundamental in developing these personal techniques will be presented, analyzing the areas that most commonly present for surgery, which include the abdomen, the upper limbs, and the lower limbs.

5.2 The Abdomen The abdomen plays a central role in a person’s profile, and this emphasizes its importance in defining body contour. Deformities of the abdominal wall cause variable aesthetic and/or functional alterations. The main causes of contour deformities of the abdominal wall are: obesity and significant weight loss; flaccidity of the muscles; pregnancy; localized lipodystrophy; sequelae of trauma or previous surgery that result in scars, hernias, and eventrations. Historically, abdominoplasties were first described for the correction of large hernias and resection of severe lipodystrophies. Many different incisions were proposed, and with time, the final scar was gradually situated in the lower abdomen. A personal approach to abdominal deformities was described in 1967 [1], where correction of function and a final aesthetic result were emphasized. A system of classification allows for correct diagnosis of abdominal contour deformities, and ensures appropriate and individualized treatment for each case. Final result should increase the patient’s self-esteem, but primarily it must improve the functional status of the abdominal wall.

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_5, © Springer-Verlag Berlin Heidelberg 2010

39

40 40 Fig. 5.1 (a) Preoperative Type I abdominal deformity. (b) Postoperative with surgical indication for liposuction

I. Pitanguy and H. N. Radwanski

a

1. Patients with type I deformities present with isolated lipodystrophy of the abdominal wall, and suction-assisted lipectomy is indicated (Fig. 5.1). 2. Type II deformity includes lipodystrophy, moderate skin flaccidity, with or without diastasis. A miniabdominoplasty is indicated, and this may be performed by video-endoscopy if the surgeon is familiar with this technique. Complementary liposuction may also be indicated (Fig. 5.2). 3. Lipodystrophy together with accentuated skin flaccidity and muscle diastasis, with or without eventration, defines type III deformities, and a classical abdominoplasty is indicated (Fig. 5.3). 4. Type IV patients present the same deformities, together with a vertical scar from the previous surgery. A classical abdominoplasty with a vertical incision is indicated (Fig. 5.4). The principles of the authors’ technique have endured over the past 5 decades. Aesthetic positioning of the

b

final scar requires the incision to be placed above the pubic area, preserving a pleasant amount of suprapubic mound. With a horizontal lateral extension, curving slightly upward, the final scar will be hidden under current beach attires. Although there may be certain variability, dictated by the patient’s preference for bathing trunks, it should be remembered that, while fashion trends change, scars are permanent (Fig. 5.5). Undermining of the abdominal flap is done over the muscle fascia, reaching the costal margins. While, in the past this dissection was extensive, it is now limited to the central tunnel above the umbilicus, thus preserving the important intercostal vessels. Muscle diastasis is repaired through the plication of the rectus abdominis aponeurosis, without opening the muscle fascia, as had been previously done. This strengthening of the abdominal wall, which was first proposed by this author, begins at the xyphoid process to correct epigastric protrusion and extends down to the pubis. Strong

5 Body Contour: A 50 Year Perspective

a

41

c

b

Fig. 5.2 (a) Preoperative Type II abdominal deformity. (b) Mini-abdominoplasty. (c) Postoperative with surgical indication for liposuction plus miniabdominoplasty

a

Fig. 5.3 (a) Preoperative Type III abdominal deformity. (b) Markings for classic abdominoplasty

b

42 42 Fig. 5.4 (a) Preoperative Type IV abdominal deformity. (b) Postoperative with surgical indication of atypical abdominoplasty

I. Pitanguy and H. N. Radwanski

a

Fig. 5.5 Demarcation of the incision is done with a curving line above the pubis

nonabsorbable sutures are placed in an “X” fashion, inverting the knot, approximating the aponeurosis of the rectus abdominis muscle (Fig. 5.6). Exceptionally, the surgeon may be forced to open the fascia when there is a large diastasis or when severe eventration precludes approximation without excessive tension. Reinforcement of the abdominal wall with a mesh, firmly fixed to healthy tissue, is necessary when hernias or eventrations do not allow for primary closure of the musculo-aponeurotic layer. Abundant adipose tissue should be left over the mesh to avoid

b

extrusion. Previous expansion of the abdominal wall with tissue expanders is an interesting recourse to close extensive scars in reparative cases. The patient’s trunk is now slightly raised at an angle of 15° and the flap is fixed by a temporary suture at the midline, over the pubis. The lateral flaps are pulled downward and toward the midline, in a rotation rather than simply pulling on the flaps. With a long Pitanguy flap demarcator, the amount of excess tissue is estimated and marked. The same is done to the opposite side, and both demarcations are checked for symmetry before excess flap is resected (Fig. 5.7). The pedicle of the umbilicus is shortened with sutures, anchoring it firmly to the abdominal wall. The umbilicus should be exteriorized at a level corresponding to its natural position, without traction to avoid displacement, and exactly along the midline (even a minimal deviation will be apparent). The flap is thus brought over the umbilicus, and not the contrary. The Pitanguy flap demarcator is used to check for the correct position of the umbilicus on the exterior surface of the abdominal wall. Our preference is to perform a transverse or semicircular incision measuring approximately 2 cm to exteriorize the umbilicus. There is no resection of the skin. This straight line becomes a natural oval-shaped incision when the flap is positioned. A gracious defatting is done below this incision in a “cork” fashion, so as to cause a smooth periumbilicus depression (Fig. 5.8).

5 Body Contour: A 50 Year Perspective

a

43

b

Fig. 5.6 (a) Undermining of the abdominal flap is restricted to a central tunnel above the umbilicus. (b) Plication of the rectus abdominus aponeurosis is done in an X-fashion using strong sutures

a

b

c

Fig. 5.7 (a) The flap is sutured to the midline. (b) A long Pitanguy flap demarcator is used to check for excess tissue. (c) Resection is done in a beveled fashion to adjust for the amount of the fatty layer to the pubic mound

44 44

a

I. Pitanguy and H. N. Radwanski

b

c

e d

f

allows for the exteriorization of the umbilicus. (e) The removal of adipose tissue below the incision results in a pleasant periumbilical depression. (f) Long-term follow-up of the umbilicus

Fig. 5.8 (a) The flap demarcator is used to check the correct level of the umbilicus. (b) A transverse incision is done. (c) Fatty tissue is removed in a cork fashion. (d) A transverse incision

a

b

Fig. 5.9 (a) Preoperative excess adipose tissue. (b) Correction by open lipectomy

Resection of the flap is done in a beveled fashion, preserving Scarpa’s fascia, an important element in assuring good perfusion to the flap. Redundant adipose tissue under the flap (below the fascia) is removed by knife, in an open lipectomy, so that the thickness of the flap matches that of the suprapubic mound (Fig. 5.9).

Suction-assisted lipectomy of the flanks is very frequently performed, contouring and enhancing the waist-line. It should be stressed that liposuction is not done to any area that has been undermined, as there is an increased risk of necrosis of the abdominal flap.

5 Body Contour: A 50 Year Perspective

16

45

15,5

14 12 10 8 6 4 2 0

6,2

4,2 3,1 3,1

3,1 1,2

2,9

2,8

0,6

0,9 1

1

1,1 0,4 0,2

0,3 0,2

Fig. 5.10 Abdominoplasty complications in 3 different time periods

Serosanguinous collections are reported as one of the most frequent complications following abdomino plasties (Fig. 5.10). A few maneuvers have been adopted as a part of the classical technique, and have proven useful in preventing collections. These include the covering of all dissected tissues with moist sterile towels to avoid desiccation during the operation. Rigorous hemostasis and the placement of suction drains are routine. A plaster shield has been used to apply an even and firm pressure over the entire abdominal wall; it is molded over a thick, soft dressing, and left for 48 h as part of our routine. A 2-kg weight is placed to assure an even and firm pressure over the dissected abdominal flap, guaranteeing the adhesion of the undermined tissues (Figs. 5.11–5.14). An important contribution to abdominoplasty has been the introduction of suction-assisted lipectomy, which has permitted the removal of fat deposits by means of minimal incisions. Contouring of the abdomen has been considerably enhanced, either as a single procedure or associated with surgery, allowing the surgeon to complement an abdominoplasty with liposuction of nonundermined areas. Liposuction has also

decreased the necessity for larger dissections, thus contributing to lessen the rate of serosanguinous collection. (More recent approaches to abdominal dermolipectomy describe an ample liposuction of the entire abdomen, but dissection of the flap is limited to the adipose tissue above Scarpa’s fascia.) (Fig. 5.15).

5.3 The Upper Limbs Treatment of contour deformities of the upper limbs requires a very critical appraisal of the patient’s complaints and expectations. The surgeon should be emphatic regarding the limitations and possibilities of surgical procedures. A visible scar is inevitable when treating larger brachial lipodystrophies. Therefore, resection of excess tissue is indicated only in selected cases, where the deformity causes a significant disharmony between the upper limbs and the patient’s overall body contour. Liposuction has become the procedure of choice in moderate cases of fat accumulation of the posterior aspect of the arm, removing excess adipose tissue

46 46 Fig. 5.11 (a1, 2) Preoperative 49-year-old female. (b1, 2) Postoperative following classic abdominoplasty

I. Pitanguy and H. N. Radwanski

a1

b1

a2

5 Body Contour: A 50 Year Perspective Fig. 5.12 (a1, 2) Preoperative 35-year-old female with extreme flaccidity. (b1, 2) Postoperative following standard abdominoplasty with reinforcement of the abdominal muscles with an alloplastic mesh

47

a2

b1

b2

48 48 Fig. 5.13 (a1, 2) Preoperative 52-year-old male after extreme weight loss of over 60 kg. (b1, 2) Postoperative after classic abdominoplasty

I. Pitanguy and H. N. Radwanski

a1

b1

a2

5 Body Contour: A 50 Year Perspective Fig. 5.14 (a) Preoperative 31-year-old female after post caesarian infection with partial loss of the abdominal wall. (b1, 2) Expansion of tissues. (c) Postoperative following placement of alloplastic mesh and advancement of local flaps

a

49

b2

50 50

I. Pitanguy and H. N. Radwanski

Fig. 5.15 Abdominoplasty: cases grouped by procedures, in two periods. When liposuction had just been introduced, and following the adoption of liposuction as a routine complementary procedure

through minimal incisions. On the other hand, a small dermolipectomy is indicated in cases where the deformity is restricted to the upper third of the arm. A transverse incision is placed inside the armpit, dissection is performed below the subcutaneous layer, and excess tissue is pulled superiorly and demarcated, and then resected (Fig. 5.16). A larger resection is warranted when the patient presents with visible looseness of the skin, secondary to the aging process or after considerable weight loss. An elliptic demarcation is done along the posterior and inner aspects of the arm, thus assuring that the final scar is placed at the least visible location of the upper limb, which is at the internal bicipital sulcus. Dissection of tissues is done in a posterior direction, so as to bring the excess flap inwardly (Fig. 5.17). Some patients present with excess tissue that affects the elbow, the upper limbs, and the lateral aspect of the thorax. These cases are treated by a technique that was described in 1975 [2], called thoracobrachial dermolipectomy. The patient is examined and marked standing up and with the arms open so as

to demonstrate excess ptotic tissue. A sinuous demarcation begins distally at the elbows, and moves along the inner aspect of the arms, continues along the armpit, where it is “broken” by a z-plasty, avoiding scar retraction. The demarcation proceeds along the lateral aspect of the upper trunk and finishes at the submammary sulcus. The final scar is seen to be more satisfactory with this sinuous demarcation than when compared to other techniques that employ straight lines, which risk developing a “bow-string” deformity along anatomical creases with consequent unfavorable retractions. Suction-assisted lipectomy has become a valuable adjunct to this procedure (Fig. 5.18).

5.4 The Gluteal Region and the Thighs Lipodystrophy of the trochanteric region is a common contour deformity that has been the subject of inter est among different authors. When accentuated, this

5 Body Contour: A 50 Year Perspective

a

c

51

b1

b2

Fig. 5.16 (a) Preoperative lipodystrophy of the upper limbs. (b1, 2) Liposuction and limited skin resection. (c) Postoperative showing correction of the lipodystrophy

a1

b1

b2

Fig. 5.17 (a1, 2) Preoperative patient with severe laxity of the arms. (b1, 2) Postoperative dermolipectomy resulting in well-placed scars

52 52

a

I. Pitanguy and H. N. Radwanski

c

b

Fig. 5.18 (a) Markings for thoracobrachioplasty in patient with severe weight loss. (b) Excision. (c) Postoperative

deformity causes severe disharmony with the patient’s ideal self-image, and may also lead to physical discomfort and bad posture. Before the advent of liposuction, surgeons were restricted in their armamentarium. Large resections that were performed resulted in extensive scars. In 1964, a personal technique was described where the natural anatomical creases were used to hide or camouflage surgical incisions. The “riding-breeches” deformity was thus treated by a single incision, rotating the flap around the upper thigh rather than pulling, and removing excess tissue, with no undermining of the remaining tissues and minimal traction on the final scar. Deep sutures should be carefully placed to assure the continuity of the subcutaneous fascia, essential to avoid the widening of scars (Fig. 5.19). Suction-assisted lipectomy has considerably decreased the indications for dermolipectomy of the thighs. Cases that present with a large volume of adipose tissue may be

treated with serial liposuctions, with intervals of no less than 6 months, allowing for skin retraction, which in selected cases is surprisingly satisfactory. However, it is interesting to observe that the principles described over 30 years ago for trochanteric dermolipectomy are still valid; the area demarcated for resection matches the exact areas that are treated today by suction-assisted lipectomy. There is currently a restricted group of patients that are still candidates for this surgery. These patients either present with a severe degree of trochanteric dystrophy or extremely severe flaccidity of thigh skin associated with lipodystrophy following massive weight loss. Some have been submitted to liposuction and present with excess skin with irregularities so that the riding-breeches techniques will be correctly indicated. Again, dermolipectomy follows the principles of the rotation technique, rather than pulling of the flaps (Figs. 5.20 and 5.21).

5 Body Contour: A 50 Year Perspective

53

b1

a

c1

c2

b2

d

Fig. 5.19 (a) Preoperative patient with riding-breeches deformity. (b1, 2) Marking for dermolipectomy. (c1, 2) Excision. (d) Postoperative. This case was operated over 30 years ago and would, perhaps, today be approached by liposuction

5.5 Combined Contour Procedures Sometimes, patients present with a variety of complaints regarding contour deformities, and the surgeon must decide and plan for two or more procedures accordingly. There are many benefits for the patient if associated procedures can be performed during one single operation and hospitalization. However, there are important aspects to be considered before attempting to establish multiple surgeries. In associating procedures, the extent of the operation and surgical

trauma, as well as the length of anesthesia, should not be greatly increased. The attention to fine details should, of course, be as great as if a single procedure were to be performed. Lastly, the greater alteration in body image may cause psychological discomfort in patients who are not prepared for this change. Only years of training and constant preparation give the surgeon sufficient dexterity and ability to be successful in operations of this magnitude. A combination of aesthetic procedures should be attempted only when the surgeon feels that he has had sufficient training, and when he has gathered a highly qualified team of residents,

54 54

I. Pitanguy and H. N. Radwanski

Fig. 5.20 Trochanteric and interfemoral regions: cases grouped by procedures, in two periods. When liposuction had just been introduced, and following the adoption of liposuction as a routine complementary procedure

a1

a2

b

Fig. 5.21 (a1, 2) Preoperative 29-year-old female with excess trochanteric skin following liposuction. (b) Excision of skin. (c1, 2) Postoperative

5 Body Contour: A 50 Year Perspective

55

c1

Fig. 5.21 (continued)

associates, nursing staff, and surgical personnel, together with a team of anesthesiologist familiar with his work. Preliminary considerations include: realistic pati ent motivation, a complete physical and laboratory

examination, and adequate hospital facilities. Lack of methodology and preparation are the main factors preventing the combination of operations, unnecessarily increasing the risk to the patient (Figs. 5.22 and 5.23).

ASSOCIATED PROCEDURES 1967-2007

30

28,3

Face Lifting + Rhinoplasty

25

Rhinoplasty + Mentoplasty

20

Face Lifting + Mammaplasty

15

14,5

Mammaplasty + Abdominoplasty

14,3 12,6

12,3

10

11,2 9

8,6

10,8

Face Lifting + Mentoplasty

8,2

7,9

6,2

5

Face Lifting + Abdominoplasty

4,1 Face Lifting + Lipo body contour 0

0 1967-1979 3,342 cases

1980-2007 3,477 cases

Total cases: 6,819

Fig. 5.22 Associated procedures: and overview of the author’s experience in a span of 40 years

56 56

I. Pitanguy and H. N. Radwanski

a1

a2

b2

b1

c1

c2

c3

Fig. 5.23 (a1, 2) Preoperative 35-year-old female with excessive weight loss of more than 60 kg. (b1) Preoperative brachioplasty. (b2) Following brachioplasty. (c1–3) Postoperative after multistage complex procedure

5 Body Contour: A 50 Year Perspective

5.6 Conclusions It is essential that today’s aesthetic surgeons understand the motivations of patients who present with body contour deformities. A request for surgical treatment should be seen as a legitimate desire to achieve a physical form that approximates the individual with his or her ideal self-image. Additionally, the surgeon must always consider the possible benefit of including the participation of a multidisciplinary team approach.

References 1. Pitanguy I. Abdominal lipectomy: an approach to it through an analysis of 300 consecutive cases. Plast Reconstr Surg. 1967;40(4):384–91. 2. Pitanguy I. Abdominal lipectomy. Clin Plast Surg. 1975; 2(3):401–10.

Further Reading 1. Pitanguy I, Lima J. Treatment of some deformities of the lower extremity. In: Young H, editor. The year book of orthopedics, traumatic and plastic surgery. Chicago: Year Book Medical Publishers; 1963. p. 538–90. 2. Pitanguy I. Trochanteric lipodystrophy. Plast Reconstr Surg. 1964;34:280–6. 3. Pitanguy I. Vantaggi dell’impiego di contenzione gessata nelle plastiche abdominali. Minerva Chirurgica. 1967;22:595–8.

57 4. Pitanguy I. Thigh lift and abdominal lipectomy. In: Goldwyn RM, editor. Unfavorable results in plastic surgery. Boston: Little Brown; 1972. p. 387. 5. Pitanguy I. Lipectomy abdominoplasty and lipodystrophy of the inner side of the arm. In: Grabb W, Smith J, editors. Plastic surgery: a concise guide to clinical practice. 2nd ed. Boston: Little Brown; 1973. p. 1005–13. 6. Pitanguy I. Correction of lipodystrophy of the lateral thoracic aspect and inner side of the arm and elbow dermosenescence. Clin Plast Surg. 1975;2(3):477–83. 7. Pitanguy I. Dermolipectomy of the abdominal wall, thighs, buttocks and upper extremity. In: Converse JM, editor. Reconstructive plastic surgery, vol 7. 2nd ed. Philadelphia: Saunders; 1977. p. 3800–23. 8. Pitanguy I, Cavalcanti MA. Methodology in combined aesthetic surgeries. Aesthetic Plast Surg. 1978;2:331–40. 9. Pitanguy I. Combined aesthetic procedures. In: Aesthetic plastic surgery of head and body. Berlin: Springer; 1981. p. 353–9. 10. Pitanguy I, Ceravolo M. Our experience with combined procedures in aesthetic plastic surgery. Plast Reconstr Surg. 1983;71(1):56–65. 11. Pitanguy I. The abdomen. In: Aesthetic surgery of head and body. Berlin: Springer; 1984. p. 100–27. 12. Pitanguy I. Gluteal region and lower extremity. In: Aesthetic surgery of head and body. Berlin: Springer; 1984. p. 129–52. 13. Pitanguy I. Upper extremity: dermolipectomy. In: Aesthetic surgery of head and body. Berlin: Springer; 1984. p. 153–8. 14. Pitanguy I. Body contour. Am J Cosmet Surg. 1987;4:283–93. 15. Pitanguy I. Thigh and buttock lift. In Lewis JR, editor. The art of aesthetic surgery, vol 2. Boston: Little Brown; 1989. p. 1060–7. 16. Pitanguy I. Abdominoplasty: classification and surgical techniques. Rev Bras Cir. 1995;85:23–44. 17. Pitanguy I. Complications in aesthetic surgery: What experience has taught us over the years. Lecture, 2nd Intern, Symposium. Israel: 1996.

6

Injection Lipolysis for Body Contouring Diane Duncan

6.1 Introduction The topic of injection lipolysis remains controversial even 5 years after of becoming a popular treatment for reducing localized fat deposits with injections rather than surgery. The technique was invented by Rittes who had studied mesotherapy with Lecoz in France. A patient, knowing of Rittes skill with injections, requested an injectable fat reduction for her lower lid bags. The patient persisted despite the absence of an injectable technique for localized fat reduction at that time. Rittes researched the pharmaceutical and clinical literature for a solution. She found Bobkova’s article describing the endovenous plaque reducing qualities in Lipostabil, a Sanofi Aventis drug containing phosphatidylcholine (PC) made from soy lecithin [1]. Rittes’ paper, published in 2001 [2], is often quoted as the origin of the injection lipolysis procedure. While the precursor of the injection lipolysis procedure was mesotherapy, the technique has evolved so much that its only resemblance to the parent technique is the delivery method: multiple injections of small amounts of pharmaceuticals [3]. Mesotherapy, originally practiced by the Chinese over 2000 years bc, is often considered as a “pharmaceutical acupuncture.” With the mesotherapy technique, very small amounts of a “cocktail” of drugs are injected, usually intradermally, at very specific sites for a variety of purposes. These techniques generally involve several hundred “pokes” and rarely deliver a

D. Duncan 1701 East Prospect Road, Fort Collins, CO 80525, USA e-mail: [email protected]

therapeutic dose of any drug. Procaine is frequently added to “enhance the microcirculation.” Treatments have multiple purposes; these can vary from treatments for baldness, indigestion, breast ptosis, to sports injuries and chronic pain [4]. The term “injection lipolysis” should not be used synonymously with mesotherapy. Injection lipolysis differs from mesotherapy in two major aspects: one is that, the only purpose of injection lipolysis is the reduction of subcutaneous localized fat and achievement of modest overlying skin retraction. The second is that, while the drug doses in injection lipolysis are small per injection, the total dose injected is clinically therapeutic. The controversy regarding injectable fat reducing treatments has been the lack of a standard, safe, and effective practice, and the “charlatan” use of these drugs by untrained physicians and nurses. These drugs are currently available for purchase online by any person with a valid credit card. Body builders are frequently targeted as buyers, and can go into chat rooms where they self-inject while discussing the best method and regions to treat [5]. Aestheticians and lay people, as well as paramedical specialists such as chiropractors and aromatherapists have used the technique as well [6]. The poor reputation of the procedure has frequently been featured by the media [7] that portrays the disasters much more frequently than its successes. Understandably, the ASPS (American Society of Plastic Surgeons) and ASAPS (American Society of Aesthetic and Plastic Surgery) have issued warnings against the use of injection lipolysis, given the lack of an FDA approved drug for these injections and the widespread problem of charlatan use. The standard of practice for injection lipolysis sets forth the basic guidelines for responsible physicians who feel that injection lipolysis can solve clinical problems [8].

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_6, © Springer-Verlag Berlin Heidelberg 2010

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6.2 Mechanism of Action Another point of concern for physicians and patients is the current lack of understanding of how injection lipolysis works. There are at least eleven currently known ways to kill fat cells in vivo or in the laboratory setting [9]. These include: 1. Mechanical avulsion, such as standard liposuction 2. Mechanical grinding, or “pressing” through a mill device 3. Sonication: cavitation using ultrasound waves 4. Toxic chemical necrolysis using compounds to lyse cell membranes and target particular organelles 5. Osmotic destruction of the cell wall 6. Apoptosis: programmed cell death 7. Acute ischemia to the fat tissue, which makes the cells swell and undergo lysis 8. Inflammatory mechanisms such as pancreatitis or neonatal panniculitis 9. Saponification of fat using a chemical to create soap 10. Freezing of fat inducing crystal formation; these “poke holes” in the cell membrane 11. Heating of fat, as with a radiofrequency device

6.3 Classification of Cell Death A classification of cell death that is a “new again” is that of oncosis (cell death with swelling as the primary pathologic hallmark) vs. apoptosis (cell death with shrinkage seen histologically). Von Recklinghausen originally proposed the term “oncosis” in 1910 to define cells that die due to a swelling mechanism [10]. Instead of calling it cell death “necrosis,” it is more correct to call the postmortem changes “necrosis,” as the term does not define the means of cell death. Biopsy specimens evaluated by independent pathologists have noted that toxic necrolysis appears to be the main mechanism of action of injection lipolysis (Colby, Personal communication 2005). The histologic findings of cell wall disruption accompanied by multiple signs of inflammation support this finding. The limited “field of destruction,” diminishing with an increase in the distance from the central injection point also points toward a direct toxic effect of the injected substance. The inflammatory infiltrate appears to be a

D. Duncan

combination of polymorphonuclear (PMN) leucocytes and lymphocytes, with the PMNs dominating. One pathologist described the infiltrate’s appearance as a “sterile cellulitis” [11]. The infiltrate appears to palisade along the injection tract. Inflammation is also noted in the overlying dermis, especially in the deep dermal adnexae and surrounding the deep and superficial dermal plexi. As the deoxycholate (DC) concentration increases, so does the degree of inflammation. Rotunda’s assertion that sodium deoxycholate is the active ingredient in most injectable lipolytic formulas is supported by two recent studies [12]. It appears that PC offers a protective effect to the cells in three ways: as a buffer, as a temporary binder to the DC molecule inducing a delay of onset of cell death, and as a “governor” of the reaction. The pH of injectable sodium deoxycholate is 8.08. The human physiologic pH averages 7.4. The pH of PC, a major component of all mammalian cell walls, is 7.0. When injected independently, DC alone causes immediate and profound cell wall disruption. When PC is added to the solution, a significant modulation of the reaction is observed. The onset of histologically visible cell wall lysis is delayed by 7–10 days as noted in serial histologic specimens, and the onset of cell wall lysis and the degree of oncosis depends on the ratio of DC to PC. While chemical buffering is a large part of this reaction, the “governing” or modulation of this reaction can be observed by increasing or decreasing the PC to DC ratio. Several early researchers have postulated the mechanism of apoptosis as a possibility in the process of injection lipolysis. Young is currently evaluating the presence of apoptotic markers in the injection lipolysis reaction [13]. Peckitt describes the mechanism of apoptosis in causing fat to “melt away” [14]. To date, there has been little scientific evidence that apoptosis has a major clinical effect in the injection lipolysis process [15]. When injected in clinical practice, the PC/DC solution causes a strong histamine reaction, as evidenced by pink wheals at each injection site, and generalized erythema in the treatment region. Itching may accompany the hives. Patients sometimes report a transient burning sensation that may last for15–30 min. Profound swelling marks this treatment, especially during the first 24–48 h postinjection. This swelling, burning, and itching are a common deterrent to the patients returning for a second treatment.

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Gross pathologic specimens harvested after injection show focal scarring at the injection sites. These small regions of white fibrous tissue are visible as early as 3 weeks postinjection [16]. The progression of histologic changes varies with the solution injected. Rotunda has advocated treatment with DC alone, as he believes that the mechanism of cell lysis is the detergent solvent of PC, and not the PC alone [17]. When plain unbuffered DC is injected subcutaneously, immediate cell death is noted in an area adjacent to the injection site. This is characterized by the presence of immediate and widespread cell wall lysis. 1 day postinjection of DC alone, macrophages have already moved in, and are surrounded by a hyaline ground substance. Those patients injected with PC and DC in a balanced solution have no evidence of cell death until about 2 weeks postinjection. At 2 weeks, signs of cell wall disruption begin to appear in traditional PC/DC patients. Those treated with DC alone show intense inflammation, firm nodules, and localized fat necrosis, often with “skip” areas between injection sites. At 3 weeks postinjection, the DC dominant solutions cause a profound and strong fibrotic reaction. DC alone is clearly more effective in causing total fat necrosis than the solutions incorporating both the drugs (Fig. 6.1). However, the clinical outcome of the strong fibrotic reaction and subsequent development of “cement-like” subcutaneous scar tissue is not a good one. Patients report restriction of the range of motion, persistent painful nodules in the injected regions, contour irregularities, and emotional distress, as a consequence of DC-only injections. Probably, the sole indication for the total eradication of fat would be for the treatment of small lipomas.

6.4 Role of Phosphatidylcholine PC is a main component of mammalian cell walls. It has been extensively studied as a cell “fluidizer,” and is purported to reduce symptoms in both Alzheimer’s patients and in those with bipolar disorders [18]. The same mechanism of action has been cited in using soy lecithin for the treatment of chronic liver disorders, including both hepatitis and alcoholic liver disease [19]. If PC is a cell stabilizer, how can it cause fat necrosis? The role of PC in injection lipolysis has been a mystery, although the clinical benefits of combining this substance with DC are clear. A stem cell study by Duncan and Rubin performed in 2007 [20] showed conclusively that PC has no effect on cell lysis or lipolysis. The only active ingredient in the injectable solution is sodium DC. Histologically, the addition of PC to a DC solvent delays the onset of cell wall lysis. As the ratio of PC to DC is roughly one to one, the possibility of initial ionic bonding followed by a slow breakdown of that bond is clinically borne out. The ratio of PC to DC also appears to “govern” the reaction, similar to that of a nuclear reactor. If the “rods” (PC) are pushed in, the reaction is minimized. If the “rods” are pulled out (little to no PC), the reaction is extreme and instantaneous. Once injected into human fat by itself, the alkaline substance DC acts on human fat in a manner similar to that of lye (KOH) on tallow; soap is rendered when fatty acids combine with calcium [21]. Therefore, by buffering the reaction, and by temporarily binding with DC, the addition of PC creates a more diffuse and delayed pattern of fat necrosis. The traditional treatment goal of excess subcutaneous fat reduction initially is to “get rid of it all.” However, as we know from cases of overaggressive fat resection

Averaged Triglyceride assay % of vehicle control

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Fig. 6.1 Stem cell study showing that deoxycholate is the active ingredient

300 250 200 150 100 50 0 PPC 5%

DC 1%

DC 2.4% treatment

Benzyl OH

Saline

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with liposuction, an extreme approach to fat reduction is not a good one. Fairly recently, our subcutaneous fat has been identified as the body’s largest endocrine organ [22]. Clinically, an extremely thin or absent subcutaneous layer makes the overlying skin appear old, lax, and damaged. A layer of subcutaneous fat ranging from 1 to 2 cm in most regions is necessary in order to allow the overlying skin to appear youthful. The desired clinical endpoint of any fat reduction procedure would be a smooth, unblemished skin surface with no depressions or protrusions, discolorations, or overly firm, tethered, or depressed areas. The ideal thickness of the underlying fat layer varies with location from 0 mm (lips, eyelid skin) to about 2 cm. Localized protuberances or irregular surfaces are judged as unsightly. The tissue underlying the skin should be soft, not too firm or too flabby, and should glide over the underlying fascia freely, as would a normal tissue. Any procedure which causes excessive scarring or fat necrosis that cannot be controlled safely is clinically undesirable. Skin that is firmly adherent to muscle or fascia and that does not glide appears abnormal. What happens to the dead fat cells? This question has been asked by patients, the ASAPS and ASPS, and multiple media sources. The textbook of cellular pathology [23] describes the process by which necrotic fat is processed in detail. The primary mechanism of adipocyte lysis in injection lipolysis can be studied by following serial histologic specimens. Following the injections, both clinically and microscopically, the tissues begin to swell profoundly. This is due to oxygen deprivation, causing failure of the ion pumps across the cell membrane. The regional pH drops sharply, and after histamine-induced “flush,” the tissues in the injected region begin to become less rosy, due to a reduction in blood flow induced by ischemia. Glycogen becomes the fuel of the cell, as circulation impairment reduces external glucose supplies for cellular respiration. The cells then produce lactic acid due to the anaerobic respiration process. The acid accumulates as no cellular circulation exists. Enzymatic leakage causes lysosomes to release hydrolases, which then attack the remaining cytoplasmic contents. Calcium then enters the cell, which activates phospholipases and more cell membrane damage follows. Serial histologic evaluation of adipose tissue treated with injection lipolysis over time shows

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minimal changes at first, unless the DC concentration is high. This is consistent with cell biology studies that dictate that even a doubling in cell size is hard to determine. A volumetric increase in diameter at the cellular level increases the visible cell size to about 25%. At 24 h, some signs of cell death are visible; these include loss of basophilic pigment in the nuclei, and formation of a “ground substance” that the necrotic cells reside in. Denaturation of protein causes the white appearance of the focal necrotic lesions seen in biopsies of adipose tissue treated with injection lipolysis. The process of processing dead fat has been followed for over a century. Steatonecrosis is defined as the inflammatory response induced by the leakage of fatty acids and glycerol from the adipocyte [24]. Macrophages infiltrate in the region of adipocyte lysis as early as 24 h postinjection. “Foamy” macrophages are those that have engulfed necrotic fat. Fibroblasts also infiltrate the region and deposit collagen. This step is what causes the nodular feel to fat necrosis – a palpable “lump” under the skin. Two mechanisms are identified in adipocyte lysis: the saponification of fatty acids mediated by calcium and noted histologically by needle-like bundles, and the binding of free fatty acids to the carrier albumin. The foamy macrophages reenter the circulation, whereupon they migrate to the liver. The triglycerides and fatty acids undergo beta oxidation, and the energy released is either used or again stored [25]. What happens to the skin in the injected area? How does skin retraction occur? Skin retraction is the result of three mechanisms: one is direct and two are secondary. The direct effect of injection lipolysis on the overlying skin is one of proximate cause. The higher the DC concentration, the more are the histologic changes seen in the overlying dermis. Histologic evaluation of the skin treated with DC dominant formulas shows “necrobiosis” of the basal layer of the dermis [26]. The bright pink collagen takes on a basophilic hue, and severe inflammatory infiltration of dermal adnexae is seen. Patchy necrosis of deep dermal vessels, nerve sheaths, and eccrine sweat glands is noted. This is not an immediate finding; it is noted at about 1 month following injection. The necrosis of the “peninsulas” of fat protruding into the basal layer of the dermis appears to cause an “accordion-like” horizontal contraction at the adipose/ dermal junction.

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Fig. 6.2 Left: specimen treated with PC50 mg/mL/ DC42 mg/mL injections 6 months previously. Right: control specimen treated with saline 6 months previously

Dermal thickening, measured using a serial micrometry technique, ranges between 12 and 14% in regions treated with PC50 mg/mL/DC42 mg/mL (Fig. 6.2). Cimino postulates that “unweighting” of the skin causes contraction. His work with the Vaser system of liposelection shows that up to a point, relief of skin distention by the underlying fat will cause skin surface area reduction [27]. Another mechanism may be the changing of the structure of the underlying fat. In a study by Duncan and Kesel [28], injection of subcutaneous adipose tissue in cats showed a “firming” of fat and a surface area reduction of flabby subcutaneous fat. The contraction of the underlying fat appears to “draw in” the overlying skin. How can you explain the “nonresponders?” Why is it that some people have a visible improvement, and others do not? There are so many variables, that it is difficult to pinpoint one causative factor. The two major influences on the outcome are the injector’s technique and the formula used. The technique would include the choice of patient and treatment region. Predictable nonresponders would include: 1. The patient with a BMI of 35; treatment region— abdomen. Here, there is such a large volume of fat over a broad surface area that the loss of 100 mL of fat would be undetectable. 2. The young athletic patient with fibrous fat. Injection lipolysis works on fat only. In fibrous fat, the septae dividing the fat into lobules are thick and tough. These form a physical barrier to the lateral and deep dispersion of the lipolytic formula. While the addition of collagenase to the formula can somewhat enhance lipolysis, clinical experience has shown that injection in these types of regions is almost always disappointing.

3. Specific regions and gender characteristics such as male flanks, women’s broad abdomen, upper arms, and outer thighs seem to be less responsive than volumetrically small regions with soft, flabby fat like inner thighs, bra rolls, and necks. It is very important to evaluate all of these parameters before offering an injection lipolysis treatment to a patient. Though the results are subtle and the treatment cannot compare with the more dramatic surgical results, the patient will expect to see a visible difference in the trouble spot after treatment. If injection lipolysis is your only tool, you’ll be tempted to use it on everyone. These injections should be limited to use only in patients with small, localized fat deposits in favorable regions. Soft fat responds much more visibly than firm, fibrous fat. The formula used should have a good balance of PC and sodium DC. If the solution is too PC dominant, not much change will be seen, as the PC dampens the lipolytic response. If the solution has too much DC, the injection regions will be painful for a prolonged period, and may have permanent numbness and fibrous scar tethering the overlying skin. Hypotonic saline and isoproterenol-based agents will not cause oncosis of the fat cells.

6.5 Evaluation of Patients Predicting who will have a good result defines the indications for treatment. There is a narrow range of indications for treatment; injection lipolysis is a finesse tool, and is not indicated for treating generalized obesity. It works well in those patients with a well

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localized, small region of soft fatty lipodystrophy. The ideal treatment region has less than 300 mL of fat. Soft fat responds far better than fibrous fat, and a mild skin laxity usually accompanies those patients with “pudding-like” fat [29]. The “muffintop” deformity—flank fat and lax skin hanging over the waistband of low rise jeans—responds well to this treatment as long as the lipodystrophic region is not voluminous. Other indications for injection lipolysis include soft lipomas, “bra rolls,” inner thigh lipodystrophy accompanied by mild skin laxity, mild to moderate cellulite, postliposuction deformities, postsurgical scar deformities, and topographic skin contour irregularities. The submental, jowl, and jawline is a very responsive region as the actual fat excess is volumetrically small. Extreme care is necessary in choosing a patient for jawline injections. A good injection candidate is relatively young, has very mild to moderate skin excess, a preponderant fatty excess, and an absence of platysmal banding. A warning: if you inject an older woman with a ropy neck, and by removing fat, you create more prominent platysmal banding, the patient will be extremely unhappy. More fat, less skin laxity, and no platysmal deformity are the keys to success with neck injections. Most practitioners have adapted injection lipolysis to more of a “problem solver” role than one of primary treatment of lipodystrophy. The role of injection lipolysis as a problem solver [30] has a great merit for surgeons practicing liposuction and scar revision. Mild asymmetry following fat grafting can also be treated well with injection lipolysis. These injections can dramatically reduce the need for surgical revisions. They are cost effective, and can be done in the exam room on the day of the patient visit. A quick response to patient concerns and a visible nonsurgical improvement can significantly increase the rate of patient satisfaction.

6.6 Contraindications to Treatment with Injection Lipolysis Patients who should not be treated with injection lipolysis include: children under the age of 18 years, pregnant or lactating women, and patients with allergies to formula components including soy proteins. Other absolute indications include patients with severe

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acute or chronic disease, patients with unrealistic expectations, poor circulation in the treatment region, and those with open sores in the treatment region. Patients with autoimmune disorders such as scleroderma and systemic lupus are not good treatment candidates. Relative contraindications include patients with broad, thick treatment regions , fibrous fatty deposits, and lipodystrophic regions that contain more than 300 mL of excess fat. Those patients with an ongoing mild chronic illness, mild to moderate autoimmune disorders, and extreme skin laxity in the treatment region should not be treated with injection lipolysis. Those patients who will not be satisfied with the subtle results obtained with this treatment should be carefully evaluated and warned that the outcome of treatment may fall well short of their expectations. There are limitations of treatment to the degree of improvement that injection lipolysis can achieve. Injection lipolysis is a finesse procedure. It is a good treatment choice for those patients with small or subtle deformities in areas or situations that are difficult to obtain good surgical results. Areas and situations in which injection lipolysis will not work well: 1. Abdominal fatty deposits in general. The broad surface area and the usual large volume of this region make it, in most cases, a poor region to treat nonsurgically. 2. Knees and areas below the knees. Due to the dependent location of these areas and their propensity to have poor circulation, the knee region and those distal have a higher than average risk for skin loss or visible neovascularization posttreatment. The appearance of prominent superficial blood vessels and persistent bruising has been noted in some patients who have undergone lower extremity treatment. These lesions can be somewhat improved with IPL or BBL treatments, but a decrease in apparent skin quality will generate many patient complaints. 3. Outer thighs and flanks. Unless the fat is clinically very soft, these regions tend to be less responsive than average. Part of the reason is that fat in these areas tends to be fibrous. The PC/DC solution does not disperse well through fibrous regions. Even with the addition of collagenase to the solution, treatments of fibrous fat with injection lipolysis do

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not have a high success rate. Large volumes of fat are not successfully reduced with safe doses of PC/ DC either. 4. Arms. Unless the patient has a modest fat deposit with good skin with almost no laxity, treatment of the upper arm region with injection lipolysis is not recommended. The results may be too subtle to see in photographs or in circumference measurements. However, pretreatment of these patients with injection lipolysis prior to liposuction may convert the brachioplasty patient into a liposuction patient, by virtue of the modest skin retraction achieved with the lipolysis procedure. It is recommended that the injections be performed at least 3 weeks before the liposuction is done. 5. Any patient who has high expectations yet wants a surgical result with injection lipolysis. The results with injection lipolysis are subtle. If the deformity is moderate to dramatic, then the chosen treatment should be correspondingly dramatic.

6.7 The Importance of a Standardized Formula for Injection The classic mesotherapy training allows for a variance of formula and technique. Most physicians have only a basic knowledge of pharmacology. Reconstitution of lyophilized drugs has a low potential for errors, as the active ingredients do not vary; only the dose per milliliter. When the active ingredients vary, unexpected drug interactions are a significant possibility. Many mesotherapists inject compounds such as ECGC (green tea) and L-carnitine that are oral “supplements” that theoretically help promote weight loss. While the idea may appear to have merit, these are not injectable drugs. Irresponsible changing of the recommended route of administration of a drug without knowing the local and systemic effects is not a good medical practice. If reproducible results with injection lipolysis are the goal, variations in the injectable formula are not recommended. One of the chief complaints about injection lipolysis is the current lack of an FDA approved, standard injectable formula. While compounding pharmacies are legally able to produce “lipolytic” injectables, the lack of standardization of both formula components and the production methods

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create a huge variability in outcomes and in the incidence of complications.

6.8 Complications of Treatment with Injection Lipolysis When injection lipolysis was first introduced by Rittes, the rate of complications was very low. Lipostabil (Aventis) was the drug injected. The location of injection was very specific and the dose was very small. When Aventis requested ANVISA to take Lipostabil off the market for use in lipolysis, alternative compounds were introduced (Rittes, Personal conversation 2006). Since no government approved drug was available for use in injection lipolysis, compounding pharmacies began making substitutes. Also, charlatan practice has been a problem. Aromatherapists, chiropractors, aestheticians, nurses, medspa employees, and other nonphysicians have been practicing injection lipolysis in the U.S. since 2003. A global survey of physician practitioners performed in 2005 [31] showed that the biggest complication of injection lipolysis was a 12.4% incidence of a less than expected aesthetic result. Other complications, such as skin necrosis, hyperpigmentation, and a lumpy or irregular skin contour were noted, but were uncommon. Following that survey, many more complications have been reported. Three factors seem to predict the relative risk of a complication: the skill level and education of the physician practitioner, the formula used, and the technique: dose, location of injection, and depth of injections.

6.8.1 Skin Loss The most feared complication – skin loss – is preventable. Intradermal injection of compounds containing sodium DC can cause immediate skin necrosis. Very superficial injections of these compounds at high doses, or in areas with relative ischemia, can also cause skin loss. Online purchasers of “Lipodissolve” kits can go into chat rooms and coach each other on injection techniques – without ever seeing a physician [32]. These people are also at a high risk for skin loss as they tend to inject the “problem spot” with high doses of solution very close together and in a superficial location.

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6.8.2 Hyperpigmentation Both the location of the injections and the patient’s skin type play a role in hyperpigmentation. Clinical evidence shows that the lower the injection site (midthigh and distal), the higher the chance of pigmentation that persists. Bleaching creams such as hydroquinone do not help in most cases. The postulation that hemosiderin pigments,left behind when bruising resolves, is the causative factor, sounds logical, but it has not been proven. Many patients with post injection hyperpigmentation do see an improvement within 3–4 months, but a few patients have reported a long-term problem.

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injection. Reports of draining liquid fat through small punctuate ulcers in the overlying skin have substantiated this theory [34]. Other conditions which could cause a subcutaneous “compartment syndrome” include the wearing of a very tight compression garment without removal for several days, and treatment of a patient or an area with nondistensible thick skin. Any situation in which the profound postinjection swelling is severely limited could cause this “compartment syndrome” with the possibility of extensive fat necrosis accompanied by skin loss.

6.8.5 Skin Contour Irregularity 6.8.3 Neovascular Response A small number of patients have reported the development of a fine network of visible blood vessels just under the epidermis, discoloring the skin. This appears to be a response to temporary ischemia of the region. While this reaction may fade with time, it may not completely resolve. The degree of an existing healthy blood supply to the region of injection should be evaluated prior to treatment; an area near the knee and below is prone to this postinjection deformity. Treatment with IPL or a vascular laser can help in this situation.

6.8.4 Compartment Syndrome Small spots of focal skin ulceration at each injection site have been reported in patients with pre-existing ischemia, or heavy scar tissue formation after a procedure such as liposuction. A “compartment syndrome” in the subcutaneous fat layer has been postulated as the causative factor in this situation [33]. Especially susceptible are those patients with previous aggressive liposuction in the proposed treatment region. Because the fibrous scar tethers the skin to the underlying fascia, the ability of the region to swell in response to the injectable solution is impaired. The closing pressure of venules and arterioles is exceeded, and for a critical duration of time, the fat tissue does not receive an adequate blood supply. Massive fat necrosis ensues, unlike the focal fat necrosis seen in the normal reaction to

With the correct injection technique, the probability of a skin contour irregularity is rare. When injections are regularly spaced and follow dispersion characteristics, and the standard formula is injected using equal volumes and depths, lumps and divots are unusual. If the injections are placed too far apart, the dose is too large, or the solution contains too much DC, “skip” areas are likely to occur, which will manifest as lumps and divots in the skin. Less than expected response to treatment is common, almost expected. Results with injection lipolysis are subtle. A reduction of 100 mL of fat in a single treatment is a significant response. Patients with soft fat respond better, as fibrous tissue is not lysed by injection lipolysis. The degree of skin retraction is modest. Therefore, the use of this treatment as a finesse procedure for the treatment of small volumes of fat accompanied by minor degrees of skin laxity is recommended. The FDA characterizes injection lipolysis as a “gray” area in that, while there is no FDA approved compound for injection lipolysis, the agency recognizes that the practice is widespread (Parks personal conversation 2006). A bill before Congress that would allow the FDA jurisdiction over compounded drugs was defeated in 2007 [35]. Currently, compounding pharmacies are the major source of injection lipolysis formulas. These are regulated at the state level. A physician wishing to practice injection lipolysis must abide by the physician/patient/ pharmacy triad. The potential patient is evaluated by the prescribing physician. A recommendation for the treatment of the condition troubling the patient is made. If injection lipolysis is

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recommended, the physician writes a prescription for the lipolysis formula for that particular patient, which is sent to the pharmacy. The pharmacy will then send the treatment solution to the physician, with the patient’s name on the label. No unlabeled “office stock” vials are shipped. The number of vials and the volume of solution is specific for each patient. The board of medicine and board of pharmacy in each state dictate the rules of use (Rosen, private communication 2006).

6.9 Technique Dispersion characteristics dictate the importance of volume per injection, the distance between injections, and the depth of injection. The injection technique is very important; it is critical to the achievement of a predictable and reproducible outcome. Dispersion studies [15] show that the PC/DC compound travels only a short distance through the subcutaneous fat layer when injected. The guidelines for injections are as follows: 1. In facial, jowl, and jawline regions, the optimal depth of injection is 6 mm. The superficial injection will treat the very superficial neck and jowl fat, and will slightly tighten the overlying skin. Injection volumes are 0.2–0.4 mL, and the distance between injections is optimal at 1 cm. 2. In body regions, the optimal depth of injection is a little deeper at 9–13 mm. Volume of injection of a 75% solution (PC37.5/DC31.5) ranges between 0.4 mL for thinner fatty regions to 0.6 mL per injection site for thick protuberant regions. A distance of 1.5 cm between injection sites appears optimal [36]. Treating the protrusions and depressions can be enhanced with the use of collagenase in combination with PC/DC. The philosophy of treating contour irregularities is basically to reduce the “hills” and elevate the valleys in order to create a flat landscape. Fatty protrusions are treated with PC/DC. Tethered depressions are injected with collagenase, 250 U/mL. Fibrofatty deposits, such as deformities following liposuction, may be injected with a mixture of both. Do not mix collagenase and PC/DC in the vial as this action will render the solution inactive within a short period of time. It is always wise to use fresh solutions for injection. The solution undergoes oxidation with time. Use of outdated PC/DC is a common cause of little to no response.

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6.10 Example of Technique Injection of the jowls and neck: One of the best regions to treat with injection lipolysis is the submandibular neck, submental fat pad, and the jowl region. If the accompanying skin laxity is minimal to moderate, and heavy platysmal bands are absent, a dramatic response to this treatment can be seen. Usually, two to three treatment sessions are necessary. However, in the right patient, even one treatment can result in a dramatic improvement. One reason for this responsiveness is the relatively small amount of excess fat present. The second reason is that by varying the location of the injections, the depth of injection, and the volume/dose injection, the degree of change in the skin and underlying fat can be precisely manipulated. This degree of precision is difficult to attain in liposuction type techniques. Four goals of treatment include 1. The creation of a smooth, well-defined submandibular shadow 2. The enhancement of an acute cervicomental angle 3. The tightening of submental and submandibular skin 4. The volumetric reduction of hanging jowls, with retraction to the level of the jawline. The patients for neck lipolysis usually range in age from 35 to 55 years. The deformity in the neck, jowl, and jawline region is preponderantly a fatty excess, with only mild skin laxity. As skin laxity increases, the quality of the post injection result decreases, as injection lipolysis can only cause about 12–14% degree of skin retraction [37]. The patient with prominent platysmal banding can actually be made worse by injection lipolysis treatments. In these types of patients, the need for a secondary corset platysmaplasty should be advised at the time of the initial consultation; otherwise, the patient will be angry about the worsening of the appearance of platysmal bands. Great care should also be taken in injecting the jowl region. I now taper the dose of injection solution, with a larger 0.5 mL dose being given in the lower jowl, and a 0.3-mL dose used to taper the upper pole of the jowl. On two occasions, the upper pole of the jowl responded so vigorously to injection lipolysis that a depression was created, causing an asymmetry and hollow that had to be filled with subsequent fat grafting.

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Fig. 6.3 Marking the patient for facial treatment

Markings are placed following the photographic documentation of the patient’s deformity (Fig. 6.3). While it may appear that there is no subcutaneous fat at the earlobe region, injection here is very important in obtaining a sharp shadow around the mandibular angle. The importance of creation of a submandibular shadow from the angle of the mandible to the masseteric ligament is often overlooked by surgeons. The shadow underneath the mandible is highly desired by patients, as it creates the appearance of a thinner and longer neck. Reduction of a double chin resulting in the creation of a flat or convex profile below the submental crease is universally recognized as an aesthetic goal. If skin is too lax, or the platysmal component too strong, injection lipolysis will not adequately improve the problem spot. The patient should be advised of this limitation before the treatment commences.

6.11 Injection Technique A 1.0-cm grid is used to mark the distance between injection points (Fig. 6.3). The injection region reaches from just behind the earlobe to the submental crease superiorly and the top of the thyroid cartilage inferiorly. PC37.5/DC32 is a good balanced solution to inject in the neck region. A dose of 0.2 mL per

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injection point in the region from the earlobe to the masseteric ligament is suggested. For the region under the jowl, 0.3 mL per injection site is the usual dose. In the submental region, 0.4 mL per injection site is used. In very thick or protuberant regions, the dose may increase to 0.5 mL in the fattiest central region. Jowls are injected using 0.5 mL in three points just above the mandible, and 0.3 mL in two points 1 cm above the lower injections. The author usually avoids injecting marionette lines. Deflation of these lines can create an even more prominent laxity in this region [38]. Expected reactions: The patient should be told to expect immediate and profound swelling. The appearance of “mumps” is a good visual picture to give the patient. Physiologically, oncosis in the injection region creates a peak of swelling at 6 h. Gradual reduction of swelling occurs over the next 7–10 days, by which time most of the bruising and swelling subsides. Bruising is usually minimal; the swelling is remarkable. At 2 weeks postinjection, the patient may begin to notice small subcutaneous nodules in the injection sites. These are punctate regions of fat necrosis and usually disappear by 8–10 weeks. At 3–4 weeks, a visible reduction of fat and retraction of skin begins to be seen. At 8 weeks, the reaction appears to be undergoing a transition from the inflammatory phase to a phase of resolution. At this point, it is safe to perform a second treatment if necessary. However, if palpable nodules are still present, or prolonged swelling is still apparent, it is wise to delay the second treatment. Otherwise, too much of the fat contour may be reduced, creating a “divot” or hollow that will need secondary filling. Adjunctive procedures used in combination with injection lipolysis: Occasionally, patients will complain about persistent lumps, or less than perfect fat reduction in a certain localized treatment region. The most effective nonsurgical treatment booster is external ultrasound. In a study conducted in 2007, the Medsculpttm machine outperformed external focused light and massage therapy for protuberance reduction in regions of localized thick subcutaneous fat [37]. Definite reduction of protuberant fat was seen with external ultrasound treatments, and patient satisfaction was high. While both light therapy and ultrasound treatment showed histologic evidence of cell wall lysis, only the ultrasound treatments produced a visible clinical change.

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6.12 Conclusions The evolution of injection lipolysis from an alternative medicine procedure to a scientifically-based and predictable treatment form has legitimized the formerly dubious reputation of mesotherapy. When performed correctly by a well-trained physician using proper techniques and formula, the procedure can provide excellent results in patient situations that might otherwise be treated less effectively with surgery (Figs. 6.4 and 6.5) Choosing the right region to treat in the right patient is important; otherwise a poor outcome may result. When performed properly, complications of treatment are rare. While as yet there is no FDA approved formula, pharmaceutical firms in Europe are researching a standardized formula that may be available in several years.

Fig. 6.5 Top: Preoperative 33-year-old female requesting a reduction of the size of arms without surgery. Bottom: 8 weeks after one injection session

Fig. 6.4 Left: preoperative 51-year-old with combination of abdominal fat and excess skin. Middle: 6 weeks after first treatment. Right: 8 weeks after second treatment

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By advising the patient of the limitations of injection lipolysis, their expectations are more likely to be met. Injection lipolysis remains a good option for the treatment of small, localized fat deposits accompanied by mild skin laxity in the treatment region.

References 1. Bobkova VI, Lokshina LI, Korsunskii VN, Tananova GV. Metabolic effect of lipostabil forte. Kardiologia 1989;29(10):57–60. 2. Rittes P. The use of phosphatidylcholine in the correction of lower lid bulging due to prominent fat pads. Dermatol Surg. 2001;27(4):391–2. 3. Duncan D, Rubin JP, Golitz L, Badylak S, Kesel L, Freund J, Duncan D. Refinement of technique in injection lipolysis based on scientific studies and clinical evaluation. Clin Plast Surg. 2009;36(2):195–209. 4. LeCoz J. Traite de Mesotherapie. Paris: Masson; 2004. p. 212–22. 5. www.elitefitness.com/forum/bodybuilding-chemistr. Accessed 29 Mar 2009. 6. www.dermanetwork.org/facility/FL/Miami/miami-bea. Accessed 21 Nov 2008. 7. www.mandjshow.com/videos. Accessed 17 Dec 2007. 8. Duncan D, Palmer M. Fat reduction using phosphatidylcholine/sodium deoxycholate injections: standard of practice. Aesthetic Plast Surg. 2008;32(6):858–72. 9. Thermo Fisher Scientific. Thermo scientific pierce cell lysis technical handbook. 2008. 10. Majno G, Joris I. Cells, tissues and disease. New York: Oxford University Press; 2004. p. 202. 11. Golitz L. Histopathologic findings in injection lipolysis. Presented at Dermatopathology conference. July 27, Denver: 2008. 12. Rotunda A, Suzuki H, Moy R, Kolodny MS. Detergent effects of sodium deoxycholate are a major feature of an injectable phosphatidylcholine formulation used for localized fat dissolution. Dermatol Surg. 2004;30(7):1001–8. 13. Young VL. Early results from ASERF injection lipolysis study. ASAPS annual conference, Las Vegas: 2009. 14. Ninian Peckitt N. Evidence-based practice. Yorkshire (UK): Jeremy Mills Publishing; 2005. 15. Rotunda AR, Kolodney MS. Mesotherapy and phosphatidylcholine injections: historical clarification and review. Dermatol Surg. 2006;32(4):465–80. 16. Duncan DI, Hasengschwandtner F. Lipodissolve for subcutaneous fat reduction and skin retraction. Aesthetic Surg J. 2005;25(5):530–43. 17. Rotunda A, Weiss S, Rivkin L. Randomized double-blind clinical trial of subcutaneously injected deoxycholate versus a phosphatidylcholine-deoxycholate combination for the reduction of submental fat. Dermatol Surg. 2009;35(5): 795–803.

D. Duncan 18. Little A, Levy R, Chua-Kidd P, Hand D. A double-blind, placebo controlled trial of high dose lecithin in Alzheimer’s disease. J Neurol Neurosurg Psychiatr. 1985;84(8):736–42. 19. Kidd PM. Phosphatidylcholine, a superior protectant against liver damage. Altern Med Rev. 1996;1:258–74. 20. Duncan D, Rubin JP. Cytotoxicity and lipolytic activity of individual injection lipolysis formula components: a stem cell study. IFATS conference. Oct 18, Toulouse, France: 2008. 21. www.en.wikipedia.org/wiki/Fat_necrosis. Accessed 19 Nov 2008. 22. www.ncbi.nlm.nih.gov/pubmed/15195692. Accessed 2 Mar 2009. 23. Majno G, Joris I. Cells, Tissues and Disease. New York: Oxford University Press; 2004. p. 204. 24. www.medical-dictionary.thefreedictionary.com/fat+nec. Accessed 17 2008. 25. www.answers.com/topic/beta-oxidation. Accessed 18 Jan 2009. 26. www.en.wikipedia.org/wiki/Necrobiosis_lipoidica. Accessed 2 Mar 2009. 27. Cimino W. Physics and mechanics of Vaser liposelection. ASAPS annual conference. New York: USA; 2006. 28. Duncan DI, Kesel ML. Safety and efficacy of injection lipolysis in felis cattus. Conducted 4/2/07 to 6/16/07, CSU Veterinary School. 29. Hasengschwandtner F. Injection lipolysis. 1st International Convention for Lipodissolve. Jun 18–19, Salzburg, Austria; 2005. 30. Duncan DI. Injection lipolysis as a problem solver. Florida State Plastic Surgery Society Annual Meeting, Florida: 2008. 31. Duncan DI, Chubaty R. Clinical safety data and standards of practice for injection lipolysis: a retrospective study. Aesthetic Surg J. 2006;26(5):575–85. 32. www.lipostabil-diy.com/disclaimer.html. Accessed 2 Mar 2009. 33. Duncan DI. Evolution of injection lipolysis. International Masters Course on Aging Skin. Jan 11, Paris: 2009. 34. Hasengschwandtner F. Treatment with phosphatidylcholine for localized fat. Lipodissolve seminar, Oct 30. New York: 2004. 35. www.the-scientist.com/news/display/24266. Accessed 17 Jan 2009. 36. Duncan DI. Injection lipolysis for fat reduction and skin retraction. British Association of Cosmetic Doctors Annual Meeting. Oct 11, Gleneagles, Scotland; 2008. 37. Duncan D. Adjunct treatments: use of external ultrasound vs. oscillating light therapy to supercharge injection lipolysis results. International Masters Course on Aging Skin. Jan 12, Paris; 2009. 38. Palmer M, Curran J, Bowler P. Clinical experience and safety using phosphatidylcholine injections for the localized reduction of subcutaneous fat: a multicentre, retrospective UK study. J Cosmet Dermatol. 2006;5:218–26.

Part Breast

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7

History of Breast Augmentation Melvin A. Shiffman

7.1 Introduction The history of breast augmentation takes us through research over 100 years in the development of clinical ideas and techniques to increase breast size. Many procedures were not successful and certainly even the present techniques are not perfect. There remain many risks and complications of augmentation of the breasts with prostheses and injectable substances.

7.2 History 7.2.1 Fat Transfer Czerny [1] transplanted a lipoma from a patient’s back to the breast to replace resected breast tissue from a benign adenoma. Berson [2] claimed that free fat grafting with dermis-fat and dermis-fascia-fat caused unpredictable rates of resorption. The graft was usually taken from the inferior buttock. Bames [3, 4], Maliniac [5], Marino [6], O’Connor [7], and Goulian and McDivitt [8] reported on the use of local flaps of deepithelialized tissue for cosmetic breast augmentation. Conway and Smith [9] and Watson [10] noted significant fat graft resorption of the augmented breast as well as unsightly donor sites and a high incidence of fat necrosis with chronic drainage.

M. A. Shiffman 17501 Chatham Drive, Tustin, CA 92780-2302, USA e-mail: [email protected]

Longacre [11, 12] described the dermis-fat fat flap based at the inframammary fold that was folded upward to treat small breasts Fat from suction-assisted lipectomy was ultimately used to augment the breast [13, 14].

7.2.2 Injectable Foreign Substances Paraffin was first reported to be used by Gersuny [15]. Paraffinomas were one of the complications [16, 17] and death was reported following paraffin injections into the breast [18]. Also injected were petroleum jelly and bees wax that led to infection, granulomas, fistulas, and breast firmness [19, 20]. Silicone injected into the breast began in the late 1940s [21]. There followed reports of nodules, cysts, chronic inflammation, and skin and breast necrosis [22]. Silicone became hard nodules in some patients, and in others, caused inflammation of the skin followed by seeping of the silicone through the epidermis. Partial or total mastectomy was the only way to resolve the problems. The contents of the Sakari formula, used in the late1940s, for injection into the breast for augmentation were unknown, but probably consisted of silicone with either vegetable oil or peanut oil. The oils were used to cause inflammation that would inhibit migration of the silicone. Polyacrylamide hydrogel injections were used, but may give rise to inflammation and masses [23, 24].

7.2.3 Insertion of Foreign Materials Breasts were augmented with balls of glass, rubber, terylene wool, and ivory [19, 20]. These materials led to infection, tissue necrosis, and firmness of the breast [25, 26].

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7.2.4 Sponges The first sponge of Ivalon (polyvinyl) for breast augmentation was reported by Pangman [27]. This was followed by sponges made of Etheron (diisocyanate polyether), polyurethane, and polytetrafluoroethy lene (Teflon, Gore-Tex, or expanded polytetrafluoroeth ylene) [28–34]. These sponges became hardened, immobile, asymmetric, and irregular in shape. Porous sponges had a higher incidence of infection and chronic drainage.

7.2.5 Prostheses Cronin and Gerow performed the first implantation of silicone gel prostheses in 1962 and the implant became available in 1963. Their first report was in 1964 [35]. The original implant was teardrop-shaped and had a Dacron (polyester) patch posteriorly for fixation to surrounding tissues, which was ultimately discarded. The teardrop-shape was replaced with a round shape, the shell thinned, and the silicone viscosity decreased in 1974 [36]. This, however, resulted in significant gel bleed. In 1981, the Silastic implant was produced with an inner surface of hard polymeric silicone that reduced silicone bleed [37]. The capsule was thinner and had a lower rate of capsule contracture [38]. Carboxymethylcellulose hydrogel-filled implants were used since 1984 by Arion [39]. Novagold hydrogel implants had an osmotic gradient causing the implants to swell and weaken the elastomer shell [40, 41]. Trilucent soybean oil filled implant and the hydrogel implants were filled with an organic polymer. They have all been withdrawn [42, 43] due to viability and safety concerns. Trilucents (triglycerides) were produced, but there were problems [44, 45] including separation of the triglycerides and serous fluid, and when the triglycerides decomposed they become rancid and could be smelled through the skin. Misty Gold (policloruro of pyrrolidone, polyvinyl pyrrolidone) implants were produced for a short time, but were ultimately removed from the marketplace [46]. The double-lumen implant was introduced in 1974 with a fixed silicone gel-filled lumen and separate saline-filled lumen. The inner lumen could be with

M. A. Shiffman

silicone gel or saline [47]. Becker [48] produced the expander prosthesis that allowed volume adjustments prior to its removal and insertion of a permanent implant. Ashley [49] introduced the polyurethane-covered silicone gel prosthesis (Natural Y) to lower the incidence of capsule contracture. Meme and Replicon versions of the polyurethane-covered prosthesis were also produced [50, 51]. There was less capsule contracture, but the polyurethane covering tended to separate from the shell and fragment. These fragments became associated with foreign body reaction [52] and, theoretically, could degrade to toluene 2,4-diisocyanate [53] and toluene diamine [54]. Toluene diamine has been linked with an increased incidence of rodent tumors, especially liver tumors [54], and therefore, all polyurethane-coated implants were voluntarily removed from the market in 1991. Textured silicone shells [55] were produced with silicone gel-filled, saline-filled, or double-lumen implants. The inflatable prosthesis was introduced by Arion [56]. A similar prosthesis, the Mammatech, was reported in 1973 [57]. Although initially filled with dextran, the silastic (silicone) implant was filled with normal saline solution and sealed by a polytetrafluoroethylene plug. This had a 30% incidence of capsule contracture [58] and had a high incidence of implant failure with deflation reported by Williams (76% at 3 years) [59] and a low incidence reported by Grossman (0.5%) [60]. Early failure was usually due to valve and valve stem problems, whereas late failure was considered to be from internal abrasion or fold flaw [61]. Closed compression capsulotomy [62] was used to treat capsule contracture but because of the complications of hematoma, ruptured implants [63], and migration of silicone this was discarded as a viable technique. Johnson and Christ [64] reported the use of the transumbilical approach for insertion of breast implants. This approach has a lower incidence of capsule contracture probably because of the use of expandable implant to mold the implant space and compress possible bleeders. The cohesive gel implant, which has increased cross-linking of the silicone molecules, was produced in the early 1990s [65]. These were palpably firmer than the regular silicone gel prostheses. The anatomic form (teardrop-shape) requires accurate

7 History of Breast Augmentation

pocket dissection because of the problem of rotation of the implant causing breast distortion and requiring surgical correction [66]. There are presently cohesive breast implant trials in the United States by Allergan (410), Mentor (CPG), and Silimed/Sientra (Nuance and Enhance).

7.3 Conclusions The history of breast augmentation is fascinating in the attempts to find substances that the body would accept without rejection or other complications. So far the cohesive gel implant appears to be adequate for augmentation, but requires a larger incision than saline implants.

References 1. Czerny V. Plastischer ersatz der brustdruse durch ein lipoma. Chi Kong Verhandl. 1895;2:126. 2. Berson M. Dermal-fat transplant used in building up the breasts. Surgery 1945;15:451. 3. Bames HO. Breast malformation and a new approach to the problem of small breasts. Plast Recontr Surg. 1950; 5(6):499–506. 4. Bames HO. Augmentation mammaplasty by lipotransplant. Plast Reconstr Surg. 1953;11(5):404–12. 5. Maliniac J. Harmful fallacies in mammaplasty. At the International Congress of Plastic Surgery. London: 1956. 6. Marino H. Glandular mastectomy: immediate reconstruction. Plast Reconstr Surg. 1952;10(3):204–8. 7. O’Connor CM. Glandular excision with immediate mammary reconstruction. Plast Surg. 1964;33:57. 8. Goulian D Jr, McDivitt RW. Subcutaneous mastectomy with immediate reconstruction of the breast using the dermal mastopexy technique. Plast Reconstr Surg. 1972;50(3):211–5. 9. Conway H, Smith J. Breast plastic surgery: reduction mammaplasty, mastopexy, augmentation mammaplasty and mammary reconstruction; analysis of two hundred and fortyfive cases. Plast Reconstr Surg. 1958;21(1):8–19. 10. Watson J. Some observations on free fat grafts with reference to their use in mammaplasty. Br J Plast Surg. 1959;12:263–74. 11. Longacre JJ. The use of the local pedicle flaps for reconstruction of the breast after sub-total extirpation of the mammary gland and for the correction of distortion and atrophy of the breast due to excessive scar. Plast Reconstr Surg. 1953;11(5):350–403. 12. Longacre JJ. Surgical reconstruction of the flat discoid breast. Plast Reconstr Surg. 1956;17(5):358–66. 13. Bircoll M. Cosmetic breast augmentation utilizing autologous fat and liposuction techniques. Plast Reconstr Surg. 1987;79(2):267–71.

75 14. Johnson G. Body contouring by macroinjection of autologous fat. Am J Cosm Surg. 1987;4:103. 15. Thorek M. Plastic surgery of the breast and abdominal wall. Springfield: Charles C. Thomas; 1942. 16. Zekri A, Ho WS, King WW. Destructive paraffinoma of the breast and thoracic wall caused by paraffin injection for mammary increase: apropos of 3 cases with review of the literature. Ann Chir Plast Esthet. 1996;41(1):90–3. 17. Erguvan-Dogan B, Yang WT. Direct injection of paraffin into the breast: mammographic, sonographic, and MRI features or early complications. Am J Roentgenol. 2006; 186(3):888–904. 18. Pang TC. Death following injection of paraffin into the breast. Br Med J. 1957;1(5125):992. 19. Institute of Medicine: Bondurant S, Ernster V, Herdman R, editors. Safety of Silicone Breast Implants. Washington, DC: National Academy Press; 2000. 20. Young VL, Watson ME. Breast implant research: where we have been, where we are, where we need to go. Clin Plast Surg. 2001;28(3):451–83. 21. Uchida J. Clinical application of cross-linked dimethylpolysiloxane; restoration of breast, cheeks, atrophy of infantile paralysis, funnel-shaped chest, etc. Jpn J Plast Reconstr Surg. 1961;4:303. 22. Boo-Chai K. The complications of augmentation mammaplasty by silicone injection. Br J Plast Surg. 1969;22(3): 281–5. 23. Hu H, Liu X, Zhu H, Gong L, Li Z. Clinical results of breast augmentation with polyacrylamide hydrogel injections. Zhonghua Zheng Xing Wai Ke Zhi. 2002;18(2):81–2. 24. Leung KM, Yeoh GP, Chan KW. Breast pathology in complications associated with polyacrylamide hydrogel (PAAG) mammoplasty. Hong Kong Med J. 2007;13(2):137–40. 25. http://www.eskimo.com/~bloo/bformfaq/imphist.html 26. http://www.aboardcertifiedplasticsurgeonresource.com/ breast_implants/history.html 27. Pangman WJ II. Comments on breast plasty. South Gen Pract Med Surg. 1953;115:256. 28. Moore AM, Brown JB. Investigation of polyvinyl compounds for use as subcutaneous prostheses. Plast Reconstr Surg. (1946) 1952;10(6):453–9. 29. Pangman WJ, Wallace RM. The use of plastic prostheses in breast plastic and other soft tissue surgery. Presented at the 6th Congress of the Pan-Pacific Surgical Association, 7 Oct 1954. 30. Edgerton MT, McClary AR. Augmentation mammaplasty. Plast Reconstr Surg. 1958;21(4):279–305. 31. Edgerton MT, Meyer E, Jacobson WE. Augmentation mammaplasty. II. Further surgical and psychiatric evaluation. Plast Reconstr Surg. 1961;27:279–302. 32. Conway H, Dietz GH. Augmentation mammaplasty. Surg Gynecol Obstet. 1962;114:573. 33. Pickrell KL. An evaluation of Etheron as an augmentation material in plastic and reconstructive surgery. A long term clinical and experimental study. Presented at the Annual Meeting of the American Society of Plastic and Reconstructive Surgery. Honolulu: Oct 1962. 34. Pollet J. The treatment of mammary hypoplasia by insertion of Etheron sponges. Mem Acad Chir. (Paris) 1965;91(17): 525–30. 35. Cronin T, Gerow F. Augmentation mammaplasty – a new natural feel prosthesis. In: Transactions of the Third

76 International Congress of Plastic Surgeons. Amsterdam: Excerpta Medica; 1964. p. 41–9. 36. Weiner DL, Aiache AE, Silver L. A new soft, round, silicone breast implant. Plast Reconstr Surg. 1974;53(2):174–8. 37. Barker DE, Retsky M, Schultz SL. The new low bleed mammary prosthesis: an experimental study in mice. Aesthetic Plast Surg. 1981;5(1):85–91. 38. Caffee HH. The influence of silicone bleed on capsular contracture. Ann Plast Surg. 1986;17(4):284–7. 39. Arion H. Carboxymethylcellulose hydrogel-filled breast implants. Our experience in 15 years. Ann Chir Plast Esthet. 2001;46(1):55–9. 40. Hardwicke J, Gaze NR, Laitung JK. A retrospective audit of Novagold “Hydrogel” breast implants. J Plast Reconstr Aesthet Surg. 2007;60(12):1313–6. 41. Berthe JV, Van Geertruyden JP. Osmotic instability of hydrogen-filled breast implants. Br J Plast Surg. 2001;54(5):465–6. 42. Gherardini G, Zaccheddu R, Basoccu G. Trilucent breast implants: voluntary removal following the medical device agency recommendation. Report on 115 consecutive patients. Plast Reconstr Surg. 2004;113(3):1024–7. 43. MHRA UK. Medical Device Alert DA 2000(07) Breast Implants – PIP Hydrogel. Dec 2000. 44. McGregor JC. Trilucent breast implants – a personal review of the current controversies (May 1999). Br J Plast Surg. 1999;52(6):512–3. 45. Cole RP, Morris AD. MRI diagnosis of trilucent breast implant rupture. Br J Plast Surg. 2000;53(3):251–2. 46. http://ezinearticles.com/?History-of-Breat-Implants &id=1411957 47. Hartley JH. Specific application of the double lumen prosthesis. Clin Plast Surg. 1976;3(2):247–63. 48. Becker H. Breast augmentation using the expander mammary prosthesis. Plast Reconstr Surg. 1987;79(2):192–9. 49. Ashley FL. A new type of breast prosthesis. Plast Reconstr Surg. 1970;45(5):421–425. 50. Herman S. The Meme implant. Plast Reconstr Surg. 1984;73(3):411–4. 51. Hoffman S. Correction of established capsule contractures with polyurethane implants. Aesthetic Plast Surg. 1989;13(1): 33–40.

M. A. Shiffman 52. Smahel J. Tissue reactions to breast implants coated with polyurethane. Plast Reconstr Surg. 1978;61(1):80–5. 53. Zedda S, Cirla A, Aresin G, Sala C. Occupational type test for the etiological diagnosis of asthma due to toluene diisocyanate. Respiration. 1976;33(1):14–21. 54. Pienta R, Shah M, Lebherz W, Andrews A. Correlation of bacterial mutagenicity and hamster cell transformation with tumorgenicity induced by 2,4-toluenediamine. Cancer Lett. 1977;3(1–2):45–52. 55. Whalen RL. Improved textured surfaces for implantable prostheses. ASAIO Trans. 1988;34(3):887–92. 56. Arion HG. Retromammry prosthesis. C R Soc Fr Gyncol. 1965;35(5):427. 57. Rees TD, Guy CL, Coburn RJ. The use of inflatable breast implants. Plast Reconstr Surg. 1973;52(6):609–15. 58. Regnault P, Baker TJ, Gleason MC, Gordon HL, Grossman AR, Lewis JR Jr, Waters WR, Williams JE. Clinical trial and evaluation of a proposed new inflatable mammary prosthesis. Plast Reconstr Surg. 1972;50(3):220–6. 59. Williams JE. Experience with a large series of silastic breast implants. Plast Reconstr Surg. 1972;49(3):253–8. 60. Grossman AR. The current status of augmentation mammaplasty. Plast Reconstr Surg. 1973;52(1):1–7. 61. Worton EW, Seifert LN, Sherwood R. Late leakage of inflatable breast prostheses. Plast Reconstr Surg. 1978;65(3): 302–6. 62. Baker JL Jr, Bartels RJ, Douglas WM. Closed compression technique for rupturing a contracted capsule around a breast implant. Plast Reconstr Surg. 1976;58(2):137–41. 63. Rempel JH. On closed compression rupturing of con tracted implant capsules. Plast Reconstr Surg. 1977;59(6): 838–9. 64. Johnson GW, Christ JE. The endoscopic breast augmentation: the transumbilical insertion of saline-filled breast implants. Plast Reconstr Surg. 1993;92(5):801–8. 65. http://cohesivebreastimpllnats.com/breastimplants_history. html 66. Niechajev I, Jurell G, Lohjelm L. Prospective study comparing two brands of cohesive gel breast implants with anatomic shape: 5-year follow-up evaluation. Aesthetic Plast Surg. 2007;31(6):697–710.

8

Inframammary Approach to Subglandular Breast Augmentation Anthony Erian and Amal Dass

8.1 Introduction Breast augmentation is the most popular cosmetic surgical procedure both in the US and the United Kingdom today. In 2005 alone, there were approximately 2,79,000 such procedures performed in the US [1] and a year-over-year increase of 51% in the number of women having breast augmentation in the UK [2]. Attempts at surgical enhancement of the breasts are not new. From paraffin injections in the early twentieth century to liquid silicone injections in the 1950s and 60s [3], various foreign materials were used in early efforts to augment the breasts. These ranged from petroleum jelly to solid materials such as rubber, polyurethane, Teflon and various plastic sponges [4], but were all either rejected as a foreign body or failed to produce a favourable aesthetic result. Autologous tissue augmentation was also attempted in the form of dermal fat grafts, but failed due to fat resorption [5]. It was the introduction of the silicone gel prosthesis in 1963 by Cronin and Gerow [6] that ushered in the current era of breast augmentation. Through myriad changes and refinements in both the implants and surgical techniques since, breast augmentation is today performed with minimal morbidity and with an expectation of a reasonable aesthetic result. The breast is a complex symbol that relates to a female’s femininity, sexuality and her role as a woman and mother. Her attachment to them physically and psychologically is much more than that of a secondary sexual characteristic [7]. While not every woman with

A. Erian (*) Orwell Grange, 43 Cambridge Road, Wimpole, Cambridge, UK e-mail: [email protected]

small breasts seeks augmentation, the ones that do are invariably psychologically and socially uncomfortable with them [8]. These concerns seem to be well addressed by breast augmentation. The vast majority of women who have undergone breast augmentations are pleased that they did so, even if the results were less than ideal or were accompanied by complications [9]. The popularity and success of breast augmentation are thought to result from the predictability and success of the procedure.

8.2 Breast Implants and Subglandular Breast Augmentation The choice of approach and placement of implants has been historically influenced more by implant constraints than aesthetic ideals. Subglandular breast augmentation requires the placement of current generation silicone implants for the best aesthetic results. These implants are considered by many to have the most natural feel while providing the best aesthetic outcome with a favourable safety profile and complication rate [10]. The hangover from the days of their moratorium, however, will ensure that cosmetic surgeons will still be faced with many questions regarding the use and safety of silicone implants, especially in the USA. Knowledge of the critical issues that have shaped our perspectives on breast implants and their use in breast augmentation is, thus, vital.

8.3 Capsular Contracture This remains the single most important factor in influencing the techniques of breast augmentation. The very

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first silicone gel implants were thick silicone shelled implants which were filled with viscous silicone gel and had a Dacron fixation patch on its base [6]. Unfortunately, they became associated with a very high incidence of capsular contracture of up to 40–60% [11–13]. To address this problem, thin shelled smooth silicone gel implants without Dacron patches were introduced. Though they may have decreased the capsular contracture rate somewhat, they suffered from a higher incidence of implant rupture and silicone bleed [14] where particles of silicone extravasated out of the capsule. Silicone bleed has been postulated to increase the incidence of capsular contracture [15]. The next generation of implants were the first to have a double lumen – two layers of high performance elastomer with a thin fluorosilicone barrier between – to solve the problem of implant rupture and bleeding. There has been some evidence that this enhanced shell life and improved capsular contracture rates [15]. The emphasis then changed to submuscular placement of implants after a lower rate of capsular contracture was found in a study that reconstructed the breast submuscularly after a subcutaneous mastectomy [12, 16]. This was validated by numerous other studies [17, 18]. In fact, the incidence of capsular contracture was found to decrease even further after insertion of a saline implant submuscularly [12]. Capsular contracture rates had now decreased from 40 to 60% to under 10%, which was considered acceptable. Saline implants were first introduced in the 1960s not to reduce capsular contracture rates, but to minimise the size of the incisions used in their insertion [15]. Only subsequently were they found to be associated with a lower rate of capsular contracture [12, 17, 18]. While the major problems of deflation [20] and valve failure [21] have been addressed in newer generations of saline implants, they still suffer from significant disadvantages such as wrinkling and folding if left underfilled and a hard spherical appearance if overfilled [10], especially when used in a subglandular pocket. However, they are still popular due to both the low capsular contracture rates seen and the FDA moratorium on silicone implants.

8.4 Texturization Texturing implant surfaces came to the fore in the 1990s. Lower capsular contracture rates with polyurethane-

A. Erian and A. Dass

covered silicone implants was attributed not only to delamination of the polyurethane surface, but also to its surface texture [12, 16]. These have since been withdrawn due to concerns over the breakdown products of polyurethane [22]. The importance of texturization to subglandular breast augmentation was not recognized immediately [10]. This was due to several factors. Firstly, the capsular contracture rates for submuscular breast augmentation were already low. Texturing showed significant benefits primarily in the subglandular position reducing capsular contracture to rates comparable to insertion submuscularly [6, 23]. Secondly, the degree of texturing varies between manufacturers [16, 24]. Lastly, animal models actually showed an increase in the capsular contracture rate with Texturization [25]. However, this has not been upheld in a 10-year prospective randomized clinical trial which showed capsular contracture rates of 11% with textured implants compared to 65% with smooth implants [23]. Thus evolved the current 5th generation silicone implant – the double lumen form stable cohesive gel silicone implant. These are available in smooth or textured surfaces, round or anatomic shapes and a variety of profiles, i.e. implant heights. Subsequent enhancements to this version included a textured surface, shown to reduce the incidence of capsular contracture, and a cohesive silicone gel which had superior consistency and form stability, i.e. does not leak when ruptured (Fig. 8.1) [15]. A host of other implants have been tested and brought to market over the years. Among the more popular were the Surgitek polyurethane-covered silicone implants, the Trilucent soybean oil filled implant and the Hydrogel implants which were filled with an organic polymer (Fig. 8.2). They have all been withdrawn [26, 27] due to viability and safety concerns leaving silicone or saline implants as the only viable options available to the cosmetic surgeon today.

8.5 Safety Issues with Silicone Implants In November 2006, the Food and Drug Administration lifted a 14-year ban on the use of silicone gel implants outside of clinical studies. This ban was initially enforced in 1992 by the FDA commissioner against the recommendations of the advisory panel, noting that although breast implants were not unsafe, more

8 Inframammary Approach to Subglandular Breast Augmentation

a

b

Fig. 8.1 Fifth generation double lumen cohesive gel silicone implants – Eurosilicone (MediCor Ltd) very high profile, round, textured

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data were required to establish their safety [28]. This was interpreted by the media and public to mean that breast implants were not safe. The subsequent media frenzy that followed and several lay jury decisions which found silicone implants to be responsible for common pathological conditions culminated in a class action lawsuit involving more than 4,00,000 women, a four billion dollar out of court settlement and the withdrawal of major implant makers from the market. Silicone implants were, thus, implicated in causing a higher risk of connective tissue disorders and an increased risk of breast cancer. The evidence, however, contradicted or failed to confirm both these allegations. The Independent Expert Advisory Group (IEAG) set up by the UK Department of Health found in a report published in 1993 that there was “no evidence of an increased incidence of connective tissue disease associated with silicone gel breast implants” [29]. Similar reviews were conducted by Canada (Cana dian Expert advisory Committee review, 1992), France (ANDEM, 1996), USA (US National Science Panel, 1997–1998 and Institute of Medicine, 1999) and the European Parliament (STOA report), out of which a clear consensus emerged that there was no link appreciable between silicone gel breast implants and connective tissue diseases. By the late 1990s, more than 20 studies had upheld this conclusion. The risk of tumours in patients implanted with silicone gel breast implants was also considered by the Independent Review Group (IRG), which was

Fig. 8.2 (From left to right) Silicone gel, Trilucent and Hydrogel implants

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commissioned by the Chief Medical Officer UK. Their 1998 report [30] stated that “analyses of large groups of women both with and without breast implants have shown there is a slightly reduced incidence of breast cancer in women with breast implants. Studies looking at the incidence of other cancers have failed to demonstrate a statistically significant increase among women with breast implants”. Moreover, the IRG also concluded that silicone gel breast implants posed no greater risk than any other surgical implant and that it induces a conventional biological response rather than a toxic one. It must be noted that silicone has been used in medical practice for decades as a coating for hypodermic needles and in various prostheses. It is an inert substance which has become highly purified with technological advances. It is ironic that perspectives on breast augmentation have been driven not by aesthetic ideals, but implant constraints. For years, American surgeons were prevented from using silicone implants for non-reconstructive work. Across the Atlantic, however, cosmetic surgeons have had the option of using either silicone or saline implants even through the 1990s. The popularity of silicone implants, with over 80% of implants used in the UK being silicone-based [29], bears out the authors’ view that the current generation of silicone gel breast implants provide the best aesthetic result with a low complication rate and an excellent safety profile. With the removal of restrictions on its use in the US, a marked increase in preference for silicone gel breast implants and for the subglandular approach for their placement is expected.

8.6 Subglandular Breast Augmentation via an Inframammary Approach The authors’ current preference is for a subglandular approach using double-lumen textured round silicone gel implant. Breast augmentation via a subglandular approach is, at least in theory, an anatomically correct approach, i.e. we seek augmentation of the breasts and not the pectoral muscles. The ideal breast has a teardrop shape, a well-defined inframammary fold, good volume and adequate projection. With subpectoral augmentation, the breast assumes a hemispherical shape especially when viewed laterally due to pectoral muscle cover and compression of the implant by it [10]. This fullness of the superior pole is also contributed by

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contraction of the muscle, which has a tendency to push the implant upwards. It has been noted that patients have a preference for the shape of the breast after subglandular augmentation when compared with submuscular placement [31]. Many surgeons who prefer subglandular breast augmentation also have difficulty in justifying the division of the inferior medial fibres of the pectoralis major muscle during submuscular placement for an aesthetic procedure [10]. The inframammary fold anchors the breast to the chest wall [24] and is important to the eventual aesthetic result of breast augmentation. Submuscular placement of the implant frequently blunts the inframammary fold. Destruction of the inframammary fold or placement of the implant inferior to it, as has been suggested by a few authors [13, 32], frequently leads to migration of the implant beneath it creating a “double-bubble” phenomenon. The inframammary approach also gives better control over the inframammary fold which may need to be lowered with inferior quadrant hypomastia. It also permits complete visualisation of the pocket enabling an easier dissection. The scar can fashioned such that it is hidden by the lower pole of the augmented breast. The inframammary approach can also accommodate larger implants, unlike the periareolar or transumbilical approaches. The transaxillary approach is most likely to lead to asymmetric pocket dissection and a doublebubble phenomenon [32]. It is interesting that Tebbetts [33], one of the early proponents of the transaxillary approach, now prefers the inframammary approach. Implant sizes are frequently 20–50 mL smaller in subglandular augmentations to achieve the same volume and projection as in subpectoral augmentations due to the added muscle coverage over the implant.

8.7 Contraindications to Subglandular Augmentation There are only a few absolute contraindications to subglandular breast augmentation. These are: 1. Deficient skin cover/breast parenchyma (skin pinch test <2 cm) 2. Irradiated breast Thin skin/tissue cover is seen in hypomastia or postpartum. Implant placement subglandularly will lead to visible implant edges, and more than likely, rippling.

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Fig. 8.3 (a) Pre-operative Grade I ptosis. (b) Subglandular breast augmentation via an inframammary approach. The breasts look aesthetically pleasing with volume restoration, projection, camouflage of scars and lack of implant visibility

Interference with the blood supply in radiated breasts makes subglandular implant placement the safer and more sensible choice. Ptosis is only a relative contraindication. Subglandular breast augmentation in women with glandular ptosis or grade I ptosis can produce excellent results [32]. In larger degrees of ptosis, the patient may benefit from a concomitant mastopexy. The detection of breast pathology and the interference with mammography used to be another argument for placement of implants submuscularly. The advent of magnetic resonance imaging of the breast as the most specific and sensitive modality in detecting breast cancer even in subglandularly implanted breasts has somewhat mitigated that argument [34]. The issues with capsular contracture, implant bleed, rupture and migration are no longer the problems they were with fifth generation textured cohesive gel silicone implants. With proper patient selection, subglandular augmentation produces an excellent and predictable aesthetic result with significantly lower morbidity (Fig. 8.3, Table 8.1).

8.8 Patient Evaluation The patient is ultimately the judge of the success of any cosmetic surgery. Complication free surgery does not guarantee an acceptable result to the patient. It is no different with breast augmentation.

Table 8.1 The advantages and disadvantages of subglandular breast augmentation [36] Tradeoffs

Potential benefits

Increased risk of edge Increased control of breast shape visibility or palpability Increased risk of rippling

Usually a more rapid post-operative recovery

Possible increased incidence of capsular contracturea

Minimal or no distortion with pectoralis contraction

Possible increased interference with mammographyb

Increased control of inframammary fold position and shape

a The incidence of capsular contracture has decreased dramatically with evolution in texturization of the implant. Capsular contracture rates of textured implants in the subglandular position are comparable to those seen with submuscular placement [23] b Mammograms are more difficult to perform in subglandularly augmented patients. There is also a risk of rupturing the implants due to compression of the breasts to obtain adequate views. There is also a risk that some of the breast tissue may be obscured by the implants. However, the advent of MR imaging of the breast has now presented patients with an imaging modality that is much more sensitive and specific albeit more expensive [34]

Up to 40% of claims relating to cosmetic surgery arise from breast operations with breast augmentations accounting for almost half of these [35]. Patient evaluation is, thus, a critical step in determining the successful outcome of the operation. Any consultation needs to cover in detail any past medical history including psychiatric history. Red

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flags are raised in patients with a psychiatric history, depression, body dysmorphia or recent change in psychiatric medication. In these cases, psychiatric evaluation is advised even when the patients appear to exhibit normal orientation and behaviour. The motivation for surgery is always sought. In our experience, the typical patient presenting for breast augmentation is in her 20–40s with congenital hypomastia or loss of volume after pregnancy who has been considering the procedure for some time. It is always important to elicit any history of recent separation, divorce, bereavement or any other psychological trauma. Patients who elect to have breast augmentation to alleviate their psychological trauma or at the behest of their partners seldom make the best candidates. The patient’s expectations are also discussed to make sure they are realistic. Informed consent implies more than a legally worded signed document explaining the procedure and risks. The patient must be an adult capable of understanding the facts and coming to a rational decision about the surgery. The patient must be provided with adequate information about the procedure, risks, benefits and alternatives to make a choice to proceed with the surgery. The discussion should always be conducted by the surgeon performing the procedure. A second consultation before surgery is preferred. Consent also needs to be obtained for pre- and postoperative photography, which should be considered part of the mandatory documentation.

8.9 Patient Examination The evaluation of the breast and chest wall is used to determine the approach and suitability for the procedure. The examination should always start with an evaluation of the patient’s chest and thorax. This includes noting if the patient has a short or long thorax, assessment of the bony and muscular component of the chest wall and any deformities of the chest wall such as pectus excavatum or carinatum. Next, the skin envelope is assessed. Factors to note include skin elasticity and laxity. The appearance of stretch marks must be noted. The pinch test is then performed. This involves gathering of both the skin and breast parenchyma in the superior pole of the breast with the thumb and index finger. The distance between the two is measured. A pinch test of less than 2 cm may preclude subglandular

A. Erian and A. Dass

Fig. 8.4 Breast measurements for pre-operative planning

augmentation due to implant visibility and palpability through a deficient skin and glandular cover. Next, the breast is characterised. This includes describing the quantity and quality of breast parenchyma. The shape of the breasts is noted. Tuberous breasts, ptosis, pseudoptosis and any nipple–areolar complex abnormalities/asymmetries are noted. The correction of these deformities is beyond the scope of this chapter; however, a determination is made as to whether these will be corrected concomitantly or as separate procedures. Precise measurements are taken in the standing position (Fig. 8.4). These include suprasternal notch to nipple, nipple to inframammary line, breast width or diameter and distance from midline to medial edge of breast. A prospective implant size can then be determined using the breast diameter, the base width of the projected implant and the patient’s desired cup size. The incision and approach can then be determined. The breast diameter describes the width of the base of the breast. This extends from the medial edge of the breast to the anterior axillary fold. This determines the size of the pocket that can be created for the implant. The patient’s expectations must be matched to the size of the implant that can be fitted given the existing breast dimensions.

8.10 Operative Technique The patient is cleaned and draped under general anaesthesia in the supine position with arms placed by the side. All pre-operative markings are rechecked.

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8.10.1 Incision The incision is placed in the projected inframammary crease. The true inframammary crease may need to be lowered in cases with hypomastia of the inferior pole to give the projected crease. This usually corresponds to a distance of 6 cm from the nipple. A vertical line is drawn from the nipple down to the inframammary crease. One-third of the incision should be placed medial to this point, the rest extending laterally along the crease. The incision is usually between 4.5 and 6 cm in length depending on the size of the implant. Fashioning the incision in this manner hides the scar in the resulting inframammary crease and avoids the weight of the implant riding on the bulk of the scar. The sternal region and medial cheat wall are also avoided as these are the areas most prone to hypertrophic and keloid scarring.

8.11 Dissection: Inframammary Approach The patient is cleaned and draped supine under general anaesthesia with arms at right angles to the thorax. The incision sites are infiltrated with 2–3 mL of 1% lignocaine with 1:1,000 epinephrine to aid hemostasis. This infiltration is extended via a long 22 gauge needle into the subglandular fascial component where approximately 120 mL of the same solution is infiltrated under the breast tissue directly above the pectoralis muscle on each side. The incision is made and dissection continued through Scarpa’s fascia till the prepectoral fascia is identified (Fig. 8.5). Dissection is then continued using a fiberoptic light retractors. Meticulous hemostasis is mandatory while creating a precise pocket that conforms to the pre-operative markings to accommodate the implant (Fig. 8.6). Medial dissection must be especially cautious due to some medial perforating vessels and thinning breast parenchyma in this area. Exact sizers are introduced to check the pockets and evaluate the eventual results (Fig. 8.7). Any asymmetry or undissected areas are corrected. The implants and the dissected pockets are then prepared by irrigation in an antibiotic solution (50,000 units of bacitracin, 1 g cefazolin and 80 mg gentamicin in 500 mL normal saline).

Fig. 8.5 Inframammary approach to subglandular breast augmen tation

Fig. 8.6 Commonly encountered vessels during subglandular dissection

After further checking the pockets to ensure haemostasis, the implants are introduced via a no-touch technique and the final result checked. If satisfactory, a multilayer closure is performed with absorbable Vicryl

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b

Fig. 8.7 Example of Internal Sizer used to check dissected pocket and verify final implant size and volume

sutures. The most important step with this is to close the implant pocket meticulously as one layer before proceeding with the rest. The skin edges are approximated with subcuticular Vicryl to the skin. Once complete, the wound is dressed with SteriStrips and dressings applied. No drains are used. The authors’ is not to strap the chest with figure of eight bandages or bandages, but to place a well-fitting sports bra instead to provide support post-operatively.

Fig. 8.8 Subglandular breast augmentation – 6 weeks post-operatively. 280 cc medium profile round cohesive gel Eurosilicone (style ES 802) implants were placed bilaterally in subglandular pockets

the breast for lumps and have their implants checked every 5 years or so (Figs. 8.8–8.10).

8.12 Complications 8.11.1 Post-Operative Care Patients are usually kept for overnight observation after breast augmentation, although many surgeons perform breast augmentation as an outpatient procedure. The patient is discharged the next day with oral analgesics and a 7 day course of a first generation cephalosporin. Vigorous activity and lifting are not permitted for 3–4 weeks. The patient is seen at 1 and 6 weeks post-operatively. If free from complications, they are discharged from care with advice to continue with surveillance of

The complications of breast augmentation are covered in detail in Part IV. Briefly, the more commonly described complications of subglandular breast augmentation are infection, haematoma, seroma, nipple paresthesia or hypersensitivity, capsular contracture, asymmetry, rippling, implant migration or herniation. Implant deflation or rupture, valve failure, rippling and fold failure are much less commonly seen in the enhanced cohesive silicone gel implants and are problems that have been largely avoided in our practice due to this.

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Fig. 8.9 (a) Pre-operative. (b) Six weeks after subglandular breast augmentation via an inframammary approach. 240 cc medium profile round cohesive gel Eurosilicone (style ES 802) implants were placed bilaterally in subglandular pockets

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Fig. 8.10 (a) Pre-operative. (b) Six weeks after subglandular breast augmentation via an inframammary approach. 260 cc high profile round cohesive gel Eurosilicone (style ES 81) implants were placed bilaterally in subglandular pockets

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References 1. American Society of Plastic Surgeons. 2005 Quick facts, cosmetic and plastic surgery trends. Illinois: ASPS; 2006. 2. British Association of Aesthetic Plastic Surgeons. Over 22,000 surgical procedures in the UK in 2005. London: BAAPS; 2006. 3. Ellenbogen R, Ellenbogen R, Rubin L. Injectable fluid silicone therapy. J Am Med Assoc. 1975;234(3):308–9. 4. Gonzales-Ulloa M. Correction of hypotrophy of the breast by means of exogenous material. Plast Reconstr Surg. 1965; 25:15. 5. Conway H, Smith J Jr. Breast plastic surgery: reduction mammaplasty, mastopexy, augmentation mammaplasty and mammary construction: analysis of two hundred fortyfive cases. Plast Reconstr Surg. 1958;21(1):8–19. 6. Cronin T, Gerow F. Augmentation mammaplasty; a new natural feel prosthesis. Transactions of the Third International Congress of Plastic Surgery. Amsterdam: Excerpta Medica Foundation; 1964. p. 41. 7. Beale S, Lisper H, Palm B. A psychological study of patients seeking augmentation mammaplasty. Br J Psychol. 1980;136:133. 8. Sarwer DB, LaRossa D, Bartlett SP, Low DW, Bucky LP, Whitaker LA. Body image concerns of breast augmentation patients. Plast Reconstr Surg. 2003;112(1):83–90. 9. Park AJ, Chetty U, Watson AC. Patient satisfaction after insertion of silicone breast implants. Br J Plast Surg. 1996;49(8):515–8. 10. Hudson DA. Submuscle saline breast augmentation: are we making sense in the new millenium? Aesthetic Plast Surg. 2002;26(4):287–90. 11. Biggs TM, Yarish RS. Augmentation mammaplasty: retropectoral versus retromammary implantation. Clin Plast Surg. 1988;15(4):549–55. 12. Burkhardt BR. Capsular contracture: hard breasts, soft data. Clin Plast Surg. 1988;15(4):521–32. 13. Hidalgo DA. Breast augmentation: choosing the optimal incision, implant, and pocket plane. Plast Reconstr Surg. 2000;105(6):2202–16; discussion 2217–8. 14. Feng LJ, Amini SB. Analysis of risk factors associated with rupture of silicone breast implants. Plast Reconstr Surg. 1999;104(4):955–63. 15. Maxwell PG, Hartley WR. Breast augmentation. In: Mathes SJ, editor. Plastic surgery. 2nd ed. Philadelphia: Elsevier; 2006. p. 1–33. 16. Spear SL, Elmaraghy M, Hess C. Textured-surface salinefilled silicone breast implants for augmentation mammaplasty. Plast Reconstr Surg. 2000;105(4):1542–52; discussion 1553–4. 17. Burkhardt BR, Dempsey PD, Schnur PL, Tofield JJ. Capsular contracture: a prospective study of the effect of local antibacterial agents. Plast Reconstr Surg. 1986;77(6):919–32. 18. Puckett CL, Croll GH, Reichel CA, Concannon MJ. A critical look at capsule contracture in subglandular versus

A. Erian and A. Dass subpectoral mammary augmentation. Aesthetic Plast Surg. 1987;11(1):23–28. 19. Gylbert L, Asplund O, Jurell G. Capsular contracture after breast reconstruction with silicone-gel and saline-filled implants: a 6-year follow-up. Plast Reconstr Surg. 1990; 85(3):373–7. 20. Gutowski KA, Mesna GT, Cunningham BL. Saline-filled breast implants: a Plastic Surgery Educational Foundation multicenter outcomes study. Plast Reconstr Surg. 1997; 100(4):1019–27. 21. Cederna JP. Valve design as a cause of saline-filled implant deflation. Plast Reconstr Surg. 2002;109(6):2166. 22. Hester TR Jr, Tebbetts JB, Maxwell GP. The polyurethanecovered mammary prosthesis: facts and fiction (II): a look back and a “peek” ahead. Clin Plast Surg. 2001;28(3):579–86. 23. Collis N, Coleman D, Foo IT, Sharpe DT. Ten-year review of a prospective randomized controlled trial of textured versus smooth subglandular silicone gel breast implants. Plast Reconstr Surg. 2000;106(4):786–91. 24. Muntan CD, Sundine M, Rink RD, Acland RD. Inframammary fold: a histologic reappraisal. Plast Reconstr Surg. 2000;105(2):549–56; discussion 557. 25. Caffee HH. Textured silicone and capsule contracture. Ann Plast Surg. 1990;24(3):197–9. 26. Gherardini G, Zaccheddu R, Basoccu G. Trilucent breast implants: voluntary removal following the Medical Device Agency recommendation. Report on 115 consecutive patients. Plast Reconstr Surg. 2004;113(3):1024–7. 27. MHRA UK. Medical device alert DA 2000(07) breast implants – PIP hydrogel, 2000. 28. Kessler DA. The basis of the FDA’s decision on breast implants. N Engl J Med. 1992;326(25):1713–5. 29. MDA. Evidence for an association between the implantation of silicones and connective tissue disease. MDD Report, No MDD/92/42, 1993. 30. The Report of the Independent Review Group. Silicone gel breast implants, 1998:25–6. 31. Baker JL. Augmentation mammaplasty: general considerations. In: Spear SL, editor. Breast principles and art. Philadelphia: Lippincott Raven; 1998. 32. Tebbetts JB. Transaxillary subpectoral augmentation mammaplasty: long-term follow-up and refinements. Plast Reconstr Surg. 1984;74(5):636–49. 33. Tebbetts JB. A surgical perspective from two decades of breast augmentation: toward state of the art in 2001. Clin Plast Surg. 2001;28(3):425–34. 34. Ahn CY, DeBruhl ND, Gorcyzca DP, Shaw WW, Bassett LW. Comparative silicone breast implant evaluation using mammography, sonography, and magnetic resonance imaging: experience with 59 implants. Plast Reconstr Surg. 1994;94(5):620–7. 35. Gorney M. Preventing litigation in breast augmentation. Clin Plast Surg. 2001;28(3):607–15. 36. Tebbets JB. Dual plane breast augmentation: optimizing implant-soft-tissue relationships in a wide range of breast types. Plast Reconstr Surg. 2001;107(5):1255–72.

9

Hydrodissection Axillary Approach Breast Augmentation Sid J. Mirrafati and Melvin A. Shiffman

9.1 Introduction Breast augmentation is a procedure that has been done for many years, but the technique has not advanced. There are four routes through which the augmentation can be done: Inframammary, periareolar, axillary, and umbilical. The inframammary is the original route that was done when the breast augmentation first started. Although it is the most direct route for the placement of the implant, the scar can be unfavorable. The most common approach is the periareolar. Most surgeons and the patients choose this route for the ease of the implant placement, and the scar is pretty unnoticeable. The periareolar route, however, causes too much damage to the breast tissue and this may be the cause of capsular contraction. The axillary approach is the least damaging one to the breast tissue. There is a learning curve to the axillary approach, but once the technique is mastered, it is the fastest to perform, with the shortest period of recovery for breast augmentation. The scar can be pretty much undetectable. The umbilical route is too far away from the breast and there is no hand feeling in the pocket. The hydrodissection axillary augmentation is the best way to do a breast augmentation. Tumescent fluid is injected into the pocket under high pressure and this will dissect the pocket causing

less damage to the breast which in turn will allow faster recovery with fewer complications. Cautery (Bovie) is not used since it can cause heat damage to the surrounding breast tissues. The only time that a scalpel blade is used is in making the axillary fold incision. The rest of the surgery is done by finger and blunt instrument dissection.

9.2 Preoperative Patients are prepared starting 3–4 weeks before surgery. The chest size is measured by drawing a line in the middle of the sternum, and at 1.5 cm lateral to this line, the distance to the anterior axillary line is measured. This will determine the diameter of the implant for the largest implant size that the patient can choose, but of course, the patient can choose a smaller im plant size. All the possible risks and complications of breast augmentation are discussed with the patient. Statistically, there is a 3–5% chance of capsular contraction. All patients are started on vitamin K and vitamin C (2,000–3,000 mg/day) 7 days before surgery along with Keflex the day before surgery and continuing for 9 days after surgery. Patient is told on the morning of the surgery to shave their armpit and wash their breast and the armpit area with a surgical scrub that is given to them.

9.3 Surgical Technique S. J. Mirrafati (*) 3140 Redhill Avenue, Costa Mesa, CA 92626, USA e-mail: [email protected]

The photos are taken straight, 45° angle, and the 90° angle.

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Fig. 9.1 A Metzenbaum scissor is used to expand the incision down to the pectoralis fascia

Marking (Fig. 9.1) is done at the anterior axillary line and the midline margin of the breast. The author prefers to lower the inframammary fold line in order to avoid having the implant placed too high. The axillary fold is marked and extended to one inch. The patient is placed in a supine position and after the patient is placed under general anesthesia, the intermittent leg compression garments are placed. The patient’s breast and axilla are prepped with Betadine gel. The patient’s arms should be at a 65° angle from the body. The axillary marking in the axilla is infiltrated with lidocaine with 1:200,000 epinephrine. Two milliliters is injected into each axillary marking. The incision is then made using a Senn retractor and the skin is retracted over the pectoralis major muscle. Using a Metzenbaum scissor, the incision is expanded down to the pectoralis fascia (Fig. 9.2).

Fig. 9.2 The finger is rolled under the muscle and pushed through to provide an opening

S. J. Mirrafati and M. A. Shiffman

Fig. 9.3 The tumescent infiltrating cannula is placed into the opening and pushed through to the inframammary fold and to the lower edge of the marking

When you see the white glistening of the fascia using your index finger, the edge of the pectoralis is felt. If the placement is subpectoral, then roll the finger under the muscle, push through, and provide an opening (Fig. 9.3). If the placement is subglandular, stay on top of the muscle, then push through the tissue and provide an opening. The tumescent infiltrating cannula is placed into the opening and pushed through to the inframammary fold and to the lower edge of the marking (Fig. 9.4). The tumescent fluid, consisting of 1 L of saline, 2 mL of 1:1,000 epinephrine, and 500 mg of lidocaine, is infiltrated under high pressure inferiorly, medially, and laterally. About 300–400 mL of tumescent is injected and the pocket is expanded (Fig. 9.5). The same is done to the opposite breast to allow the tumescent fluid to stay in the pocket for at least 10 min. By now the pocket is literally made by hydrodissection and is further expanded by using the Iconoclast, paddle, and the hockey stick (Fig. 9.6). Antibiotic irrigation is done

Fig. 9.4 The pocket is expanded with tumescent fluid

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Fig. 9.5 (a1, 2) Use of the iconoclast as a dissector. (b) Use of the paddle dissector. (c1, 2) Use of the hockey stick dissector

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Fig. 9.6 (a1) The expander implant is placed in the pocket. (a2) The expander is filled with saline. (a3) Expander fully expanded. (a4) Compression is applied for hemostasis

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b Fig. 9.7 Implant is folded and inserted into the pocket

Fig. 9.9 (a) Initial dressings with foam and breast strap. (b) Bra applied

9.4 Postoperative Care Fig. 9.8 Axillary incision is closed with running mattress suture of 5–0 nylon

and the expander implant is placed in the pocket to check for any retraction and proper pocket formation (Fig. 9.7). Compression is applied from outside as well by my assistant as I prepare the other breast pocket. This will provide further homeostasis. The expanders are removed and the implants are placed in the pocket (Fig. 9.8). The incision is closed using a 5.0-nylon running mattress suture (Fig. 9.9). Compression dressing is applied (Fig. 9.10).

The patient is seen on the first postoperative day. The compression dressing is removed and a Band-Aid isv applied to the incision. The patient is told to wash the armpit 3 times a day with alcohol and apply antibiotic ointment. The patient is taught a set of arm exercises, such as rotation of the arm forward and backward. The patient is also advised to walk as often as possible. The sutures in the axilla are removed in 6–7 days. At the same time, the patient is told to massage the breast and rotate over the implant in a circular motion 5 min a day. At first, the implant appears to be sitting too high but as weeks go by, the implant will start to

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Fig. 9.10 (a1, 2) Preoperative hypotrophic breasts. (b1, 2) Postoperative hydrodissection augmentation

settle and get softer. The patient can start taking showers on the second postoperative day and start working on the third postoperative day as long as the work is not physically too strenuous. Patient can resume normal exercises in 6 weeks.

There was one case of postoperative bleeding and the patient had to be taken back to surgery the first postoperative day at which time, the pocket was irrigated, the hematoma was removed, and the incision closed. There has been no capsular contraction.

9.5 Complications With this technique of breast augmentation there is a learning curve, but once the technique is mastered, there are very few complications and there is rapid recovery. There is less tenderness compared to the other techniques of augmentation.

9.6 Conclusions Hydrodissection for axillary breast augmentation is an excellent way to enlarge the patient’s breasts (Fig. 9.10). There are fewer complications, recovery is rapid, and the surgery can be performed in less than 40 min.

Complications of Breast Augmentation

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Anthony Erian and Melvin A. Shiffman

10.1 Introduction There are a number of complications from breast augmentation. The surgeon performing breast augmentation should be aware of these complications and understand the possible cause and the treatment.

10.2 Areolar Retraction Areolar retraction occurs from fibrotic bands extending from the areola to the underlying fascia (Fig. 10.1). Treatment consists of changing the implant from the submuscular position to the submammary position. Transection or resection of the fibrous band alone will almost always result in recurrence of the indentation.

10.3 Axillary Banding There have been reports of transient axillary banding in patients following transaxillary approach to breast augmentation [1–4]. Maximovich [1] reported

M. A. Shiffman () 17501 Chatham Drive, Tustin, CA 92780-2302, USA e-mail: [email protected]

that microscopic examination (done by Ellenbogen) showed the band to be “lymphatic” in origin. The band is more likely a phlebitis of a superficial vein of the axilla and medial upper arm (branch of basilic vein) [5, 6] that is another form of Mondor’s disease. A superficial lymphatic vessel has never been reported to form a thick subcutaneous band, and superficially would not be large enough to form a fibrous band that would be palpable and visible. Mondor’s disease (superficial breast phlebitis, sclerosing breast phlebitis) is an obliterative phlebitis of the thoracoepigastric vein, frequently with a history of trauma. The phlebitis normally crosses the anterior chest region and breast from the epigastrium or hypochondroic region to the axilla. The symptoms are usually a red linear cord attached to the skin and not the deep fascia with slight to no discomfort. Manifestations usually disappear in 3–6 weeks without treatment. For discomfort, minor analgesics and the application of heat will help. Injection of steroids is not usually necessary and surgical transection is unnecessary. A recent suggestion by Rassel, Borsand, and Jonov for symptomatic Mondor’s disease is to stabilize the proximal portion of the vessel with the operators thumb, and very firm pressure is placed along the direction of the vessel with the operator’s opposite thumb as if “milking” the vessel (Fig. 10.1). While the operator’s upper hand is stabilizing the vessel, the inferior hand applies a firm downward stroke. This disrupts the cord and resolves the problem including the pain.

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94 Fig. 10.1 Axillary banding (Mondor’s disease involving the axilla). (a) Thumb firmly on proximal portion of the cord. (b) Opposite thumb on distal portion of cord for firm stretch of cord. (c) Prior to stretch type of manipulation. (d) After manipulation

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10.4 Autoinflation, Spontaneous There have been reports of spontaneous autoinflation of implants [7–11].

10.5 Calcifications Any long-standing fibrous capsule can develop calcifications (Fig. 10.2). These are usually asymptomatic. The calcifications appear benign on mammography. When the fibrous capsule is thick and calcifications occur, capsule contracture may be present as well. Calcifications may be associated with the presence of the implant stabilization patch [12].

If the calcifications are extensive and associated with symptomatic capsule contracture, capsulectomy should be performed rather than capsulotomy. Otherwise, the remaining calcified fibrous capsule may be palpable.

10.6 Capsule Contracture Capsule contracture is the most common complication of breast augmentation surgery. There are three main themes that need to be considered with capsule contracture: 1. The management of capsule contracture 2. The evolution of implants in response to it 3. Possible etiologies of capsule contracture and their influence on breast augmentation surgery

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95 Table 10.1 CDC recommendations on clinical management of CA-MRSA SSTIs [40] Consider methicillin-resistant Staphylococcus aureus (MRSA) in the diagnosis of SSTIs “Spider bites” may be MRSA Consider MRSA in the event of syndromes such as: Sepsis Osteomyelitis Septic arthritis Severe pneumonia Pneumonia following flu-like illness Culture and test susceptibility of abscesses/purulent SSTIs Incise and drain furuncles, abscesses, septic joints Initiate empiric antibiotic therapy if infection is: Severe Progressive

Fig. 10.2 Calcifications in fibrous capsule

10.6.1 The Management of Capsule Contracture Capsule contracture is essentially an exaggerated scar around the breast implant. Any foreign material incites an immune response that results in some degree of scar formation, which in the case of breast implants surrounds them. With capsule contracture, however, there is exaggerated scar formation which, if progressive, contracts around the implant causing deformity and discomfort. This, in many ways, is similar to hypertrophic scarring, which can be described as overzealous healing. The reported incidence of capsule contracture varies from 0.5 to 30% [13]. Capsule contractures are usually detected by palpation though various other modalities such as applanation tonometry [14], measure of mammary compliance, ultrasonography, and magnetic resonance imaging [15] (Figs. 10.1 and 10.2) that have been employed particularly in the context of clinical studies. The Baker classification [16] remains the prevalent system for grading capsule contracture (Table 10.1). Grade III and IV capsules generally require intervention to correct distortions or alleviate discomfort.

Initiate empiric antibiotic therapy in the presence of: Cellulitis Systemic illness Immune suppression Serious comorbidities Very young and elderly patients Lack of response to incision/drainage

Closed capsulotomy used to be a popular method of addressing significant capsule contractures where the capsule was torn by manually squeezing the breast till a tear was heard or palpated [17]. However, implant ruptures were common as were hematomas, dumbbell deformity, silicone bleed, and incomplete capsule rupture [18]. These complications have made this procedure obsolete. However, some surgeons still believe this maneuver may benefit those with early capsules in the immediate months following surgery. Established capsules are dealt with in two primary ways: 1. Open capsulotomy 2. Open partial or total capsulectomy Both these procedures may involve implant removal, exchange or reinsertion of the implant in a new pocket.

10.6.2 Open Capsulotomy The implant pocket is opened and reexplored. The capsule is then scored to achieve a release of the contracture

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caused by the capsule. The scoring may consist of circumferential or cross-hatched incisions of the capsule. Open capsulotomy is effective in early capsules, correcting asymmetries, and in patients with thin tissue cover where capsulectomy may result in skin penetration or devitalization of tissue.

10.6.3 Open Partial or Total Capsulectomy Partial or total capsulectomy is indicated in thick fibrous capsules, capsules with significant calcification, and for those with silicone granulomas which may need partial or total resection. Total capsulectomy virtually creates a new pocket for placement of a new implant and is usually accompanied by insertion of a new implant. Changing the placement of implant is also a common way of dealing with capsule formation. The implant may be placed subpectorally if previously in a subglandular position, and vice-versa providing adequate soft-tissue cover [19]. Less commonly, a new pocket is created just in front of or behind the capsule.

10.6.4 Evolution of Implants in Response to Capsule Contracture The very first implants made by Dow Corning were smooth teardrop-shaped silicon implants with a Dacron fixation patch on its posterior surface [20]. These were plagued with an unacceptably high capsular contracture rate of up to 40% [21–23]. The Dacron patch was then removed as it was thought to be the cause of capsular contracture. However, the contracture rates still remained unsatisfactory. Thinner shells and less viscous gels were then used in a direct attempt to reduce capsular contracture. They resulted in a far greater incidence of implant leak or rupture without significantly addressing the intended purpose [24]. Thus, by the 70s, most surgeons had few alternatives to the smooth silicone implant. Emphasis shifted to placement of the implant from the subglandular to subpectoral plane. Earlier trials involving subglandular placement with displacement exercises and implant massage led to improvements in the capsule contracture rate. This led to placement of the implant subpectorally

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where massage by pectoral muscle contraction was expected to limit capsule formation around the implant. This was confirmed by a significant decrease in capsule contracture rates [25, 26]. Thus, it was believed that the key to limiting capsular contracture was to maintain implant mobility within the pocket [13]. In fact, implant massage and displacement exercises are still recommended after implantation of smooth walled prosthesis. This serves to make the implant capsule more pliable, the implant mobile with a lower likelihood that the capsule will contract. The polyurethane-covered silicone implant was first introduced in the late 60s. The polyurethane was found to shed from the surface of the implant affecting the collagen orientation in the developing capsule, allowing the implant to remain soft without contracture of the capsule. Thus, it was now possible for implants to remain soft while immobile in a fixed pocket. The dramatic decrease in capsule contracture rates to fewer than 3% [27, 28] made these implants very popular in the 80s till concern over the breakdown products of polyurethane led to the withdrawal of these implants from the market by the manufacturer in 1991 [19]. Then came advances in surface texturing of silicone implants. Texturing was thought to result in greater adherence of the implant surface to the developing capsule resulting in thinner more pliable capsules less likely to contract around them. This surface texturing along with the development of stronger cohesive silicone gels and a double lumen protective barrier created an implant less prone to bleeding or rupture, which had a very low incidence of capsule contracture when placed subglandularly [29–31]. In a further twist, saline implants came back into vogue after the FDA ruling on silicone implants in 1992. While the capsule contracture rates were significantly decreased with saline implants, limitations such as rippling, folding, and palpability forced many surgeons to place these implants submuscularly [32]. Thus, the choice and placement of breast implants have been historically influenced by capsular contracture. This remains so to this day. Most of the data which show a lower rate of capsular contracture with saline implants compare them to the older generation silicone implants that were either nontextured or did not have a cohesive gel leading to a higher bleed rate. Current evidence points to the newer generation of silicone implants having low rates of capsular contracture in the subglandular position.

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10.6.5 Etiology of Capsular Contracture

10.6.8 Subclinical Infection

The cause of capsular contracture is thought to be multifactorial in origin, but remains as yet unconfirmed. There are, however, two main theories which attempt to explain it. These are hypertrophic scarring and subclinical infection.

Staphylococcus epidermidis is thought to cause an early subclinical infectious process, which triggers more vigorous capsule formation [36]. One study suggested a possible link of capsule contracture with a biofilm covering the implant surface which harbored Staphylococcus epidermidis. Staphylococcus epidermidis requires special identification techniques, which may explain why swab cultures are routinely negative. Moreover, capsule formation was shown to be reduced with the use of local antibacterial agents, which is further suggestive of a link. The subclinical infection would logically make total capsulectomy, site drainage, and insertion of a new breast implant the treatment of choice for capsule contracture [37]. The initial response to this link with bacterial infection was irrigation of the implant with Betadine (5% povidone iodine), antibiotics, and a “no-touch” technique. Betadine serves to disinfect the implant surface and has been shown to decrease the risk of capsule contracture. However, it was thought to weaken the implant surface leading the FDA to issue a caution regarding its use. This has since not been substantiated [13, 1]. Many surgeons now use antibiotic irrigation of the implant and the pocket prior to insertion. Commonly used is a combination of 50,000 units of bacitracin, 1 g cefazolin, and 80 mg gentamicin in 500 mL normal saline. This practice has been supported by favorable results from clinical studies, which show a decreased capsular contracture rate with the use of antibiotic irrigation [38, 39]. The no-touch technique involves handling of the implant with fresh gloves with insertion through a sterile plastic sleeve or into a pocket treated with antibiotic irrigation in an attempt to reduce bacterial seeding of the implant. Many surgeons now routinely use both antibiotic irrigation and the no-touch technique with breast augmentation.

10.6.6 Leukotriene Receptor Antagonists Zafirlukast (Accolate) and Montelukast (Singulair) are leukotriene receptor antagonists used in the treatment of asthma. Their use has been implicated in the reversal of capsular contracture via an abatement of inflammatory processes [33]. This has led some surgeons to prophylactically prescribe these medications. However, the medications can have side effects (reversible druginduced hepatitis) albeit uncommonly and their use has not been validated by any significant clinical trials to date. Further research into the mechanism of action of these drugs may provide insights into preventing capsular contracture at a cellular level.

10.6.7 Hypertrophic Scarring This is thought to be triggered by an irritation such as hematoma, seroma, silicone bleed, or the silicone within the capsule itself, which stimulates the formation of myofibroblasts within the capsule [34]. These myofibroblasts cause enhanced scar formation and subsequently contract resulting in capsule contracture. The link between silicone in the implant shell and subsequent capsular contracture or the link between hematomas and subsequent capsular contracture has not been confirmed. Corticosteroids, which are used in the treatment of hypertrophic scarring of the skin, have been shown to decrease capsular contracture rates when used via intracapsular injections within the dissected pocket or when incorporated into the implant double lumen [35]. However, steroid-related complications such as delayed wound healing, implant herniation, and thinning of tissues have prevented their use. However, low dose steroid irrigation may see a rise in popularity in the future following the approval of silicone implants for general use [13].

10.7 Chronic Pain Chronic pain can occur following breast augmentation from capsule contraction, nerve entrapment (Fig. 10.3), neuromas, or submuscular placement of the prosthesis.

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The treatment would be to take the implant out of the subfascial space and replacing it into the submammary space. The use of Gore-Tex or autologous fat to fill the defect is unnecessary.

10.9 Elevated Platinum Levels There has been one report by Lykissa and Maharaj [41] that studied the platinum levels in a variety of tissues of patients who have had silicone and saline implants for augmentation. There was an increase in the levels of platinum in implant patients that was higher than the normal population. However, there are no symptoms or disorders attributed to these elevated levels.

Fig. 10.3 Nerve entrapment. Arrow shows the 4th intercostal nerve on the fibrous capsule of the implant

With 4th intercostal nerve entrapment, the pain may be sharp or burning in character starting in the lateral breast, over the nerve, and radiating to the nipple–areola complex. Regional block of the 4th intercostal nerve may help, but usually surgical neurolysis is necessary. Delayed onset (years) of breast and subscapular pain was reported in 8 out of 146 patients who had submuscular (under pectoral major and serratus anterior muscles) placement of the prostheses [40].

10.8 Double Bubble The cause of the appearance of a double bubble is usually the implant placed under the pectoralis major muscle and the inframammary fold lowered. The attachment of the skin to the underlying fascia from the original inframammary fold, if it is not adequately broken up during surgery, gives the appearance of a double bubble (Fig. 10.4). During surgery, the ligament between muscle fascia and skin should be transected and it may be necessary to make multiple incisions into the fibrous tissue before expanding the crease with the finger and/or a dissection paddle. This can be resolved postoperatively by postoperative compressions to push the fold outward.

10.10 Fibrotic Retraction Fibrosis at the inferior margin of the implant is rare. It is probably caused by excessive scarring in the area such as with capsule contracture.

10.11 Galactorrhea Rothkopf and Rosen [42] reported on a patient with galactorrhea following breast augmentation. The prolactin levels in the patient were elevated. It was presumed that the lactation was secondary to prolactin elevation due to stimulation of the thoracic nerve endings that produced impulses that travel via the dorsal nerve roots to the hypothalamus and pituitary causing a rise in prolactin secretion. There have been other reports of lactation following breast augmentation [43, 44]. Bromocriptine 1.25 mg daily orally will usually resolve the problem.

10.12 Hematoma The risk of developing a hematoma after breast augmentation is reported to be in the region of 3–4% (Fig. 10.5). Prevention of hematoma is important to minimize blood loss, relieve postoperative discomfort, and limit the incidence of capsular contracture.

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b

c

Fig. 10.4 (a) Postoperative double bubble with submuscular implant. (b) Treatment consists of compressing the inframammary fold with the ipsilateral hand and then compressing the upper breast and implant with the contralateral hand using firm

pressure several times, at least 4 times daily to stretch the attachment. (c) One month after treatment. Only minimal attachment remains that resolved completely after 3 months

Prior to surgery, it should be ensured that the patient has not been on medications that promote bleeding. Hemostasis intraoperatively should be meticulous with electrocautery of tissues avoiding blunt tissue dissection as far as possible. The dissection pocket should be irrigated with saline and drains inserted where necessary to prevent postoperative collections.

Hematomas usually present as either an expanding haematoma or as a delayed collection some 1–2 weeks after surgery. An expanding haematoma must always be surgically explored. An actively bleeding vessel is usually found. Meticulous hemostasis is performed and the pocket is irrigated and cleared of any excess blood before reinsertion of the implant. Small delayed

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The incidence of silicone implant rupture has steadily decreased with successive generation of implants. Rates of less than 1% after 6 years have been reported with 4th generation silicone implants. Rupture rates vary greatly with the type of implant used. Risk factors are the type of implant [21], implant age [46], degree of capsular contracture, history of trauma (including mammography), and symptoms present [13]. Diagnosis and monitoring are achieved by palpation, mammography, ultrasound, or MRI. Intracapsular gel rupture can be treated by simple implant exchange while extracapsular extravasation requires debulking, washout, and implant replacement.

10.15 Implant Displacement Fig. 10.5 Patient post right lumpectomy and radiation therapy for breast cancer had capsulectomy because of capsule contracture. Hematoma was diagnosed 1 week postoperatively, and because of the late diagnosis, necrosis of the right nipple–areola complex occurred

collections can be left alone bearing in mind the higher risk of capsular contracture. All other large or expanding collections are routinely explored.

10.13 Idiosyncratic Allergic Reaction There is one report of an idiosyncratic reaction to textured Becker expander saline implants [45]. The patient developed erythematous papules and pustules that showed a perivascular lymphohistiocytic infiltrate that resolved with the removal of the implants. The textured shell patch was placed on the skin and itching, hives, and urticarial plaques developed under the patch.

10.14 Implant Deflation/Rupture Implant deflation is usually seen with saline implants and can be caused by trauma or can be spontaneous. Underfilling of the implant, intraluminal antibiotics, and steroids are thought to be potential risk factors. Deflation rates of 5.5% have been reported with saline implants [35]. The only treatment is replacement of the implant.

Implant displacement is the second most common source of distress to the patient after capsular contracture. It is usually caused by inappropriate dissection, erroneous incisions, capsular contracture, or malposition in initial placement. Displacement is usually inferior and is more commonly seen with the inframammary approach [47] with inferior migration of the implant probably due to disruption of the inframammary fold. Displacement may be associated with the double bubble phenomenon. Superior displacement can also happen, particularly in submuscular augmentations where repeated contraction of the pectoralis muscle drives the implant upward (though it can cause inferior migration of the implant as well). If detected early, taping in the desired position for a few weeks may suffice. If unsuccessful, surgical correction is often necessary. Surgical correction may involve dissecting the subcutaneous flap free and reapproximating the fascia of the chest wall with a nonabsorbable suture [48]. Any irregularities of the pockets are also corrected. Improper or excessive pocket dissection can also result in synmastia and asymmetry.

10.16 Implant Rippling Rippling is either caused by traction of deficient softtissue cover or an underfilled saline implant [13]. An underfilled saline implant has a tendency to knuckle

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a

Fig. 10.6 Rippling

especially in the lower poles where the shell actually folds in on itself. This is less commonly seen in silicone gel implants. With saline implants, it is customary to slightly overfill them and place them submuscularly to prevent this deformity. Implants can be palpable or visible (Fig. 10.6). With traction deformities, the weight of the implant placed subglandularly tugs on the upper poles of the breast causing traction wrinkles or rippling. This can be avoided by placing the implant submuscularly in those with deficient soft-tissue cover.

b

10.17 Implant Rotation The placement of anatomic implants requires creation of an exact pocket into which the implant fits. Failure to accomplish this can result in rotation of the implants which can be disfiguring.

10.18 Improper Implant Placement The implants may be placed too high because of inadequate dissection of the pocket at the inframmary fold. This is most common during the learning phase of the umbilical approach. More often the implant shifts upward when the patient is at home and remains in that position too long. Postoperatively compressing the superior portion of the breasts with an ace bandage will usually prevent the upward shift of the prostheses. In the umbilical approach for breast augmentation, there is a learning curve to produce an adequate pocket and compression to keep the implant in position. Many

Fig. 10.7 (a) Preoperative patient for augmentation wanting to have good cleavage. (b) Implant placed too medial to give the patient more cleavage

times in the umbilical approach the implant will slowly settle into the proper position. When a patient requests a large cleavage fold, there is only so much the surgeon can do depending on the nipple position and what placement of the implant centered under the nipple will do. Placing the implant too medial just to make cleavage is a serious error since this is a cosmetic procedure and nipples shifted outward are aesthetically poor (Fig. 10.7).

10.19 Infection Infections can range from superficial wound infections to deep purulent infections of the implant pocket.

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Staphylococcus epidermidis is the most frequently identified pathogen making it an opportunistic infection. The risk of infection ranges from 2.0 to 2.5% in most studies. Surgical technique and the patient’s underlying condition are thought to be the most important determinants of infection. Many causes have been suggested, but have been hard to pin down. These include a contaminated implant, contaminated saline, the surgery itself or the surgical environment, the patient’s skin or mammary ducts, or as suggested by many reports, seeding of the implant from remote infection sites. Late infection usually results from secondary bacteremia or an invasive procedure at a location other than breasts. Any delay in wound healing, unresolving wound erythema, or discharge must be promptly swabbed for culture along with the initiation of antibiotics. An oral second generation cephalosporin is commonly used. Most wound infections are superficial and resolve with oral antibiotics with healing of the wound and tissues by secondary intention. However, if unresponsive to antibiotics or with worsening symptoms such as pain, tenderness, distension, or cellulites, reexploration is mandatory. The pocket is reopened and the implant removed with thorough irrigation and debridement of the pocket. Reimplantation is delayed for at least 3 months. Broad spectrum intravenous (IV) antibiotics are commenced which can be converted to oral dosing once culture and sensitivity results from the wound swab are available. As with any surgery, prevention is the key to limiting infections. Observation of aseptic technique intraoperatively should be meticulous. Intraoperative antibiotics, such as IV cephalosporin, with continuation of oral antibiotics for 3–7 days postoperatively is the norm. Antibiotic irrigation of both the implant and the pocket is usual as is employment of the “no-touch” technique when handling the implant. If ever in doubt, always opt for implant removal with reimplantation after resolution.

10.20 Lactation Problems There have been reports of inability to produce enough breast milk to breast feed an infant following breast augmentation [48–51].

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The causes of unsuccessful lactation include inadequate glandular development [51], the periareolar approach [48], severed milk ducts [48], altered nipple sensation [48], and lack of or little breast changes during pregnancy with little or no postpartum engorgement [48].

10.21 Late Bleeding After Breast Augmentation There are multiple reports of late bleeding into the pocket after breast augmentation [52–57]. Some of the causes have been attributed to chronic inflammatory reaction to the polyurethane-coated implant, granulating tissue with new capillary ingrowth, and the use of corticosteroids in the saline prosthesis. Another cause that should be ruled out is blood dyscrasia

10.22 Malposition of the Inframammary Scar Breast augmentation scars should be as inconspicuous as possible. Scars can be hidden in the transumbilical approach as well as axillary approach. Axillary scars can get thickened. The position of an inframammary scar should be close to the inframammary crease, within a centimeter, but not in the crease itself since this can result in irritation of the scars by the brassiere’s elastic band or wire rubbing the scar. If the incision is placed too far above the inframammary fold, it will cause a problem when performing a repeat augmentation and inserting a larger prosthesis. This can result in an inframammary scar to appear even higher on the breast and away from the inframammary fold.

10.23 Methicillin-Resistant Staphylococcus aureus Infection Methicillin-resistant Staphylococcus aureus (MRSA) is now the most common contaminant of surgical infections. Previously it was Staphylococcus aureus and the Pseudomonas.

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One legal case that involved the author was a case that the plastic surgeon delayed taking a culture and sensitivity of an infected wound following insertion of expanders in a patient with breast carcinoma treated with bilateral mastectomies [58]. A culture and sensitivity after the implants were removed showed MRSA sensitive to Vancomycin, tetracycline, Rifampin, and Trimethoprim Sulfamethyloxazole. For 5 months the patient was treated with antibiotics that were not sensitive to MRSA, despite having received the sensitivities on the culture and sensitivity, temperature ranging from 104.4 to 102°, and even following debridement of the chest wound with infection invading the rib. She developed extensive osteomyelitis involving the sternum and ribs that required resection of ribs and sternum.

10.23.1 Community-Acquired MethicillinResistant Staphylococcus aureus (CA-MRSA) CA-MRSA is becoming an increasingly important, major pathogen [59–61]. Particular strains of MRSA have recently arisen in CA-MRSA, which have been identified by pulsed-field gel electrophoresis typing as USA300 that have genetic differences from the typical strain that has been circulating [62]. The USA300 and USA400 strains are quite different from the typical Hospital-acquired Methicillinresistant Staphylococcus aureus (HA-MRSA) [63, 64]. The USA300 strain occurs in diverse regions of the United States [65], while the USA400 strain has been found in several outbreaks and “endemic” CA-MRSA infections in the US Midwest [66]. CA-MRSA accounts for 59% of skin infections (ranges from 15 to 74% in different cities). The drugresistant strain can cause painful skin lesions that resemble infected spider bites, necrotizing pneumonia, and toxic shock syndrome. CA-MRSA is resistant to erythromycin, cephalexin (Keflex), and dicloxacillin (Diclocil), and more or less susceptible to clindamycin, fluoroquinolones, tetracycline, rifampin, and trimethoprim-sulfamethoxazole (TMP-SMX) [63, 64, 67] Moran et al. [67] studied skin and soft-tissue infections seen in the emergency room in Los Angeles, California with cultures and clinical information. Staphylococcus aureus isolates were characterized by

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antimicrobial-susceptibility testing, pulsed-field gel electrophoresis, and detection of toxin genes. On MRSA isolates, typing of the staphylococcal cassette chromosome mec (SCCmec), the genetic element that carries the mecA gene encoding Methicillin resistance, was performed. The presence of MRSA was 57% overall (ranging from 15 to 74%). Pulsed-field type USA300 isolates accounted for 97% of MRSA isolates; 74% of these were a single strain (USA300– 0114). SCCmec type IV and the Panton-Valentine leukocidin (PVL) toxin gene were detected in 98% of MRSA. Among the MRSA isolates, 100% were susceptible to rifampin and trimethoprim-sulfamethoxazole, 95% to clindamycin, 92% to tetracycline, and 60% to fluoroquinolones. When antimicrobial therapy is indicated for the treatment of skin and soft-tissue infections, clinicians should consider obtaining culture and modifying empirical therapy to provide MRSA coverage.

10.23.2 Virulence Virulence factors may allow pathogens to adhere to surfaces and invade or avoid the immune system, while causing toxic effects to the host [68]. There may be the production of exotoxins related to the infection [69]. Superantigens that have been identified include TSST-1 (toxic shock syndrome toxin-1), staphylococcal enterotoxin serotype B (SEB), or staphylococcal enterotoxin serotype C (SEC). Along with PVL, these toxins are associated with toxic shock syndrome, purpura fulminans, and hemorrhagic, necrotizing MRSA pneumonia [69–71]. The superantigens induce massive cytokine release from the T cells and macrophages. The ensuing hypotension and shock are believed to be the result of tumor necrosis factor a and b (TNF-a and TNF-b)mediated activity [69]. There is a 70% mortality rate from community-acquired pneumonia caused by PVLpositive CA-MRSA [71]. PVL has a possible role in virulence either directly or as a marker for closely associated pathogenic factors. PVL is a 2-component staphylococcal pore-forming membrane cytotoxin that operates by targeting mononuclear and polymorphonuclear cells producing severe inflammatory lesions, capillary dilation, chemotaxis, polymorphonuclear karyorrhexis, and tissue necrosis [63, 68].

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10.23.3 Reservoirs and Transmission Humans serve as a reservoir for Staphylococcus aureus through asymptomatic colonization [63]. Higher carriage rates of Staphylococcus aureus, compared to the general population, are associated with IV drug users, insulin-dependent diabetes, patients with dermatologic conditions, patients with indwelling catheters, and health care workers [63, 72].

10.23.4 Prevention and Management To prevent spread of MRSA in hospitals, it is recommended that those at higher risk for MRSA carriage be screened at admission and isolated if found to be colonized [73]. Surfaces in examination rooms should be cleaned with commercial disinfectants or diluted bleach (one tablespoon to one quart of water), and wound dressings and other materials that come into contact with pus, nasal discharge, blood, and urine should be disposed of carefully [60]. Health care providers need to wash their hands between contacts with patients [54] and should use barrier precautions and don fresh gowns and gloves for contact with each patient [74, 75]. Guidelines have been developed by the Centers for Disease Control (CDC) for prevention of infection among members of competitive sports teams and others in close contact. These include avoiding sharing equipment and towels, common surfaces should be cleaned on a regular basis, wounds should be covered, individuals with potentially infectious skin lesions should be excluded from practice and competition until the lesions have healed or are covered, and frequent showering and use of soap and hot water should be encouraged [61]. A rapid, easy to use identification of MRSA in nasal carriers has been developed that consists of real-time polymerase chain reaction (PCR) assay.

10.23.5 Clinical Management The CDC has recommended guidelines for CA-MRSA (Table 10.1) [76].

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Once an infection has been established, wound cultures should be obtained, ideally from pus or grossly infected tissue. Cultures form ulcers are of dubious value since bacteria isolated may be due to colonizing strains and not pathogens [77]. Antibiotics may not be needed in SSTIs when adequate surgical drainage can be achieved [77–79]. When antibiotics are not prescribed, patients should have follow-up care and be instructed to seek medical care if symptoms worsen or do not resolve. When antibiotics are used, local patterns of antibiotic susceptibility among CA-MRSA should be used to help direct empiric therapy against this pathogen.

10.23.6 Antibiotics Antimicrobial therapy is critical [80]. Vancomycin has been a mainstay of treatment for serious infections that are resistant to b-lactams [81]. However, in the treatment of Methicillin-sensitive Staphylococcus aureus (MSSA), Vancomycin has been associated with a slower clinical response and longer duration of bacteremia compared to b-lactams [64]. There has been a recent emergence of Vancomycin-resistant Staphylococcus aureus (VRSA) and Vancomycin-intermediate susceptible Staphylococcus aureus (VISA) [64]. Fluoroquinolones have variable activity against CA-MRSA strains, and in some locales, there has been over 40–50% fluoroquinolones resistance among MRSA strains [82–84]. Susceptibility to ciprofloxacin indicates that low-level or partial fluoroquinolones resistance is probably not present. There is little clinical data on the use of moxifloxacin and gemifloxacin for the treatment of CA-MRSA. Clindamycin has been useful to treat CA-MRSA disease [76, 85, 86], but resistance has been encountered greater than 10–15% [63, 82, 83]. In a Taiwan study the resistance was 93% [87]. Some strains that are Clindamycin susceptible and erythromycin resistant can develop resistance when exposed to Clin damycin (lincosamide), erythromycin (macrolide), and quinupristin/dalfopristin (streptogramin B). This inducible resistance can be detected by the D-test that, if positive, is considered diagnostic for inducible resistance [88]. It is believed that Clindamycin should not be used to treat D-test-positive strains, especially in a serious syndrome [88].

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For multidrug-resistant infections caused by MRSA that require parenteral therapy, Vancomycin, linezolid, Daptomycin, and quinupristin/dalfopristin are the only agents that are reliably active against many HA-MRSA infections [86]. TMP-SMX, tetracyclines, Clindamycin, and fluoroquinolones may be alternatives if susceptibility to these agents is documented.

10.24 Guidelines The CDC [89] developed, with internationally recognized experts, guidelines to control MRSA through hospitals and health care facilities. These include: 1. Ensure prevention programs are funded and adequately staffed. 2. Carefully track infection rates and related data to monitor the impact of prevention efforts. 3. Ensure that staff use standard infection control practices and follow guidelines regarding the correct use of antibiotics. 4. Promote the best practices with health education campaigns to increase adherence to established recommendations. 5. Designing robust prevention programs customized to specific settings and local need.

10.25 Discussion A postoperative infection with MRSA in the pocket of a breast implant patient must be treated promptly and properly. This is a hospital-acquired MRSA (HA-MRSA). The correct antibiotic must be used, from cultures and sensitivities, for at least 1 week and then the wound recultured. The antibiotic is continued as long as the wound cultures out MRSA on a weekly basis. The implant must be removed and not replaced for at least 3 months from the time the infected wound has completely healed (not from the time when the culture is negative).

10.26 Definitions CA-MRSA: Community-acquired MRSA HA-MRSA: Hospital-acquired MRSA

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PCR: Polymerase chain reaction PVL: Panton-valentine leukocidin MRSA: Methicillin-resistant Staphylococcus aureus MSSA: Methicillin-susceptible Staphylococcus aureus SCC: Staphylococcus cassette-chromosome SSTI: Skin and soft-tissue infection TMP-SMX: Trimethoprim-sulfamethoxazole TNF: Tumor necrosis factor TSST: Toxic shock syndrome toxin VISA: V ancomycin-intermediate susceptible Staph ylococcus aureus VRSA: Vancomycin-resistant Staphylococcus aureus

10.27 Migration of Implant There is one report of a left breast implant migrating into the thoracic cavity [90]. An axillary approach had been used and the patient developed sudden dyspnea during the operation on the left side, but this was alleviated by the administration of oxygen. The basis for the migration was believed to be from a large defect of the chest wall, breast massage after surgery, and the difference in pressure between the outside and the inside of the chest wall. However, it is this author’s opinion that initially there was perforation into the thoracic cavity during surgery as the cause of the sudden dyspnea during the procedure and this evolved into the large defect in the chest wall with subsequent migration of the implant.

10.28 Mondor’s Disease Mondor’s disease is a superficial thrombophlebitis of the breast and chest wall involving the lateral thoracic, thoracoepigastric, and superior epigastic veins (although described in the arm and penis), which occurs in 1–2% of patients usually after an inframammary augmentation (Fig. 10.8). It is a self-limiting problem of unknown etiology that resolves several weeks after surgery. Any discomfort should be treated with antiinflammatory drugs and/or warm compresses. The patient should be reassured.

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b

Fig. 10.8 Mondor’s disease

10.29 Myospasm of Pectoralis Major Muscle Myospasm with spontaneous myoclonic jerks of the left pectoralis muscle was reported following subpectoral breast augmentation [91]. This disorder did not respond to Klonopin, excision of a segment of the lateral pectoral nerve, or open capsulotomy and transection of the pectoralis major muscle head to the humerus. Explantation relieved the spasms. The presumptive cause was myospasm from a mechanical irritation of the nerve from the implant.

10.30 Necrosis The causes of necrosis include prior radiation therapy for breast cancer, uncontrolled diabetes followed by infection, late diagnosis of hematoma, smoking (Fig. 10.9), infection, electrocoagulation too close to the skin, or a combination of these factors. Radiation reduces the vascularity of the exposed area that makes the breast more susceptible to complications such as infection and necrosis. In combination with other factors such as uncontrolled diabetes, smoking, or hematoma, the risk of problems increases.

Fig. 10.9 (a) Preoperative patient. (b) Necrosis with residual scarring left breast following breast augmentation (through periareolar incision) in a smoker

10.31 Neurologic Injury The axillary approach to cosmetic breast surgery is an excellent alternative to the inframammary, periareolar, areolar, and umbilical incisions. The scar is rarely visible except with the arms raised, but does occasionally become hypertrophic. The risks associated with this approach include all the usual risks of any breast implant surgery plus the possibility of neurologic damage, both motor and sensory. The surgeon must be aware of the risks of the axillary approach and convey those risks to the patient to allow a knowledgeable and informed consent to the procedure. The surgery must be performed with cautious attention to the nerves in the area and the methods to avoid injury to those nerves. There can be a chronic pain syndrome not only from injury to the fourth intercostal nerve, but to other sensory nerves higher on the chest wall.

10 Complications of Breast Augmentation

10.31.1 Brachial Plexus Injury to the brachial plexus is most often caused at the time of surgery by positioning the arm in an abducted position more than 90° from the side of the body. Those patients susceptible to this type of injury usually have some form of actual or potential thoracic outlet syndrome. If the head is turned in the opposite direction during surgery, there is even more likelihood for brachial plexus nerve or vascular compression. There is rarely a need to keep the arm abducted more than 85° except, perhaps, in making the initial skin incision at the high point of the axilla in the axillary approach to breast augmentation. Although the brachial plexus may be at risk with the axillary approach to cosmetic breast surgery, the plexus is superior to the axillary vessels and is most likely to be injured when bleeding occurs from vessel disruption and a hemostat or clip is placed to control the bleeding without clearly visualizing the surrounding structures. This type of injury can occur following a long period of compression to control the bleeding without direct injury from a hemostat or clip. There can be permanent injury to the inferior cord of the brachial plexus (ulnar nerve distribution). The brachial plexus has three cords from which the infraclavicular branches are derived (Table 10.2). The long thoracic (nerve of Bell) is located along the side of the chest wall on the outer surface of the serratus anterior supplying filaments to each of its digitations. This nerve is not normally at risk during breast augmentation from any approach, but it is theoretically possible to injure the nerve when doing a very wide pocket dissection during a capsulectomy or in making a megapocket in a patient with an extremely large implant (over 800 mL). The one medical legal case [92] encountered by the author was with a permanent long thoracic nerve injury causing a winged scapula in a patient who had simple capsulotomies for breast implants and not utilizing an axillary incision. The neurosurgeon expert witness testified that the long thoracic nerve was injured by brachial plexus compression; however, he did not remember that the nerve has three roots (5, 6, and 7 cervical) which do not pass through the thoracic outlet but descend behind the brachial plexus and form the long thoracic nerve inferior to the outlet. The most likely cause of injury in this case was

107 Table 10.2 Infraclavicular branches of the brachial plexus Cord Nerve Spinal origin Lateral

Musculocutaneous Lateral anterior thoracic Lateral head of median

5, 6, 7 C 5, 6, 7 C 6, 7 C

Medial

Medial anterior thoracic Medial antebrachial cutaneous Medial brachial cutaneous Ulnar Medial head of median

8 C, 1 T 8 C, 1 T

Upper subscapular Lower subscapular Thoracodorsal Axillary Radial

5, 6 C 5, 6 C 5, 6, 7 C 5, 6 C 5, 6, 7, 8 C, 1 T

Posterior

8 C, 1 T 8 C, 1 T 8 C, 1 T

excessively tight dressings which compressed the long thoracic nerve against the chest wall below the axilla or an unrecorded fall with injury to the lateral chest wall. The lateral anterior thoracic nerve crosses the axillary artery and vein piercing the coracoclavicular fascia and enters the deep surface of the pectoralis major muscle. It sends a filament to join the medial anterior thoracic nerve in front of the axillary artery. The nerve supplies the clavicular, manubrial, and sternal portions of the pectoralis major muscle. This nerve can be injured by dissecting too superiorly when forming a submuscular pocket. Injury to the lateral anterior thoracic nerve may affect the strength of the pectoralis major muscle which flexes, adducts, and rotates the arm medially. The medial anterior thoracic nerve enters and innervates the pectoralis minor muscle and two or three branches end in the pectoralis major muscle. The nerve supplies the lower sternocostal and abdominal portions of the pectoralis major muscle as well as the pectoralis minor muscle. This nerve is lateral to the lateral anterior thoracic nerve. The medial anterior thoracic nerve may be injured when dissecting a retropectoral pocket using the axillary approach when the lateral edge of the pectoralis major muscle is not identified before dissecting under the muscle and by approaching the muscle from too superior a position.

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Injury to the medial anterior thoracic nerve leaves no clinical muscle deficit since the nerve only sends a few fibers to the pectoralis major muscle and mainly supplies the pectoralis minor muscle which helps to adduct the arm by rotating the scapula downward and forward.

10.31.2 Intercostal Nerves The sensory nerves, which are unrelated to the brachial plexus, likely to be injured during the axillary approach include the intercostobrachial nerves and the lateral branches of the third and fourth intercostal nerves. When forming a subpectoral pocket, injury to the nerves is more likely to occur if the dissection is not started anteriorly against the fascia of the pectoralis major muscle prior to dissecting along the lateral edge and then under the muscle. One cause of injury to the fourth intercostal nerve is placing a large implant (over 400 mL) in a subpectoral pocket without making sure the nerve is carefully dissected free from the intercostal muscles if the implant impinges on the nerve. The nerve may not be transected, but if folded posteriorly with implant compression, there can be anesthesia of the nipple–areola complex and/or a chronic pain syndrome with associated scarring around the nerve.

10.31.3 Nerve Injury The most common mistake after making the axillary skin incision at the highest point of the axilla is approaching the lateral edge of the pectoralis major muscle from a superior–lateral direction, rather than from an antero-medial-inferior position. The proper method is to make the skin incision and then pull the skin antero-medially over the lateral edge of the muscle and slightly inferiorly followed by dissecting downward onto the muscle exposing the lateral edge [93]. By carefully staying on the muscle fascia and dissecting around the muscle edge and under the muscle, the submuscular pocket can be formed without approaching any of the axillary nerves. Elective intraoperative division of the medial thoracic (pectoral) nerve denervates the lower third of

A. Erian and M. A. Shiffman

the pectoralis minor muscle making it more flaccid, and has been used clinically to allow more anterior breast projection and minimize postoperative flexion induced breast deformity in the patient with retromuscular breast implants [94, 95]. There was no clinical problem described with transection of the nerve. Arm position during surgery with abduction to 90° or greater may result in brachial plexus or vascular compression, which can cause temporary or permanent nerve damage. The surgeon should always be aware of arm positioning at the beginning of surgery so that excessive abduction does not occur. The elbow should be padded to prevent ulnar nerve paresis.

10.32 Periareolar Scar Indentation There have been some instances of depression of the periareolar scar following breast augmentation (Mirra fati, Personal communication, 2007) (Fig. 10.10). The cause has been attributed to the technique, after the skin incision, of extending the dissection under the skin in an oblique method pointing inferiorly to avoid damage to the breast ducts or to dissect around the inferior portion of the breast gland to avoid cutting through the breast tissue. This creates a potential space after closure of the skin incision since the subcutaneous fat may not line up properly to fill the space under the skin. The usual method is to dissect straight down through the breast tissue to form the underlying pocket in the submammary or subpectoral space. Cutting through the breast tissue does not destroy any major ducts, but does cut smaller ductules. There have been no infections directly attributed to transecting the small ductules.

10.33 Pneumothorax Care must be taken when performing breast augmentation under local anesthesia. Any sharp needle inserted into the tissues around the breast has the potential of perforation into the pleural space causing a pneumothorax or tension pneumothorax. When an implant pocket is made in the retropectoral area, there is the possibility of pneumothorax when a bleeder is electrocoagulated in the intercostal

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a

b

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If a pneumothorax is suspected, a chest X-ray should be taken. A pneumothorax that is less than 15% can be observed with repeat chest X-ray. If the air is increasing or if the air is over 15%, a tube should be inserted into the chest, usually at the anterior 2nd intercostal space and connected to an under water seal. An unusual cause of pneumothorax in breast augmentation was described by Fayman et al. [97]. Four patients developed bilateral and one unilateral pneumothorax, after transaxillary approach to submuscular placement of implants. Two patients were symptomatic. The assumption was that air was trapped in the subpectoral pocket that was sealed by the implant and wound closure. The air was forced into the pleural cavity as a result of the high pressure created in the subpectoral pocket by the advancing implant. The problem was resolved by placing a large-bore suction catheter into the subpectoral pocket before the implant was inserted.

10.34 Scarring

Fig. 10.10 (a) Preoperative patient. (b) Periareolar indentation after breast augmentation through a periareolar incision

space. This can leave a hole in the pleura. If noted at the time of surgery, insert a Robinson catheter in the pleural space, complete the procedure, and insert the implant. Have the anesthesiologist expand the lungs or, if under local anesthesia, have the patient take a deep breath and then withdraw the catheter. The implant will plug the small opening until fully healed. General anesthesia can cause a pneumothorax [96] when too much pressure is used in bagging the patient, especially if the patient has lung blebs. It is possible for a spontaneous pneumothorax to occur when a lung bleb ruptures without general anesthesia.

Keloid and hypertrophic scars result from excessive collagen deposition, the cause of which remains elusive. Hypertrophic scarring can occur in 2–5% of patients, while true keloid scars are uncommon. Incision planning is important. Inframammary scars should be placed more laterally to avoid the sternal area which is prone to aggressive scarring. Incisions should be planned and placed to maximally camouflage the scars. The periareolar incision is associated with a slightly lower incidence of hypertrophic scarring. However, if reexploration of the breast via the periareolar incision is required, scarring of the nipple–areolar complex can cause marked distortion or indentation of the nipple– areolar complex. Wound closure should be meticulous, and in layers to approximate the epidermis under, as little tension as possible. Prevention remains the best strategy with keloid and hypertrophic scarring. Patients with a predisposition to develop excessive scar formation should avoid nonessential surgery. Hypertrophic scars and keloids have been shown to respond to radiation, pressure therapy, cryotherapy, intralesional injections of corticosteroid, interferon and fluorouracil, topical silicone or other dressings, and pulsed-dye laser treatment. Simple

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surgical excision is usually followed by recurrence unless adjunct therapies are employed. No one treatment has been shown to be superior to another with most treatments only offering some improvement while falling far short of a cure [98]. Intralesional steroids are a commonly used treatment modality which suffers from the pitfalls of skin atrophy, striae, and pigmentary changes, and thus, should be used judiciously.

10.35 Sensory Changes to Nipple/ Areolar Complex Changes in sensation of the nipple–areolar complex are usually due to stretching or irritation of the 4th lateral intercostal nerve which supplies the majority of the nipple. Care should be taken to preserve it during dissection where it can be found at the 4 and 8 o’clock positions in the left and right breasts, respectively. The periareolar approach is thought to have a slightly higher incidence of changes in nipple sensation, though recent evidence suggests otherwise [99]. Reports vary widely in reported incidences. However, it is generally agreed that patients be told that the risk of permanent alteration to nipple sensation is in the region of 3–5%.

10.36 Serous Fluid Drainage Seroma is a tumor-like collection of serum in the tissues. This postoperative collection of seroma fluid can occur in breast augmentation surgery [100] and can result in increased morbidity and in chronic serous drainage. In a histopathologic study, it was noted that seromas may incite an inflammatory reaction that subsequently becomes a contributing factor in persistent seroma formation [101]. The author has seen one case of persistent serous drainage that was caused by a large amount of granulation tissue in the pocket. When the granulation tissue was cleaned off and the implant replaced, there was no further problem.

A. Erian and M. A. Shiffman

Movement of the textured implant in the pocket may cause chronic tissue irritation and inflammation with subsequent seroma formation. Removing and exchanging a textured implant for a smooth one will usually resolve the problem. If a smooth implant is in place, then consider exuberant granulation tissue as a possible cause. Exploration of the wound and curetting all the granulations will allow resolution.

10.37 Steroids and Other Complications Steroids were used intraluminally or via injections and irrigation in the prevention of capsular contracture. However, complications such as marked atrophy of breast tissues, delayed healing of wounds, and implant herniation due to localized atrophy of tissues quickly brought it into disfavor [102]. However, low dose steroid irrigation may return in favor with the return of silicone gel implants to the American market.

10.38 Synmastia (Symmastia) Syn means with or together (Greek), while sym in the dictionary always refers to the Greek syn. Therefore, both spellings are correct. Synmastia is a fusion of both breasts in the midline, or in breast augmentation, means the meeting or near meeting of both prostheses in the midline. This disorder can be a result of dissection of the pockets to the midline of the sternum, thereby weakening the medial tissues that allow the implant to migrate medially (Fig. 10.11) or from thin and weak tissues near the sternum that, postoperatively, are pushed medially by the implants. This can be corrected by approaching the midline with the implants removed and suturing the anterior fibrous capsule to the underlying fibrous capsule and fascia or periosteum bilaterally and then doing lateral capsulotomies before replacing the implants. The excess capsule can be excised or electrocoagulated to expose a healing surface. The midline should be compressed for at least 5 days either by bulky dressings or a garment designed to compress the midline.

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a

111

b

Fig. 10.11 Synmastia secondary to dissection of the pockets to the midline of the sternum. (a) Without contraction of muscles. (b) With contraction of muscles

10.39 Thromboembolism Patients who undergo surgery are at risk for venous thromboembolic complications. This is especially critical in the cosmetic surgery patient who, having an elective procedure, would not expect to have the morbidity or mortality associated with thromboembolic disease. The cosmetic surgeon must be aware of the possibility of thromboembolism in every patient and should take a careful history to disclose predisposing risk factors. The surgeon should also be aware of the clinical manifestations of pulmonary embolus in order to make a timely diagnosis.

10.39.1 Risk Factors Minor surgery <30 min in patients over 40 years of age without additional risk factors and uncomplicated surgery in patients under 40 years of age without additional risk factors are in the low-risk category. General surgery in patients over 40 years of age lasting >30 min and patients under 40 years on oral contraceptives are in the moderate-risk category [103]. High-risk

category would be major surgery in patients over 40 years of age with recent history of deep vein thrombosis or pulmonary embolism, extensive pelvic or abdominal surgery for malignancy, and major orthopedic surgery of the lower extremities. Predisposing risk factors include age over 50 years, malignancy, obesity, prior history of thromboembolism, varicose veins, recent operative procedures, and thrombophilia. These risks are further modified by duration and type of anesthesia, preoperative and postoperative immobilization, level of hydration, and the presence of sepsis [104]. Medical problems associated with increased risk include acute myocardial infarction, stroke, and immobilization [105]. Estrogen therapy and pregnancy are common risk factors, while uncommon factors include lupus anticoagulant, nephrotic syndrome, inflammatory bowel disease, polycythemia vera, persistent thrombocytosis, paroxysmal nocturnal hemoglobinuria, and inherited factors such as antithrombin III deficiency, protein C deficiency, protein S deficiency, plasminogen activator deficiency, elevated plasminogen activator inhibitor, and homocystinuria [106]. Superficial calf vein thrombosis, proximal deep vein thrombosis, and fatal pulmonary embolus increase in incidence as the risk category increases from low to high (Table 10.3).

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Table 10.3 Risk categories and associated thromboembolism Proximal vein Fatal pulmonary Risk Calf vein thrombosis (%) embolism (%) thrombosis (%) Low

<10

<1

<0.01

Moderate

10–40

2–10

0.1–0.7

High

40–80

10–30

1–5

10.39.2 Clinical Manifestations Superficial thrombophlebitis (an inflamed vein) appears as a red, tender cord. Deep-vein thrombosis may be associated with pain at rest or only during exercise with edema distal to the obstructed vein. The first manifestation can be pulmonary embolism. There may be tenderness in the extremity and the temperature of the skin may be increased. Increased resistance or pain on voluntary dorsiflexion of the foot (Homan’s sign) and/ or tenderness of the calf on palpation is useful diagnostic criteria. Pulmonary embolism is usually manifested by one of three clinical patterns: (1) onset of sudden dyspnea with tachypnea and no other symptoms; (2) sudden pleuritic chest pain and dyspnea associated with findings of pleural effusion or lung consolidation; and (3) sudden apprehension, chest discomfort, and dyspnea with findings of cor pulmonale and systemic hypotension. The symptoms occasionally consist of fever, arrhythmias, or refractory congestive heart failure.

10.39.3 Diagnosis Deep-vein thrombosis is best diagnosed with duplex ultrasonography, which combines pulsed gated Doppler evaluation of blood flow with real-time ultrasound imaging. Other diagnostic tests include X-ray venography, radionucleide venography, radioisotope-labeled fibrinogen, ultrasonography, and impedance plethysmography. Liquid crystal thermography detects increases in skin temperature and is a useful adjunct to ultrasonography or impedance plethysmography. Ventilation-perfusion (VP scan) lung scan is a safe, sensitive means of diagnosing pulmonary embolism. Isotope pulmonary perfusion scan (Q scan) is more specific with inclusion of the isotope ventilation scan

(V scan). The definitive diagnosis can be made by pulmonary arteriography. Arterial blood gas typically shows reduction in PaO2 and PaCO2, while electrocardiogram will show tachycardia but is best used for ruling out myocardial infarction. Chest X-ray may show basilar atelectasis, infiltrates, pleural effusion, or cardiac dilatation.

10.39.4 Prophylactic Treatment Low-risk general surgical patients may be treated with graduated compression stockings applied during surgery, early ambulation, and adequate hydration [107]. Keeping the knees flexed on pillows during surgery and avoiding local compression on any areas of the legs are helpful. All patients are treated the same if there are any low-risk factors. The type of surgery does not matter as long as general anesthesia or IV sedation is given. Compression stockings (20–30 mm support hose is adequate) are applied in the operating room and ambulation is begun when the patient is awake and capable of ambulating with assistance. When the patient is ambulating on a regular basis during the day, the compression stockings can be removed. For moderate-risk patients, low-dose heparin (5,000 units 2 h before surgery and then every 8–12 h until ambulatory), low molecular weight heparin (LMWH), dextran, or aspirin is recommended. Alternatively, graduated compression stockings or intermittent pneumatic compression started during surgery, used continuously until ambulatory, or a combination of both is recommended [104]. All high-risk patients (unlikely in cosmetic surgery) should be treated with low-dose heparin or LMWH, and combined pharmacologic and mechanical methods. Dextran can result in cardiac overload, and high dose aspirin (1,000–1,500 mg/day) has limited efficacy in preventing deep-vein thrombosis. In cosmetic surgery the use of aspirin or heparin may result in postoperative bleeding The best prophylaxis for low-risk cosmetic surgery patients would appear to be mechanical methods including knee compression stockings and early ambulation. For low-risk patients, the knees should be slightly flexed and extremity compression avoided [108].

10 Complications of Breast Augmentation

10.39.5 Hereditary Hypercoagulable States Patients with a family history of thrombosis, earlyonset, or recurring thrombosis, thrombosis at unusual sites or warfarin-induced skin necrosis should be evaluated for possible underlying inherited hypercoagulable disorders. Antithrombin III (AT-III) is a heparin cofactor that allows heparin to inactivate primarily factor IIa, but also factors IXa, Xa, XIa, and XIIa [109]. A deficiency in AT-III predisposes to thrombosis by allowing uncontrolled activity of many of the coagulation factors. Endothelial surfaces have receptors called thrombomodulin that function as anticoagulants because of the ability to neutralize thrombin. The thrombin– thrombomodulin complex activates protein C, a vitamin K-dependent factor that is facilitated by protein S, another vitamin K-dependent factor. Activated proteins C and S metabolize activated factors V and VIII, which results in down-regulating the coagulation system. Patients with protein C deficiency may have recurrent episodes of superficial thrombophlebitis as well as thromboembolism [110]. Patients with protein S deficiency experience more arterial thromboembolism including stroke [111]. Deficiency in protein C or S may present as neonatal purpura fulminans in the newborn or skin necrosis in adults treated with warfarin, a drug known to cause a sudden fall in protein C or S. Venous thromboembolism occurs in one out of every thousand people with activated protein C resistance (APC-R) responsible for up to 64% of the cases. APC-R is due to a single point mutation in the FV gene for clotting factor V. This mutated FV may be referred to as factor V Leiden (FVL), FV:Q506 allele, or APCgene, and is less efficiently degraded by APC. A hypercoagulable state results from impairment of the inactivation of factor V by activated protein C (APC). This creates a lifelong increased risk of thrombosis and thromboembolism. Within the intact vessel, thrombin binds to thrombomodulin on the endothelial cell acting as an anticoagulant bay activating the protein C system. APC, potentiated by cofactor protein S, down-regulates the activity of the coagulation system (limits clot formation) by cleaving and inhibiting factors V (FV) and VIII [112–114].

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APC testing can be performed with DNA genotyping. This can differentiate acquired from inherited APC-R. Approximately 10% of patients with APC-R phenotype lack the FV mutation (genotype) and the diagnosis of APC-R in these patients will be missed [115]. The combination of phenotype and genotype information aids in establishing prophylactic and therapeutic guidelines. Asymptomatic patients with APC-R , as well as their family members, who never had a thromboembolic event should receive counseling regarding the implications of the diagnosis and information concerning the signs and symptoms of venous thromboembolism [116]. Short-term prophylaxis with heparin should be considered when there are high-risk circumstances encountered such as immobilization, surgery, trauma, or obstetrical procedures. After a thrombotic event, these patients need extended anticoagulation balancing the risk of bleeding against the risk of recurrence when therapy is discontinued. Empirical treatment is for at least 1 year after two episodes of thromboembolism and life-long treatment after three episodes.

10.39.6 Antiphospholipid Syndrome Antiphospholipid syndrome is an acquired condition that can result in thrombosis.

10.40 Toxic Shock Syndrome Toxic shock syndrome has been reported in breast augmentation [117–119]. The syndrome is caused by the exotoxins (superantigens) secreted with infection from Staphylococcus aureus and group A Streptococci. Knowledge of the criteria for diagnosis is important in order to treat this potentially fatal disease. These include: 1. Fever (>102°) 2. Rash (diffuse, macular erythroderma 3. Desquamation (1–2 weeks after onset, especially of palms and sole) 4. Hypotension 5. Involvement of three or more organ systems: (a) Gastrointestinal (vomiting, diarrhea at onset) (b) Muscular (myalgia, elevated CPK)

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(c) Mucous membrane (conjunctiva, oropharynx) (d) Renal (BUN or creatinine > 2 times normal) (e) Hepatic (bilirubin, SGOT, SGPT > 2 times normal (f) Hematologic (platelets < 1,00,000) 6. Negative results on the following studies (if obtained) (a) Blood, throat, or cerebral spinal fluid (CSF) cultures (b) Serologic tests for rocky mountain spotted fever, leptospirosis, measles Treatment consists of surgical debridement for necrosis, antibiotics, circulatory and respiratory care, anticoagulant therapy for disseminated intravascular coagulation, and immunoglobulin. Experimental approaches have included the use of antitumor necrosis factor monoclonal antibodies and plasmapheresis.

References 1. Maximovich SP. Transient axillary-upper inner arm subcutaneous fibrous banding following transaxillary subpectoral endoscopic breast augmentation. Plast Reconstr Surg. 1996;97(6):1304–5. 2. Young RV. Transaxillary submuscular breast augmentation and subcutaneous fibrous bands. Plast Reconstr Surg. 1997;99(1):257. 3. Laufer E. Fibrous bands following subpectoral endoscopic breast augmentation. Plast Reconstr Surg. 1997;99(1):257. 4. Munhoz AM, Fells K, Arruda E Montag E, Okada A, Aldrighi C, Aldrighi JM, Gemperli R, Ferreira MC. Subfascial transaxillary breast augmentation without endoscopic assistance: technical aspects and outcome. Aesthetic Plast Surg. 2006;30:503–12. 5. Dowden RV. Subcutaneous fibrous banding after transaxillary subpectoral endoscopic breast augmentation. Plast Reconstr Surg. 1997;99(1):257. 6. Shiffman MA. Transient axillary-upper inner arm subcutaneous fibrous banding. Plast Reconstr Surg. 1997;99(2):596. 7. Botti G. Postoperative self-expansion in augmentation mammaplasty. Plast Reconstr Surg. 1994;93(6):1310. 8. Signorini M, Grisotti A, Ponzielli G, Pajardi G, Gilardino P. Self-expanding prosthesis complicating augmentation mammoplasties. Aesthetic Plast Surg. 1994;18(2):195–9. 9. Robinson OG, Benos DJ. Spontaneous autoinflation of saline mammary implants. Ann Plast Surg. 1997;39(2):114–8. 10. Ketene M, Saray A, Kara SA. Unilateral osmotic swelling in textured, single-lumen mammary implants: clinical and MRI findings. Aesthetic Plast Surg. 2002;26(3):206–10. 11. Chien CH, Ding ZZ, Yang ZS. Spontaneous autoinflation and deflation of double-lumen breast implants. Aesthetic Plast Surg. 2006;30(1):113–7. 12. Luke JL, Kalasinsky VF, Turnicky RP, Centeno JA, Johnson FB, Mullick FG. Pathological and biophysical findings asso-

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10 Complications of Breast Augmentation 31. Hakelius L, Ohlsen L. Tendency to capsular contracture around smooth and textured gel-filled silicone mammary implants: a five-year follow-up. Plast Reconstr Surg. 1997; 100(6):1566–9. 32. Hudson DA. Submuscle saline breast augmentation: are we making sense in the new millennium? Aesthetic Plast Surg. 2002;26(4):287–90. 33. Scuderi N, Mazzocchi M, Fioramonti P, Bistoni G. The effects of zafirlukast on capsular contracture: preliminary report. Aesthet Plast Surg. 2006;30(5):513–20. 34. Baker JL Jr, Chandler ML, LeVier RR. Occurrence and activity of myofibroblasts in human capsular tissue surrounding mammary implants. Plast Reconstr Surg. 1981; 68(6):905–12. 35. Gutowski KA, Mesna GT, Cunningham BL. Saline-filled breast implants: a Plastic Surgery Educational Foundation multicenter outcomes study. Plast Reconstr Surg. 1997; 100(4):1019–27. 36. Virden CP, Dobke MK, Stein P, Parsons CL, Frank DH. Subclinical infection of the silicone breast implant surface as a possible cause of capsular contracture. Aesthet Plast Surg. 1992;16(2):173–9. 37. Pajkos A, Deva AK, Vickery K, Cope C, Chang L, Cossart YE. Detection of subclinical infection in significant breast implant capsules. Plast Reconstr Surg. 2003;111(5):1605–11. 38. Burkhardt BR, Dempsey PD, Schnur PL, Tofield JJ. Capsular contracture: a prospective study of the effect of local antibacterial agents. Plast Reconstr Surg. 1986;77(6): 919–32. 39. Adams WP Jr, Rios JL, Smith SJ. Enhancing patient outcomes in aesthetic and reconstructive breast surgery using triple antibiotic breast irrigation: six-year prospective clinical study. Plast Reconstr Surg. 2006;118(7 Suppl):46S–52S. 40. Huang TT. Breast and subscapular pain following submuscular placement of breast prostheses. Plast Reconstr Surg. 1990;86(2):275–80. 41. Lykissa ED, Maharaj SV. Total platinum concentration and platinum oxidation states in bodily fluids, tissue, and explants from women exposed to silicone and saline breast implants by IC-ICPMS. Anal Chem. 2006;78(9):2925–33. 42. Rothkopf DM, Rosen HM. Lactation as a complication of aesthetic breast surgery successfully treated with bromocriptine. Br J Plast Surg. 1990;43(3):373–5. 43. Hartley JH Jr, Schatten WE. Postoperative complication of lactation after augmentation mammaplasty. Plast Reconstr Surg. 1971;47(2):150–3. 44. Hugill JV. Lactation following breast augmentation: a third case. Plast Reconstr Surg. 1991;87(4):806–7. 45. Sabbagh WH, Murphy RX Jr, Kucirka SJ, Okunski WJ. Idiosyncratic allergic reaction to textured saline implants. Plast Reconstr Surg. 1996;97(4):820–3. 46. Rohrich RJ, Adams WP Jr, Beran SJ, Rathakrishnan R, Griffith J, Robinson JB Jr, Kenkel JM. An analysis of silicone gel-filled breast implants: diagnosis and failure rates. Plast Reconstr Surg. 1998;102(7):2304–8. 47. Baker JL Jr. Augmentation mammaplasty. In: Peck GC, editor. Complications and problems in aesthetic plastic surgery. Hampshire, UK: Gower Medical Publishing; 1992. 48. Widdice L. The effects of breast reduction and breast augmentation surgery on lactation: an annotated bibliography. J Hum Lact. 1993;9(3):161–7.

115 49. Hill PD, Wilhelm PA, Aldag JC, Chatterton RT Jr. Breast augmentation and lactation outcome: a case report. MCN Am J Matern Child Nurs. 2004;29(4):238–42. 50. Hurst NM. Lactation after augmentation mammoplasty. Obstet Gynecol. 1996;87(1):30–4. 51. Neifert MR, Seacat JM, Jobe WE. Lactation failure due to inadequate glandular development of the breast. Pediatrics 1985;76(5):823–8. 52. Georgiade NG, Serafin D, Barwick W. Late development of hematoma around a breast implant. Plast Reconstr Surg. 1979;64(5):708–10. 53. Dawl JL, Lewis VL, Smith JW. Chronic expanding hematoma within a periprosthetic breast capsule. Plast Reconstr Surg. 1996;97(7):1469–72. 54. Görgü M, Aslan G, Tuncel A, Erdogan B. Late and longstanding capsular hematoma after aesthetic breast augmentation with a saline-filled silicone prosthesis: a case report. Aesthetic Plast Surg. 1999;23(6):443–4. 55. Hsiao HT, Tung KY, Lin CS. Late hematoma after aesthetic breast augmentation with saline-filled, textured silicone prosthesis. Aesthetic Plast Surg. 2002;26(5):368–71. 56. Brickman M, Parsa NN, Parsa FD. Late hematoma after breast implantation. Aesthetic Plast Surg. 2004;28(2):80–2. 57. Veiga DF, Filho JV, Schnaider CS, Archangelo I Jr. Late hematoma after aesthetic breast augmentation with textured silicone prosthesis: a case report. Aesthetic Plast Surg. 2005; 29(5):431–3. 58. Hall v Rothman, State of South Carolina, County of Greenville, Court of Common Pleas, No. 2005-CP-23. 59. Dufour P, Gillet Y, Bes M, Lina G, Vandenesch F, Floret D, Etienne A, Richet H. Community-acquired methicillinresistant Staphylococcus aureus infections in France: emergence of a single clone that produces Panton-Valentine leukocidin. Clin Infect Dis. 2002;35(7):819–24. 60. Centers for Disease Control and Prevention (CDC). Outbreaks of community-associated methicillin-resistant Staphylococcus aureus skin infections – Los Angeles County, California, 2002–2003. MMWR Morb Mortal Wkly Rep. 2003;52(5):88. 61. Centers for Disease Control and Prevention (CDC). Methicillin-resistant Staphylococcus aureus infections among competitive sports participants – Colorado, Indiana, Pennsylvania, and Los Angeles County, 2002–2003. MMWR Morb Mortal Wkly Rep. 2003;52(33):793–5. 62. Tenover FC, McDougal LK, Goering RV, Killgore G, Projan SJ, Patel JB, Dunman PM. Characterization of a strain of community-associated methicillin-resistant Staphylococcus aureus widely disseminated in the United States. J Clin Microbiol. 2006;44(1):108–18. 63. Chambers HF. The changing epidemiology of Staphylococcus aureus? Emerging Infect Dis. 2001;7(2):178–82. 64. Deresinski S. Methicillin-resistant Staphylococcus aureus: an evolutionary, epidemiologic, and therapeutic odyssey. Clin Infect Dis. 2005;40(4):562–73. 65. Kazakova SV, Hagerman JC, Matava M, Srinivasan A, Phelan L, Garfinkel B, Boo T, McAllister S, Anderson J, Jensen B, Dodson D, Lonsway D, McDougal LK, Aduino M, Fraser VJ, Killgore G, Tenover FC, Cody S, Jernigan DB. A clone of methicillin-resistant Staphylococcus among professional football players. N Engl J Med. 2005;352(5): 468–75.

116 66. Bratu S, Eramo A, Kopec R, Coughlin E, Ghitan M, Yost R, Chpanick EK, Landman D, Quale J. Community-associated methicillin-resistant Staphylococcus in hospital and nursery and maternity units. Emerg Infect Dis. 2005;11(6):808–13. 67. Moran GJ, Krishnadasan A, Gorwits RJ, Fosheim GE, McDougal LK, Carey RB, Talan DA: Emergency ID Net Study Group. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med. 2006;355(7):666–74. 68. Holmes A, Ganner M, McGuane S, Pitt TL, Cookson BD, Kearns AM. Staphylococcus aureus isolates carrying PantonValentine leucocidin genes in England and Wales: frequency, characterization, and association with clinical disease. J Clin Microbiol. 2005;43(5):2384–90. 69. Kravitz GR, Dries DJ, Peterson ML, Schlievert PM. Purpura fulminans due to Staphylococcus aureus. Clin Infect Dis. 2005;40(7):948–50. 70. Gillet Y, Issartel B, Vanhems P, Fournet JC, Lina G, Bes M, Vandenesch F, Piemont Y, Brousse N, Floret D, Etienne J. Association between Staphylococcus aureus strains carrying gene for Panton-Valentine leukocidin and highly lethal necrotizing pneumonia in young immunocompetent patients. Lancet 2002;359(9308):753–9. 71. Francis JS, Doherty MC, Lopatin U, Johnston CP, Sinha G, Ross T, Cai M, Hansel NN, Perl T, Ticehurst JR, Carroll K, Thomas DL, Nuermberger E, Bartlett JG. Severe community-onset pneumonia in healthy adults caused by methicillin-resistant Staphylococcus aureus carrying the Panton-Valentine leukocidin genes. Clin Infect Dis. 2005; 40(1):100–7. 72. Waldvogel FA. Staphylococcus aureus (including staphylococcal toxic shock). In: Mandelll GL, Bennett JE, Dolin R, editors. Principles and practice of infectious diseases. 5th ed. Philadelphia, PA: Churchill Livingstone; 2000. p. 2072–3. 73. Hidron AI, Kourbatova EV, Halvosa JS, Terrell BJ, McDougal LK, Tenover FC, Blumberg HM, King MD. Risk factors for colonization with methicillin-resistant Staphylococcus aureus (MRSA) in patients admitted to an urban hospital: emergence of community-associated MRSA in nasal carriage. Clin Infect Dis. 2005;41(2):159–66. 74. Boyce JM. New insights for improving hand hygiene practices. Infect Control Hosp Epidemiol. 2004;25(3):187–8. 75. Boyce JM, Havill NL, Kohan C, Dumigan DG, Ligi CE. Do infection control measures work for methicillin-resistant Staphylococcus aureus? Infect Control Hosp Epidemiol. 2004;25(5):395–401. 77. Gowan JE, Miller LG. Community-acquired methicillinresistant Staphylococcus aureus: right here, right now. ISMR Update. 2006;1(3):1–12. 78. Lee MC, Rios AM, Aten MF, Mejias A, Cavuoti D, McCracken GH Jr, Hardy RD. Management and outcome of children with skin and soft tissue abscesses caused by community-acquired methicillin-resistant Staphylococcus aureus. Pediatr Infect Dis J. 2004;23(2):123–7. 79. Llera JL, Levy RC. Treatment of cutaneous abscess: a double-blind clinical study. Ann Emerg Med. 1985;14(1):15–9. 80. Gorwitz RJ, Jernigan DB, Powers JH, Jernigan JA. Management of MRSA in the Community. Centers for Disease Control and Prevention. http://www.ccar-ccra.com/ english/pdfs/CAMRSA_ExpMtgStrategies.pdf. Accessed on Mar 2006.

A. Erian and M. A. Shiffman 81. Kollef MH, Micek ST. Methicillin-resistant Staphylococcus aureus: a new community-acquired pathogen? Curr Opin Infect Dis. 2006;19(2):161–8. 82. Fridkin SK, Hageman JC, Morrison M, Sanza LT, ComoSabetti K, Jernigan JA, Harriman K, Harrison LH, Lynfield R, Farley MM. Active bacterial core surveillance program of the emerging infections program network: Methicillinresistant Staphylococcus aureus disease in three communities. N Engl J Med. 2005;352(14):1436–44. 83. Miller LG, Tagudar G, Tsui J, et al. A prospective investigation of risk factors for community-acquired MRSA infection in a non-outbreak setting. Program and Abstracts of the 42nd Annual Meeting of the Infectious Disease Society of America, Boston, MA: Sep 29–Oct 3 2004, Abstract LB-7. 84. Frazee BW, Salz TO, Lambert L, Perdreau-Remington F. Fatal community-associated methicillin-resistant Staphylococcus aureus pneumonia in an immunocompetent young adult. Ann Emerg Med. 2005;46(5):401–4. 85. Frank AL, Marcinak JF, Mangat PD, Tjhio JT, Kelkar S, Schreckenberger PC, Quinn JP. Clindamycin treatment of methicillin-resistant Staphylococcus aureus infections in children. Pediatr Infect Dis J. 2002;21(6):530–4. 86. Martinez-Aguilar G, Avalos-Mishaan A, Hulten K, Hammerman W, Mason EO Jr, Kaplan SL. Communityacquired, methicillin resistant and methicillin-susceptible Staphylococcus aureus musculoskeletal infections in children. Pediatr Infect Dis J. 2004;23(8):701–6. 87. Chen CJ, Huang YC. Community-acquired methicillinresistant Staphylococcus aureus in Taiwan. J Microbiol Immunol Infect. 2005;38(6):376–82. 88. Siberry GK, Tekle T, Carroll K, Dick J. Failure of clindamycin in treatment of methicillin-resistant Staphylococcus aureus expressing inducible clindamycin resistance in vitro. Clin Infect Dis. 2003;37(9):1257–60. 89. Management of multiple-resistant organisms in healthcare settings. www.cdc.gov/ncidod/dhgp. 90. Chen ZY, Wang ZG, Kuang RX, Su YP. Implant found in thoracic cavity after breast augmentation. Plast Reconstr Surg. 2005;116(6):1826–7. 91. Wong L. Pectoralis major myospasm resulting from subpectoral implant. Plast Reconstr Surg. 2000;105(4):1571–2. 92. Weaver v Borsand, No. CV 99–02491, Maricopa County, AZ: 1999. 93. Shiffman MA, Mirrafati S. Possible nerve injuries in the axillary approach to breast augmentation surgery. Am J Cosm Surg. 2001;18(3):149. 94. Maxwell GP, Tornambe R. Management of mammary subpectoral implant distortion. Clin Plast Surg. 1988;15: 601–11. 95. Georgiade NG, Georgiade GS, Riefkohl R. Aesthetic surgery of the breast. Philadelphia: Saunders, 1990. p. 80–1. 96. Osborn JM, Stevenson TR. Pneumothorax as a complication of breast augmentation. Plast Reconstr Surg. 2005; 116(4):1122–6. 97. Fayman MS, Beeton A, Potgieter E. Barotrauma: an unrecognized mechanism for pneumothorax in breast augmentation. Plast Reconstr Surg. 2005;116(6):1825–6. 98. Leventhal D, Furr M, Reiter D. Treatment of keloids and hypertrophic scars: a meta-analysis and review of the literature. Arch Facial Plast Surg. 2006;8(6):362–8.

10 Complications of Breast Augmentation 99. Mofid MM, Klatsky SA, Singh NK, Nahabedian MY. Nipple-areola complex sensitivity after primary breast augmentation: a comparison of periareolar and inframammary incision approaches. Plast Reconstr Surg. 2006;117(6): 1694–8. 100. Picha GJ, Batra MK. Breast augmentation. In: Achauer BM, Eriksson E, Guyuron B, Coleman JJ III, Russell RC, Vander Kolk CA, editors. Plastic surgery. St. Louis: Mosby, Inc.; 2000. p. 2743–67. 101. Bacilious N, Kulber D, Peters E, Gayle LB, Chen MJ, Harper AD, Hoffman L. Harvesting of the latissimus dorsi muscle: a small animal model for seroma formation. Microsurgery 1995;16(9):646–9. 102. Carrico TJ, Cohen IK. Capsular contracture and steroidrelated complications after augmentation mammaplasty. A preliminary study. Plast Reconstr Surg. 1979;64(3): 377–80. 103. European Consensus Statement of the prevention of venous thromboembolism. Int Angiol. 1992;11:151. 104. Bick RL, Haas SK. International consensus recommendations: summary statement and additional suggested guidelines. Med Clin North Am. 1998;82(3):613–33. 105. Clement DI, Gheeraert P, Buysere M, Medical patients. In: Bergquist D, Comerota AJ, Nicolaides AN, et al. editors. Prevention of venous thromboembolism. London: MedOrion; 1994. p. 319. 106. Senior RM. Pulmonary embolism. In Wyngaarden JB, Smith, LH, Jr, Bennett JC, editors. Cecil textbook of medicine. Philadelphia: WB Saunders; 1992. p. 421–8. 107. Prevention of venous thromboembolism. International consensus statement: guideline according to scientific evidence. Int Angiol. 1997;16:3. 108. McDevitt NB. Deep vein thrombosis prophylaxis. Plast Reconstr Surg. 1999;104:1923–8.

117 109. Alving BM. The hypercoagulable states. Hosp Pract. 1993;28(2):109–21. 110. Bovill EG, Bauer KA, Dickerman JD, Callas P, West B. The clinical spectrum of heterozygous protein C deficiency in a large New England kindred. Blood 1989;73(3):712–7. 111. Engesser L, Broekman AW, Briet E, Brommer EJ, Bertina RM. Hereditary protein S deficiency: clinical manifestations. Ann Intern Med. 1987;106(5):677–82. 112. Zoller B, Hillarp A, Dahlback B. Activated protein C resistance due to a common factor V gene mutation is a major risk factor for venous thrombosis. Annu Rev Med. 1997; 48:45–58. 113. Svensson PJ, Dahlback B. Resistance to activated protein C as a basis for venous thrombosis. N Engl J Med. 1994;330(8):517–22. 114. Bertina RM, Koeleman BP, Koster T, Rosendaal FR, Dirven RJ, de Ronde H, van der Velden PA, Rei8tsma PH. Mutation in blood coagulation factor V associated with resistance to activated protein C. Nature 1994;369(6475):64–7. 115. Bridgen ML. The hypercoagulable state. Who, how, and when to test and treat. Postgrad Med. 1997;101(5): 249–67. 116. Ginsberg JS. Management of venous thromboembolism. N Engl J Med. 1996;335:1816–28. 117. Olesen LL, Ejlertsen T, Nielsen T. Toxic shock syndrome following insertion of breast prostheses. Br J Surg. 1991; 78(5):585–6. 118. Poblete JV, Rodgers JA, Wolfort FG. Toxic shock syndrome as a complication of breast prostheses. Plast Reconstr Surg. 1995;96(7):1702–8. 119. Walker LE, Breiner MJ, Goodman CM. Toxic shock syndrome after explantation of breast implants: a case report and review of the literature. Plast Reconstr Surg. 1997; 99(3):875–9.

Regnault B Mastopexy: A Versatile Approach to Breast Lifting and Reduction

11

Howard A. Tobin

11.1 Introduction Mastopexy remains a challenging operation for most surgeons. In some ways, patients and surgeons alike are fighting a losing battle in that we are trying to uplift a sagging breast that is usually the result of a lack of tensile strength in the skin. Since it is only the skin that supports the breast, recurrent skin stretch is the rule rather than the exception. While women with pseudoptosis or mild ptosis may be satisfied with breast augmentation alone, mastopexy is often indicated to obtain the desired “lift” when there is more significant ptosis. The disadvantage of choosing mastopexy over augmentation alone is the resulting scars on the breasts. Classic mastopexy produces a scar around the areola, as well as a vertical scar extending from the areola down to a transverse scar in the fold beneath the breasts. A number of techniques have been developed over the years in an effort to minimize the extent of scarring. In 1976, Regnault [1] published the B Mastopexy technique that unites the vertical and horizontal scars into a single curving incision, thus eliminating the medial scar. This technique may also be used in breast reductions. This technique has been the preferred technique in the author’s hands for over 15 years. The advantage of this procedure is that a long inframammary incision is avoided and replaced by a much shorter lateral continuation of the vertical incision. Since there are no specific markings to guide the surgeon, the procedure requires more experience and judgment than the more standard cookie-cutter techniques using anchor-shaped incisions. H. A. Tobin Facial Plastic and Cosmetic Surgery Center, 6300 Regional Plaza, Suite 475, Abilene, TX 79606, USA e-mail: [email protected]

Conceptually, the operating can be viewed as creating a laterally based rotation flap that is advanced around and under the breast to provide tightening and lifting.

11.2 Surgical Technique Patients undergo extensive consultation related to risks, limitations, and benefits of mastopexy with or without simultaneous augmentation. Patients are always advised that mastopexy procedures often fall short of ideal expectations. This was stressed to attempt to discourage patients with unrealistic expectations. Detailed before and after photos are reviewed. These pictures were selected to clearly show the nature and extent of the incisions as well as the resulting scars. Patients are educated that scars “look bad before they look good” and it may take up to a year for scar maturation and final breast contour. Since most mastopexy patients also undergo simultaneous augmentation at our Center, a thorough discussion of the limitations and risks of augmentation is discussed, including the alternative of staged procedures. Patients who undergo simultaneous augmentation have the implants inserted endoscopically beneath the muscle through a transaxillary incision. The two procedures are accomplished simultaneously. A major advantage of this technique is that there is no continuity between the implant pocket and the mastopexy itself. Therefore, if there is an infection at the mastopexy site, it is far less likely to reach the implant. In spite of the recent release of gel-filled implants, the author continues to prefer and recommend saline-filled implants, although patients do have the option of choosing gel. In either case, the technique is the same.

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_11, © Springer-Verlag Berlin Heidelberg 2010

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Fig. 11.2 The medial aspect of the new position of the areola is marked approximately 10–11 cm from the midline along the mid breast

Fig. 11.1 The inframammary fold is identified and marked on the anterior breast as an indication of the level to which the nipple is to be elevated

It is recognized that it will take months for the breasts to fully settle and take on a pleasing shape. Therefore, patients are shown photographs of various stages of healing to help reassure them during their postoperative course, since the breasts will usually look quite distorted initially. Preoperative markings are performed with the patient in the standing position. The distance from the suprasternal notch to the nipple is measured and documented. The inframammary fold is identified and marked on the anterior breast as an indication of the level to which the nipple is to be elevated (Fig. 11.1). The medial aspect of the new position of the areola is marked approximately 10–11 cm from the midline along the mid breast (Fig. 11.2). A 38-mm diameter line is marked around the nipple corresponding to the new preserved areola. An estimate of the incisions is outlined, recognizing that this will be modified in surgery. The estimate must take into account that usually implants will be used, which will reduce the amount of skin excision. Photographs are taken to be used for reference in the operating room. The patient is then brought to surgery. In surgery, under general anesthesia, the patient is then placed in the supine position on the operating table and a freehand “B type pattern” is drawn (Fig. 11.3).

Using the initial landmarks, a semicircular pattern is made around the nipple. The upper portion of this semicircle represents the level to which the nipple areolar complex will be elevated. The medial extent of the semicircle represents the distance that will be created between the nipple areolar complex and the medial limit of the breast, near the sternum. The vertical and horizontal component of the mastopexy is created using a tapering curvilinear incision from the lower portion of the areola to the lateral breast crease. This results in vertical closure that will be about 5–7 cm from the bottom of the areola to the inframammary fold. The medial component of the usual inframammary incision is thus eliminated. A simple maneuver is performed to assess closure tension by infolding the breast over the index finger (Fig. 11.4). One must allow for the added volume that will result when implants are used. A modified tumescent infiltration consisting of 100 mL of normal saline, 25 mL of 1% lidocaine plain and 0.25 mL of 1:1,000 adrenaline is injected into the dermis in the area to be deepithelialized as planned using a 20-gauge 1-in. needle (Fig. 11.5). If simultaneous breast augmentation is to be performed, an additional solution of 250 mL of normal saline, 50 mL of 1% lidocaine plain, and 0.5 mL of 1:1,000 adrenaline is injected using a 20-gauge 3 ½-in. needle. This is injected above and below the pectoralis muscle and around the circumference of the breast, as well as in the axilla. To facilitate the submuscular injection, the muscle is gently grasped and elevated to help position the needle into the correct plane. Great care must be

11 Regnault B Mastopexy: A Versatile Approach to Breast Lifting and Reduction

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Fig. 11.3 The patient is placed in the supine position on the operating table and a freehand “B type pattern” is drawn

Fig. 11.4 Assess closure tension by infolding the breast over the index finger

taken to make the plane of infiltration parallel to the ribcage to avoid inadvertent penetration of the pleura. Deepithelialization is carried out using a sharp razor scalpel following injection of the tumescent fluid. During this process, deepithelialization of the skin edges is continued 3–4 mm to allow closure of the skin without tension. Deepithelialization is typically performed after implant sizers are inserted as when simultaneous augmentation is accomplished the amount of skin to be removed can only be estimated after the sizers are in place. When the patient has elected to undergo simultaneous submuscular breast augmentation, a transaxillary endoscopic approach to place the implant is preferred. The endoscope is used to aid in visualization as the pectoralis major muscle is divided from the sternum

and ribs. After developing a pocket, implant sizers are used to insure best possible symmetry. At this point, final markings are made and deepithelialization is performed. During dermal closure, the sizer can then be displaced up into the pocket or partially deflated to allow approximation with minimal tension. If the closure demonstrates too much tension, this can be corrected by inserting a smaller implant or by reducing the final fill volume. Fine cannula liposuction of the breast tissue may also be performed to reduce the breast volume and aid in closure in certain cases. A tension-free closure is critical for optimal healing and avoiding the formation of wide scars. The dermis is used to provide the initial closure. Subepithelial undermining at the edge of the incision allows the performance of a dermal closure to avoid any tension on the skin. During dermal closure, the nipple is brought into its new position based on the pedicle of dermis. The lateral flap is rotated down and medially to create the curvilinear scar that results. Adjustment of this rotation determines the length of the distance between the inferior margin of the areola and the inframammary crease. The more of the flap that is rotated around the areola, the shorter this distance will be to the inframammary fold (Fig. 11.6). The deep dermis is approximated using 3–0 and 4–0 Monocryl in a simple interrupted fashion. The key suture is at the junction where the lateral flap meets the medial skin edge at the inferior margin of the areola because this is the area of greatest tension. Subcutaneous dermal closure is performed with interrupted 4–0 Monocryl, avoiding any tension on the skin. Final adjustments prior to skin closure may include micro

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b

a

Fig. 11.5 (a) A modified tumescent solution is injected into the dermis in the area to be deepithelialized as planned using a 20-gauge 1-in. needle. (b) Scalpel deepithelialization is performed

Fig. 11.6 The lateral flap is rotated down and medially to create the curvilinear scar that results. Adjustment of this rotation determines the length of the distance between the inferior margin of the areola and the inframammary crease. The more of the flap that is rotated around the areola, the shorter this distance will be to the inframammary fold

liposuction or additional deepithelialization, if needed. After dermal closure, 5–0 or 6–0 plain catgut is used to approximate the areola to the adjacent skin edge and the lower skin incisions in a continuous fashion (Fig. 11.7). Following the mastopexy closure, if combining breast augmentation, the sizers are replaced by the final implant that is then filled to the desired amount.

Fig. 11.7 After dermal closure, 5–0 or 6–0 plain catgut is used to approximate the areola to the adjacent skin edge and the lower skin incisions in a continuous fashion

The axillary incision is closed with a simple interrupted layer of 6–0 plain catgut. Postoperative care is minimal. The breast is supported with a porous soft elastic tape. The tape is removed in 7–10 days and may be reapplied to the incisions for an additional week, or the patient may

11 Regnault B Mastopexy: A Versatile Approach to Breast Lifting and Reduction

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Fig. 11.8 Before and after view of patient illustrated above

simply elect to cover the incision with a preparation such as Scarguard®. A surgical bra is worn for comfort, and an underwire bra is avoided until the implants have settled into position. If the implants tend to rise, as may be the case with submuscular implants, an elastic wrap may be used for a few weeks after surgery. Patients’ activity is not limited after surgery and they are encouraged to resume normal activity as soon as possible. Intravenous antibiotics are given immediately before surgery and continued orally for 2 days afterwards. Pain medication is prescribed as needed, but rarely is any type of narcotic required for more than 2 or 3 days (Fig. 11.8).

11.3 Complications Complications are infrequent following the B mastopexy since the procedure does not completely

penetrate the skin. It goes without saying that when combined with breast augmentation, all complications related to that procedure are possible. An unsatisfactory cosmetic result is always possible but this is largely related to the experience of the surgeon. There is no question that there is a fairly steep learning curve to the operation. Wound separation can occur if the closure is too tight, but it is important to include some degree of over correction since there will be some skin stretching during healing. Thickened or widened scars are always possible, however undermining with a good dermal closure minimizes this problem. Sensory disturbance should not occur since the procedure is carried out above the dermis. Regnault has also described no increased incidence of hypertrophic scarring or loss of nipple sensation [1, 2], although it must be kept in mind that loss of nipple sensation can occur with augmentation alone, regardless of the approach.

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11.4 Discussion Mastopexy results in scars on the breast. Some women cannot live with the thought of a scar on the breast while others are willing to bear these to obtain a more desirable breast shape. Periareolar mastopexy often results in a breast with a “bottoming out” appearance and puckering. The inverted T technique results in a better aesthetic looking breast but there is more scarring. The B Mastopexy technique offers elevations through both a vertical and horizontal component with elimination of the medial scar. It provides good projection, ensured nipple viability, with great flexibility and relatively short operating time, in experienced hands. The B-type incision is versatile and can be used for mastopexy and breast reductions. Frey [3] and Giovanoli et al. [4] report that secondary corrections are less frequent, and there is a better transposition of lateral excess tissue using the B-shaped skin incisions. The principle of the procedure is to create a rotational flap in which the elevated epidermal flap is rotated around the nipple. The patient’s expectations and desired results must be evaluated carefully. In our experience, the majority of patients seeking breast lift, also desire added fullness and therefore undergo combined augmentation mastopexy. The complication rate has not been higher when combining the procedures. Satisfaction is higher with the combined procedure compared to mastopexy alone. Perhaps, the technique of isolating the procedures, even as they are done concurrently helps to minimize complications. Since we are not initially committed to implant size prior to closing the mastopexy, the risk of an overly tight closure is avoided. Additionally, the two surgical fields remain isolated, so that a wound break down following the mastopexy is much less likely to reach the implant. Combined mastopexy/augmentation has been a controversial subject. Spear et al. report [5] that combined mastopexy/augmentation is the most frequently litigated operation, and reported 8.7% revision rate compared to a 1.7% revision rate for mastopexy alone. On the other hand, Stevens et al. [6] reported no major complications in a series of 100 consecutive secondary mastopexy/augmentation

H. A. Tobin

cases, although 15% did require secondary revision surgery, most often for size change or capsular contracture. The author’s most recent 35 B type mastopexies had no patient that required early revision, although one subsequently requested revision with larger implants. The author continues to favor the use of smooth saline-filled implants. This allows us to use a very small incision in the axilla as well as allowing for some final adjustment of saline fill. Since the author is using relatively small implants and placing them beneath the muscle, rippling has not been a significant problem. Of significant importance is the fact that saline-filled implants are far less likely to become firm.

11.5 Conclusions The B Mastopexy is a very versatile technique that allows simultaneous submuscular or subglandular breast augmentation. Careful patient selection is necessary along with full explanation of expected course and outcome. This technique is an excellent choice for optimal breast shape with less scarring.

References 1. Regnault P. Breast ptosis. Definition and treatment. Clin Plast Surg. 1976;3(2):193–203. 2. Regnault P. Breast reduction: B technique. Plast Reconstr Surg. 1980 65(6): 840–5. 3. Frey M. A new technique of reduction mammoplasty: dermis suspension and elimination of medial scars. Br J Plast Surg. 1999;52(1):45–51. 4. Giovanoli P, Meuli-Simmen C, Meyer VE, Frey M Which technique for which breast? A prospective study of different techniques of reduction mammaplasty. Br J Plast Surg. 1999;52(1):52–9. 5. Spear SL, Boehmler JH IV, Clemens MW Augmen tation/ mastopexy: a 3-year review of a single surgeon’s practice. Plast Reconstr Surg. 2006;118(7 Suppl): 136S–47S. 6. Stevens WG, Spring M, Stoker D, Freeman M, Cohen R, Quardt S, Hirsch E A review of 100 consecutive seconary augmentation/mastopexies. Aesthetic Surg J. 2007;27: 485–92.

Mastopexy/Reduction and Augmentation Without Vertical Scar

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Sid J. Mirrafati

12.1 Introduction Breast lift or reduction is a common procedure frequently performed by a cosmetic breast surgeon. Breast reduction is a very satisfying procedure for the patient because they do not have to carry such a massive weight and there is relief of the shoulder pain radiating to the arm or the low back pain. The results are so satisfying that patients, for most part, do not complain about the scarring that is left behind from the breast reduction procedure. In the case of breast lift with augmentation, the patients are so happy with the new upright, fuller breast that they are not too concerned about the incisional scar. As a cosmetic surgeon, we owe it to our patients to always strive for the best results with minimal incision. Cosmetic surgeons around the world have been introducing new techniques that would deliver results with minimal scarring. There have been several techniques that have been introduced for the full breast lift/reduction procedure that entail having a vertical scar running down from the areolar to the inframammary fold. The only scar that seems to bother the majority of the patients is the vertical scar and the scar on the sides when the inframammary scar is not kept under the breast such as with the McKissock reduction and the Lejour technique. The lift/reduction that the author utilizes avoids the vertical incisional scar and keeps the inframammary incisional scar invisible under the breast. This technique would not work for extremely large breast that would like to be moderately small or cup size “A” but

would work for most other instances. If the patient adamantly does not want the vertical scar and there is too much skin or the surface area is too large, then the inferior part of the vertical scar that is mostly hidden by the inferior pole of the breast can be added. This technique would work great for ptotic breast that requires a full breast lift and an augmentation.

12.2 Consultation During the consultation, it is important that you completely assess the patient and review all the available options, especially in a ptotic breast that the patient would like to have a moderately large implant. Generally in grade II ptosis, if the patient is willing to place a large implant and if the skin integrity is good with not much stretch marks, the patient can have a crescent lift with augmentation and can avoid the full lift, but in grade III ptosis, the patient would require a full breast lift no matter how big the implant size would be. The chest size is measured from the midline going 2 cm laterally to the anterior axillary line. One centimeter is reduced from this measurement and this would be the diameter of the implant that can be placed in. Even though the vertical scar is not done, the patients are still told about the other scars. Patients are told that the scar takes 1 year to be less visible. The scar will first look red, turn dark, and eventually will be the color of the skin.

12.3 Surgical Procedure S. J. Mirrafati 3140 Redhill Avenue, Costa Mesa, CA 92626, USA e-mail: [email protected]

Preoperative photos are taken with a straight forward position, 45° angle, and 90° angle.

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12.3.1 Marking Preoperative markings are done (Fig. 12.1). The areolar is marked with a cookie cutter with a 4-cm diameter. The new nipple position is marked by palpating the inframammary fold and transferring this to the surface of the breast. The new areolar position is marked with a 6-cm cookie cutter. The midclavicular line to the areolar superior pole is measured to be 19 cm and if planning to place an implant, this measurement should be 20 cm. This precaution should be taken to make sure that the areolar does not sit too high and will show through the patient’s bikini top or the bra. Be conservative because the areolar position can be raised higher at a later time but once it is pulled too high, it would be very difficult to lower the position. A 5-cm line is drawn from the inferior pole of the new areolar position. The inframammary line is drawn so that the line cannot be seen when the breast is placed in a relaxed

S. J. Mirrafati

position. The medial and the lateral aspect of the inframammary breast line is marked and then marked in 1 cm further from each side. This will ensure that the incision will not be visible after the surgery. The breast is retracted laterally and a straight line is drawn from the end of the 5 cm line to the inframammary fold. The breast is then retracted medially and another line is drawn to the lateral mark of the inframmary fold line. This will create a triangle that would be later cut to act as a support and shape the breast (Fig. 12.1a). The 5 cm vertical line can sometimes be extended if planning to place a large implant, depending on the shape of the patient chest and the size of the implant. Double check again to make sure that the inframammary marking is not seen when the patient is standing. Sometimes if the breast is too ptotic and there is too much skin, the marking is modified to have a vertical scar only on the inferior aspect 2 cm from the inframammary line. This is usually hidden by the bottom pole of the breast when the surgery is completed (Fig. 12.1b).

a

12.3.2 Technique

b

Fig. 12.1 Marking the breast

The patient is placed in a supine position and the breast prepped with Betadine. If breast reduction, lift, and augmentation are to be performed, the procedure is begun with the reduction. Tumescent fluid is injected into the breast until it is moderately firm and full. The tumescent fluid consists of 1 L of saline with 2 mL of 1:1,000 epinephrine and 500 mg of lidocaine. Approximately 500 mL is injected into each breast. Liposuction may be performed to reduce the breast using a 5-mm open spiral cannula and a 4-mm cannula to fine-tune the area. The superior pole of the breast is usually not liposuctioned so that there is good projection after surgery. If the breast is to be reduced 500 g, then 500 mL is liposuctioned from each breast. This will require a lot of palpation to make sure that it feels the same in both breasts. Incisions are made along the preoperative markings around the areola as well as the new position of the areolar complex (Fig. 12.2). Deepithelialization of the skin is done, as well as 1 cm undermining. The areolar is lifted and anchored to its new position using the 4–0 Monocryl. The four quadrants are evenly distributed and sutured to the areola using the 4–0 Monocryl. The skin is closed using the 5–0 nylon.

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There is going to be some pleating when the areolar is completely closed. This will usually resolve and the skin will become evenly retracted. If there is some pleating that persists after 6 weeks, be patient, because a

Fig. 12.3 The line from the lowest aspect of the areola to the superior point of the lower triangle should be 5 cm but can be adjusted to accommodate an implant

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essentially most pleating resolve by 6 months. If for some reason it did not resolve after 6 months, revision can be performed to even out the pleating. The inframammary incision is performed and the dissection taken down to the pectoralis fascia. A pocket is developed in the subglandular plane. In reduction mammoplasty, the implant is generally placed in a subglandular plane unless the skin in the medial superior region is thin or the patient requests submuscular placement. In either situation, a pocket is developed and the implant is placed in after proper hemostasis and antibiotic irrigation. The triangle that is preoperatively marked is resected with the breast tissue (Fig. 12.2). This is where the preoperative marking has to be modified depending on the size of the implant. The 5 cm line can be 6 cm or longer depending on the size of the implant (Fig. 12.3). The incisions may be modified to include an inferior vertical scar if the skin is too loose (Fig. 12.4). After taking out the triangle, the incision is closed using a 4–0-monocryl subcutaneously and the skin is closed using a 5–0-nylon. A compression dressing is applied.

12.4 Postoperative Care

Fig. 12.2 (a) The areola is incised and the excess skin deepithelialized. (b1,2) The inferior triangle is incised and deepithelialized or can be resected if breast reduction is to be performed

The patient should be seen on the first postoperative day. The dressing is changed and the compression dressing left off. In this technique of reduction mammoplasty or mastopexy, there is no real concern about

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nipple–areolar necrosis since there is no vertical incision. The patient is examined for proper implant position, hematoma, and incision healing. Patients are told to apply antibiotic ointment to the incision and change the dressings daily. Patients are given simple arm exercises and can take showers starting 48 h after the surgery. Patients are told to continue taking Keflex 500 mg twice daily and 2,000–3,000 mg vitamin C daily.

12.5 Complications

Fig. 12.4 Modify the markings to include an inferior vertical scar 2 cm long if skin is too loose

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Other than one patient having hypertrophic scarring around the areola, there has not been any other complication. Sometimes when the implant size is large, there

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Fig. 12.5 (a1,2) Preoperative patient. (b1,2) Postoperative without visible inframammary fold scar and no vertical scar

12 Mastopexy/Reduction and Augmentation Without Vertical Scar

is an indentation in the center that will stretch out in time. There is always some settling or sometimes bottoming out of the lift with time, but this is a problem that can happen with any lift or reduction procedure.

12.6 Conclusions This is a lift that avoids the most unwanted and the most obvious scar associated with a breast lift or

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reduction procedure, the vertical scar (Fig. 12.5). There have been many different types of lift that have been introduced in text books or the literature but they mostly involve the vertical scar that this technique avoids. Patient satisfaction is high and the complication rate is very low.

Breast Reduction and Mastopexy with Vaser in Male Breast Hypertrophy

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Alberto Di Giuseppe

13.1 Introduction In the early 1980, few articles were published on suction lipectomy as part of a combined surgical solution for gynecomastia, and it was suggested to utilize SAL (suction assisted lipoplasty) in conjunction with sharp surgical resection of the subareolar breast bud and wherever the parenchymal tissue (Fig. 13.1). Courtiss [1] suggested extensive removal of fat with suction lipectomy, and used knife or scissors to remove the subareolar breast cone (Fig. 13.2). It was a general thought that it was impossible to remove parenchymal tissue via SAL alone, due to the resistance fibrosis of the gland. Rosenberg [2] showed to be competent in utilizing SAL alone to remove fat and parenchymal tissue successfully, without complications (Fig. 13.3). Histology confirmed the accuracy of fat as well as breast tissue cleaning in gynecomastia treatment with SAL. Nydick [3] showed there was an incidence of gynecomastia in 65% of pubertal males, resolution almost always occurs, but in another study by Nuttal [4] of 306 adult males, clinical gynecomastia was seen in 36% with a greater incidence (57%) in men over 44 years. Regarding the etiology, an increasing responsibility has been addressed to drugs and medications, as steroids, Zantac, Tagamet, Nizoral, as well as Marijuana. Anabolics, of course, can increase male breast volume [5]. Obesity is part of the problem, as a certain deposit A. Di Giuseppe Department of Plastic and Reconstructive Surgery, School of Medicine, University of Ancona, 1, Piazza Cappelli, 60121 Ancona, Italy e-mail: [email protected] e-mail: [email protected]

of fat in male breast is always connected with an increase in body weight by man, with intensification with age and loss of breast tone and pectoralis muscle power. Surgical intervention is the only real radical treatment, which does not interfere with hormone balance. Nearly 80% of American/U.S. plastic and cosmetic surgeons seem to approach gynecomastia with open surgical breast tissue excision with or without SAL as a support for defining contouring of the thorax-breast [6]. The consistency of the fibrous male breast can be expressively addressed with the new Vaser ultrasound assisted technique. Vaser (vibration assisted sound et resonance) (S.S.T. Denver, Co US) utilizes solid probes introduced via small cutaneous incisions, to emulsify fat as well as breast tissue, dissolve them, thus aspirating the emulsion through a suction cannula.

13.2 Selection The author has used Vaser system technology as the sole treatment of male gynecomastia for the past 4 years, including the treatment of all types of gynecomastia (pure fatty, mixed, or fibrous bud) depending on incidence of type of tissue in the clinical case presentation (Fig. 13.4). The volume of tissue removed typically varies from 150 mL in a small gland up to 700 mL per side in an obese patient, including the tumescent solution. The infranatant aspirate may vary from 200 mL in minor cases and up to 1,800 mL in large volumes. Ptosis correction may vary from virtually 0 up to 4 cm and in the postoperative period that is noticeable already 1 week after surgery. Preoperative assessment is done with the patient standing. The central cone of breast is marked and

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132 Fig. 13.1 (a) Planned fat removal. (b) Skin incisions: axilla-areola. (c) Subareolar adenectomy

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areas of undermining, which include breast fat tissue or residual fibrous tissue are marked. Lines of surgical incisions (axillary – inframammary crease – periareolar, if necessary) are marked. All cases are performed under tumescent anesthesia, sometimes modified, with intravenous sedation. Modified tumescent anesthesia includes:

even 1,700 mL for each side. The infiltrated solution has approximately 2:1 ratio with the aspirate. The Vaser system provides a set of solid probes with diameters of 2.9 mm, 3.8 mm, 4.1 mm, and a recently introduced new probe, which has a sort of arrow tip expressively designed to target more aggressively the breast central bud (Fig. 13.5).

1. Ringer lactate 1,000 mL 2. Adrenaline 1 mL 3. Lidocaine 750–1,000 mg 4. Sodium bicarbonate 12.5 meq

13.3 Technique

In multiple areas, general anesthesia is preferred such as when gynecomastia is treated with abdomen contouring and/or thighs contouring. When performed under general anesthesia, lidocaine dose is reduced to some 100 mg/L only to provide postoperative analgesia. Depending on the dimension of the breasts, total tumescent solution infused may vary from 500 mL to

Via an inframammary incision, tumescent solution is infiltrated in superficial as well as deep layers (Fig. 13.6). When completed, the infiltration should be uniform. There must be a wait of a minimum of 15 min for the adrenaline to have its effect. To prevent friction injuries at entrance site, a plastic skin protector should be used. To help its introduction, a special dilator and a skin protector are used (Fig. 13.7).

13 Breast Reduction and Mastopexy with Vaser in Male Breast Hypertrophy

Fig. 13.2 Courtiss’ original design of breast liposuction in large area of thorax

The initial phase, after setting the power of the Vaser at 80–90% of its total, consists in undermining the skin of the thorax remaining in the subdermal plane (Fig. 13.8). This superficial undermining is performed with the 3.8 mm probe with the Vaser system tuned to 70% of its total power. The continuous mode provides full administration of ultrasound energy on time. The Vaser System provides what is called the Vaser mode, which means an interrupted administration of energy by time that diminishes the total energy given by half for fraction of time (thus increasing margin of safety of the instrument). The author believes that the continuous mode works well since the probes are designed to emulsify the target tissue. The careful

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superficial undermining with the solid probe is essential to fully display the subcutaneous tissues at the sub dermal layer from the deeper planes. This extensive subdermal undermining is realized through the help of the solid titanium probe: with the proper tumescent infiltration. Vaser helps find the correct cleavage plane preserving the supporting structures of the connective tissue, as vessels, nerves, collagen vertical fibers. In this way, Vaser realizes a selective emulsification of just the fat tissue, sparing “noble” supporting structures of the dermis and skin [7]. Rudolph [8] stated that dermis plays a considerable role in skin retraction. As thin is the flap obtained with the probe undermining, as much skin retraction is achieved; this is best obtained raising subdermally a thin vascularized flap similar to what happens in subdermal liposuction. The standard aspirate is not different from typically emulsified fat taken elsewhere in the body. This proves the high quality cavitation and efficacy of the designed probes, which have rings (1–3) at the tip to increase power and quantity of emulsified fat per unit of time. The subdermal flap is checked to be correctly and uniformly raised (Fig. 13.9). Also, the nipple– areola area, where most of fibrous parenchymal tissue is localized, is thinned carefully. Lack of zone of adherence is verified all the way around the undermined areas. Suction drainages are left in place for 24 h, to prevent seroma collection. Symmetry of result is verified with a double check (surgeon and assistant) (Fig. 13.10). A silicone baked foam dressing (Epifoam) is positioned for 10–15 days to soften the underlying tissues (Fig. 13.11). An elastic compressive garment that helps obliterate dead space is left in place for 4 weeks. With larger breasts or breast with ptosis and excess skin, cross-suctioning is used to improve the results. A 5 mm incision is made in the axilla, which is best to conceal the scar. Another incision, if necessary, is made at the areola, to help defatting this area or better sculpturing and thinning the breast cone, which has to be flat (not overdone and depressed). Avoiding waviness and irregularity and destroying lumps and nodules of the breast parenchymal are essential to prevent postoperative sequelae and complications. In large gynecomastia and ptotic gynecomastia, with excess skin even the inframammary crease must be obliterated to allow proper redraping of the skin.

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Fig. 13.3 (a) Rosenberg’s original design. (b) Local anesthesia for periareolar approach. (c) Cannula for breast reduction. (d) Periareolar aggressive tissue removal. (e) Level of suction

Fig. 13.4 Extent of liposuction marked Fig. 13.6 With an inframammary incision, tumescent solution is infiltrated in superficial as well as deep layers

Fig. 13.5 New probe with arrow tip

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Fig. 13.9 Check flaps after removal of emulsified fat

Fig. 13.10 Suction catheters in place and symmetry of result is verified with a double check Fig. 13.7 (a) Skin dilator. (b) Skin protector in place

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b Fig. 13.11 Epifoam-dressing

Fig. 13.8 (a) Superficial undermining with probe. (b) Note tip of probe at work

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13.4 Complications

secondary touch up revision under local anesthesia occurred in a series of 200 patients.

Vaser is a solid technology with high standard of quality and safety. Three types of alarms are present in case of technical failure (never experienced in 4 years) or wrong use of probe or elevation of skin temperature. So burns, seroma, and skin slough that were a serious potential complication in previously used technologies are not really an issue with the present technology. Two small hematomas that required aspiration and ten cases of residual central bud that required

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13.5 Conclusions With the new technology, Vaser UAL is safe and effective in all forms of gynecomastia (Figs. 13.12 and 13.13).

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Fig. 13.12 (a1,2) Preoperative patient with moderate pure gynecomastia with asymmetry. (b1,2) Postoperative following 350 mL aspirate and Vaser 15 min each side

13 Breast Reduction and Mastopexy with Vaser in Male Breast Hypertrophy Fig. 13.13 (a1,2) Preoperative 19-year-old male with secondary gynecomastia, ptotic skin and gland, and abdominal laxity. (b1,2) Postoperative following Vaser and 1,100 mL aspirate from breasts

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References 1. Courtiss EH. Mammoplasty with minimal scar. Annual meeting of the American Society of Plastic and Reconstructive Surgeons. Washington, D.C; 1992. 2. Nydick M, Bustos J, Dale JH Jr, Rawson RW. Gynecomastia in adolescent boys. J Am Med Assoc. 1961;178:449–54. 3. Nuttal FQ. Gynecomastia as a physical finding in normal men. J Clin Endocrinal Metab. 1979;48(2):338–40. 4. Rosenberg GJ. A new cannula for suction removal of parenchymal tissue of gynecomastia. Plast Reconstr Surg. 1994; 94(3):548–51.

5. Letterman G, Schurter M. Gynecomastia. In: Courtiss EH, editor. Male aesthetic surgery. St Louis: CV Mosby; 1976. p. 229–53. 6. Mladick RA. Gynecomastia: liposuction and excision. Clin Plast Surg. 1991;18(4);815–22. 7. Spears SL. The breast: principles and art. Philadelphia: Lippincott-Raven; 1998. 8. Rudolph R. The life cycle of the myofibroblast. Surg Gynecol Obstet. 1977;145(3):389–94.

Gynecomastia Repair Using PowerAssisted Superficial Liposuction and Endoscopic Assisted Pull-Through Excision

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Yitzchak Ramon and Yehuda Ullmann

14.1 Introduction

14.2 Technique

Optimal result for the treatment of gynecomastia deformity is hard to achieve, and occasionally, the postoperative results may disturb the patient physically and psychologically, almost as the original deformity. Numerous methods of treatment have been described that accomplish removal of the breast tissue by direct excision, liposuction, or a combined approach [1–3]. Suction lipectomy has improved the aesthetic results of gynecomastia repair operations [4]. However, liposuction does not remove the dense glandular tissue, and some of the patients may need additional local excision of the residual core of the breast tissue [5]. Extended scars, postoperative bleeding, and donut or saucer deformities were described as possible complications of this procedure. In order to reduce the risk of postoperative contour deformities and those complications, different type of cannulas have been developed [6], and ultrasonic liposuction has been adapted for this purpose [7]. Although, these techniques have improved the resection of the glandular tissue, some residual breast parenchyma and stroma, needed direct excision [6], resulting in all the complications associated with this procedure. Our multimodality approach for gynecomastia repair is a modification and combination of several previously described methods: power-assisted [8] superficial [9] liposuction, endoscopic-assisted breast excision [10], the pull-through technique of Morselli [11], the combined approach of Hammond et al. [12], and the crosschest liposuction described by Walden et al. [13].

The patient is marked in the upright position just before the operation, using the topographic map technique. The patient is placed in a supine position on the operating table with the arms abducted on arm boards. The procedure is done under general anesthesia, or monitored cared anesthesia (MAC). After prepping and draping, two 7 mm incisions are done in the 3 and 9-h periareolar region (Fig. 14.1).

Y. Ramon (*) Elisha and Rambam Medical Centers, Haifa, Israel e-mail: [email protected]

Fig. 14.1 Two 7-mm incisions in the periareolar area

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The entire surgical area is infiltrated with 50 mL of 1% lidocaine, 1 mg of epinephrine 1:1,000, and 5 mL of 8.4% sodium bicarbonate in 1,000 mL of saline. The fluid is injected across the chest, using a long, blunt, multiport needle, inserted through the two periareolar incisions (Fig. 14.2). The tumescent technique is used injecting 2 mL of fluid to each 1 mL of anticipated fat removal. Power-assisted liposuction using micro air surgical instruments device is performed using a 3- or 4-mm triple-hole cannula, inserted through the contralateral periareolar medial incision, in order to suction the contralateral prepectoral fatty breast (Fig. 14.3). The lateral chest is then suctioned through the ipsilateral lateral periareolar incision site. Additional stab incisions are not necessary. Liposuction is done all over the chest wall, 2–3 cm beyond the boundaries marked and through and below the inframammary line. Superficial liposuction using 3 mm cannula is done

Y. Ramon and Y. Ullmann

first, just under the skin, a maneuver that dissects the parenchyma from the skin, especially under the nipple– areola complex, which enables the skin contraction. A 4-mm cannula is used next to aspirate the fatty tissue and to dissect the glandular tissue from the pectoralis fascia.. After the suction is completed, 2/0 silk suture is passed through the nipple–areola complex to elevate the breast skin, in order to form a space for the insertion of the endoscope. The endoscope is introduced through the contralateral incision to enable excision of the remaining fibrous tissue under vision (Fig. 14.4). The fibrous tissue is easily pulled through the ipsilateral stab wound using forceps (Fig. 14.5). The adhered tissue is dissected from the holding fibrous septa using Metsenbaum scissor (Fig. 14.6). The ipsilateral stab wounds serves as a conve nient access site for the removal of the remaining

Fig. 14.4 Endoscope is introduced through the contralateral incision

Fig. 14.2 Cross-chest injection of the tumescent solution using a long, blunt, multiport needle inserted through two periareolar incisions

Fig. 14.3 Power-assisted liposuction of the entire chest wall is done

Fig. 14.5 Fibrous glandular tissue is easily pulled through the ipsilateral stab wound using forceps

14 Gynecomastia Repair Using Power-Assisted Superficial Liposuction and Endoscopic Assisted Pull-Through Excision 141

binder smoothly, without folds, to keep the patient’s skin. The patient is instructed not to remove the binder for 3 days. He can take his first shower without the binder after 3 days, but, the binder should be applied again immediately and should be worn continuously till his next appointment visit 2 weeks after the operation.

14.3 Complications

Fig. 14.7 Endoscopic view of the pectoral fascia at the end of the procedure

All our patients recovered remarkably well. No complications such as nipple–areola complex necrosis, epidermolysis, seroma, hematoma, infection, saucer deformity, or contour irregularities were recorded. Scars were inconspicuous, since the small periareolar incisions give well camouflaged scars within the margins of the areola, avoiding the stigma of the traditional gynecomastia surgery (Fig. 14.8). All patients were satisfied with their results, having a smooth, masculine breast contour. The results were not affected by the original grading of the gynecomastia (Figs. 14.9–14.11) Long-term follow-up showed that results were stable, and no revisions were necessary. Histologic analysis of the resected specimens revealed a benign hypertrophy consistent with gynecomastia. There was no evidence of malignancy in any of the specimens.

parenchyma, which is located usually under the nipple–areola complex, and around it. The excision is controlled by the endoscope, which enables: adequate removal, good bleeding control, and preservation of the pectoral fascia. A uniform and smooth pectoral fascia can be seen through the endoscope at the end of the procedure (Fig. 14.7). One or two dermal 4–0 Monocryl sutures (Ethicon, Inc., Somerville, N.J.) are used to close each incision site. Drains are not used, as the endoscopic view enables us a meticulous bleeding control. Steri-Strips (3M, Minneapolis, Minn.) and a gauze dressing are then applied. A 9” unisex one-piece waistbinder (Caromed surgical garments, Mentor, Santa Barbara, CA) is placed under the patient’s back, while the patient is still in the supine position, and closed over the chest wall. A special care is taken to apply the

Fig. 14.8 The small periareolar scars are hardly noticeable after 2 months

Fig. 14.6 Metsenbaum scissor dissecting the glandular tissue from the attached fibrous septae

142 Fig. 14.9 (a) Preoperative grade I gynecomastia. (b) Postoperative following gynecomastia repair

Y. Ramon and Y. Ullmann

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14.4 Discussion Adequate management of gynecomastia needs to fulfill a dual challenge: total removal of the breast tissue and minimal perceptible stigma of breast surgery. The proposed technique accomplishes both of these tasks consistently, no matter what grade of gynecomastia the patient started with. The small lateral and medial stab incisions in each periareolar region serve : injection of the tumescent fluids, liposuction of the chest wall, pull-through excision of the fibrous tissue, and introduction of the endoscope. The resulting periareolar scars are hardly noticeable after scar maturation, thus, leaving no stigma of breast surgery. Cross-chest liposuction above the sternum through these holes is much more convenient than the inframammary or axillary access, since there is no need to work

against the convexity of the chest wall. These incisions allow good access site for the endoscope all the way to the contralateral breast, directly over the sternum. Power-assisted liposuction effectively removes the fat tissue out of the fibrous parenchymal framework of the breast. The remaining fibrous breast is then easily mobilized and sharply excised via the two 7-mm periareolar incisions. The removal of this tissue under endoscopic supervision facilitates precise control of the resection, decreasing the potential for contour defects and the risk of hematoma formation due to uncontrolled bleeding. The extensive superficial liposuction over the entire chest wall, using the 3 mm cannula, enhances skin contraction, and eliminates the need for skin resection that may leave the patient with long and noticeable scars. Power-assisted liposuction offers several advantages in the treatment of gynecomastia, over both

14 Gynecomastia Repair Using Power-Assisted Superficial Liposuction and Endoscopic Assisted Pull-Through Excision 143 Fig. 14.10 (a) Preoperative. (b) Postoperative

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Fig. 14.11 (a) Preoperative. (b) Postoperative

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conventional and ultrasonic liposuction. It is physically less strenuous and much more effective in treating the fibrous areas compared with the traditional liposuction, without the tendency for seroma formation, and entrance site burn, de scribed as possible consequences of the ultrasonic liposuction.

14.5 Conclusions According to our experience, this multimodality technique is easy to perform, no revisions are necessary, and it avoids complications encountered with the commonly used gynecomastia repair techniques. A smooth masculine breast contour is consistently achieved without the stigma of breast surgery.

References 1. Teimurian B, Perlman R. Surgery for gynecomastia. Aesthetic Plast Surg. 1983;7(3):155–7. 2. Lewis OM. Lipoplasty: treatment for gynecomastia. Aesthetic Plast Surg. 1985;94:287–92.

Y. Ramon and Y. Ullmann 3. Courtiss EH. Gynecomastia: analysis of 159 patients and current recommendations for treatment. Plast Reconstr Surg. 1987;79(5):740–53. 4. Rosenberg GJ. Gynecomastia: suction lipectomy as a contemporary solution. Plast Reconstr Surg. 1987;80(3):379–86. 5. Cohen IK. Gynecomastia: suction lipectomy as a con temporary solution (Discussion). Plast Reconstr Surg. 1987;80(3):386. 6. Samdal F, Kleppe G, Aabyholm F. A new suction-assisted device for removing glandular gynecomastia (Letter). Plast Reconstr Surg. 1991;87(2):383–5. 7. Rohrich RJ, Ha RY, Kenkel JM, Adams WP. Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction. Plast Reconstr Surg. 2003; 111(2):909–23. 8. Young VL. Plastic surgery educational foundation DATA committee: power-assisted lipoplasty. Plast Reconstr Surg. 2001;108(5):1429–32. 9. Gasperoni C, Salgarello M, Gasperoni P. Technical refinements in the surgical correction of gynecomastia. Ann Plast Surg. 1998;44:455. 10. Ohyama T, Takada A, Fujikawa M, Hosokawa K. Endoscopeassisted transaxillary removal of glandular tissue in gynecomastia. Ann Plast Surg. 1998;40(1):62–4. 11. Morselli PG. “Pull-through”: a new technique for breast reduction in gynecomastia. Plast Reconstr Surg. 1996;97(2):450–4. 12. Hammond DC, Arnold JF, Simon AM, Capraro PA. Com bined use of ultrasonic liposuction with the pull-through technique for the treatment of gynecomastia. Plast Reconstr Surg. 2003;112(3):891–5. 13. Walden JL, Schmid RP, Blackwell SJ. Cross-chest lipoplasty and surgical excision for gynecomastia: a 10-year experience. Aesthetic Surg J. 2004;24:216.

Mastopexy Complications

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Melvin A. Shiffman

15.1 Introduction Each form of mastopexy has its own types of complications. Some general principles from many years of past experience are presented to help the surgeon minimize and possibly avoid the complications.

15.2 Complications 15.2.1 Asymmetry Most patients have some asymmetry before surgery and it should be specifically discussed with the patient. Correction of the asymmetry can be performed at the time of surgery. Sometimes the postoperative asymmetry is from the procedure because of improper marking, not following the original markings, or because there is uneven healing and scarring from the procedure.

15.2.2 Bleeding, Hematoma

bleeding is usually due to causes other than missing bleeders at the time of surgery. Clots can be dislodged from hypertension, coughing, or too much motion of the implant, especially with textured implants. Medications should be considered, especially aspirin and nonsteroidal antiinflammatory drugs (NSAIDS). The use of Toradol after cosmetic procedures is a breach of the standard of care since it is a drug that will inhibit platelet reaction and cause bleeding. Hematoma should be treated immediately by evacuation and coagulation of active bleeders since distention of the tissues from the hematoma may result in tissue necrosis, especially of the nipple-areolar complex.

15.2.3 Bottoming Out (Fig. 15.1) Most mastopexies do not fix the breast to the chest wall by sutures and, therefore, the weight of the breast can cause inferior migration with “bottoming out” as the result. This will usually require fixation of the breast to the underlying pectoralis major fascia with permanent sutures to hold the breast in a high enough position and prevent future downward migration.

As with any surgical procedure, hemostasis at the time of surgery is important. However, postoperative

15.2.4 Flattening of the Breast M. A. Shiffman 17501 Chatham Drive, Tustin, CA 92780-2302, USA e-mail: [email protected]

The periareolar mastopexy is very prone to flattening of the breast and patients should be forewarned of this possible problem.

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Fig. 15.2 Necrosis and dehiscence following periareolar mastopexy and breast augmentation

15.2.6 Necrosis (Fig. 15.2) Necrosis, especially of the nipple-areolar complex, is unusual but can occur when the blood supply has been compromised (usually from prior breast surgery) or when there is infection or hematoma. Tight closure of the skin can result in necrosis if the vessels become stretched and thrombose causing interrupted blood supply. There is a slightly increased incidence of necrosis when breast augmentation is concomitantly used at the time of the mastopexy.

15.2.7 Pleating Fig. 15.1 Bottoming out after modified Arie Pitanguy mastopexy

15.2.5 Infection Possible infection can occur with any surgical procedure. With the inset of fever and/or erythema, the surgeon should always be aware of possible inflammation vs. infection. Usually, the patient is on antibiotics after surgery and a decision has to be made as to whether to increase the dose of the medication or start a different antibiotic. If there is drainage, then culture and sensitivity should be done and appropriate antibiotic utilized when the particular offending germ or germs is known. An abscess must be drained surgically and the cavity irrigated with saline. A drain (penrose or suction catheter) is usually necessary. If an implant is present, it should be removed if the pocket is involved and replaced at least 3 months after complete healing has occurred.

The effect of closing the periareolar type of mastopexy is prone to a “pleating effect” since the larger outer rim is attached to a shorter inner rim and the discrepancy results in pleating. This usually resolves without treatment in 6–12 months. However, when the pleating persists, the excess tissue may need to be excised taking care not to disrupt the circumareolar pursestring suture that holds the scar from spreading.

15.2.8 Poor Implant Position (Fig. 15.3) If a breast augmentation is performed with mastopexy, it is possible to place the implant in the proper position since the pocket is determined preoperatively with marking prior to the breast lift. This pocket position may need to be adjusted following the mastopexy and before the implant is placed or

15 Mastopexy Complications

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Fig. 15.4 Thickened scar following mastopexy

Fig. 15.3 Poor implant position following mastopexy

after the implant is in the pocket and the patient examined is in a sitting position.

15.2.9 Recurrent Breast Ptosis Recurrent breast ptosis is usually a problem of loose skin and gravity. Without fixation of the breast to the underlying pectoral major fascia by permanent sutures, the breast may descend postoperatively either within months or years.

15.2.10 Scar (Fig. 15.4) Any surgical scar can become hypertrophic or keloid. Tight skin closure may result in widening of the scar

except with the pursestring suture(s) of the periareolar mastopexy. The hypertrophic scar may resolve without treatment whereas the keloid scar may become a difficult problem to treat since it tends to recur in 80% of patients after treatment. Kenalog (10–20 mg) injection diluted with 5-fluorouracil, 50 mg, seems to work fairly well for hypertrophic scars and keloids but requires reinjection every few weeks. One must be careful to inject into the center of the scar to prevent leakage into the deeper fatty tissues with resultant steroid fat atrophy. If steroid fat atrophy occurs, then tumescence with saline solution that may be repeated in 30 days will usually resolve the problem.

15.3 Discussion It would behove the surgeon performing mastopexy to learn how to avoid and to treat the various possible complications.

History of Breast Reduction

16

Melvin A. Shiffman

16.1 Introduction The history of breast reduction covers the innovative techniques of surgeons around the world. The ability of surgeons to report on a variety of techniques to accomplish a cosmetic reduction in breast tissue shows perseverance in finding better ways.

16.2 History Durston [1] gave a description of gigantomastia occurring suddenly in a 23 or 24-year-old woman. This woman developed ulcerations of the breasts that were painful and became considerably larger [2]. In another publication the same year, Durston [3] described that she died and one breast weighed 64 pounds and the other about 40 pounds. No cancer was found. Dieffenbach [4] reported on aesthetic breast surgery involving a “small” incision in the SMF. Pousson [5] reported removing a crescent-shaped section from the upper anterior portion of the breasts in order to treat bilateral mammary hypertrophy. The skin and subcutaneous tissues were excised down to the pectoralis fascia and the breast elevated and suspended by suturing to the pectoralis fascia. Guinard [6] reported on a patient with macromastia using semicircular incisions in the submammary folds to remove a large amount of skin and breast tissue.

M. A. Shiffman 17501 Chatham Drive, Tustin, CA 92780-2302, USA e-mail: [email protected]

Morestin and Guinard [7] reported their experience with discontinuous resections of up to 1,400 g performed through an inframammary incision. Thorek [8] reported on breast amputation and free nipple graft. Kraske [9] described reduction of large breast. Aubert [10] performed resection and transposition of the nipple. Hollander [11] described an inferolateral excision of skin and breast tissue in order to eliminate the inframammary scar of the inverted T incision. Biesenberger [12] noted the importance of leaving subcutaneous tissue attached to the skin. He performed extensive undermining and severing of the suspensory ligaments (Cooper’s ligaments), and then wedge excisions of breast tissue in an inverted “S” shape involved the lateral aspect of the breast. This resulted in a high risk of skin and breast loss and the technique was largely abandoned. Schwarzmann [13] fashioned a periareolar “cutis bridge” for maintenance of the blood supply to the nipple. This allowed a superiorly based dermoglandular pedicle to revascularize the nipple-areolar complex. The Schwarzmann [14] maneuver was developed that involved cleavage between skin and gland, preserving a periareolar zone stripped of skin. Maliniac [15] used strips of dermis graft for stabilization of the breast. Maliniac [16] presented a two-stage breast reduction in order to preserve the blood supply. Bames [17] preserved the lateral and medial breast segments and resected the superior portion to preserve perforating vessels. Aufricht [18] introduced an inferior pedicle technique and showed a geometric method to plan the reduction rather than using a free hand method and preserving perforating vessels by preserving the lateral

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and medial segments of breast and resecting the superior portion. Reports on free nipple transplantation for reduction mammaplasty included Conway [19], Conway and Smith [20], Marino [21] and May [22]. Maliniac [23] did total gland excision, nippleareolar graft, and deepithelialized the inferior flap that was folded superiorly under the superior flap. Wise [24] devised a pattern to predetermine the shape of skin flaps (Fig. 16.1) and a horizontal dermal parenchymal bridge for the preservation of the arteriovenous and cutaneous nervous system from above and below the dermal pedicle. Arie [25] described a superior pedicle technique and Gillies and Marino [26] described the “periwinkle shell” (spiral rotation) technique for moderate ptosis. Strombeck [27] modified a keyhole pattern. He extended the concept of a dermal bridge technique, described by Schwarzmann [14] to reintroduce the dermal pedicle for nipple transposition. He used a pattern similar to that described by Wise [24]. This was a horizontal dermal pedicle that consisted of the dermis of the two, lateral pedicles to transpose the nipple and create a fibrous “balcony” to prevent postoperative ptosis. The skin and gland above the areola were excised. Pitanguy [28] performed a horizontal dermal bridge and “keel” shaped resection of the gland from the

Fig. 16.1 Wise pattern. The solid line is Wise’s technique compared to the dotted lines that are other authors’ techniques

M. A. Shiffman

inferior and central portions of the breast. Had excellent results when used for limited breast reductions (<300 g) and breast ptosis. Dufourmental and Mouly [29] introduced the lateral wedge resection of skin, fat, and gland with a resultant inferior oblique lateral scar. Preoperative markings were made in the supine position. Strombeck [30] reported the use of the horizontal bipedicle procedure for reduction mammaplasty. Pitanguy [31, 32] described the superior dermal pedicle technique. Wise et al. [33] used a modification of the breast amputation and nipple-areola transfer. Skoog [34] described a superior laterally based dermal flap separated from the gland at the subcutaneous level. He transposed the nipple on a unilateral skin flap disconnecting nipple from gland. This was an intermediate procedure to free nipple transplantation. Robertson [35] reported on the inferior flap mammaplasty in conjunction with free nipple grafting. Hoopes and Jabalay [36] described amputation with nipple areola transplant, and prosthesis. Hoopes [37] performed amputation and mammoplasty for gigantomastia using nipple areolar transplant and prosthesis. Hinderer [38] described dermopexy with reduction and reported attaching dermis strips to help fixate

16 History of Breast Reduction

the breast to the chest wall to support the breast in 1972 [39]. McKissock [40] described the bipedicle vertical pedicle for nipple transposition that had simplicity of design and safety. Lalardrie [41] reported a dermopexy with reduction “Dermal Vault” technique. Weiner et al. [42] described a modified superior dermal pedicle technique for nipple transposition. This technique cannot be used if the nipple site is to be more than 7.5 cm above its original position. Pontes [43] described removal of the lower half of the breast starting 2 cm below the inferior edge of the areola after de-epithelialization of the periareolar area and superior pedicle. The nipple-areolar complex is placed into position after closure of the breast. Regnault [44] reported on a reduction mammaplasty using the B technique that resulted in a lateral oblique scar without a medial extension. Lalarde [45] performed reduction with transposition of the nipple. Gsell [46] described a superior based dermal flap similar to the McKissock pedicle but transected at the inframmary end. This is risky since much of the blood supply to the parenchyma is transected. Nipple-areola necrosis may occur. Ribeiro [47] described an inferior pedicle technique. A vertical scar was avoided by bringing the nipple-areola complex under and through the superior skin flap and into position while tubing the inferior dermal pedicle. Orlando and Guthrie [48] described a superior medial dermal pedicle. de Castro [49] described a modified Pitanguy technique using curved incisions to define the medial and lateral breast flap borders and resection of the breast tissue on a horizontal plane. He believed this modification produced breasts that were less tense and more desirable in shape. Cramer and Chong [50] reported on a unipedicle cutaneous flap with Areolar-nipple transposition or an end-bearing, superiorly based flap. Weiner [51] described the modified superior pedicle technique. Wise [52] discussed nipple transposition vs. nipple transplantation. Courtiss and Goldwyn [53] described an inferior dermal pedicle technique as an alternative to free nipple-areola grafting in severe macromastia or ptosis. The inferior dermal pedicle extends transversely across

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the full length of the inframammary fold incision. A keyhole pattern, described by McKissock, was used. Robbins [54] described the inferior dermal pedicle technique. Georgiade et al. [55] performed reduction mammaplasty utilizing an inferior pedicle nipple-areola flap. Marchac and de Olarte [56] tried to prevent ptosis by fixation of the gland to the pectoral fascia. Ribeiro [57] reported on the inferior dermal pedicle technique. Meyer and Kesselring [58] described closure with an L-shaped suture line. Galvao [59] described a method of preserving the subdermal plexus of vessels with the nipple-areolar complex detached from the breast gland, leaving a completely free de-epithelialized superior and inferior based dermal pedicle with only the subcutaneous fat that is folded and the breast closed after resection of the gland. The nipple-areola complex is brought out through the new position after complete closure. Cardoso [60] used three dermal pedicles for nipple-areolar complex movement in reduction of gigantomastia. Hester et al. [61] performed breast reduction utilizing the maximally vascularized central pedicle. Renó [62] described the periareolar mastopexy. Teimourian et al. [63] reported on reduction mammaplasty with liposuction. Marshak [64] described a short horizontal scar mastopexy. Benelli [65] reported on the periareolar mastopexy described as the “round block” technique. Lejour et al. [66] introduced the vertical mammaplasty without an inframammary scar. Georgiade [67] reported on the inferior pedicle technique. Lejour and Abboud [68] described a vertical mastopexy without an inframammary scar combined with liposuction for breast reduction. Sampaio-Goes [69] described periareolar mammaplasty with the double skin technique. Menesi [70] reported on a distally based dermal flap for gland fixation. Renó [71] reported on reduction mammaplasty with a circular folded pedicle technique. Goes [72] performed the double skin technique with application of polyglactine or mixed mesh to fix the gland with allogenic mesh using a circular flap of dermis with a central pedicle.

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16.3 Discussion The progression of techniques and modifications of techniques speaks of the ingenuity of surgeons over the years. Cosmetic breast surgery of mastopexy and breast reduction is a continuously changing specialty and surgeons should maintain vigilance over the medical literature and attend meetings to keep up with these advances.

References 1. Durston W. Concerning a very sudden and excessive swelling of a woman’s breasts. Phil Trans R Soc London. 1970;4:1047–9. 2. Durston W. Observations about the unusual swelling of the breasts. Phil Trans R Soc London. 1970;4:1049–50. 3. Durston W. Concerning the death of the big-breasted woman. Phil Trans R Soc London. 1970;4:1068–9 4. Dieffenbach JF. Die Extirpation der Bruestdruese. In: Dieffenbach JF, editor. Die operative Chirurgie. Leipzig: Brockhaus; 1848. p. 359–73. 5. Pousson: Bulletin et Memoire de la Societe de Chirurgie de Paris 1897. 6. Guinard: Societe de Chirurgie de Paris 1903. 7. Morestin H, Guinard A. Hypertrophie mammaire traitee par la reduction discoide. Bull Soc Chir (Paris). 1908;33:649. 8. Thorek M. Possibilities in the reconstruction of the human form. N Y Med J. 1922;116:572. 9. Kraske II. Die Operation der atropischen und hypertrophi schen Hängebrust. Münch Med Wschr. 1923;60:672–3. 10. Aubert V. Hypertrophie mammaire de la puberte. Resec tion partielle restauratrice. Arch Franco-Belg Chir. 1923; 3:284–9. 11. Hollander E. Die Operation der Mammahypertrophie und der Hängebrust, Deutsch Med Wschr. 1924;50:1400. 12. Biesenberger H. Eine neue Methode der Mammaplastik. Zbl Chir. 1928;38:2382–7. 13. Schwartzmann E. Die Technik der Mammaplastik. Chirurgica 1930;2:932–43. 14. Schwartzmann E. Beitrag zur Vermeidung von Mamillen nekrose bei einzeitiger Mammaplastik schwerer Fälle. Rev Chir Struct. 1937;7:206–9. 15. Maliniac JW. Breast deformities. Anatomical and physiological considerations in plastic repair. Am J Surg. 1938; 39:54. 16. Maliniac JW. Two-stage mammaplasty in relation to blood supply. Am J Surg. 1945;68:55. 17. Bames H. Reduction of the massive breast hypertrophy. Plast Reconstr Surg. 1948;3:560. 18. Aufricht GL. Mammaplasty for pendulous breasts: empiric and geometric planning. Plast Reconstr Surg. 1949;4(1): 13–29. 19. Conway H. Mammaplasty: analysis of 110 consecutive cases with end results. Plast Reconstr Surg. 1952;10(5):303–15.

M. A. Shiffman 20. Conway H, Smith J. Breast plastic surgery: reduction mammaplasty, mastopexy, and mammary construction; analysis of two hundred forty-five cases. Plast Reconstr Surg. 1958; 21(1):8–19. 21. Marino H. Glandular mastectomy: immediate reconstruction. Plast Reconstr Surg. 1952;10(3):204–8. 22. May H. Breast plasty in the female. Plast Reconstr Surg. 1956;17(5):351–7. 23. Maliniac JW. Use of pedicle dermo-fat flap in mammaplasty. Plast Reconstr Surg. 1953;12:110–5. 24. Wise RJ. Preliminary report on method of planning the mammaplasty. Plast Reconstr Surg. 1956;17:367–75. 25. Arie G. Una nueva tecnica de mastoplastia. Rev Lat Amer Cirug Plast. 1957;3:23–38. 26. Gillies H, Marino H. L’opération en colimaçon ou rotation spirale dans les ptoses mammaires modérées. Ann Chir Plast. 1958;3:90. 27. Strombeck JO. Mammaplasty: report of a new technique based on the two pedicle procedure. Br J Plast Surg. 1960;13:79–90. 28. Pitanguy I. Breast hypertrophy. In: Wallace AB, editor. Transactions of the international society of plastic surgeons. 2nd ed. Edinburgh, UK: E&S Livingstone; 1960. p. 509–22. 29. Dufourmentel C, Mouly R. Plastie mammaire par la methode oblique. Ann Chir Plast. 1961;6:45–58. 30. Strombeck JO. Mammaplasty: report of a new technique based on the two-pedicle procedure. Br J Plast Surg. 1961;13:79–90. 31. Pitanguy I. Mammaplastias estudio de 245 casos consecutivos e apresentacao de tecnica pessoal. Rev Bras Cirurg. 1961;42:201–20. 32. Pitanguy I. Une nouvelle technique de plastie mammaire. Etude de 245 cas consecutifs et presentation d’une technique personelle. Ann Chir Plast. 1962;7:199–208. 33. Wise RJ, Gannon JP, Hill JR. Further experience with reduction mammaplasty. Plast Reconstr Surg. 1963;32:12–20. 34. Skoog T. A technique of breast reduction. Acta Chir Scand. 1963;126:453–65. 35. Robertson DC. The technique of inferior flap mammaplasty. Plast Reconstr Surg. 1967;40(4):372–7. 36. Hoopes JE, Jabaley ME. Reduction mammaplasty: amputation and augmentation. Plast Reconstr Surg. 1969; 44(5):441–6. 37. Hoopes JE, Jabaley ME. Amputation and mammoplasty for gigantomastia. Mod Med. 1971;22:137–8. 38. Hinderer UT. Plastia mamaria modelante de dermopexia superficial y retromamaria. Rec Esp Cir Plast. 1971;5(1):65. 39. Hinderer UT. Remodelling mammaplasty with superficial and retromammary dermopexy. In: Transacta der III Tatung der Vereinigung der Deutschen Plastischen Chirurgen, Koln 1972. p. 93. 40. McKissock PK. Reduction mammaplasty with a vertical dermal flap. Plast Reconstr Surg. 1972;49(3):245–52. 41. Lalardrie JP. The “dermal vault” technique. Reduction mammaplasty for hypertrophy with ptosis. In: Transacta der III Tagung der Vereinigung der Deutschen Plastischen Chirurgen, Ko·ln 1972: p. 105–8. 42. Weiner DL, Aiache AE, Silver L, Tittiranonda T. A single dermal pedicle for nipple transposition in subcutaneous

16 History of Breast Reduction mastectomy, reduction mammaplasty, or mastopexy. Plast Reconstr Surg. 1973;51(2)115–20. 43. Pontes R. A technique for reduction mammaplasty. Br J Plast Surg. 1973;26:365–70. 44. Regnault P. Reduction mammaplasty by the “B” technique. Plast Reconstr Surg. 1974;53(1):19–24. 45. Lalardrie JP, Jouglard JP. Chirurgie plastique du sien. Paris: Masson et Cie; 1974. 46. Gsell F. Reduction mammaplasty for extremely large breasts. Plast Reconstr Surg. 1974;53(6):643–6. 47. Ribeiro L. A new technique for reduction mammaplasty. Plast Reconstr Surg. 1975;55(3):330–4. 48. Orlando J, Guthrie R. The superomedial dermal pedicle for nipple transposition. Br J Plast Surg. 1975;28(1):42–5. 49. de Castro CC. Mammaplasty with curved incisions. Plast Reconstr Surg. 1976;57(5):595–600. 50. Cramer L, Chong J. Unipedicle cutaneous flap: Areolanipple transposition or an end-bearing, superiorly based flap. In: Georgiade NG, editor. Reconstructive breast surgery. St. Louis: Mosby; 1976. p. 143. 51. Weiner DL. Reduction mammaplasty with a single supe rior dermal pedicle. In: Plastic and reconstructive surgery of the breast. Goldwyn RM, editor. Boston: Little Brown; 1976. 52. Wise RJ. Treatment of breast hypertrophy. Clin Plast Surg. 1976;3(2):2879–300. 53. Courtiss EH, Goldwyn RM. Reduction mammaplasty by the inferior pedicle technique: An alternative to free nipple and areola grafting for severe macromastia or extreme ptosis. Plast Reconstr Surg. 1977;59(1):500–7. 54. Robbins TH. A reduction mammaplasty with the areolanipple based on an inferior dermal pedicle. Plast Reconstr Surg. 1977;59(1):64–7. 55. Georgiade NG, Serafin D, Morris R, Georgiade G. Reduction mammaplasty utilizing an inferior pedicle nipple-areola flap. Ann Plast Surg. 1979;3(3):211–8. 56. Marchac D, De Olarte G. Reduction mammaplasty and correction of ptosis with a short inframammary scar. Plast Reconstr Surg. 1982;69(1):45–55. 57. Ribeiro L, Backer E. Inferior based pedicles in mammoplasties. In: Georgiade NG, editor. Aesthetic breast surgery. Baltimore: Williams & Wilkins; 1983. p. 260. 58. Meyer R, Kesselring U. Reduction mammoplasty (twelve years’ experience with the L-shaped suture line). In: Georgiade

153 NG, editor. Aesthetic Breast Surgery. Baltimore: Williams & Wilkins; 1983. p. 219. 59. Galvao MSL. Reduction mammaplasty with preservation of the superior, medial, lateral, and inferior pedicles. In: Georgiade NG, editor. Aesthetic Breast Surgery. Baltimore: Williams & Wilkins; 1983. p. 175. 60. Cardoso AD, Cardoso AD, Pessanha MC, Peralta JM. Three dermal pedicles for nipple-areolar complex movement in reduction of gigantomastia. Ann Plast Surg. 1984; 12(5): 419–27. 61. Hester TR Jr., Bostwick J III, Miller L, Cunningham SJ. Breast reduction utilizing the maximally vascularized central pedicle. Plast Reconstr Surg. 1985;76(6);890–900. 62. Renó WT. Mamaplastia periareolar em cone. Presented at 2nd Congresso Brasileiro de Cirurgia Plástica, Sessão PingaFogo, Gramado, Brazil: 1985. 63. Teimourian B, Massac E Jr, Wiegering CE. Reduction suction mammaplasty and suction lipectomy as an ad junct to breast surgery. Aesthetic Plast Surg. 1985;9(2):97–100. 64. Marchac D, Sagher U. Mammaplasty with a short horizontal scar. Evaluation and results after 9 years. Clin Plast Surg. 1988;15(4):627–39. 65. Benelli L. Technique de plastie mammaire: le “round block.” Rev Fr Chir Esthet. 1988;50:7. 66. Lejour M, Abboud M, Declety A, Kertesz P. Reduction des cicatrices de plastie mammaire: De l’ancre courte a la verticale. Ann Chir Plast Esthet. 1989;35:369. 67. Georgiade G, Riefkohl R, Georgiade NG. Inferior dermalpyramidal type breast reduction: long-term evaluation. Ann Plast Surg. 1989;23(3):203–11. 68. Lejour M, Abboud M. Vertical mammoplasty without inframammary scar and with liposuction. Perspect Plast Surg. 1990:4:67. 69. Sampaio-Goes JC. Periareolar mammaplasty double skin technique. Breast Dis. 1991;4:111. 70. Menesi L. Mammaplasty with dermal flap. Transactions of the Xth Congress of the IPRS. vol III. Madrid: Elsevier Science; 1992. p. 122. 71. Renó WT. Reduction mammaplasty with a circular folded pedicle technique. Plast Reconstr Surg. 1992;90:65. 72. Goes JC. Periareolar mammaplasty: Double skin technique with application of polyglactine or mixed mesh. Plast Reconstr Surg. 1996;97(5):959–68.

Strombeck Breast Reduction Technique

17

Pierre F. Fournier

17.1 Introduction Choosing a technique of breast reduction today may be difficult for a young plastic surgeon. Will he choose a lateral technique or a technique with an inverted T? A bipedicle technique, horizontal, or vertical? With one pedicle or two pedicles? Oblique, superior, or inferior? With skin undermining or no skin undermining? Which technique is the safest and gives the best results? Some techniques are praised and others are denigrated by experienced surgeons with a reliable opinion and an authority in breast reduction. The choice of the young surgeon is in addition more difficult in the apparent difficulties of the techniques that are described. But is it the technique which is a bad or the surgeon? The author believes anyhow that the situation is simple. Around 1960, this situation changed radically with the publication of Strömbeck [1] and his new concepts, in breast reduction surgery. His concept simplified the situation and were so successful that they have been copied, modified, adapted, faked up, disguised, republished, that his original technique is confused or mistaken and found with difficulty, in the middle of plagiarisms or modifications. The author believes that in breast reduction surgery, we can distinguish: Before Strömbeck and

in this difficult surgery that he has greatly simplified and made safer for the surgeons and for the patients.

17.2 Before Strömbeck Breast reduction techniques were very numerous and large undermining with glandular remodelling was necessary. The consequence of such techniques was very complicated; bleeding hematomas, necrosis of the different mammary tissues, or wound disruption. Evidently, it was impossible to have good results in many cases but an operation for breast reduction was often an adventure for the surgeon, even with an experienced one, as well as for the patient. The most common technique used at that time was the Biesenberger [2] technique and the lateral technique described by Marc [3].

17.3 After Strömbeck The situation changed radically when Strömbeck described his two principles:

We should credit those who make science and it is sometimes difficult to distinguish them. The author wishes to give to Strömbeck the place that he deserves

1. The dermal glandular resection has to be done as a block of tissue without any undermining, perpendicularly to the skin. 2. The areola and nipple are supplied by the skin and the flap on which the nipple may be carved (or cut?), in any direction, in the breast tissue.

P. F. Fournier 55 boulevard de Strasbourg, Paris 75010, France e-mail: [email protected]

In his technique, the flap is horizontal or curved with an upper concavity. The final result is a scar as an anchor with a superior resection of slight importance. This bipedicle flap, if necessary, could be severed. As

After Strömbeck

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_17, © Springer-Verlag Berlin Heidelberg 2010

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Fig. 17.1 Thorek amputation technique. 1 The lower side of the second rib is marked as well as the meridian line and the submammary sulcus. 2 Submammary skin glandular tissue resection. 3 After nipple–areolar graft

time passed, sectioning this flap was done frequently and Strömbeck decided to increase the base of this flap with an additional deepithelialization to give more safety to this part of the operation. The Strömbeck technique has been developed for big breast, with a long pedicle and in moderately hypertrophied breasts or mild hypertrophies with ptosis, the pedicle is short and needs to be sectioned to be placed in a higher position easily. Origin of the Strömbeck technique: The amputation technique of Thorek [4] (Fig. 17.1) In large hypertrophied breasts with ptosis, the treatment of choice was the bloc amputation with areolar

nipple graft. This operation was easy and quick, the only hazard was the “take” of the areolar nipple graft. Aesthetic results were good since Thorek, in 1922, added to the inferior resection, a superior wedge-shaped resection giving more conicity to the mammary gland. This Strombeck technique is always good even today in large breast hypertrophy and gigantomastia. In the majority of the cases that the author has to treat, with or without ptosis, are average hypertrophies. Evenif a patient accepts a possible risk of a nipple– areolar necrosis for a gigantomastia, she will not accept this risk with an average hypertrophy and the surgeon will not accept the risk as well.

17 Strombeck Breast Reduction Technique

As a flap bearing the nipple–areola is much safer than a free graft, Strömbeck decided to do (instead of a free graft as it is done in Thorek technique) a flap carrying the nipple–areola complex. In the beginning, it was a bipedicle flap and later he decided to cut one side of this flap and to increase the deepithelialization of the base of this flap. Then, it was possible to easily place the nipple–areola complex in a higher position. Block amputation of the mammary gland was a safe procedure with Thorek technique and has not been changed by Strömbeck. But with Strömbeck placing the nipple–areola complex in a high position, this operation became easy and safe with the Strömbeck bipedicle technique or with the one pedicle technique with increased deepithelialization of the base of the pedicle when it was necessary. Sir Harold Gillies: A graft is a piece of skin completely detached from the place where we took it, which is dead when you put it on and which comes back to life after. A flap is a piece of skin, which is incompletely detached from where you took it, which is alive when you put it on and who may die later.

If Strömbeck started from Thorek amputation technique, for what is the dermal glandular resection, he has improved this technique transplanting the nipple– areola complex with a bipedicle flap with upper concavity first, and later when this flap was too short, he did not hesitate to section it, usually the lateral pedicle, to be able to rotate more easily without any tension on this flap. For more safety, when the surgeon has to section this pedicle, he should not hesitate, as Strömbeck did later to deepithelialize the base of this pedicle to increase the deepithelialized surface on one side. When the pedicle is long, this deepithelialization has to be increased on both sides even when it is unnecessary to section one of them. The nipple–areola complex will be transposed easily as both flaps are very long. Since this last technical improvements, section of one pedicle after increasing the deepithelialized portion of its base, practically all cases of pure ptosis with average or important hypertrophy or even gigantomastia may be treated with this technique. Montaigne, the French philosopher and writer of the 1800s:

157 Who ever saw a physician using the recipe of one of his peers without adding or removing something.

A short time after Strömbeck publication, one can see, in the surgical literature, minor modifications of the original technique of Strömbeck. They are named technique of Doctor… or of Professor… Such techniques are offered and praised as better than Strömbeck technique. We do not want to call such authors plagiarists but the humble modifications that they brought to Strömbeck technique even if the details that they offer are interesting and reliable, do not deserve to have their name given to this modification and to be proposed as “original techniques.” When looking at the diagrams of the newer “techniques,” there are similarities to the Strombeck technique (Fig. 17.2). The dermal glandular technique is rigorously identical to the Strömbeck technique, that is to say to the Thorek technique. Only, the transposition of the nipple–areola flap is different. The pedicle may be a bipedicle vertical instead of a horizontal one or a slightly upward concave one or after section of the medial implantation, a single pedicle with a lateral pedicle instead of a medial pedicle, an upper flap, a lower flap, or a wide deepithelialization around the areola, creating a vital pedicle that will be buried after the inferior and intraglandular resection are performed. Such techniques are not new. They only consist in minor modification of the emplacement of the flaps bearing the nipple–areola complex, associated with a dermal glandular resection identical to the Strömbeck technique only slightly modified. Such “techniques” have no other interest than to complicate the understanding of this operation for a surgeon beginning to learn breast reduction. Strömbeck has completely modifiedthe surgery of breast reduction, and all the modification procedures of the flap bearing the nipple–areola complex to a higher position do not change the concept of breast reduction given by Strömbeck even if they may be interesting. They do not deserve the name of a technique that may only be of “a different way to transpose the nipple–areola complex.” Strömbeck is the only one to have made a giant step in the surgery of breast reduction bringing simplicity and safety. His principles are also adopted when doing a modern lateral technique.

158 Fig. 17.2 Inverted T techniques (anchor shape scar) drafted from Strömbeck technique. All of them are variations of the nipple– areolar complex transposition. 1 External pedicle. 2 Long upper pedicle. 3 Sharp upper pedicle. 4 Vertical bipedicle. 5 Lower pedicle. 6 Extended periareolar deepithelialization without pedicle

P. F. Fournier

17 Strombeck Breast Reduction Technique

17.4 Preoperative Marking A good drawing will give a good result and all the steps of the operation will be easy. The immediate result and late result will be good. We could compare a breast reduction operation for pure ptosis, pure hypertrophy, or ptosis with hypertrophy to the readjustment of a garment too ample, after measuring, drawing, making pattern, cutting according to this pattern, and assembling and saving together the different parts of the pattern. During such steps, the most important will be done by the fashion designer, the surgeon. The sewing work, long and tedious, whose future is dictated but who needs less experience, will be given to the assistants whose work has to be excellent and faultless. The final aesthetic result as well as its duration in time cannot be identical with all patients, and it will be necessary to explain this to the patients before the operation, and this may be sometimes difficult. A good result, aesthetically speaking as well as its duration in time, depends on one side of the work of the surgeon and consequently of the drawing, and on another side of the patient herself and of the tissues that she offers for the operation (Fig. 17.3). Even if the marking is perfect, the breast obtained will not be identical in a woman of small stature, mature, multiparous with a thorax that may be too short or too wide, the implantation of the breast may be high or low or too wide, the skin may be thin with striae, and the inner tissues may be predominately fatty. Another patient may be younger, taller, nulliparous with a thorax, with nice proportions, and the implantation of the breast may be in a normal situation and of normal surface, neither too large, neither too narrow with a skin of good quality, thick and without striae and whose deep tissues are made essentially of glandular tissue. We can say as the tailors say when making a garment: So is the material so will be the garment. The surgeon may say also: So are the tissues so will be the result.

A great painter with a mediocre model will never paint the “Venus of Botticelli” and the great sculptor of the Antiquity could have wonderful statues with blocks of marble of great quality easy to be carved, polished and that could not be spoiled with time. All this has to be explained to the patient, which also has to be well understood by her. A patient believes sometimes that

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all is possible in aesthetic surgery, showing to the surgeon ladies’ fashion magazines, requesting the breast of such or such model. The preoperative discussions are very important to avoid any unjustified claims of the patients. Together with a morphologic work, the surgeon has to do a psychological work. The marking gives, at the end of the operation, a scar as an anchor or an inverted T. The author has used the technique of Strömbeck for more than 40 years and this technique has not one single wrinkle. This marking can be also applied when using others techniques described by Skoog [5], Pitanguy [6], McKissock [7] or with an upper or lower pedicle, techniques that are only more others modifications of Strömbeck technique. The concept in modern breast reductions are: 1. Bloc resection of the skin and glandular tissue, only on the skin when we have a case of pure ptosis, on the skin and glandular tissue when we have cases of hypertrophy or ptosis with hypertrophy. 2. No skin undermining (or very little when necessary). Undermining severs Cooper’s ligaments and may give haematomas or necrosis. Marking the patient has to be done the night before the operation. The Wise pattern used by Strömbeck is unnecessary but may be useful at the beginning if it is adapted to the breast of the patient. It may be a source of errors and of bad results if it is used without being adapted to the breast. We have to do a tailor made work and not a ready made work.

All the markings used are wrong for 20% of patients, which is more or less due to the deformations of the tissues. The idea is to do marking adapted to the breast that we have to operate on, and this marking will be different according to the breast of the patient and the thorax of the patient. We have to use common point of reference. Moreover, in nose reduction, we have to respect the proportions of the nose between each others and the proportions of the nose on the face. In breast reduction, we have to respect the proper proportions of the breast in regard to the rest of the body. A centimeter tape, a marking pen, and metal rings of different diameters are necessary for the areola marking. The patient will be standing and not seated but the surgeon will be seated. The first thing to check is

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9

Fig. 17.3 1 The lower side of the second rib, the meridian line, and the submammary sulcus are marked. 2 On the meridian line, the center of the future areolar is marked as well as on the present areola, the circumference (circle) of the future areola. 3 An identical circumference (circle) is marked around the center of the future areola. 4 The distance AA’ from the lower side of the second rib to the upper part of the new areola is measured (marked) and a curved line with an upper concavity is traced (marked) below the inferior side of the new areola. This line is situated exactly at the middle of the AA’distance. 5 It is on this curved line that we mark the two halves of the present submammary sulcus and they have the same length as the original half sulcus. 6 From the meeting point (or check point), a straight line

will be drawn toward the new areola. 7 The angles of the new areola are joined by a curved line passing 1 cm above the areola that have to be transferred. The lower angles are joined by a curved line passing 2 cm below the limit of the areola that we have to transfer. 8 The circumference of the place of the new areola is increased with the distance between the upper angles (generally 4 or 5 cm), in horizontal direction and reach the final drawing, limiting the upper resection, the lower resection, and the pedicles that we have to deepithelialize. 9 If the pedicles are long, the widening of the base has to be marked. In case of short pedicle, the medial surface is broadened (increase) that has to be deepithelialized, and the external pedicle is cut

17 Strombeck Breast Reduction Technique

whether the shoulders are horizontal. If they are oblique, this is a cause of pseudo mammary asymmetry. After establishing horizontal shoulders, we have to check the implantation of the breasts on the thorax, whether it is high or low, and it is necessary to inform the patient about this. An eventual breast asymmetry may also exist preoperatively. Further examination of the thorax and the breast will be done at this time, checking the condition of the skin, whether it is thin or thick, striae or no striae, the surface of the areola, condition of the nipple normal, invaginated, or over developed, its color, and is there a scar from a previous operation. The surgeon should also palpate the consistence of the breast, whether it is pure firm gland tissue, fat without any consistence, or intermediary condition. The patient will be informed of the result of this examination. The midline of the body is traced first from the manubrium to the xyphoid process. Then, a horizontal line is traced again, on the second rib localized by palpation at the angle of Louis. The submammary sulcus is finally marked from the parasternal line to the anterior axillary line. This last marking has to be checked with the patient lying down as this sulcus is not always fixed but misplaced in a lower position in case of breast hypertrophy. The marking in the horizontal position will be adopted and this marking is usually 1 cm higher or more. This marking, with experience, has to be diminished as much as possible, on each side, mostly on the sternal side. The second intercostal space and sixth intercostal space are the upper and lower limits of projection of a nonptotic breast that is located between these two limits. The meridian of the breast has to be marked starting either 5 or 6 cm from the midline, on the collarbone or placing a centimeter a tape behind the neck, on the nape of the neck, each end of this tape held by the patient. The tape is passed on a line to the areolas. This line has to be very well traced; the areola has to be exactly on it on the meridian of the breast. Its symmetry has to be checked measuring it in relation with the midline. This line is prolonged below the areola and divided in two parts at the submammary sulcus. The two parts have to be measured and marked on the skin. Too lateral or too medial jeopardizes the harmony and proportions of the future breast.

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The placement of the center of the future areola has to be estimated finally. It will be on the breast meridian, and to find the true placement, one of the following maneuvers has to be done: 1. The forward projection on the meridian of the submammary sulcus; it is the most faithful maneuver. 2. By estimation (according the thorax and the degree of ptosis), this place is between 18 and 23 cm from the sternal notch, on a line starting from this place and crossing the meridian line. We have to remember that it is much better to place a new areola too low as it is always possible to correct it without scar sequelae. The reverse is not possible. 3. A horizontal line passing at the level of the mid portion of the arm or at the level of the xyphoid process after the ptosis has been corrected. 4. On a horizontal line passing at the level of the six rib. Radiographic studies of the projection of the areola, on a nonptotic breast have shown that it was at the level of the sixth rib. This sixth rib is identified by palpation of the angle of Louis. 5. Using the maneuver of Claoué: Asking the patient to contract the pectoralis major muscle with the patient having her hands on her hips and in the supine position. The placement is given by the crossing of the line of the cutaneous projection of the inferior part of the pectoralis major and of the meridian line. This is easily understood if we remember that the lowest palpable digitation of the pectoralis major is inserted on the sixth rib. With the arm in the anatomic position, a horizontal line passing at the level of the nipple is marked on the midline. Then, the patient raises both arms vertically, and a new horizontal line passing through the midline gives the new position of the areola. This maneuver is excellent but is good only for mild cases of breast ptosis. The difference between the two lines indicates the correction desired. The placement of the future areola is then marked with a point. When the place of the center of the areola is made and marked with a point, on the meridian line, we have to choose the diameter of the new areola to be transposed and we have to mark it on the areola of the

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ptotic breast. If the areola is small or of normal size (4–5 cm), we shall keep it as it is. The most common diameter is 5 cm, sometimes four but less, often. It is better to do a too large areola instead of a too small one. We ask the advice of the patient but we have to guide her. The diameter of the future areola chosen by the surgeon and the patient is marked with an incision line with a metal ring of appropriate diameter. This ring has its center above the nipple and is applied firmly for a few seconds on the breast tissue. The line created on the skin by the pressure will be marked immediately after the ring has been removed. This maneuver is done when the patient is lying down, when the breast is a large one, and that its weight could exaggerate the surface of the areola, which at the end of the operation should be too small. Next marking is on the meridian line with this ring, making an identical circle on the place chosen as center of the future areola. The length of this circle will be modified when the marking will be finished. Measure the distance between the upper line of the future areola that was just marked and the horizontal line passing at the level of the second rib. This distance is generally between 9 and 15 cm according to the thorax and the ptosis. A slightly curved line is traced, parallel to the inferior marking of the new areola, at the distance, which is the half of the upper measurement (that is to say 4.5–7.5 cm). On a normal breast seen on profile, the areola submammary sulcus distance is half of the distance from areola to the second rib. A point has to be marked on this curved line, toward each of its extremities. Such points are parted from the extremity of each submammary sulcus by a distance equal to the distance parting the point of crossing of the meridian line, from the extremity of the corresponding submammary sulcus. Once marked, such points will be joined to the homologous extremity of the submammary sulcus by a curved line with an upper convexity or sometimes a lazy S. Two such lines are the upper edge of the future submammary sulcus divided in two, the lower edge being the inferior portion of the submammary primary sulcus marked before and divided in two by the meridian line. The two points are then joined at the center of the new areola with an oblique line above and medial. Such two points will be later joined together by a curved line. This line, when at the level of the meridian line, will be 1 cm from the areolar

P. F. Fournier

marking to be excised. The points obtained by the crossing of the inferior side of the new areola by the oblique lines will be joined together by a curved line with an upper concavity that will be 2 cm from the upper side of the areola. Such four points and the lines joining (uniting) them are the limits of the cutaneous glandular bridge bearing the areola. All this surface is deepithelialized using conventional techniques or using the strip technique. The marking is finished except the final circumference of the placement of the future areola. The circumference delineating the areola will be increased by the distance between the two superior points placed on the inferior side of the areola using a metal ring of appropriated circumference. We have now: 1. An upper zone of resection. 2. A lower zone of resection. 3. A dermal glandular bridge bearing the nipple–areola complex with a medial and lateral pedicle. In many cases, the length of this cutaneous glandular bridge is not long enough and it is not possible to raise the areola into its new position. It is necessary then to deepithelialize the medial pedicle (the lateral one may also be used). The lateral pedicle will be sectioned completely and the areola will ascend without any problem. It is better to have only one pedicle with an excellent blood supply instead of two pedicles with a deficient blood supply. Such marking allows the surgeon to place the areola on an upper or a lower pedicle or to do a dermal mastopexy.

17.5 Surgical Technique (Figs. 17.4 and 17.5) General anesthesia with intubation. Often, this operation is done in two steps 1 week apart to avoid blood transfusion and for a short anesthesia. The patient is placed in a supine horizontal position on the table. The author starts on the right breast and from the same side of the patient; the left breast is operated on after the first one is finished. Deepithelialization is performed on the pedicles and if it is scheduled, on the additional surface, on their base. The second step is the upper resection of skin and glandular tissue. It is necessary to leave some

17 Strombeck Breast Reduction Technique

163

Fig. 17.4 1 Upper resection, the lower resection, and the two deepithelialized pedicles. 2 The external pedicle is sectioned. 3 Widening of the base of the pedicle has to be done if we intend to cut the external pedicle and deepithelialization has to be done at this place. 4 Final result

glandular tissue as Strömbeck advises. Resecting until the pectoralis major muscle may give an invaginated nipple. This resection is mostly useful to make room for the transplanted areola after the bearing flap has been sectioned. Hemostasis is done with electrical cautery during the whole operation. The lower resection that is the true resection is done secondly. Either side can be started on, it does

not matter! Under the base of the flap, the resection should be oblique. Only the dermis and a small amount of subcutaneous tissue have to be saved. After a careful hemostasis, the different elements are sutured together without any tension. A small conical piece of glandular tissue is resected between the upper and lower resection to allow the drainage of the upper resection.

164

P. F. Fournier

Fig. 17.5 Different possible pedicles when doing Strömbeck technique. 1 Long pedicles. 2 Long pedicles with widening of the deepithelialized base. 3 Short pedicles. 4 Short pedicles. The external pedicle may be cut completely without widening of the base. 5 Short pedicles with widening of the bases

If the marking has been correctly done, there are no special difficulties and no modifications to do. Should the surgeon believe that there is too much tension, he should resect some more glandular tissue even if necessary to go below the bearing flap.

Deep suture of Dexon® should give a firm breast with a low or very moderate tension. The skin on the T line is sutured with a subcuticular nylon suture reinforced by a few interrupted sutures. An over and over continuous suture is done on the

17 Strombeck Breast Reduction Technique

areola. Suction drainage is a must. All the skin sutures are done when the two breasts are completed. The surgeon will suture one breast and his assistant the second one. The breast tissue removed is weighed and placed in a sterile glass container filled with 500 mL normal saline. One container is used for each breast. This will allow an identical resection on both sides, whatever are the tissues resected, fat or gland. Fat and gland may be different in each breast and we are interested more by the volume resected than by the weight resected. The skin removed may be dissected and kept in a sterile container filled with normal saline and antibiotics, and kept in the deep freeze. This skin may be used later (3 weeks) in case of wound dehiscence or infection. The periareolar sutures are removed after 1 week. The intradermal suture is removed after 3 weeks and the interrupted sutures on the vertical part of the T, after 10 days.

165

17.8 Conclusions The Strömbeck technique is a very safe one, giving excellent results, with minor complications [7–10] (Figs. 17.6–17.8). The most important thing for the surgeon to do is to make very accurate markings preoperatively.

a

17.6 Postoperative Care The postoperative period is usually without problem. The drains are removed after 1 or 2 days. Antibiotics are given routinely. The patient may leave the hospital after 2 or 3 days. Blood is not given routinely. The breast tissue removed is sent for pathology study.

b

17.7 Complications Necrosis of the areola or of the glandular tissue is not part of the postoperative period as well as bleeding, as it was seen with procedures involving large skin undermining and glandular tissue removal. In case of large hypertrophy, the author may operate on the right breast first and 5 days later, on the second one. The marking on the second breast is kept visible until the second breast is done if we scratch the skin very slightly with the tip of a n 11 blade. The reasons are to avoid too long general anesthesia and a blood transfusion not desired by the patients.

Fig. 17.6 (a) Preoperative. (b) Postoperative after Strombeck reduction

166

a

P. F. Fournier

b

c

Fig. 17.7 (a) Preoperative. (b) One breast reduced to avoid blood transfusion and for a shorter anesthesia. (c) Left reduction done 1 week later

17 Strombeck Breast Reduction Technique

a

b

Fig. 17.8 (a) Preoperative. (b) Postoperative

167

References 1. Strombeck JO. Mammaplasty: report of a new technique based on the two-pedicle procedure. Br J Plast Surg. 1960;13:79–90. 2. Biesenberger H. Eine neue Methode der Mammaplastik. Zentrabl Chir. 1928;38:2382–7. 3. Marc H. La Plastie Mammaire par la “Methode Oblique”. Paris: G.Doing & Cie; 1952. 4. Thorek M. Possibilities in the reconstruction of the human form. N Y Med J. 1922;116:572. 5. Skoog T. A technique of breast reduction: transposition of the nipple on a cutaneous vascular pedicle. Acta Chir Scand. 1963;126:453–65. 6. Pitanguy I. Mammaplstias estudio de 245 casos consecutivos e apresentacao de tecnica pessoal. Rev Bras Cir. 1961;42:201–20. 7. McKissock PK. Reduction mammaplasty by the vertical pedicle flap technique: rationale and results. Clin Plast Surg. 1976;3(2):309–20. 8. Fournier PF. Un procedemiento de desepidermisacion. Secundo Congresso Argentino de Cirurgia Estetica, Buenos Aires, Marzo: 1974.Cite in: Ulrich T. Hinderer. 9. Fournier PF. The dermal brassiere mammaplasty. Clin Plast Surg. 1976;3(2):355. 10. Fournier PF. Un procédé pour désépithélialiser dans les réductions mammaires. In: Faivre J, editor. Rhinoplasties. Paris: Ptoses et Hypertrophies mammaires modérées; 1984. p. 263–8. 11. Fournier PF. La technique de Strömbeck. In: Faivre J, editor. Rhinoplasties. Paris: Ptoses et Hypertrophies mammaires modérées; 1984. p. 201–16.

Inverted Keel Resection Breast Reduction

18

Ivo Pitanguy and Henrique N. Radwanski

18.1 Introduction Patients presenting with breast hypertrophy invariably complain of physical discomfort, especially of the skeletal system. Psychological evaluation many times reveals a state of unhappiness and self-consciousness, and may result in difficult social adaptation. In warm climates, as in Brazil, where participation in outdoor activities and sports is stimulated year-round, and where the media promote the use of lighter and more revealing attire, aesthetic complaints because of large, cumbersome breasts become more relevant. In our country, breast hypertrophy is among the most common contour deformities that present for surgical correction. A personal modification of Arié’s technique was initially presented in 1959, and published the following year [1]. With the description of point A, which is the projection of the submammary sulcus along the mid-clavicular line, the vertical incision was extended above the nipple–areolar complex, with more satisfactory and longer-lasting results. Soon after, with the same principles, the Pitanguy technique [2], with the inverted keel resection, was developed for the treatment of large breast hypertrophy. These two procedures have served the purpose of approaching most aesthetic deformities of the breast, such as hypertrophy with or without ptosis, and represent the technical basis of many subsequent procedures. The senior author will focus on his techniques for breast reduction and for mastopexy that involve the

I. Pitanguy (*) Ivo Pitanguy Clinic, Rua Dona Mariana, 65, Rio de Janeiro 22280-020, Brazil e-mail: [email protected]

inverted keel approach to resection, covering a personal experience of over five decades. The following principles are emphasized: all resection is limited to the lower pole of the breast; no dissection of parenchyma is done, thus eliminating dead space and maintaining the intimate relationship between skin and parenchyma; the great feasibility of these procedures, allowing easy understanding and replication of the technique.

18.2 Historical Considerations The personal techniques for breast reduction were developed from comprehension of, and respect for, breast embryology. Breast buds develop from vertical thickening of the ectoderm, thus establishing an intimate relationship between skin and gland. The continuity between breast parenchyma and skin should be preserved in all breast reduction operations. This principle may be stated as such: the “continent” should not be separated from the “content.” In a historical context, previous techniques, principally the Biesengberger [3] approach, included extensive skin undermining, resulting in poor upper pole definition and ptosis in the postoperative follow-up, along with a high rate of complications. Other techniques, such as Lexer’s [4], and Arié’s [5], were quite popular, but they did not address the projection of the upper pole, and the results were generally lacking in producing a pleasing breast cone. This aspect has currently become more important with the popularization of breast augmentation, where patients seek specifically a fuller upper pole. The authors’ modification of Arié’s technique [1] described point A as the initial landmark, from which

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the other points are developed. With this concept, the lower pole undergoes a rotation to the upper pole, filling up the breast and assuring a long-term aesthetic result. Later, when the limitations of the single vertical scar were perceived in larger breasts, an improvement was presented utilizing the inverted keel resection, then called the Pitanguy technique, where a greater amount of skin and parenchyma can safely be removed, assuring the ascension of the nipple to a new position, where point A is located, and finishing with very acceptable scars. The technical points of interest in the teaching of my techniques are to: 1. Maintain function and sensibility 2. Achieve satisfactory volume and lasting form 3. Reduce scars 4. Allow a greater feasibility in teaching the techniques

18.3 Personal Technique 18.3.1 For Large Hypertrophy General anesthesia is almost always utilized. The patient is intubated and then placed in a semi-sitting position, flexed at 45° and with the arms outstretched. Two long sutures are placed along the midline, one at the sternal notch and the second at the xyphoid. These will help the surgeon check for symmetry during demarcation and at the end of the procedure. The mid-clavicular line is drawn, passing through the nipple–areola complex (NAC) all the way to the sulcus. Point A is determined along this line, at or slightly lower than the breast sulcus. This point determines the future position of the NAC. Points B and C are determined by pinching excess skin. They form a triangle with point A. The surgeon should, at this moment, feel how much tissue will be sufficient to allow for a pleasant final conical shape. Two strong hooks, on either side, help determine the amount of resection. The last two points, D and E, define the medial and lateral extension of the horizontal incision. Care should be taken not to extend beyond the midline and the anterior axillary line. The lines uniting these points are either straight, or curved when excess skin is present. The periareolar incision is done along the new diameter of the areola, previously determined with an

I. Pitanguy and H. N. Radwanski

appropriately sized demarcator. The area between points ABC is deepithelialized (Schwartzmann’s maneuver). This assures the maintenance of the dermal capsule of the superior pole, which is considered the third neurovascular pedicle of the NAC. Glandular resection is always restricted to the inferior pole and is straight when the breast is composed mainly of fatty tissue or in an inverted ship’s keel fashion if the parenchyma is more glandular. The inverted keel resection allows for the creation of two pillars, medial and lateral, that will be brought together after removal of adequate parenchyma. If a wedge-like space is not created in breasts that are very dense, bringing the remaining tissues together will cause excess tension and will also make it very difficult to ascend the NAC. The inverted keel addresses this by allowing the upper-pedicled NAC to slide upwards as the pillars are approximated. On the other hand, the straight resection in fatty breasts permits the ascension of the NAC because the two pillars will be defined once the assistant raises the remaining tissues using a long hemostatic forceps. After resection and hemostasis have been done, the operated breast is wrapped in moist towels and the same procedure is done on the opposite breast. The two are then lifted by the assistant, and inspected from a distance to compare remaining parenchyma, one side with the other. Tissues are now brought together with one main suture, bringing points ABC to the midline. Sutures are done from deep to superficial planes. The new position of the NAC is determined. The breast mound should be seen as a cone, with the NAC resting on its top. The NAC on both sides is demarcated and symmetry is checked once again, using the two long sutures. This is one of the main advantages of this technique: the surgeon feels that he is free to demarcate the new position of the NAC, and is not bound to fixed measures as in other techniques. When all excess skin has been trimmed and fine sutures placed, a useful procedure has been adopted in our service, which consists of a mold made of plaster, placed over the dressing, which guarantees the immobilization of the breast. It has been noted that this firm pressure has resulted in a very low rate of serosanguinous collection over the years. This plaster shield is removed in 24 h, when the breast is inspected. Placement of drains is not routinely used, as all dead space has been closed.

18 Inverted Keel Resection Breast Reduction

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18.4 The Rhomboid Technique (Figs. 18.1–18.3)

a pproximation of the two columns of breast tissue. Flap ischemia is also avoided, since no undermining is done between skin and parenchyma. A certain degree of hypesthesia of the NAC can occur, which usually resolves in the first 2 months postoperatively (Table 18.1).

18.4.1 For Moderate Hypertrophy, with or Without Ptosis This technique, also called the Arié-Pitanguy procedure, has an initial rhomboid demarcation and finishes with a single vertical scar. It has these indications: mild to moderate hypertrophy; breast ptosis; ptosis with hypoplasia (augmentation procedure). Initially, point A is determined as previously described, along the mid-clavicular line, at the level of the submammary sulcus. By pinching the medial and lateral skin on either side of the nipple, the surgeon “feels” how much skin must be removed, and points B and C are determined. Point D, which should not be lower than the sulcus, will complete the elliptical demarcation. The final incision is a vertical scar, ending at (or slightly below) the submammary sulcus. Resection can be restricted to skin when simple ptosis is present, or can include a variable amount of breast tissue from the lower pole, when the patient desires reduction of volume. As described in the classic technique, the inverted keel resection creates two pillars or columns. Once these are approximated, the superior pole is defined and the nipple will rise to the new position. The appropriate areola demarcator is chosen for placement of the NAC, which, again, is around the area of point A. The rhomboid technique is very suitable for resection of excess skin and placement of a breast implant, resulting in a single vertical scar. The surgeon should be careful to demarcate the excess skin envelope but not too much, as the implant will tend to fill up the breast cone. When necessary, the final vertical incision can be complemented with a small horizontal component, converting the single scar into an “L” or inverted “T” so as not to extend the scar beyond the sulcus (Figs. 18.4–18.6).

18.5 Complications of Breast Reductions The rate of complications for both techniques is very small, because all dead space is closed with the

18.6 Discussion These procedures have been adopted and systematized by the author producing satisfactory and predictable results with a very low rate of complications [6–14]. An important aspect of the breast reduction techniques is the relative ease with which it is taught. The feasibility of the technique is proven by the ease with which it is executed (Table 18.2). Sound anatomical principles and respect for physiology are the basis for these procedures. In breast reduction, as emphasized by the author since his first publications, resection of breast tissue is restricted to the lower pole. The vascularity and innervation of the NAC are thus preserved, and all dead space is closed with the approximation of remaining tissue. There is also little risk of flap or nipple ischemia, because breast parenchyma is not separated from overlying skin. Depending on the degree of breast hypertrophy, the surgeon may choose to perform either the rhomboid technique or the classic Pitanguy breast reduction technique. Although it is possible to apply the rhomboid approach to larger breasts, this is not recommended, since the single vertical scar will become quite long. It is therefore more appropriate to utilize the classic technique. In either case, the inverted keel resection has allowed for safe removal of excess parenchyma of the lower pole, facilitating the closure of remaining tissues, leaving no dead space and assuring the rising of the nipple to its new position. The periareolar approach has been mostly abandoned, as the final results have not been consistently favorable (Fig. 18.7). Plastic surgeons have noted that patients are requesting a fuller upper pole and this may be due to what the media has emphasized as the result of a breast augmentation. The two techniques allow for a projection of the superior aspect of the breast following rotation of the lower to the upper pole.

172

a

d

g

j

I. Pitanguy and H. N. Radwanski

b

c

e

f

h

i

k

l

18 Inverted Keel Resection Breast Reduction

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Fig. 18.2 (a1,2) Preoperative 26-year-old female. (b1,2) Postoperative after mastopexy done through the Pitanguy rhomboid procedure. Breast tissue was used to fill the upper pole Fig. 18.1 (a) Point A (also called Pitanguy’s Point) is found at the level of the submammary sulcus, along the mid-clavicular line. (b) A pinching maneuver allows the surgeon to estimate how much parenchyma should be removed. (c) Final demarcation is checked with long sutures and a compass. (d) Lines of resection are curved to permit removal of excess skin. (e) Finally, two strong hooks are pulled together to ascertain that demarcation is correct. (f) Deepithelialization around the nipple–areolar complex (NAC) (Schwartzmann’s maneuver) guarantees the vascular integrity of this important structure.

(g) Resection of breast tissue is always restricted to the lower pole. (h) A straight resection is indicated in breasts that are mostly fatty in nature. (i) The inverted keel resection should be applied to breasts that are mainly composed of glandular tissue. (j) With the inverted keel resection, the surgeon creates two pillars; this also allows the NAC to rise to its new position. (k) Closing of the pillars eliminates all dead space. (l) The final position of the NAC, which will lie around Point A, is not a fixed measurement, but depends on the aesthetic feeling of the surgeon

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a1

a2

b1

b2

Fig. 18.3 (a1,2) Preoperative 32-year-old female. (b1,2) Postoperative following Pitanguy rhomboid technique applied to large breasts

18 Inverted Keel Resection Breast Reduction

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a

b

c

d

Fig. 18.4 (a) The Pitanguy rhomboid technique has an elliptical shape of demarcation. (b) In smaller breasts, resection is restricted to skin. (c) An inverted keel resection in the rhomboid

technique is indicated for larger breasts. (d) Positioning of the NAC is done after checking for symmetry of the breasts

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a1

a2

b1

b2

Fig. 18.5 (a1,2) Preoperative 41-year-old female. (b1,2) Postoperative after reducing very large breasts with the classic Pitanguy approach (inverted keel)

18 Inverted Keel Resection Breast Reduction

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a1

a2

b1

b2

Fig. 18.6 (a1,2) Preoperative 25-year-old female with breast asymmetry. (b1,2) Postoperative following inverted keel approach

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Table 18.1 Breast hypertrophy: 1957–2006. Complications Breast Hypertrophy

1957−2006 Ivo Pitanguy Clinic − 3.476 casos th 38 Ward Santa Casa − 6,403 casos Total cases: 9,879

Complications

IPC

SC

Lesser Larger Lesser

1.3 0 0.1

6.0 1.2 2.0

Larger

Heamatoma

0.3 0.2

0.4 0.4

Hypertrophic scars

0.6

7.0

Dehiscence of incision Dehiscence of areola

Table 18.2 Breast hypertrophy: 1957–2006. Ages of patients Breast Hypertrophy 1957−2006 Total cases: 9,879 Ivo Pitanguy Clinic − 3.476 cases th 38 Ward of the Santa Casa − 6,403 cases

Idade

IPC

SC

10 – 19 years

4.0

11.0

20 – 29 years

26.0

33.0

30 – 39 years

32.0

29.0

40 – 49 years

21.0

50 – 59 years > − − 60 years

14.0

17.0 7.0

3.0

3.0

2. Pitanguy I. Une nouvelle technique de plastique mammaire: Estude de 245 cas consecutifs et presentation d’une technique personelle. Ann Chir Plastique. 1962;7(3): 199–208. 3. Biesenberger H. Eine neue methode der mammaplastik. Zentrabl Chir. 1928;38:2382–7. 4. Lexer E. Zur operation der mammahypertrophie und der hängebrust. Dtsch Med Wochenschr. 1925;51:26. 5. Arié G. Una nueva técnica de mastoplastia. Rev Latinoamericana Cir Plast. 1957;3:23. 6. Pitanguy I. Contribuição a técnica do enxerto livre para a correção das grandes hipertrofias mamárias. (Personal contribution to the free-grafting technique in very large breasts). Rev Lat Americana Cir Plástica. 1963;7(2):75. 7. Pitanguy I. Surgical treatment of breast hypertrophy. Br J Plast Surg. 1967;20(1):78–85. 8. Pitanguy I. The breast. In: Pitanguy I, editor. Aesthetic plastic surgery of head and body. Berlin: Springer; 1981. 9. Pitanguy I. Reduction mammaplasty by the personal technique. In: Chang WHJ, editor. The breast: an atlas of reconstruction. Baltimore: Williams & Wilkins; 1984. p. 75–160. 10. Pitanguy I. Personal preferences for reduction mammaplasty. In: Georgiade ND, editor. Aesthetic surgery of the breast. Philadelphia: WB Saunders; 1990. p. 167. 11. Pitanguy I. Principles of reduction mammaplasty. In: Georgiade ND, editor. Aesthetic surgery of the breast. Philadelphia: WB Saunders; 1990. p. 191. 12. Pitanguy I. Reduction mammaplasty: A personal odyssey. In: Goldwyn RM, editor. Reduction mammaplasty. Boston: Little Brown; 1990. p. 95. 13. Pitanguy I, Radwanski HN. Philosophy and principles in the correction of breast hypertrophy. In: Mang WL, Bull HG, editors. Ästhetische Chirurgie. Germany: Einhorn; 1996. p. 216–32. 14. Pitanguy I. Evaluation of body contouring surgery today: A 30-year perspective. Plast Reconstr Surg. 2000;105(4): 1499–514.

Further Reading

Fig. 18.7 Breast hypertrophy: 1957–2006. Techniques used

References 1. Pitanguy I. Breast hypertrophy. In: Wallace AB, editor. Transactions of the international society of plastic surgeons, second congress. Edinburgh: E. & S. Livingstone; 1960. p. 509.

1. Goin MK. Psychological aspects of aesthetic surgery of the breast. In: Georgiade ND, editor. Aesthetic surgery of the breast. Philadelphia: WB Saunders; 1990. p. 19. 2. Gifford S. Emotional attitudes toward cosmetic breast surgery: Loss and restitution of the “ideal self”. In: Goldwyn RM, editor. Plastic and reconstructive surgery of the breast. Boston: Little Brown; 1976. p. 103. 3. Rees TD. Concepts of beauty. In: Rees TD, editor. Aesthetic plastic surgery. Philadelphia: WB Saunders; 1980. p. 1. 4. Baroudi R. Preoperative evaluation for breast surgery. In: Georgiade ND, editor. Aesthetic surgery of the breast. Philadelphia: WB Saunders; 1990. p. 19. 5. McCarty KS Jr, Glaubitz L, Thienemann M, Riefkohl R. The breast: Embryology, anatomy and physiology. In: Georgiade ND, editor. Aesthetic surgery of the breast. Philadelphia: WB Saunders; 1990. p. 3.

Vaser-Assisted Breast Reduction

19

Alberto Di Giuseppe

19.1 Introduction Ultrasound energy has been applied to the adipose component of the breast parenchyma in case of breast hypertrophy to reduce the volume of the breast mold. As is known, ultrasound energy was initially used by Zocchi [1–6] to emulsify fat. A special instrument composed of an ultrasound generator, a crystal piezoelectric transducer, and a titanium probe transmitter was utilized to target adipocyte cell. This new technology was first applied to body fat to emulsify only fat cells while sparing the other supporting vascular and connective components of the cutaneous vascular network. More recently, Goes [7], Zocchi [1–6], Benelli [8] and the author [9–12], have started to apply this technology to the breast tissue to achieve breast reduction and correction of mild- to mediumdegree breast ptosis.

Between 60 and 70% of women with large breasts are candidates for reduction with UAL. Preoperative assessment includes a mammographic study, breast clinical history, evaluation of breast ptosis, and evaluation of the consistency of breast parenchyma.

19.3 Preoperative Mammography Preoperative mammograms (anteroposterior and lateral views), the so-called Eklund view, are taken to evaluate the nature and consistency of the breast tissue (fibrotic, mixed, or fatty parenchyma), the distribution of the fat, the presence of calcifications, and areas of dysplasia or nodularity that might necessitate further study or biopsy (Fig. 19.1). The presence of fibroadenomas, calcifications, and other suspected or doubtful radiologic findings should be double-checked with ultrasound and a radiologist experienced in breasttissue resonance.

19.2 Patient Selection The ideal candidate for breast reduction with ultrasoundassisted lipoplasty (UAL) is a patient with juvenile breasts, which are usually characterized by fatty parenchyma, or a patient with postmenopausal involution parenchyma, with good skin tone and elasticity present.

A. Di Giuseppe Department of Plastic and Reconstructive Surgery, School of Medicine, University of Ancona, 1, Piazza Cappelli, 60121 Ancona, Italy e-mail: [email protected] e-mail: [email protected]

19.4 Contraindications Patients with a history of breast cancer or mastodynia and fearful of potential sequelae from this new technique were not considered for the author’s study. Furthermore, because the amount of fat in the breast is variable as is its distribution, not all women are candidates for breast volume reduction with UAL. If fat tissue and glandular tissue are mixed, penetration of the tissue may be impossible, as noted by Lejour [13] and Lejour and Abboud [14]. If the breast tissue is primarily glandular, the technique is not indicated.

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180

a

A. Di Giuseppe

c

b

Fig. 19.1 Mammographic evaluation of candidates for breast reduction with the use of ultrasound-assisted lipoplasty (UAL). (a) A typical fatty breast. This patient is an ideal candidate for

UAL. (b) Fibrotic glandular tissue is a contraindication for UAL. (c) Fibrotic mixed tissue. This patient is a candidate for UAL of the posterior upper and lower cone

19.5 Infiltration Infiltration should be divided into the three different layers of the breast: deep, intermediate, and superficial (Fig. 19.2). In deeper and intermediate layers, there should be a 1.5:1 ratio between infiltration and aspirate. In the superficial layer, the author normally infiltrates twice of what is expected to be extracted (2:1 ratio). A blunt infiltration cannulas is used, as described by Klein, 15–20 cm long. It is essential a meticulous infiltration of the superficial layers, than wait 15 min minimum to allow adrenaline make its effect, before starting ultrasound. A total of 500 mL of infiltration fluid is infused; normally 400 mL is for deeper and intermediate layers and 100 mL for superficial.

port is designed to protect against friction injuries of the solid titanium probe during its continuous movement. The fatty breast is emulsified in the lateral and medial compartments, the upper quadrants, and the inferior aspect of the periareolar area. All the periareolar area, where most of the glandular tissue is localized (5 cm circumference around the nipple–areola complex) is preserved. The deep portion, mostly fat, is also emulsified, allowing the breast mold to regain a natural shape through upward rotation, thus increasing the elevation from initial position, taken from the mid-clavicular notch. Up to 4 cm of breast elevation is obtained after proper reduction and stimulation to allow skin retraction and correction of the ptosis.

19.6 Technique

19.7 Incisions

The operation begins with the introduction of the skin protector placed at the incision site, normally 1 cm below the inframammary crease (Fig. 19.3). This skin

Two 1.5–2.0 cm stab incisions, one at the axillary line and the other 2 cm below the inframammary crease, are made to allow entrance of the titanium probe.

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Fig. 19.3 Skin ports

Fig. 19.2 Infiltration divided into three different layers: deep, intermediate, superficial (1.5:1/2:1 ratio)

A periareolar incision can be made in patients with very lax skin for further subcutaneous stimulation. Through these incisions, the surgeon can reach all the breast tissues, working in a crisscross manner. The skin is protected from friction injuries with a specially made skin protector. Recently, the ultrasound device software has been upgraded to provide the same degree of cavitation with less power, which reduces the risk of friction injury and burn at the entrance site, which even allows discontinuing the use of the skin protector.

allows fat fragmentation and destruction. Moreover, the level of ultrasound energy, conveyed by a hollow probe is limited, and consequently the level of the cavitations obtained in the tissue is diminished. The Vaser system (sound surgical technologies, Denver, CO,US) provides different sizes and length solid titanium probes, expressively designed to fulfill all purposes in body contouring, as well in capability of emulsification through the cavitation effect produced by the ultrasound energy (Fig. 19.4). The piezoelectric transducer transforms electric energy into “vibration energy,” thus allowing the solid titanium probe to emulsify the target fat cells. Four different probe diameters are actually provided by the manufacturers:

19.8 Probes

1. 2.2 mm diameter, for face. 2. 2.9–3.7 mm diameter, for body contouring, including breasts. 3. 4.1 mm diameter, for larger areas and big volumes of fat. 3.7 mm diameter probe with a special “cone tip” designed to emulsify male breasts, but very aggressive also in fibrous tissue.

With the existing technology, a solid probe has been found to be more efficacious than a hollow probe for cavitation, which is the physics phenomenon that

The efficacy of these probes, which are narrower of the previous technologies available on the market, is connected with their design, as they are provided of rings (one-two-three) at the tip of each probe.

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Fig. 19.4 Probes

Rings have two special scopes: 1. To enhance the efficiency of the emulsification that is not limited to the tip, but extended to the last 1.5 cm of the shaft. 2. To allow a larger selection of options, for targeting the various tissue types (purely fat, mixed, fibrotic), by utilizing different probes. The number of rings to be chosen depends on types of tissue encountered: the most fibrotic is treated with one ring, the less dense tissue (pure fat) with the three rings. These options are not purely an academic difference: the energy and the wave length of each probe is selected for the target tissue, avoiding unnecessary extra power, thus energy, which is useless and a potential cause of secondary unwanted complications (already seen with previous technologies). In breast reduction with pure Vaser, the author prefers the 2.9 mm probe, one ring, for deep layers, and the 3.7 mm, three rings for superficial layers (Fig 19.5). Recently, the Vaser surgeon may utilize two further options: (1) The 4.1 mm large probe, for larger volumes, which has a higher percentage of fat emulsification for minute of time/depending on the diameter of the probe (Figs. 19.6 and 19.2). The “cone” tip probe, which is very aggressive in fibrous tissue, and has been designed for the male breast (gynecomastia) for breast tissue destruction (Fig. 19.7).

Fig. 19.5 Technique: 2.9 mm probe, one ring for deep layers and 3.7 mm probe, three rings for superficial layers

Fig. 19.6 New probe

The author recommends the larger probe in all massive volume cases, including big breasts, and the cone tip in really fibrotic breast.

19.9 Fat Emulsification In breast reduction with UAL, the duration of the procedure varies depending on the volume of reduction,

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Fig. 19.7 One ring: 4.1 mm

the type of breast tissue encountered, and the amount of skin retraction required. A breast with purely fatty tissue is easier to treat than one with mixed glandular tissue, in which fat cells are smaller, stronger, and denser. The author started utilizing the Vaser ultrasound device with solid probes (2.9–3.7 mm wide). It delivers 50% of the ultrasound energy in comparison with the older Sculpture unit (by SMEI, Casale Monferrato, Italy), which was used from 1990 to 2001, while emulsifying fatty tissue much more efficiently. The duration of the procedure and the amount of energy required to liquefy the excess fat may vary depending on the

a

characteristics of the tissues encountered, the volume of the planned reduction, and the type of the breast tissue. Purely fatty breast tissue is easier to treat than mixed glandular tissue, in which fat cells are smaller, stronger, and denser. Treatment of the target tissues starts with 10–15 min of ultrasound energy in fat tissue, which usually produces between 250 and 300 mL of emulsion (Fig. 19.8). The surgical planes, with good crisscross tunneling and adequate undermining, are routinely followed, as planned in the preoperative drawings. If large undermining is required for skin retraction, the superficial layers are treated initially. Then the deeper planes are reached, more time is spent in thicker areas. Surgeons inexperienced in the procedure should be especially cautious when performing the technique, particularly in the subdermal planes [9–12, 15–19].

19.10 Subcutaneous UAL Undermining Together with UAL application to the fat layers, starting from the deeper layers and progressing to the more

a

Fig. 19.8 Time of procedure. Upper quadrants, superficial layer, 2–3 min. Lower quadrants, deep layer, 7–20 min (a) Section, (b) Zone of action of the Probe

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superficial ones, it is advisable to thin the superficial layer of the subcutaneous tissue of the upper and lower quadrants by using a different angles pattern, as in standard lipoplasty [20, 21]. This superficial undermining with low-frequency ultrasound energy helps to enhance the retraction of the breast skin and to redrape the breast skin to the newly shaped and reduced mammary cone (Fig. 19.8). To facilitate these maneuvers, I often place a second tiny incision at the axilla, and (sometimes) at the areola border. This helps the superficial work of the probe. The undermining has to be complete, with full liberation of all adherences with the deeper layers. The purpose is to thin the dermal flap all over the breast tissue, thus maintaining its vascularity, sensibility, etc. Vaser is selective, does not interfere with the vascular network of the dermal tissue, if properly made. It spares the connective and supporting structures of the skin. Gibson and Kenedi [22] showed the great potential of the dermal layer in wound contracture. As much as the dermis is thinned, as much the contraction will result, providing the tissue vascularization is preserved. This is what happens in all tissue when superficial dermal thinning is accomplished. Tissues contract more easily, and combined with the gravity forces, which help the upward rotation of the gland (when decreased in weight), the final result is a greater contraction of the breast, with a superior antigravity effect.

19.11 Postoperative Care Suction drainage is routinely applied in the breast for at least 24–48 h. A custom-made elastic compression support (silicone-backed adhesive foam pads) is applied for 7–10 days and a brasserie completes the dressing. These items together with skin redraping help support the breast in the immediate postoperative period.

19.12 Clinical Results Results are visible immediately after surgery; the skin envelope redrapes nicely and contours the new breast

A. Di Giuseppe

shape and mold. The skin and treated breast tissue appear soft and pliable. The elevation of the nippleareola complex resulting from skin contraction and the rotation of the breast mold was immediately visible. The major postoperative nipple-areola complex elevation was 5 cm. Emulsification of fatty breast tissue ranged from a minimum of 300 mL per breast in mild reductions and breast lifts to a maximum of 1,200 mL of aspirate for each breast in large breasts. The author was able to easily obtain a mean of 500 mL of fat emulsion from each breast, after infiltration of 700 mL of Klein’s modified solution for tumescence, followed by wide thinning of the subcutaneous breast envelope, to allow skin redraping. Elevation of the nipple-areola complex up to 5 cm was obtained in large-volume reductions in combination with thinning of the subcutaneous layer. There was no evidence of suspicious calcifications resulting from surgery at the 5-years postoperative follow-up. Essentially, an increase in breast tissue fibrosis was noticeable in the postoperative mammograms, which was responsible for the new consistency, texture, and tone of the breasts. The increase was also responsible for the lifting of the breasts (Fig. 19.9).

19.13 Mastopexy Vaser can be applied in breast surgery also in clinical cases, which present minor degree glandular ptosis. As we know, by decreasing the volume of the breast, it is normal to have an upward rotation of the gland itself. Also, the areola tends to shrink when the underlying tissue is diminished in size and volume. The author has applied the technique in clinicalcases where the patient expressly refused visible breast cutaneous scars or the potential correction of ptosis with an anatomical implant. The upward rotation of the breast and the retraction can finally elevate the breast by 2–4 cm from the initial position. The result is readily visible a week after surgery, with minimal bruising and edema. A supporting bra has to be applied for the first 4 weeks after surgery; despite I strongly believe that a similar bra should be advised forever in patient with

19 Vaser-Assisted Breast Reduction

a

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b

Fig. 19.9 (a) Preoperative breast hypertrophy and planning. Red dotted area indicates fibrotic breast tissue not to be addressed. (b) One year postoperative. Breast nipple raised from 21 to 18 cm from suprasternal notch

large breasts or a tendency to ptosis, which with age is common to majority of females.

19.14 Histologic Changes The breast tissue that underwent emulsification with ultrasound-assisted lipoplasty with the Genesis Contour device (Mentor HS, Santa Barbara, CA) has been analyzed histologically. No gross pathological changes were noted at the time of surgery and microscopic diagnosis included fibrocystic change of stromal fibrosis [23]. No atypia or malignancy was found. With long-term followup, it was shown that the emulsified fat, when not aspirated, will eventually dissolve in few days or weeks. Areas of relative fibrosis may appear at 1–2 months interval, palpable nodes or lumps were a rare event in a survey of 200 patients with breast reduction and/or mastopexy that were performed alone or in combination with other body contouring procedures. Nagy and McCraw [24] presented the combination of breast fat emulsification by Vaser with open surgery breast reduction. They reintroduced the technique of

Passot [25] who in 1925 published the so-called “Button” mammoplasty or the “no vertical scar” reduction that became the most common method of breast shaping in Europe before World War II (Fig. 19.10).

19.15 Marking The new nipple position is marked that is between 19 and 21 cm from the mid-clavicular point (as in all classic measurement – it is the Pitanguy referral point). The existing inframammary and new inframammary folds (ranging from 15 to 23 cm), the flap margin 8–9 cm below the new nipple site, and the medial and lateral points are marked (Fig 19.11). The upper quadrants of breast are infiltrated with tumescent solution, then Vaser is applied to emulsify the fat of this area (Fig. 19.12). In this case, no skin protector is applied, as the skin in this area is due to be deepithelialized for breast reduction. After completing aspiration of emulsified fat, the lower flap is detached from the chest wall, with a

186

a

A. Di Giuseppe

b

Fig. 19.10 Passot’s Button mammaplasty (a) Before, Nipple position in the mid-clavicular point. (b) After, new nipple is positioned and centered

a1

a2

Fig. 19.11 (a1,2) [1] Inframammary fold ranges from 15 to 23 cm. [2] Pointing to inframammary fold. (b1,2) [1] Flap margin 8–9 cm. [2] Inframammary fold. (c1,2) Medial point. (d1,2) Lateral point

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b1

b2

c1

c2

d1

d2

Fig. 19.11 (continued)

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A. Di Giuseppe

b

Fig. 19.12 (a) Prior to infiltration. (b) After Vaser and 500 mL aspiration

central, large inferior pedicle based on perforators from the pectoralis muscle (Fig. 19.13). The upper quadrants, already treated with Vaser, show the network of the subcutaneous breast tissue, as it appears after emulsification of fat and aspiration (Fig. 19.14). All the supporting structures of the skin, as elastic bundles, vessels, nerves, connective supports, are conserved. This pattern is similar to what happens in close breast reduction. As the flap is reduced, it is advanced to fill the empty space (Fig. 19.15). The new nipple is positioned and centered on its pedicle (Fig. 19.16). The Passot technique combined with Vaser has been applied to several types of breast ptosis. The author has performed, with this technique, large reductions (up to 2,900 g from each side) (Fig. 19.17), and operated on the so-called “long breast” (Fig. 19.18), with 1,500 g removal from each side. The typical case where the author actually combines the Passot technique with Vaser is a moderate degree ptosis, 26–28 cm from middle-clavicular point,

with mild to moderate hypertrophy. Results are satisfactory and tend to improve over time. The secrets of the success of the Passot technique combined with the breast reduction are: 1. Shaping under control, the upper and lower quadrants of breast. 2. Maintaining the vascularization of the upper quadrants by using Vaser, as it is a selective technique of emulsification. 3. Repositioning of nipple-areola complex without tension, which ensures good scar (no distortion, no widening). 4. Surgeons must possibly reconsider the priority in scar selection for breast reduction. For most women, the inframammary scar is preferable to the vertical scar, as less visible, despite longer. This could be a subject of debate among modern plastic surgeon who advocated the short vertical scar techniques for all types of breast reduction.

19 Vaser-Assisted Breast Reduction

189

a

b

Fig. 19.13 Following 500 mL aspiration (a) Flaps after removal of emulsified fat. (b) The lower flap is detached from the chest wall

a

b

Fig. 19.14 Vaser effect with fat loss (a) The network of the subcutaneous breast tissue. (b) All the supporting structures are conserved

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a

A. Di Giuseppe

b

Fig. 19.15 After 500 mL aspiration (a) The flap reduced. (b) The flap advanced to fill the empty space

19.16 Complications

Fig. 19.16 Accentuated medial fullness and center nipple on pedicle

No major complications occurred in the author’s series of patients. It should be emphasized that such good results require extensive experience with UAL. As stated by a task force on UAL established by the American Society for Aesthetic Plastic Surgery (ASAPS), the plastic surgery educational foundation (PSEF), the Lipoplasty Society of North America (LSNA), the aesthetic society education and research foundation (ASERF), the learning curve for UAL is longer than that for standard lipoplasty. Specifically, practitioners must learn how to work close to the subdermal layer with a solid titanium probe to defat this layer and obtain good skin retraction while avoiding complications, such as skin burns and skin necrosis. To safely work close to the skin, two conditions are mandatory. The surgeon must be experienced in ultrasound-assisted body contouring and the correct ultrasound device (one that is able to maximize the cavitations effects while minimizing the thermal effects) must be selected.

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a

191

b

Fig. 19.17 (a) Preoperative large breasts. (b) Following reduction by removing 2,900 g from each side

19.16.1 Skin Necrosis Fat necrosis with secondary tissue induration is a typical sequela of ultrasound surgery. When it is localized in small areas, such necrosis can be treated with massage or local infiltration of corticosteroids to soften the area. Skin necrosis can occur (Fig. 19.19).

19.16.2 Loss of Sensation Loss of sensation is generally limited to the first 3 weeks after surgery. Recovery is rapid because the central cone of the breast is composed mainly of pure parenchyma and is not touched during surgery. Skin sensation is recovered in a few weeks time.

19.16.3 Hematoma Hematoma formation is another potential complication, though no cases occurred in this series. In a case of hematoma in a patient treated by another surgeon (Fig. 19.20), the hematoma was localized in the subaxillary region, where the tumescent infiltration was initially administered. The surgeon who performed the operation revealed that the anesthesiologist, who regularly

performed the tumescent anesthesia infiltration, incorrectly used standard sharp needles rather than blunt infiltration cannulas. The formation of the hematoma, which appeared immediately after the infiltration, was thus related to an incorrect tumescent infiltration technique and not to the breast reduction with UAL.

19.16.4 Mastitis Mastitis, an inflammatory response of the breast parenchyma to surgery, occurred in a few patients early in the series. Once surgery was avoided for patients at or near their menstrual period, only a minor inflammatory response was noted. When encountered, mastitis rapidly subsided with immediate treatment consisting of oral antiinflammatory drugs and wide-spectrum antibiotics for 3 days.

19.16.5 Seroma Seroma formation is a potential complication of any breast surgery. Regular application of suction drainages and breast compression for several days with a foam pad and a bra prevent this event.

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a1

A. Di Giuseppe

a2

b1

Fig. 19.18 (a1,2) Preoperative long breast. (b1,2) Five months postoperatively after removal of 1,500 g from each side

19 Vaser-Assisted Breast Reduction

Fig. 19.19 Skin necrosis of the breast medial flap. The surgeon performed a standard breast reduction and then attempted to debulk the medial flap without infiltration of tumescent solution. Skin necrosis resulted, with spontaneous healing after 3 weeks

Fig. 19.20 Breast hematoma caused by infiltration of Klein’s solution with sharp needle instead of the classic atraumatic blunt needle. The hematoma required evacuation after which regular healing followed

19.16.6 Selectivity and Specificity of Ultrasound Large amounts of fat are often found in patients with breast hypertrophy, even among thin adolescents. Lejour and Abboud [14] emphasized that once the fat is removed by lipoplasty before breast reduction, the proportion of glandular tissue, connective tissue

193

vessels, and nerves is increased. These structures are important for maintaining vascularity, sensitivity, and lactation potential. Unlike fat, they are not likely to be affected by patient weight fluctuations. Lejour [13] affirmed that if the breasts contain substantial fat, weight loss may result in breast ptosis. The degree of recurrent ptosis can be minimized if lipoplasty is performed preoperatively to reduce the fatty component of the breasts. This observation anticipated the great potential of UAL for breast surgery. The clear limits of standard lipoplasty with mechanical indiscriminate destruction of fat and surrounding elements followed by power aspiration of the destroyed tissue are particularly enhanced in breast surgery, where specialized structures (e.g., lactation ducts, vessels, sensitive nerves, elastic bounding structures of the subcutaneous tissue) have to be carefully preserved. Because it is a selective technique, Vaser UAL may be applied in breast surgery to destroy and emulsify only the fatty component of the breast tissue without affecting the breast parenchyma for which the ultrasound energy has no specificity. The specificity of the technique is connected with the cavitation phenomenon, and the efficiency of the system hinges on the type of the titanium probe used and the energy level selected. Lejour [13] argued that the suctioning of breast fat also made the breast suppler and more pliable, which facilitates shaping, especially when the areola pedicle was long. This consideration is particularly important with fatty breasts, which have a less reliable blood supply. These benefits are significantly increased by the use of UAL because the specificity of this technique spares the vessel network. The selectivity of UAL was demonstrated by Fischer [26, 27], and Palmieri [28] in their studies on the action of the ultrasound probe in rat mesenteric vessels. Later, Maillard et al. [29] introduced endoscopic evaluation of UAL. They used a Stortz endoscopic system and camera (Stortz, Tuttlingen, Germany) to videotape the action of the titanium probe within the ultrasound device in the superficial layers of the subcutaneous fat, verified by needle depth, after standard infiltration with the tumescent technique. UAL was performed with crisscross tunnels, and the procedure was record ed on videotape. An adjacent area was treated with standard lipoplasty. The technique was compared with standard lipoplasty, which was also endoscopically assisted and monitored. The authors found that

194

standard lipoplasty appears to be the more aggressive technique, characterized by the mechanical destruction of the subcutaneous tissue, including vessels, nerves, and supporting structures, despite the use of 2–3 mm wide blunt cannulas. By contrast, UAL spared vessels, nerves, and elastic supporting fibers. Alterations in breast tissue resulting from the use of UAL were a thickened dermal undersurface, markedly thickened vertical collagenous fibers, intact lymphatic vessels, and intact blood vessels. The horizontal and vertical thickening and shortening of the collagen in the dermis and ligamentous fibers are responsible for the remarkable skin tightening that follows subcutaneous stimulation with the ultrasound probe. The closer to the skin and the more complete the removal of fat from the intermediate subdermal space, the greater the skin tightening effect. This is of great value in breast surgery, where volume reduction has to be accomplished by skin redraping and recontouring of the breast shape. As noted by Lejour [13], retraction of the skin after standard lipoplasty cannot be expected to be sufficient to produce a satisfactory breast shape. Subcutaneous aspiration must be extensive to obtain the necessary skin retraction, and the risk of localized skin necrosis resulting from excessive superficial liposuction cannot be ignored [30].

19.16.7 Calcifications Lejour [13] and Lejour and Abboud [14] argued that the risk of postoperative fat necrosis or calcifications was the reason many surgeons avoided the use of lipoplasty in the breast. The main cause of fat necrosis is breast ischemia brought about by extensive dissection or mechanical direct damage, with resultant venous drainage. This phenomenon is typical in open breast surgery. Calcification in breast reduction surgery may derive from area of fat necrosis or breast necrosis and subsequent scarring. Such calcifications are most often located at the incision lines (periareolar, or vertical scar in the inverted-T approach), where more tension is placed in approximating the lateral and medial flaps. However, when the tension is too high, areas of necrosis could arise from the approximating suture and later cause calcifications that are visible on mammography. However, the risk of such complications in UAL procedures is quite low.

A. Di Giuseppe

Calcifications in breast parenchyma are to be expected after any mammoplasty procedure. In reduction mammoplasty, it is preferable that they be localized along the breast scars [31]. When lipoplasty is performed in addition to the mammoplasty procedure, benign macrocalcifications are slightly more numerous in the parenchyma than they are in breasts reduced without lipoplasty. This may occur because of the trauma caused by lipoplasty or because lipoplasty suction is applied to the most fatty breasts, which are more prone in liponecrosis [32]. However, 1 year after fatty-breast reduction with UAL, follow-up mammography revealed only a slight increase of small microcalcifications, similar to those found after other mammary procedures.

19.16.8 Potential Risks Topaz [33] speculated that the thermal effect of UAL and the free radicals generated during UAL might result in neoplastic transformation and other long-term complications as a consequence of the physical effect known as sonoluminescence. It has been generally agreed since then that some individuals do not understand the mechanism of UAL action, though multiple mechanisms are probably involved, such as mechanical forces, cavitation, and thermal effects. Additional research has revealed that long-term complications or negative bioeffects (including DNA damage and oxidation-free radical attack) are probably not serious safety concerns for UAL. With reference to the application of UAL to breast surgery, Young and Schorr [34] investigated the histology of the breast fat tissue before and after UAL breast surgery (with serial biopsies at 6 months and 1 year after surgery) and the mammographic appearance of the breast before and 1, 2, and 3 years after surgery, particularly with respect to calcification. The results were evaluated by a senologist not directly involved with the clinical research. Histologic studies revealed an increased fibrotic response to thermal insult, with a prevalence of fatty scar tissue, in all specimens evaluated. Mammography showed a significant increase in breast parenchymal fibrosis, with a denser consistency and thicker breast trabeculae that were constant over time. The calcifications that appeared were benign and were typically small, round, less numerous, and more regular than those characteristic of malignancy. Comparison of the mammographic results typical of a

19 Vaser-Assisted Breast Reduction

standard breast reduction and those typical of breast reduction with UAL showed that microcalcifications are less likely to develop with UAL. It is likely that scar tissue caused by breast reduction with electrocautery or by necrosis resulting from the tension of internal sutures may more frequently cause calcifications or irregular mammographic aspects of the operated parenchyma. Particularly, in standard breast reduction surgery, they can appear at the areola line and at the site of the vertical scar. From a mammographic viewpoint, the typical appearance of a breast reduction with UAL demonstrates predictably less scarring and fewer calcifications than occurring in the standard open technique. Courtiss [35] reported similar mammographic evidence in a denser breast after breast reduction by lipoplasty alone. No malignancies were reported. The question of whether potential lactation is affected by UAL remains unanswered. The technique has been used for breast reduction and mastopexy in young and older patients and there has been no problem in lactation reported.

19.17 Conclusions The use of UAL for reduction of fatty breasts and mastopexy is effective and safe when applied in selected patients and performed by a surgeon with expertise in ultrasound-assisted body contouring. The selectivity of UAL enables emulsification of the fatty component of the breast parenchyma while sparing the glandular tissue and vascular network. Furthermore, long-term mammographic studies have revealed no alteration of morphology of the breast parenchyma resulting from this technique. The typical mammographic appearance of breast tissue after UAL is a denser breast. Acknowledgement Portions of this work are reprinted from Ref. [32] with permission from the International Journal of Cosmetic Surgery and Aesthetic Dermatology, Mary Ann Liebert, Inc.

References 1. Zocchi M. Clinical aspects of ultrasonic liposculpture. Perspect Plast Surg. 1993;7:153–74. 2. Zocchi M. The ultrasonic-assisted lipectomy (U.A.L): physiological principles and clinical application. Lipoplasty. 1994;11:14–20.

195 3. Zocchi M. Ultrasonic-assisted lipectomy advances. In: Plastic and reconstructive surgery. St Louis, MO: Mosby Year Book; 1995 4. Zocchi M. The ultrasonic-assisted lipectomy, instructional course. Amer Soc Aesthetic Plast Surg (ASAPS) Annual Meeting. San Francisco; March 1995. 5. Zocchi M. The treatment of axillary hyperadenosis and hyperhidrosis using ultrasonically assisted lipoplasty. Meeting of the International Society of Ultrasonic Surgery. Faro, Portugal, November 1995. 6. Zocchi ML. Basic physics for ultrasound-assisted lipoplasty. Clin Plast Surg. 1999;26(2):209–20. 7. Goes JC. Periareolar mammoplasty: double skin technique with application of polyglactine or mixed mesh. Plast Reconstr Surg. 1996;97(5):959–68. 8. Benelli L. A new periareolar mammaplasty: round block technique. Aesthetic Plast Surg. 1990;14(2):93–100. 9. Di Giuseppe A. Mammoplasty reduction and mastopexy utilizing ultrasound liposuction. Mammographic study preoperative. Abstract from 46th National Congress of Italian Society of Plastic Reconstructive and Aesthetic Surgery. Italy, Venice, June 1997. 10. Di Giuseppe A. Ultrasonically assisted liposculpturing. Am J Cosmet Surg. 1997;14(3):317–27. 11. Di Giuseppe A. Reducion mamaria y pexia con la asistencia de la lipoplastia ultrasonida. Lipoplastia. 1998;1(1):16–26. 12. Di Giuseppe A. UAL for face-lift and breast reduction. Abstract for World Congress on Liposuction Surgery. California, Pasadena, October 1998. 13. Lejour M. Reduction of large breasts by a combination of liposuction and vertical mammoplasty. In: Cohen M, editor. Master of surgery: plastic and reconstructive surgery. Boston: Little Brown; 1994. 14. Lejour M, Abboud M. Vertical mammoplasty without inframammary scar and with liposuction. Perspect Plast Surg. 1990;4:67. 15. Di Giuseppe A: Ultrasound-assisted for body contouring, breast reduction, and face lift. How to do it? Abstract at the 3rd European Congress of Cosmetic Surgery. Themes: Berlin; April 1999. p. 23–5. 16. Di Giuseppe A. Ultrasonic-assisted lipoplasty of the breast (poster). Abstract at the XV Congress of the International Society of Aesthetic Plastic Surgery (ISAPS). Tokyo, April 2000. 17. Di Giuseppe A. Ultrasonically assisted breast reduction and mastopexy. Int J Cosmet Surg Aesthet Derm. 2001;3(1): 23–9. 18. Di Giuseppe A. Ultrasound assisted breast reduction and mastopexy. Aesthet Surg J. 2001;21(6):493–506. 19. Di Giuseppe A. Breast reduction with ultrasound assisted lipoplasty. Reconstr Surg J. 2003;112(1):71–82. 20. Teimourian B. Suction lipectomy and body sculpturing. St. Louis, MO: CV Mosby; 1987. p. 219–51. 21. Teimourian B, Massac E Jr, Wiegering CE. Reduction suction mammoplasty and suction lipectomy as an adjunct to breast surgery. Aesthetic Plast Surg. 1985;9(2):97–100. 22. Gibson T, Kenedi RM. Factors affecting the mechanical characteristics of human skin. In: Proceedings of the Centennial Symposium on Repair and Regeneration. New York: Mc Graw-Hill Book; 1968. p. 87. 23. Gibson T, Stark H, Kenedi RM. The significance of Langer’s lines. In: Hueston JT, editor. Transactions of the fifth international congress of plastic and reconstructive surgery. Australia: Butterworths; 1971. p. 1213.

196 24. Nagy M, McCraw J. Presented at the Amer Soc Aesthet Plast Surg (ASAPS) meeting in Orlando. FL, May 2006. 25. Passot R. La correction esthetique du prolapsus mammaire par le procede de la transposition du mamelon. Presse Med. 1925;33:317. 26. Fischer PD, Narayanan K, Liang MD. The use of high frequency ultrasound for the dissection of small diameter blood vessels and nerves. Ann Plast Surg. 1992;28(4): 326–30. 27. Fischer PD. Revised technique for cellulitis reduction in riding breeches deformity. Bull Int Acad Cosmet Surg. 1977;2:26–38. 28. Palmieri B. Studio sull’ azione degli ultrasuoni sul tessuto vasculare del ratio. Riv Ital Chir Plast. 1994;9:635–9. 29. Maillard GF, Schleflan M, Bussein R. Ultrasonically assisted lipectomy in aesthetic breast surgery. Plast Reconstr Surg. 1997;100(1):238–41.

A. Di Giuseppe 30. Becker H. Liposuction of the breast. Presented at the Lipoplasty Society of North America meeting. September 1992. 31. Mitnick JS, Roses DF, Harris MN, Colen SR. Calcifications of the breast after reduction mammoplasty. Surg Gynecol Obstet. 1990;171(5):409–12. 32. Di Giuseppe A, Santoli M. Ultrasonically assisted breast reduction and mastopexy. Int J Cosmet Surg Aesth Derm. 2001;3(1):23–9. 33. Topaz M. Possible long-term complications in U.A.L. induced by sonoluminescence, sonochemistry, and thermal effects. Aesthetic Surg J. 1998;18:19–24. 34. Young VL, Schorr MV. Report from the conference on ultrasound-assisted liposuction safety and effects. Clin Plast Surg. 1999;26(3):481–524. 35. Courtiss EH. Breast reduction by section alone. In: Spear S, editor. Surgery of the breast: principles and art. Philadelphia: Lippincott-Raven; 1998.

Complications of Breast Reduction

20

Melvin A. Shiffman

20.1 Introduction Complications following breast reduction can be difficult to prevent and should be timely diagnosed so that proper treatment can be instituted. The surgeon should be aware of means to avoid complications and how to treat those complications that occur in a timely fashion.

20.2 Complications 20.2.1 Calcifications (Fig. 20.1) Yalin et al. [1] reported on mammographic and ultrasonographic findings of calcifications following breast reduction. Masses were seen with coarse and thick spiculations, irregular margins, central radiolucencies, and amorphous and pleomorphic, dystrophic, coarse and branching microcalcifications. There were eggshell-like oil cyst calcifications. Fat necrosis and oil cysts are associated with all types of surgical procedures in the breast. Parenchymal redistribution, asymmetry, scarring, parenchymal or retroareolar linear bands and calcifications, high position of the nipple, and discontinuity of the ducts were reported by Brown [2] and Miller [3].

M. A. Shiffman 17501 Chatham Drive, Tustin, CA 92780-2302, USA e-mail: [email protected]

Mendelson [4] noted skin thickening of the lower pole of the breast around the incision sites in the periareolar area and inframammary fold. Spicules were thicker and more curvilinear than the fine and straight speculations of breast cancer. There were needle-like calcifications. Mitnick et al. [5] reported calcifications following breast reduction were found within the skin of the breast, mainly at a periareolar location. Mitnick et al. [6] noted suspicious mammographic findings, including 31 stellate lesions, 20 regions of grouped calcifications, two nodules, and one area of trabecular markings. Adenocarcinoma was diagnosed by fine needle biopsy in five patients. There was a higher incidence of contralateral breast cancer in patients who had cancer on one side and breast reduction on the other side. Heywang-Kobrunner [7] reported calcifications of fat necrosis and oil cysts that are round and have ring or eggshell-like wall calcifications with radiolucent centers.

Fig. 20.1 Calcifications following breast reduction

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_20, © Springer-Verlag Berlin Heidelberg 2010

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20.3 Cancer Breast cancer has been diagnosed intraoperatively [8–10] and in the postoperative specimen following reduction [11]. This is the reason that all patients for breast reduction should have a preoperative mammogram Lund et al. stated that breast reduction may reduce the incidence of future breast cancer [12]. Of 1,245 cases having breast reduction followed for over 10 years after surgery, there were 18 cases of breast cancer. The expected number for the incidence of breast cancer in the normal population would be 30.28 cases.

20.3.1 Cyanotic Nipple–Areolar Complex The patient should be seen on the first postoperative day in order to evaluate the nipple–areolar complex (NAC) for cyanosis. If there is any question of the blood supply to the NAC, test for capillary refill that should be less than 6 s. Six seconds or more requires that the wound sutures be removed to relieve the tension and check the pedicle for rotation. With an “anchor” incision, the sutures can be removed along the lower half of the areola and along the vertical portion of the wound. If necessary, remove all sutures and allow secondary healing. Nitropaste has not been effective in preventing necrosis. Continued cyanosis with refill of 6 s or more may be best treated with nipple– areola transplant.

M. A. Shiffman

substance or a mass that may have to be treated with excision or drainage. An untreated area of fat necrosis may result in a fat cyst followed by calcification.

20.3.4 Hematoma Excessive bleeding with hematoma should be treated with exploration, evacuation of the hematoma, and coagulation of any bleeders. It is probably prudent to place a suction catheter or penrose in the space for at least 24 h.

20.3.5 High Nipple–Areolar Complex (Fig. 20.2) The cause of a postoperative high NAC is either “bottoming out” of the breast where the breast falls behind the NAC to a more inferior position or because the surgeon has not adjusted to a lower position for the large a

20.3.2 Excessive Breast Reduction Some surgeons use techniques that consistently reduce the breast excessively. A patient with a DD should not be made an A cup but should be made a cup size that is adequate for the height and weight. Agarwal [13] has described a flap augmentation for excessive breast reduction. Most of the time, implants can be used to augment the breast to a proper size.

b

20.3.3 Fat Necrosis As with any necrosis problem, there can be loss of vascular supply to parts of the fat along incision sites. This can result in postoperative drainage of an oily

Fig. 20.2 High nipple–areolar complexes (NACs) secondary to “bottoming out”. (a) Before, (b) after

20 Complications of Breast Reduction

breast weight stretching the skin. The new nipple point, instead of being at the inframammary fold, should be adjusted 1–2 cm lower for the heavy breast.

20.3.6 Infection Infection should be treated with proper antibiotics, if possible following culture and sensitivity. Cellulitis is most often a Strep infection. An abscess needs open drainage with culture and sensitivity.

20.3.7 Methcillin Resistant Staphylococcus aureus Methicillin-resistant Staphylococcus aureus (MRSA) is now the most common contaminant of surgical infections. Previously, it was Staphylococcus aureus and the Pseudomonas.

20.3.7.1 Community-Acquired MethicillinResistant Staphylococcus aureus (CA-MRSA) CA-MRSA is becoming an increasingly important, major pathogen [24–26]. Particular strains of MRSA have recently arisen in CA-MRSA that have been identified by pulsed-field gel electrophoresis typing as USA300 that have genetic differences from the typical strain that has been circulating [27]. The USA300 and USA400 strains are quite different from the typical Hospital-acquired Methicillin resistant Staphylococcus aureus (HA-MRSA) [28, 29]. The USA300 strain occurs in diverse regions of the United States [30] while the USA400 strain has been found in several outbreaks and “endemic” CA-MRSA infections in the US Midwest [31]. CA-MRSA accounts for 59% of skin infections (ranges from 15 to 74% in different cities). The drugresistant strain can cause painful skin lesions that resemble infected spider bites, necrotizing pneumonia, and toxic shock syndrome. CA-MRSA is resistant to erythromycin, cephalexin (Keflex), and dicloxacillin (Diclocil), and more or less susceptible to clindamycin,

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fluoroquinolones, tetracycline, rifampin, and trimethoprim-sulfamethoxazole (TMP-SMX) [28, 29, 32]. Moran et al. [32] studied skin and soft tissue infections (SSTIs) seen in the emergency room in Los Angeles, California with cultures and clinical information. Staphylococcus aureus isolates were characterized by antimicrobial susceptibility testing, pulsed-field gel electrophoresis, and detection of toxin genes. On MRSA isolates, typing of the staphylococcal cassette chromosome mec (SCCmec), the genetic element that carries the mecA gene encoding methicillin resistance, was performed The presence of MRSA was 57% overall (ranging from 15 to 74%). Pulsed-field type USA300 isolates accounted for 97% of MRSA isolates; 74% of these were a single strain (USA300–0114). SCCmec type IV and the Panton-Valentine leukocidin (PVL) toxin gene were detected in 98% of MRSA. Among the MRSA isolates, 100% were susceptible to rifampin and TMP-SMX, 95% to clindamycin, 92% to tetracycline, and 60% to fluoroquinolones. When antimicrobial therapy is indicated for the treatment of SSTIs, clinicians should consider obtaining culture and modifying empirical therapy to provide MRSA coverage.

20.3.7.2 Virulence Virulence factors may allow pathogens to adhere to surfaces and invade or avoid the immune system, while causing toxic effects to the host [33]. There may be the production of exotoxins related to the infection [34]. Superantigens that have been identified include TSST-1 (toxic shock syndrome toxin-1), staphylococcal enterotoxin serotype B (SEB), or staphylococcal enterotoxin serotype C (SEC). Along with PVL, these toxins are associated with toxic shock syndrome, pupura fulminans, and hemorrhagic, necrotizing MRSA pneumonia [34–36]. The superantigens induce massive cytokine release from the T cells and macrophages. The ensuing hypotension and shock are believed to be the result of tumor necrosis factor a and b (TNF-a and TNF-b)mediated activity [34]. There is a 70% mortality rate from community-acquired pneumonia caused by PVLpositive CA-MRSA [36]. PVL has a possible role in virulence either directly or as a marker for closely associated pathogenic factors. PVL is a 2-component staphylococcal poreforming membrane cytotoxin that operates by targeting mononuclear and polymorphonuclear cells producing

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severe inflammatory lesions, capillary dilation, chemotaxis, polymorphonuclear karyorrhexis, and tissue necrosis [28,33].

20.3.7.3 Reservoirs and Transmission Humans serve as a reservoir for Staphylococcus aureus through asymptomatic colonization [28]. Higher carriage rates of Staphylococcus aureus, compared to the general population, are associated with intravenous drug users, insulin-dependent diabetics, patients with dermatologic conditions, patients with indwelling catheters, and healthcare workers [28,37].

20.3.7.4 Prevention and Management To prevent spread of MRSA in hospitals, it is recommended that those at higher risk for MRSA carriage be screened at admission and isolated if found to be colonized.38 Surfaces in examination rooms should be cleaned with commercial disinfectants or diluted bleach (one tablespoon to one quart of water), and wound dressings and other materials that come into contact with pus, nasal discharge, blood, and urine should be disposed of carefully [25]. Healthcare providers need to wash their hands between contacts with patients [25]. and should use barrier precautions and don fresh gowns and gloves for contact with each patient [39,40]. Guidelines have been developed by the Centers for Disease Control (CDC) for prevention of infection among members of competitive sports teams and others in close contact. These include avoiding sharing equipment and towels, common surfaces should be cleaned on a regular basis, wounds should be covered, individuals with potentially infectious skin lesions should be excluded from practice and competition until the lesions have healed or are covered, and frequent showering and use of soap and hot water should be encouraged [26]. A rapid, easy-to-use identification of MRSA in nasal carriers has been developed that consists of realtime polymerase chain reaction (PCR) assay.

20.3.7.5 Clinical Management Once an infection has been established, wound cultures should be obtained, ideally from pus or

M. A. Shiffman

grossly infected tissue. Cultures from ulcers are of dubious value since bacteria isolated may be due to colonizing strains and not pathogens [42]. Antibiotics may not be needed in SSTIs when adequate surgical drainage can be achieved [42–44]. When antibiotics are not prescribed, patients should have follow-up care and be instructed to seek medical care if symptoms worsen or do not resolve. When antibiotics are used, local patterns of antibiotic susceptibility among CA-MRSA should be used to help direct empiric therapy against this pathogen.

20.3.7.6 Antibiotics Antimicrobial therapy is critical [45]. Vancomycin has been a mainstay of treatment for serious infections that are resistant to b-lactams [46]. However, in the treatment of methicillin-sensitive Staphylococcus aureus (MSSA), Vancomycin has been associated with a slower clinical response and longer duration of bacteremia compared to b-lactams [29]. There has been a recent emergence of Vancomycin-resistant Staphylococcus aureus (VRSA) and Vancomycinintermediate susceptible Staphylococcus aureus (VISA) [29]. Fluoroquinolones have variable activity against CA-MRSA strains and in some locales, there has been over 40–50% fluoroquinolones resistance among MRSA strains [47–49]. Susceptibility to ciprofloxacin indicates that low-level or partial fluoroquinolones resistance is probably not present. There is little clinical data on the use of moxifloxacin and gemifloxacin for the treatment of CA-MRSA. Clindamycin has been useful to treat CA-MRSA disease, [41,50,51] but resistance has been encountered greater than 10–15% [28,47,48]. In a Taiwan study, the resistance was 93% [52]. Some strains that are Clindamycin susceptible and erythromycin resistant can develop resistance when exposed to Clindamycin (lincosamide), erythromycin (macrolide), and quinupristin/dalfopristin (streptogramin B). This inducible resistance can be detected by the D-test that, if positive, is considered diagnostic for inducible resistance [53]. It is believed that Clindamycin should not be used to treat D-test-positive strains, especially in a serious syndrome [53]. For multidrug-resistant infections caused by MRSA that require parenteral therapy, Vancomycin, linezolid,

20 Complications of Breast Reduction

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Daptomycin, and quinupristin/dalfopristin are the only agents that are reliably active against many HA-MRSA infections [51]. TMP-SMX, tetracyclines, Clindamycin, and fluoroquinolones may be alternatives if susceptibility to these agents is documented.

20.3.7.7 Guidelines The CDC [54]. developed, with internationally recognized experts, guidelines to control MRSA through hospitals and healthcare facilities. These include: 1. Ensure prevention programs are funded and adequately staffed. 2. Carefully track infection rates and related data to monitor the impact of prevention efforts. 3. Ensure that staff use standard infection control practices and follow guidelines regarding the correct use of antibiotics. 4. Promote the best practices with health education campaigns to increase adherence to established recommendations. 5. Designing robust prevention programs customized to specific settings and local need.

20.3.7.8 Definitions • • • • • • • • • • • •

CA-MRSA community-acquired MRSA HA-MRSA hospital-acquired MRSA PCR polymerase chain reaction PVL panton-valentine leukocidin MRSA methicillin-resistant Staphylococcus aureus MSSA methicillin-susceptible Staphylococcus aureus SCC staphylococcus cassette-chromosome SSTI skin and soft-tissue infection TMP-SMX trimethoprim-sulfamethoxazole TNF tumor necrosis factor TSST toxic shock syndrome toxin VISA vancomycin-intermediate susceptible Staph ylococcus aureus • VRSA vancomycin-resistant Staphylococcus aureus

Fig. 20.3 Postoperative necrosis following breast reduction in a diabetic with infection

skin or compression of the pedicle, thin flaps, hematoma causing excessive tension, smoking, and uncontrolled diabetes especially with infection (Fig. 20.3). Necro tizing ulceration was reported by Berry et al. [14]. Treatment consists of debriding the necrotic areas, keeping the open wounds clean with saline soaks, and secondary closure when the granulations have properly formed. If secondary closure fails, then the wound should be left open to close on its own.

20.3.9 Neurological Pressure sensation (using the pressure-specified sensory device) of the breast was measured at nine points of the breast by Ferreira et al. [15]. All 25 patients had decreased sensation in all points measured when the upper medial pedicle technique was used. Hamdi et al. [16] noted loss of sensitivity of NAC with superior and inferior pedicle techniques that resolved with the change to the latero-central pedicle technique.

20.3.8 Necrosis

20.3.10 Pain

Necrosis of skin flaps can occur from inadequate blood supply, torsion of the pedicle, excessive tension on the

Gonzalez et al. [17] reported that headache, neck pain, back pain, shoulder pain, and bra strap groove pain

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present in 60–92% of patients, and 97% of patients had at least three of these pain symptoms preoperatively. All patients had reduction of their pain and 25% had complete elimination of pain symptoms after reduction mammaplasty. Chronic breast pain can occur following breast reduction [18].

20.3.11 Phantom Breast Pain Phantom breast pain at the site of the original nipple locations has been reported following breast reduction [19]. This was resolved with explanation to the patient of the origin of the pain and nonsteroidal antiinflammatory analgesics.

20.3.12 Retained Excess Areola In patients for breast reduction with very large areolas, the Wise pattern has to be modified to allow removal

Fig. 20.5 Hypertrophic scar

of all of the excess areola. Otherwise, the pigmented area of the residual areola will mar the cosmetic result (Fig. 20.4).

20.3.13 Scar Hypertrophic (Fig. 20.5) and keloid scars can occur with any surgical wound.

20.4 Pathology Hypertrophic scars can be distinguished from keloid scars microscopically. Both are characterized by excessive deposits of collagen in the dermis and subcutaneous tissues following trauma or surgical injuries with collagen bundles that appear stretched and aligned in the same plane. Collagen bundles in keloids are thicker and more abundant and form acellular node-like structures in the deep dermis.

20.5 Clinical Manifestations

Fig. 20.4 Residual pigmented areola tissue along the vertical scar following breast reduction

Keloids may have a genetic predisposition and occur in 15–20% of blacks, Hispanics, and Asians. Hypertrophic scars are confined to the area of injury while keloids grow beyond the confines of the original wound and can appear nodular. Hypertrophic scars may regress without treatment while keloids rarely

20 Complications of Breast Reduction

regress. The scars can cause disfigurement, contractures, pain, and itching.

20.6 Treatment Keloids and hypertrophic scars can be treated with intralesional corticosteroids alone or in combination with surgical excision, superficial radiation, laser, cryotherapy, or pressure therapy. Silicone sheeting used 8 h daily for 3–6 months is helpful in reducing the height of a thickened scar. Keloids tend to recur in about 80% of patients with most types of treatment. Other therapeutic agents [20] include 5-fluorouracil, verapamil (calcium blocker), Bleomycin, interferon-a-2b, histamine antagonist, or colchicine (with or without penicillamine and b-aminopropionitrile).

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Surgical excision of keloids followed by superficial radiotherapy for two treatments, 1/day, is very helpful. The best way to remove the keloid surgically is to excise the scar leaving about 1 mm of scar circumferentially and closing the wound with sutures in the scar edges. The use of steroid in the edges of the wound closure may be helpful in reducing the amount of scarring. In using corticosteroids, care should be taken to inject the drug into the middle of the lesion. If injected too superficially, there may be visible spots of chalky material. There may be pain with injecting steroids into scar because there is very little give to the tissues and local anesthesia may be necessary. The author uses a combination of Triamcinolone (40 mg/mL), 0.2–0.4mL, 5-fluorouracil, 1mL (50 mg), and 1mL 0.5% lidocaine with epinephrine for the injection. Hypopigmentation in the scar may occur. Inadvertent injection of steroids deep to the scar may result in steroid fat atrophy.

a1

a2

b1

b2

Fig. 20.6 (a1,2) Fat atrophy of the inferior medial quadrants of both breasts following steroid injections of the scars. (b1,2) Thirty days after tumescence with 300 mL saline on each side showing the fat content of the inferior medial quadrants to be normal

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20.6.1 Steroid Fat Atrophy The treatment for fat atrophy secondary to steroid injection has usually been with the use of fillers, including autologous fat. The author has a patient who was a post reduction mammoplasty with implant augmentation patient with postoperative hypertrophic scars that had been treated in the inferior medial aspect of both breasts with steroids, resulting in complete loss of the fat of the inferior medial portions of the breast fat 1 year before being seen (Fig. 20.6). While performing a capsulotomy for capsule contracture of the right breast, 300 mL of saline was injected as tumescent fluid into the inferior medial quadrants of both breasts for a total of 600 mL. Thirty days after the procedure, the inferior medial quadrants of the breast were found to be filled out to normal proportions with fat. Apparently, the steroids cause loss of the fat in the cell but do not destroy the fat cells. Placing the steroid crystals back in emulsion form allows the body to remove these as foreign substances.

20.7 Discussion Some form of complication occurs in about 10% of patients. Mandrekas [21] reported the incidence of: • • • • •

Hematoma 0.3% Nipple and/or pedicle necrosis 0.8% Wound dehiscence 4.6% Hypertrophic scars 3.3% Loss of sensitivity of the nipple 1.3%

References 1. Yalin CT, Bayrak IK, Katranci S, Belet U. Breast changes after breast reduction mammaplasty: a case report with mammographic and ultrasonographic findings and a literature review. Breast J. 2003;9(2):133–7. 2. Brown FE, Sargent SK, Cohen SR, Morain WD. Mammographic changes following reduction mammoplasty. Plast Reconstr Surg. 1987;80:691–8.

M. A. Shiffman 3. Miller CL, Freog SA, Fox JW. Mammographic changes after reduction mammoplasty. Am J Roentgenol. 1987;149:35–8. 4. Mendelson EB. Evaluation of the postoperative breast. Radiol Clin N Am. 1992;30:107–38. 5. Mitnick JS, Roses DF, Harris MN, Colen SR. Calcifications of the breast after reduction mammoplasty. Surg Gynecol Obstet. 1990;171(5):409–12. 6. Mitnick JS, Vazquez MF, Plesser KP, Pressman PI, Harris MN, Colen SR, Roses DF. Distinction between Postsurgical changes and carcinoma by means of stereotactic fine-needle biopsy after reduction mammaplasty. Radiology. 1993;188(2):457–62. 7. Heywang-Kobrunner SH, Scheer I, Dershaw DD. Diagnostic breast imaging. Stuttgart: Thieme; 1997. p. 280–315. 8. Butler CE, Hunt KK, Singletary SE. Management of breast carcinoma identified intraoperatively during reduction mammaplasty. Ann Plast Surg. 2003;50(2):193–7. 9. Snyderman RK. Breast carcinoma found in association with reduction mammaplasty. Plast Reconstr Surg. 1990;83(1):153–4. 10. Dinner MI, Sheldon J. Carcinoma of the breast occurring in routine reduction mammaplasty. Plast Reconstr Surg. 1989;83(6):1042–4. 11. Keleher AJ, Langstein HN, Ames FC, Ross MI, Chang DW, Reece GP, Singletary SE. Breast cancer in reduction mammaplasty specimens: case reports and guidelines. Breast J. 2003;9(2):120–5. 12. Lund K, Ewertz M, Schou G. Breast cancer incidence subsequent to surgical reducing of the female breast. Scand J Plast Reconstr Surg. 1987;21:209–12. 13. Agarwal AK, Ali SN, Erdmann MW. Free DIEP flap breast augmentation following excessive reduction. Br J Plast Surg. 2003;56(2):191–3. 14. Berry MG, Tavakkolizadeh A, Sommerlad C. Necrotizing ulceration after breast reduction. J R Soc Med. 2003;96(4):186–7. 15. Ferreira MC, Costa MP, Cunha MS, Sakae E, Fels KW. Sensibiltiy of the breast after reduction mammaplasty. Ann Plast Surg. 2003;51(1):1–5. 16. Hamdi M, Blondeel P, Van de Sijpe K, Van Landuyt K, Monstrey S. Evaluation of nipple-areola complex sensitivity after the latero-central glandular pedicle technique in breast reduction. Br J Plast Surg. 2003;56(4):360–4. 17. Gonzalez F, Walton RL, Shafer B, Matory WE Jr, Borah GL. Reduction mammaplasty improves symptoms of macromastia. Plast Reconstr Surg. 1993;91(7):1270–6. 18. Wallace MS, Wallace AM, Lee J, Dobke MK. Pain after breast surgery: a survey of 282 women. Pain. 1996;66(2): 195–205. 19. Tytherleigh MG, Koshy C, Evans J. Phantom breast pain. Plast Reconstr Surg. 1998;102(3):921. 20. Al-Attar A, Mess S, Thomassen JM, Kauffman CL, Davison SP. Keloid pathogenesis and treatment. Plast Reconstr Surg. 2006;117(1):286–300. 21. Mandrekas AD, Zambacos GJ, Anastasopoulos A, Hapsas DA. Reduction mammaplasty with the inferior pedicle technique: early and late complications in 371 patients. Br J Plast Surg. 1996;49(7):442–6.

Part Abdomen, Chest, Buttocks

III

History of Abdominoplasty

21

Giovanni Di Benedetto and William Forlini

21.1 Introduction Abdominoplasty is one of the most commonly performed aesthetic procedures. Despite the advent and popularity of liposuction, which surely is less invasive and offers a more rapid recovery, abdominoplasty has undergone a significant evolution over the past several decades and still represents nowadays a widely performed procedure. It is very difficult to identify the “father” of this procedure. We can surely say that many surgeons started to perform dermolipectomies of the abdominal wall to correct obesity and to facilitate herniorraphy to repair umbilical hernias. During the end of the nineteenth century, three different kinds of techniques arose at the same time, utilizing different types of skin incisions: transverse, vertical, reversed “T,” and crossed.

21.2 History In 1890, Demars and Marx [1] reported the first limited dermolipectomy (Fig. 21.1). Kelly [2], was one of the first surgeons to attempt to correct excess abdominal skin and fat. By meaning of a transverse incision, extending across both flanks, he resected a 7,450-g panniculus. Only 1 year later, he associated the term “aesthetic” to this kind of procedure (Fig. 21.2). Since that time, numerous variations have been suggested and several cases were reported mostly in Europe.

G. Di Benedetto (*) Marche Polytechnic University Medical School, Via Tronto, 20, Ancona, Italy e-mail: [email protected]

Gaudet and Morestin reported [3] the repair of large hernias by using a transverse incision of the abdomen in conjunction with the resection of the excess abdominal skin and fat and preservation of the umbilicus. But the importance of the umbilicus as an aesthetic unit was introduced by Beck [4], describing a transverse abdominoplasty with the reraising of the umbilicus in the center of the scar (Fig. 21.3). Frist [5] performed the first repositioning of the umbilicus above the transverse suture, by tunneling, in an abdominoplasty: This step can be considered as the birth of the modern technique of abdominoplasty (Fig. 21.4). A few years later, Thorek [6], described a procedure that preserved the umbilicus by using a half-moon excision of the abdominal skin located under the umbilicus. A particular kind of abdominoplasty was performed by Somalo [7] with a circular antero-posterior incision in a full reshaping of the torso and the abdomen. Other authors such as Pick [8], Barsky [9], and Gonzales-Ulloa [10] described a classic subumbilical lipectomy, the socalled “belt lipectomy.” In 1967, Pitanguy [11] published a report of 300 abdominal lipectomies, followed by Regnault [12], who published the W technique for abdominoplasty in 1975. In 1973, Grazer [13] was one of the first authors to describe the so-called bikini line incision and in 1967, Callia [14] described a low incision that extended below the inguinal crease. This also appears to be the first report of aponeurotic suturing. From the 1970s on, all the studies performed showed that the most convenient incision in patients undergoing abdominoplasty was the low transverse incision. Although aponeurotic suturing in the midline was noted to be able to reduce anterior projection of the abdominal wall, it did little to reduce the diameter of the waist. Liposuction radically improved the concept of body sculpturing, and gave the opportunity to develop the modern technique of abdominoplasty [15].

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208 Fig. 21.1 First limited dermolipectomy, Demars and Marx [1]

G. Di Benedetto and W. Forlini

21 History of Abdominoplasty Fig. 21.2 Kelly’s technique

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210 Fig. 21.3 Beck’s technique with preservation of the umbilicus, 1917

Fig. 21.4 Frist’s technique, with tunnelization and repositioning of the umbilicus, 1921

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21 History of Abdominoplasty

In 1984, Psillakis [16] first suggested suture plication of the external oblique musculature after raising it in a beltlike fashion. In this way, he was able to dramatically reduce the diameter of the waist. He also added refinements such as costal margin excisions in patients with a projecting upper abdomen. The concept of miniabdominoplasty was introduced by Hakme [17], combining a large liposuction of the entire abdomen with the minimal elliptic resection of the suprapubic skin, without dislocating the umbilicus: this is the first reported association of liposuction and abdominoplasty. Following this step, many authors published different kinds of mixed techniques and Matarasso [18], expanded the use of abdominal contour surgery to a classification based on variations in patients’ anatomy, from liposuction alone to limited and full abdominoplasty surgery. Since then, the use of preliposuction in the abdominoplasty procedures has become very common. In 1995, Lockwood [19] described the high lateral tension abdominoplasty. Its key features include limited direct undermining, increased lateral skin resection with high tension wound closure along lateral limbs, and two-layer superficial fascial system (SFS) repair. When the Saint Tropez bikini (with a very low waistline) was fashionable, the abdominoplasty incision was nearly horizontal in order to be concealed under such a garment. When the French-line bikini (with a very high leg cut) was popular, the abdominoplasty incision had to be converted from a nearly horizontal line to an incision line that accompanied the inguinal fold. In 1997, Gonzalez and Guerrerosantos [20] described a particular technique called Deep Torso-Abdominoplasty where the abdominal incision was positioned in a higher position in order to remain concealed under this new kind of bathing suit style (Fig. 21.5). Since the turn of the century, bikinis with very low waistlines have become more popular again. Therefore, proper adjustments in techniques are again necessary to achieve a tailor-made abdominoplasty. A sensible technical innovation has been shown in 2001 by Saldanha [21] following the work published by Avelar [22]. Saldanha developed a particular combination of full liposuction and abdominoplasty with selective undermining, saving the abdominal perforating blood vessels in the mid line and around the umbilicus. This is the so-called “Saldanha’s technique.” This new concept of “vessels preservation” is very

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Fig. 21.5 The French-bikini like incision

important to avoid ischemic complications of the lower limb and provide a good cicatrization (Fig. 21.6). We can consider three types of abdominoplasty procedures, depending on the position of the incision, with and without the association of liposculpture procedure: 1. Transverse-inguinal-pubic: the most common procedure and provides a very low incision (Fig. 21.7). 2. High transverse: for localized adiposity placed especially in the mesogastric region, often associated with general surgery (Fig. 21.8). 3. Vertical or transverse-vertical mixed: used only in selected cases of post bariatric surgery (Figs. 21.9 and 21.10). More less-invasive procedures have been developed in order to meet the requests and the needs of the patients.

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Fig. 21.6 Saldanha’s studies showing that the perforators of the abdominal panniculus after abdominoplasty work as multiple pedicles to provide normal vascularization to the remaining panniculus

Fig. 21.7 Callia’s Transverse-InguinalPubic Incision, 1965

21 History of Abdominoplasty Fig. 21.8 Thorek’s mesogastic excision, 1942

Fig. 21.9 Vertical excision Provided by Correa-Itturaspe, (1952–1961)

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214 Fig. 21.10 Castanˇares’ mixed technique

G. Di Benedetto and W. Forlini

21 History of Abdominoplasty

Nowadays, regardless of the kind of technique used, the importance of an excellent body profile and a perfect scar is the goal that every surgeon must attempt to achieve. Forlini and Manjarrez [23] described a simple trick to have an optimal distribution of the skin and the tension of the limb, avoiding awful complications such as irregular scars and dog ears in these kinds of procedures. The utilization of silicone-based medication and biologic glue for sutures have been developed to further improve results.

References 1. Demars MM, Marx M. Surgical treatment of obesity. Prog Med. 1890;11:283. 2. Kelly H. Report of gynaecological cases. Bull J Hopkins Hosp. 1899;10:197. 3. Gaudet F, Morestin H. French congress of surgeons. Paris: Hoffmann; 1905. 4. Beck C. Pendulous abdomen. Cure by removal of the excess fat and obliteration of ventral hernias. Surg Clin. 1917;1:731–6. 5. Frist J. Zur Reduktion des Bauchdeckenfattes gelegentlich von Laparotomien. Wien Klin Wochenschr. 1921;34:266–8. 6. Thorek M. Plastic surgery of the breast and abdominal wall. Springfield, IL: Charles C Thomas; 1924. 7. Somalo M. Dermolipectomia circular del tronco. Sem Med. 1940;47:1435–43. 8. Pick JF. Surgery of repair: principles, problems, procedures. Philadelphia: Lippincott; 1949. p. 435. 9. Barsky AJ. Principles and practice of plastic surgery. Baltimore: Williams & Wilkins; 1950.

215 10. Gonzales-Ulloa M. Belt lipectomy. Br J Plast Surg. 1960; 13:179. 11. Pitanguy I. Abdominal plastic surgery. Hospital (Rio J). 1967;71(6):1541–56. 12. Regnault P. Abdominoplasty by the W technique. Plast Reconstr Surg. 1975;55:(3):265–74. 13. Grazer FM. Abdominoplasty. Plast Reconstr Surg. 1973; 51(6):617–23. 14. Callia W. Uma plastica para um cirurgiao geral. Med Hosp. 1967;1:40. 15. Illouz YG. Une nouvelle technique pour les lipodystro phies localisée. Rev Chir Esthet Langue Franc. 1980;6(19): 188–98. 16. Psillakis JM. Plastic surgery of the abdomen with improvement in the body contour. Physiopathology and treatment of the aponeurotic musculature. Clin Plast Surg. 1984;11(3):465–77. 17. Hamke F. Technical details in the lipoaspiration associate with liposuction. Rev Bras Cir. 1985;75(5):331–7. 18. Matarasso A. Abdominoplasty: a system of classification and treatment for combined abdominoplasty and suction-assisted lipectomy. Aesthetic Plast Surg. 1991;15(2):111–21. 19. Lockwood T. High-tension abdominoplasty with super ficial fascial system suspension. Plast Reconstr Surg. 1995; 96(3):603–15. 20. Gonzalez M, Guerrerosantos J. Deep planed torsoabdominoplasty combined with buttocks pexy. Aesthetic Plast Surg. 1997;21(4):245–53. 21. Saldanha OR. Lipoabdominoplasty without undermining. Aesthetic Surg J. 2001;21:518–26. 22. Avelar JM. Abdominoplasty: a new technique without undermining and fat layer removal. Arq Catarinense Med. 2000;29:147–9. 23. Forlini W, Manjarrez A. A helpful trick for the abdom inoplasty scar. J Plast Reconstr Aesthetic Surg. 2007;60(5): 574–5.

Abdominoplasty Principles

22

Melvin A. Shiffman

22.1 Introduction Abdominoplasty principles are those precautions to be taken in the ordinary abdominoplasty patient and not in the patient who has had massive weight loss through diet, disease, or bariatric surgery. The principles are the result of analyzing many malpractice cases with postoperative complications following abdominoplasty and the author’s 45 years of surgical practice.

22.2 Principles 1. The decision for the type of abdominoplasty (complete, modified, mini) depends on the amount of loose skin, extent of excess fat, and muscle laxity and muscle diastasis as described by Wallach and Matarasso (Tables 22.1 and 22.2) [1]. 2. Avoid the patient who is a chronic cigarette smoker unless he/she will completely stop smoking for 2 weeks before and 2 weeks after surgery. (a) Warn the patient that reducing smoking is not enough. (b) Warn the patient that necrosis may occur if he/ she smokes even one cigarette. (c) Record in the medical record any suspicion that the patient has not stopped smoking. 3. Do not perform a complete abdominoplasty in a patient who has had extensive abdominal wall liposuction previously. (a) Flap necrosis may occur.

M. A. Shiffman 17501 Chatham Drive, Tustin, CA 92780-2302, USA e-mail: [email protected]

(b) Perform the abdominoplasty first before extensive liposuction (wait at least 6 months between surgeries). 4. Beware of infracostal upper abdominal scars. These scars have probably transected the lateral blood supply to the midline and as the flap is mobilized and pulled inferiorly, the scar migrates downward and may result in necrosis of the tissue between the scar and the midline. (a) The final transverse incision line should be at least six cm below the lowest edge of the migrated scar to prevent necrosis. 5. Carefully mark the extent of the excision and extent of the dissection. (a) Mark the transverse incision centrally, not higher than the pubic bone. (b) Use the anterior superior iliac spine as the lateral extent of the transverse incision. (c) Make sure the final scar is in a hidden aesthetic position (as low as possible). 6. Mark the inferior incision center at the superior point of the pubic bone [2–7]. (a) The lateral extent for complete abdominoplasty is usually at the anterior superior iliac spine. (b) Cosmetic surgery should have the goal of the best aesthetic results possible. 7. If there is muscle laxity after closure of the midline diastasis, imbricate the lateral muscles (external oblique muscle). 8. Hemostasis should be checked prior to closure. 9. Suction catheters (bilateral) will aid in removal of blood and serum. (a) Catheters are not necessary when the pocket under the flap is closed with sutures (fat to fascia). (b) Prophylactic antibiotics are usually used if suction catheters are present.

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Table 22.1 Abdominolipoplasty classification system [1] Category

Skin

Fat

Musculofascial system

Treatment

Type I

Minimal laxity

Variable

Minimal flaccidity

Suction-assisted lipectomy

Type II

Mild laxity

Variable

Mild lower abdominal flaccidity

Mini-abdominoplasty

Type III

Moderate laxity

Variable

Moderate lower and/or upper abdominal flaccidity

Modified abdominoplasty

Type IV

Severe laxity

Variable

Significant lower and/or upper abdominal flaccidity with suction lipectomy

Standard abdominoplasty with suction lipectomy

Table 22.2 Minimal access subtypes [1] Category

Skin

Fat

Musculofascial system

Treatment

Type Ia

Minimum laxity

��

Minimum flaccidity

Suction-assisted lipectomy

Type IIa

Mild laxity (vertical scar)

Variable

Mild lower abdominal flaccidity

“Open mini” abdominoplasty

Type IIIa

Minimum laxity

Variable

Lower/upper abdominal flaccidity

Endoscopic muscle access

10. See the patient on the first postoperative day to check the drainage and to check for flap cyanosis. (a) If cyanosis is present, a decision should be made as to whether or not to remove the midline sutures (4–6 cm on each side of the midline) to relieve any flap tension. (b) The suction catheters are removed when there is less than 50 mL drainage from each side in 24 h. 11. Flap necrosis should be treated expectantly with wound care, debridement if necessary, and prophylactic antibiotics if underlying infection is suspected (elevated WBC, fever, chills, tenderness, erythema). (a) Explain to the patient the expected period of time for healing (usually weeks to months). (b) Do not use a skin graft to close the granulating wound. The wound will heal by secondary intention with a smaller scar than with a graft. 12. Erythema of the abdominal wall may be an indication of incipient necrotizing fasciitis. (a) Increase dosage of the antibiotic or change the antibiotic. (b) Culture any drainage. (c) Check the patient daily while the erythema is decreasing.

(d) If the erythema is not decreasing within 48 h, consider intravenous antibiotics. (e) If necrosis has started, debridement may be the only way to reduce or prevent extensive superficial and/or deep necrosis.

References 1. Wallach SG, Matarasso A. Abdominoplasty: classification and patient selection. In: Shiffman MA, Mirrafati S, editors. Berlin: Springer; 2005. p. 70–86. 2. Gonzalez-Ulloa M. Belt lipectomy. Br J Plast Surg. 1960;13:179–86. 3. Pitanguy I. Abdominal lipectomy: an approach to it through an analysis of 300 consecutive cases. Plast Reconstr Surg. 1967;40(4):384–91. 4. Grazer FM. Abdominoplasty. Plast Reconstr Surg. 1973;51(6):617–23. 5. Regnault P. Abdominoplasty by the W technique. Plast Reconstr Surg. 1975;55(3):265–74. 6. Baroudi R. Body sculpting. Clin Plast Surg. 1984;11(3):419–43. 7. Moufarrege R. Horseshoe abdominoplasty. In: Shiffman MA, Mirrafati S, editors. Berlin: Springer; 2005. p. 121–9. 8. Fix RJ, Anastasatos JM. Full abdominoplasty. In: Shiffman MA, Mirrafati S, editors. Berlin: Springer; 2005. p. 94–101.

Liposculpture of the Abdomen in an Office-Based Practice

23

Peter M. Prendergast

23.1 Introduction Fat removal for the purpose of improving body shape was first described in 1921 by Dujarrier [1], whose crude technique using a uterine curette to extract fat from the lower limb of a dancer resulted in dramatic failure. Fifty five years later, Giorgio and Arpad Fischer published their work using blunt cannulae to suction fatty deposits, heralding the era of modern liposuction [2]. Ilouz and Fournier followed with their formidable work on the development of liposuction and were instrumental in popularising the technique amongst physicians of several specialties throughout the world. Although office-based surgery was performed over a 100 years ago, initially, liposuction was only practiced under general anaesthesia in a hospital setting [3]. It was not feasible to remove large volumes of fat using blunt or sharp instruments under standard infiltrative local anaesthesia, since the doses required for body contouring would have almost certainly resulted in lidocaine toxicity. The practice of liposuction was revolutionised in 1987 when Jeffrey Klein published his ingenious technique of anaesthetising large areas of subcutaneous fat using a mixture of diluted local anaesthetic and epinephrine [4]. Klein’s tumescent technique has stood the test of time, allowing liposuction to be performed safely, effectively, and outside the hospital setting with an admirable safety record [5–8]. In 2007, liposuction was the most common cosmetic surgical procedure in the United States, with over half of all cosmetic surgical procedures (54%) performed P. M. Prendergast Venus Medical Beauty, Heritage House, Dundrum Office Park, Dundrum, Dublin 14, Ireland e-mail: [email protected]

in office-based settings [9]. The abdomen is the most commonly treated area and that is the focus for this chapter. However, the principles of office-based liposculpture of the abdomen can be applied to any aesthetic unit, including thighs, back, arms and face.

23.2 Safety Since the introduction of tumescent local anaesthesia in 1986 (published 1987), the technique has been widely adopted and has enjoyed an unprecedented safety record [5–8]. The tumescent technique is currently the method of choice for liposuction patients and obviates the need for general anaesthesia. During tumescent anaesthesia, a mixture of physiologic saline, lidocaine, epinephrine, and sodium bicarbonate are infiltrated into fatty tissue until a state of “tumescence” is reached. Tumescence is characterised by firm, swollen tissue that is turgid and somewhat fixed. There are several reasons for the high safety profile of liposculpture performed under tumescent local anaesthesia without intravenous sedation or general anaesthesia. 1. The dilution of lidocaine with saline to concentrations of 0.05–0.1% and dispersion in fatty tissue alter the pharmakokinetics entirely. The maximum safe dose of lidocaine with epinephrine increases from 7 to 55 mg/kg [10]. 2. Epinephrine has a dual role. It causes vasoconstriction in the subcutaneous fat, creating an almost bloodless field that reduces blood loss to less than 1% of liposuction aspirate. The vasoconstriction also slows systemic absorption of lidocaine so that serum levels of lidocaine rise slowly and peak only 4–14 h after infiltration [10].

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3. Tumescent local anaesthesia allows liposculpture to be performed in the awake patient, eliminating the risks of intravenous sedation and general anaesthesia.

23.3 Keys for Success Liposculpture of the abdomen in the office setting is effective, safe, and cost-effective [11]. To achieve best results and minimise complications in the office, the surgeon should use appropriate instruments and proper technique in a sterile environment, ensure the office is sufficiently equipped, select patients carefully and set realistic expectations, plan the procedure carefully, use tumescent local anaesthesia only, and provide excellent aftercare.

23.4 Techniques and Technologies The evolution of liposuction over the past 30 years has seen a refinement in techniques, an improvement in

instruments, and the development of totally new technologies to achieve fat removal (Table 23.1). The goals of these developments and inventions have been to make it easier on the surgeon, make it easier on the patient, or both. Smaller multi-holed cannulae replaced larger single-holed ones to provide smoother, more precise results with less trauma to vessels, nerves, and the fibrous tissue matrix. Power-assisted lipoplasty (PAL) cannulae were later developed that girate forwards and backwards at up to 7,000 times a minute, making extraction of fat less physically demanding on the surgeon. Ultrasoundassisted lipoplasty (UAL) uses ultrasound-emitting cannulae that emulsify fat as it is aspirated. After an initial enthusiasm in the 1990s, UAL fell into disuse as complications such as burns and seromas were frequently seen. Third-generation UAL features VASER-assisted lipoplasty (VAL) and supersedes earlier UAL technologies by employing less ultrasound energy to achieve optimum emulsification of fatty tissues for small or large areas, reducing collateral damage and side-effects. Solid titanium probes emulsify fat without removing the protective wetting tumescent solution. Gentle suction follows with cannulae that are designed to minimise trauma by balancing the total area of the ports with crosssectional area of the cannula (Fig. 23.1). The author’s

Table 23.1 Technologies used for lipoplasty Method

Description

Examples

Suction-assisted lipoplasty

Traditional liposuction using motor-driven vacuum or syringes to aspirate fat

Traditional liposuction

Power-assisted lipoplasty

Motor-driven cannula that reciprocates 4,000–7,000 times/min to make mechanical fat removal less physically demanding

MicroAire®

First-generation ultrasoundasissted lipoplasty

Powerful ultrasound-emitting solid 4–6 mm probes applied to emulsify fat before aspiration. High complication rate (burns, seromas) due to power

SMEI®, Casales®

Second-generation ultrasound-assisted lipoplasty

Powerful ultrasound-emitting hollow 5 mm cannulae with simultaneous emulsification and aspiration

Lysonix®, Mentor®

Third-generation ultrasound-assisted lipoplasty

Less powerful, grooved solid probes (2.2–4.5 mm) emulsify fat efficiently before aspiration

VASER®

Laser-assisted lipoplasty

Fine Nd:YAG laser-emitting probes destroy fat by photomechanical or thermal destruction, either with or without subsequent aspiration

Smart Lipo®(Nd:YAG 1,064 nm), Cool Lipo® (Nd:YAG 1,320 nm), Smart LipoMPX® (Nd:YAG 1,064 + 1,320 nm)

Transdermal high-intensity focused ultrasound

External transducer applied to skin emits focused ultrasound that destroys small foci of fat through microcavitation or thermal injury

Ultrashape®, Liposonix®

23 Liposculpture of the Abdomen in an Office-Based Practice

Fig. 23.1 VentX suction cannula with small-sized ports relative to diameter of cannula to reduce trauma on tissues during aspiration phase of liposculpture

preferred method of lipoplasty is VAL under tumescent local anaesthesia due to the high safety profile, ease of use, uncomplicated and quick post-operative course, and high patient satisfaction.

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easy cleaning; halogen or fluorescent lighting that is sufficiently bright to illuminate surfaces but not so bright that all shadows (and contours) disappear; conveniently placed electrical power outlets for lighting, operating table, and other electrical or motor-driven devices such as monitors and aspirators; and basins for scrubbing. Ventilation should comprise a particulate filter to clean the operating room air and reduce the likelihood of wound infection. Built-in cabinets, drawers and work-top surfaces to store sterile drapes, dressings, medications and consumables are important. An inventory of all medications should be kept and checked regularly to ensure everything is in-date. Stock should include medications for tumescent anaesthesia, perioperative analgesia and anxiolysis, as well as emergency medication in the event of allergic reactions, anaphylaxis or cardiac arrrhythmias or arrest (Table 23.2). All offices performing lipoplasty, even under local anaesthesia alone, should have a defibrillator. A suitable monitor is required for monitoring noninvasive blood pressure, pulse oximetry and cardiac tracing during lipoplasty procedures (Fig. 23.2). In case of power loss, a small petrol or diesel generator

23.5 Office Set-Up Establishing an office-based practice for liposculpture requires a knowledge of local guidelines, regulations and restrictions as they can differ from state to state and country to country. Indeed, office-based surgery is entirely unregulated in some countries. All liposuction surgeons should observe the highest standards in care and practice regardless of whether regulations are imposed or not. The surgeon should provide a comfortable, clean environment for the patient, a sterile operating field, proper monitoring, and a safe procedure with suitable instruments. The office space should be sufficient to accommodate a consultation room, pre- and post-operative holding area, changing area, toilets, operating room, clean/ scrub area and sluice room. When designing the operating room, references such as the current Accreditation Association of Ambulatory Healthcare (AAAHC) Guidebook can be useful [12]. Considerations for the operating room include the following: ample space that facilitates one operating table and allows the surgeon enough room to maneuvre around the table and manipulate instruments and tubing; flooring, walls and ceiling that have smooth surfaces without cracks for

Table 23.2 Inventory of essential stock medications for officebased liposculpture Pre-medications Cephalexin 500 mg Ciprofloxacin 500 mg (penicillin allergic patients) Lorazepam 1 mg Solpadol (paracetamol + codeine) Tumescent anaesthesia Physiologic 0.9% saline 1 L bottles Lidocaine 2% plain 8.4% w/v sodium bicarbonate Epinephrine 1 mg ampoules Emergency medications Oxygen Salbutamol (inhaler/nebuliser) Atropine 1 mg ampoules Clonidine 0.1 mg tablets Hydrocortisone 100 mg ampoules Chlorpheniramine 10 mg ampoules

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Fig. 23.2 Monitor for measuring vital signs during liposculpture in the office

should be available that is sufficient to power lighting, monitors and suction devices to complete the case. Instruments and machinery required for liposculpture of the abdomen depend on the preferred method of lipoplasty, such as SAL, PAL or VAL. In the author’s practice, VAL is used extensively. The VASER console consists of an integrated system, including all the elements required for flow rate-controlled tumescent infiltration, tissue-selective destruction of fat, negative pressure aspiration, and collection of emulsified fat in disposable canisters. Foot pedals control infiltration and ultrasound delivery, and dials on the digital display component adjust flow rate and ultrasound power output (Fig. 23.3). Surgeons performing lipoplasty in the office-based setting should be fastidious towards cleaning and sterilising surgical instruments. If instruments are cleaned on-site, local guidelines and protocol should be followed. Instuments should be soaked in enzymatic cleaner, then scrubbed using special brushes and pipecleaners to clean the lumens of hollow cannulae. Alternatively, ultrasonic cleaners can be utilised. Following thorough cleaning, instruments should be packed and sterilised in a vacuum autoclave (Fig. 23.4). Steam vacuum autoclaves require distilled or de-ionised water to prevent the build-up of impurities due to carbon dioxide in the air and water in the steam. For this purpose, a water distiller can be used in the office (Fig. 23.5). After each procedure, the operating room

Fig. 23.3 The VASER integrated system

Fig. 23.4 Vacuum autoclave for sterilising instruments and cannulas in the office

23 Liposculpture of the Abdomen in an Office-Based Practice

223 Table 23.3 American Society of Anaesthesiologists (ASA) physical status classification system Category Pre-operative health status

Fig. 23.5 Water distiller to purify water for steam autoclaving

surfaces and floor should be disinfected and all waste collected in designated biological waste bags. There should be a separate area in the office for clinical waste and disposables until they are collected by a registered healthcare waste company.

23.6 Patient Selection Liposculpture of the abdomen is the most common office-based body contouring procedure. The ideal candidate has a normal body mass index (BMI), good skin tone, protruberant areas of exercise- and diet-resistant fat, no comorbid disease, is a non-smoker and has realistic expectations. Deciding whether a patient is suitable or not for the procedure involves a detailed discussion during an initial consultation to determine the patient’s wishes, a full history and examination, and appropriate body measurements such as weight and height. Listen to the patient first to gauge expectations. Demands to remove all the fat from abdomen, thighs and arms should raise a red flag. This is clearly unrealistic. Requests to improve or reduce bulges are realistic and should be entertained. Patients with systemic disease such as diabetes, hypertension, coagulopathies, cardiovascular or respiratory disorders such as arrythmias, angina or asthma should be screened carefully or refused

ASA I

Normal healthy patient, excluding very young and very old

ASA II

Patients with mild systemic disease but no functional limitations

ASA III

Patients with severe systemic disease

ASA IV

Patients with severe systemic disease that is a constant threat to life

ASA V

Moribund patients expected to die within 24 h

treatment in the office-based setting. Most patients should be ASA I, or ASA II if a thorough understanding and knowledge of the patient’s condition is present (Table 23.3). Patients on anti-platelet therapy or anticoagulation cannot be treated unless it is safe for them to stop their medication at least 10 days before the procedure. Several medications interact with lidocaine and should be discontinued before the procedure to reduce the risk of lidocaine toxicity (Table 23.4). If the medication cannot be discontinued, either the treatment is deferred or, in certain cases, the dose of lidocaine is reduced to a maximum of 35 mg/kg. During examination of the abdomen, skin laxity and striae should be noted, as poor skin contraction is likely if laxity is severe or if there are extensive striae from previous weight gain or pregnancy. An abdominoplasty is sometimes more appropriate than lipoplasty for these patients, as well as those with large “aprons” of adipose tissue. Scars should be noted, and avoided during the procedure if they appear tethered, to avoid inadvertent penetration of the abdominal wall. Abdominal wall hernias must be checked for carefully with the patient standing and supine, and if present, they should be repaired before lipoplasty. Weight and height are measured and BMI calculated (BMI = weight (kg)/height (m)2). If the BMI is greater than 30, the author advises the patient to lose weight through healthy eating and exercise before liposculpture, and refers to a nutritionist and strength and fitness conditioning professional to help achieve their goals. Explaining to patients who are obese that they are likely to become suitable candidates for liposculpture once they reach a defined weight can be highly motivating and empowering. Overweight patients

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Table 23.4 Drugs that interact with lidocaine Antibiotics Ciprofloxacin Clarithromycin Erythromycin Anti-cancer medications Tamoxifen Anti-depressants Amitriptyline Clomipramine Fluoxetine Fluvoxamine Nefazodone Paroxetine Sertraline Anti-histamines Cimetidine Anti-fungals Fluconazole Itraconazole Ketoconazole Miconazole Anti-seizure medications Carbamazepine Phenytoin Valproic acid

Benzodiazepines Alprazolam Diazepam Flurazepam Midazolam Triazolam Beta-blockers Propranolol Calcium channel blockers Amiodarone Diltiazem Felodipine Nicardipine Nifedipine Verapamil Cholesterol-lowering medications Atorvastatin Lovastatin Simvastatin Immunosuppressants Cyclosporine Protease inhibitors Indinavir Nevirapine Nelfinavir Ritonavir Saquinavir

(BMI 25–30) are not ideal candidates but are often treated successfully. The body contouring achieved in these patients is the impetus for further weight loss through exercise, providing even better results. Based on the initial discussion with the patient, as well as the history and examination, if it is decided the patient is suitable for lipoplasty, the surgeon should explain in detail what the procedure involves. This is particularly important when lipoplasty is performed under tumescent local anaesthesia alone because the patient is awake and aware of what is happening during the procedure. A full explanation of the steps involved, duration, discomfort, and what to expect afterwards should be offered, and a list of potential side-effects and complications outlined. The

patient should understand the extent and limitations of treatment and the costs involved, including the cost, if any, of a touch-up procedure if required. If a large volume area is being treated, or the patient wants to address multiple body areas, the possibility of staging the procedure should be discussed. If the patient is keen to proceed, a second visit should be rescheduled for pre-operative tests, photographs, and measurements. This interval also allows the patient digest what has already been discussed and gives them the opportunity to think of other questions or queries prior to the second visit.

23.7 Pre-Operative Considerations Following the first consultation, once the patient has decided to proceed with abdominal lipoplasty, a second visit is scheduled for further assessment and routine pre-operative tests. The patient is encouraged to ask further questions that may have arisen since the initial consultation. The surgeon should define what the patient hopes to achieve from the procedure again, since it is not uncommon for the patient to have unrealistic expectations. Following liposculpture, a dissatisifed patient represents a failed procedure, so it is better to play down expectations and counsel the patient pre-operatively that the goal of abdominal lipoplasty is improved contours and reduced volume, not perfection. It is helpful to explain that efforts to remove all fat are likely to result in a poor result, skin irregularities or laxity, and increse the risk of complications such as haematomas, seromas and asymmetry. Once the patient understands the concept of body contouring, as opposed to simply removing fat, and has realistic expectations, the likelihood of a successful outcome is higher. A detailed step-by-step explanation of the procedure is given to the patient during the pre-operative consultation. It prepares the patient what to expect and alleviates patient anxiety on the day of the procedure. The potential risks and complications associated with liposculpture of the abdomen are explained again to the patient. The safety record of office-based body contouring under tumescent anaesthesia can be highlighted to reassure the nervous or anxious patient. If the patient prefers not to know what the procedure entails, a brief

23 Liposculpture of the Abdomen in an Office-Based Practice

summary can be given instead, without giving details of injections or cannulae, which may heighten anxiety. The patient’s history and examination should be reviewed, noting any relevant points made during the first visit, and documenting any new information. Medications are reviewed, and the patient is reminded to discontinue those that may increase side-effects or complications. These include medications that interfere with the metabolism of lidocaine such as those that are metablised by the liver’s cytochrome P450 3A4 enzymes, whch should be discontinued 2 weeks before the procedure. If they are not discontinued, lidocaine doses should be reduced during tumescent anaesthesia to avoid potential lidocaine toxicity. The patient must avoid all non-steroidal anti-inflammatories such as aspirin and ibuprofen, as well as nutritional and herbal supplements 10 days before surgery to reduce the potential for bleeding due to their anti-platelet effects. Since lidocaine toxicity, should it occur, might not become clinically evident up to 14 h following infiltration when serum levels are highest, the patient must be accompanied by a family member or close friend for the first night. Immediately after the procedure, the patient is warned to expect profuse drainage of blood-tinged tumescent fluid through the compression garment for up to 18 h. The patient is reassured that this permissive drainage of residual tumescent fluid benefits them by reducing swelling, limiting systemic absorption of lidocaine, and possibly further reducing the chance of infection by irrigating the skin incisions. Blood pressure and pulse rate are measured and the patient is weighed again. The patient’s weight is used to calculate a maximum safe dose of lidocaine administered as tumescent fluid, and should never exceed 55 mg/kg [10]. The author does not exceed a lidocaine dose of 45 mg/kg and believes this to be safer in practice, and always sufficient to adequately anaesthetise large areas, such as the abdomen and the flanks. The abdomen is examined again for asymmetry, skin laxity, thickness of adipose tissue and distribution of fat. Incision sites are proposed that give easy access to all areas to be contoured whilst placing them in discrete areas when possible, such as below the bikini line or in the inframammary crease. Photographs are taken at several angles using a high-resolution camera such as a single-lens reflex digital camera, preferably with no flash to avoid illuminating all shadows that contribute

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to the appreciation of body contour (Fig. 23.6). Measurements of waist, hips, and area of maximum abdominal circumference should be taken to document treatment results later and to enable a suitably sized compression garment to be chosen for the post-operative period. Pre-operative laboratory tests should include a complete blood count (white cell count, haemoglobin, platelets), coagulation tests (PT, PTT), renal function (urea, creatinine, potassium, sodium), and liver function (AST, ALT, bilirubin, alkaline phosphatase). Any abnormalities should prompt repeat tests and further investigation before the procedure. Patients with any history of cardiac disease or arrhythmias should have an ECG. A chest X-ray is not performed routinely since the procedure is performed under local anaesthesia, but should be considered in some older patients, heavy smokers, or those with clinical signs of cardiac failure, particularly when large volumes of tumescent fluid are required that may cause fluid overload. Detailed consent forms and information leaflets should be given to the patient to take home. These provide a written version of everything that has been explained during the first and second pre-operative consultations, including the nature of the procedure, pre-operative instructions, potential complications, expected benefits, and post-operative care and instructions (Table 23.5). The patient should be given these to take home and read and should present them, signed, on the day of the procedure. Finally, a prescription for antibiotics and analgesia is given to the patient, with instructions to take the first dose of antibiotics the night before the procedure.

23.8 Planning the Procedure The author routinely prints out patient photographs before the procedure and creates new contours by drawing on the photos using marker pens. This exercise helps the surgeon decide how much fat should be taken and from where and, more importantly, what should be left behind to achieve aesthetically pleasing contours. It also highlights asymmetries and the need to sculpt differently on either side. Based on experience, an estimate is made of the volume of tumescent fluid required to achieve optimum tumescence. Large abdomens with soft fat and

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a

c

e

b

d

f

Fig. 23.6 (a–f) Pre-operative patient. Anterior, oblique, side, and posterior views are taken using digital photography

loose or slightly lax skin require more volume to reach tumescence compared to smaller abdomens or those with no striae or laxity and good skin tone (Table 23.6). The concentration of lidocaine per litre of tumescent fluid is decided depending on the total volume required

for adequate tumescence during the procedure, and the weight of the patient. For liposculpture of the abdomen, the author adds 600–800 mg lidocaine to each litre of normal saline, thus achieving an approximate lidocaine concentration in tumescent solution of 0.06–0.08%.

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Table 23.5 Instructions for patients Pre-operative instructions 1. DO NOT SMOKE for 2 weeks prior to and 2 weeks after surgery. Smoking reduces blood circulation, slows down healing and increases complications. 2. DO NOT TAKE ASPIRIN or products containing aspirin, or anti-inflammatories such as Brufen, Neurofen, Ponstan and Difene for 2 weeks prior to or following your scheduled surgery. These medications affect your blood’s ability to clot and could increase your tendency to bleed during surgery or during the post-operative period. If you need to take a mild painkiller, you can take paracetamol. 3. DO NOT TAKE DIETARY SUPPLEMENTS for 2 weeks before and after surgery. These include vitamins, ginger, ginko biloba, garlic, ginseng and fish oils. They may increase your risk of bleeding and bruising during and following surgery. 4. DO NOT DRINK ALCOHOL for 5 days prior to surgery. Alcohol may increase your risk of complications as well as bruising. 5. IF YOU DEVELOP A COLD, COLD SORE, FEVER, OR ANY OTHER ILLNESS PRIOR TO SURGERY PLEASE NOTIFY US. 6. DAY PRIOR TO AND DAY OF SURGERY: Please shower using only anti-bacterial soap. Males receiving abdominal or flank treatment may prefer to shave the treatment area; females receiving abdominal or thigh treatment may prefer to shave pubic areas below the hairline. 7. WEAR COMFORTABLE, DARK, LOOSE-FITTING CLOTHING on the day of surgery, including a shirt that buttons all the way up the front. Wear nothing that you must put on over your head. Slip-on shoes are recommended for maximum post-operative comfort. We suggest you safeguard your car seat and bedding with a protective cover as there will be some leakage of fluid following surgery. 8. LEAVE JEWELRY AND VALUABLES AT HOME. Do not wear wigs, hairpins or hairpieces. 9. AVOID WEARING MAKEUP, FACIAL OR BODY MOISTURISERS. 10. SURGERY TIMES ARE ESTIMATES ONLY. You could be at the clinic longer than indicated. 11. ARRANGE FOR A DRIVER TO AND FROM SURGERY. We cannot discharge you to a taxi. Put a pillow and blanket in the car for the trip home. 12. HAVE A LIGHT BREAKFAST on the morning of surgery. I HAVE READ AND FULLY UNDERSTAND THE ABOVE ITEMS 1–12 Patient Signature Date Post-operative instructions 1.IF YOU EXPERIENCE EXCESSIVE PAIN OR BLEEDING, FULLNESS OR SPREADING REDNESS IN TREATMENT AREAS, OR FEVER, PLEASE CALL US IMMEDIATELY 2.DRIVING: A family member or friend must drive you home from your surgery (it is best to have them stay and assist you for the first 24–48 h). Please do not drive if you are taking the prescription pain medication Tramodol. 3.COMPRESSION GARMENTS: If you had liposculpture performed on your knees, thighs, hips, arms or abdomen, a special elastic-type garment was put on at the end of surgery to provide comfort and support while helping your skin conform to your new body contour. The day following surgery, you may remove the garment once a day for laundering, sponge bathing and bandage changing (if present). Continue wearing the garment 24 h a day for the first 2 weeks, followed by 12 h a day (remove at night) for the subsequent 2 weeks. 4. BATHING OR SHOWERING: Sponge bathe only for the first 72 h when removing the compression garment. After 72 h, you may take a shower or bath when the garment has been temporarily removed. Avoid Whirl Pools and hot tubs for at least 1 week (until the incision sites have healed). 5. TREATMENT SITES: Please keep your dressings as clean and dry as possible, changing daily if wet to help prevent infection. Do not apply heat or ice to the surgical areas. You should expect significant drainage (oozing) of blood-tinged anaesthetic solution at the incision sites due to fluids injected during your procedure. Although the fluid may appear red, it is mostly anaesthetic solution and saline and only 1% blood. In general, the more drainage there is, the less bruising and swelling there will be. Many patients have found it helpful to use a shower curtain or other protective covering on their mattress for the first few days after their liposculpture procedure. When your incisions stop draining, please clean with tap water and apply petroleum jelly to the incisions. Itching, pulling, pinching, hardness, tightness and/or numbness sensations are normal. All should subside within 24 h to 1 week, but sometimes can last for months. This is part of the healing process and your patience is apppreciated.

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Table 23.5 (continued) 6. ACTIVITY: Rest for the first 12 h. It is normal to experience light-headedness when rising or removing/changing your compression garments. Please have someone help you with this for the first few days after surgery. Take it easy for the first week, resuming normal activity as tolerated. Experiencing more than mild swelling and discomfort may indicate that you are overdoing it. Avoid strenuous activities, lifting over 10 Ibs, or aerobic exercise for 2–3 weeks. Protect incisions and any bruised areas from the sun until completely healed; use SPF30 or greater for 6 months. Avoid tanning until bruising has faded, which normally takes 10–14 days. If you like, feel free to treat yourself to a gentle massage during your post-operative course. Therapeutic massage is very helpful to speed the healing process and may be done beginning 2 weeks after surgery, as often as every second day and as hard as you can tolerate. 7. DIET: If you experience any post-operative nausea, try carbonated drinks and dry crackers to settle your stomach. Take your post-operative medications with food to minimise irritation. If your stomach feels normal, start slowly with liquids and bland foods, progressing to soups, and finally a normal diet as tolerated. Drink plenty of clear fluids. 8. ALCOHOL: As well as/In addition to refraining from drinking alcohol for at least 5 days before surgery, it is especially important that you do not consume alcohol as long as you are taking over-the-counter or prescription pain medication following surgery as they may interact. 9. SMOKING: We continue to stress the importance of not smoking. Smoking reduces blood circulation to skin and tissues and delays healing. Do not smoke at all during the first 14 days following the procedure. 10. EXPECTATIONS: Remember, the goal of fat removal is not weight loss but improved contour. In fact, since the body retains fluids in response to surgery, you may notice a temporary weight gain, resolving over the first week. In addition, remember that for the majority of people the goal is significant improvement, not perfection. Lower abdominal patients may experience significant swelling in the pubic area. Post-operative discomfort usually takes the form of deep muscle soreness and normally improves over the folllowing 2–7 days. Slight temperature elevation and flushing of the face, neck, and upper chest could last 48 h. You may initially experience a mild depression that should begin lifting after the first week, once you see the bruising and swelling fade. Menstrual irregularities (premature or delayed monthly onset) are a common side effect to surgery. If areas on the thighs were treated, you may have swelling in your calves and ankles for up to 3 weeks. 11. POST-OPERATIVE MEDICATIONS. Please take the antibiotics and pain medications as advised or prescribed by your doctor. If you have no allergies, you may start with regular paracetamol (1,000 mg every 6 h). If this does not relieve discomfort or pain, you can take the prescription pain medication in addition to the paracetamol. Do not take aspirin, Brufen or Neurofen. If antibiotics are prescribed, it is very important you complete the full course. 12. POST-OPERATIVE APPOINTMENTS. For maximum healing and optimal long-term results, you must follow the schedule of appointments that are made following your surgery. I have read and fully understand the above. Patient Signature Date Liposculpture with vaser informed consent Instructions This is an informed-consent document that has been prepared to help inform you concerning liposculpture with VASER ultrasound, its risks, and alternatives to treatment. Please read this information carefully and completely. Initial each page, indicating that you have read the page, and sign the Consent for Surgery, proposed by your surgeon. Introduction Liposculpture is a surgical technique to remove unwanted deposits of fat from specific areas of the body, including the face and neck, upper arms, upper and lower back, abdomen, flanks, buttocks, hips, inner and outer thighs, knees, calves and ankles. This is not a substitute for weight reduction, but a method for removing deposits of fatty tissue. Liposculpture using VASER technology may be performed as a primary procedure for body contouring or may be combined with other surgical techniques. The best candidates for liposculpture are individuals of relatively normal weight who have excess fat in particular body areas. Having firm, elastic skin will result in a better final contour after this procedure. Skin that has diminished tone due to aging, weight loss and sun damage will not reshape itself to the new contours and may require additional techniques to tighten excess skin. Body contour irregularities due to structures other than fat cannot be improved by fat removal. Liposculpture itself is unlikely to improve areas of dimpled skin known as cellulite.

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Liposculpture with VASER is performed using advanced proprietary technology. A patented grooved solid metal probe is first inserted through small skin incisions. Ultrasonic energy emitted from sides and ends of the probe as it is passed back and forth breaks down fatty deposits. A hollow metal surgical instrument known as a cannula is then inserted and is directed through the area of emulsified fat cells. The cannula is attached to a vacuum source, which provides gentle suction to remove the emulsified fat. Because liposculpture using VASER procedure first targets and dissolves fat cells and then draws off emulsified fat, leaving the collagen matrix intact, surgical trauma, complications and potential for post-operative pain and bruising are minimised while skin retraction is optimal. There are a variety of different techniques used for lipoplasty (fat removal) and care following surgery. Liposculpture using VASER can be performed under local or general anaesthesia. At Venus Medical Beauty, local anaesthesia only is used. This requires the infiltration of fluid containing dilute local anaesthetic and epinephrine into areas of fat. This reduces discomfort at the time of surgery, and reduces post-operative bruising. Support garments are worn after surgery to control potential swelling and promote healing, to provide comfort and support, and to help skin better fit new body contours. Alternative Treatment Alternatives to liposculpture with VASER for body contouring include no treatment at all. Diet and exercise regimens may be beneficial in the overall reduction of excess body fat. Other forms of lipoplasty can involve traditional liposuction, power-assisted lipoplasty, laser-assisted lipoplasty, injection lipolysis and the removal of excess skin surgically. Alternative surgical treatments carry their own risks and potential complications. Risks and Side-Effects of Liposculpture using VASER Every surgical procedure involves a certain amount of risk, and it is important that you understand the risks involved with liposculpture with VASER. Although the majority of patients do not experience these complications, it is important that you understand the potential complications before treatment. Patient selection Individuals with poor skin tone, medical problems, obesity, or unrealistic expectations might not be suitable candidates for liposculpture. Allergic reactions Rarely, local allergies to tape, suture material or topical solutions used during the procedure have been reported. More serious systemic reactions due to drugs administered during surgery or prescription medicines may require additional treatment. Asymmetry Due to factors such as skin tone, bony prominences, and muscle tone, which can contribute to normal asymmetry in body features, it may not be possible to achieve symmetrical body appearance through lipoplasty procedures. Bleeding While unusual, it is possible to have a bleeding episode during or after surgery. Should post-operative bleeding occur, it may require emergency treatment to drain accumulated blood or require a blood transfusion. Non-prescription herbs and dietary supplements can increase the risk of surgical bleeding. Do not take any aspirin or anti-inflammatory medications for 2 weeks before surgery, as this may increase the risk of bleeding. Please review our Pre-Operative Instructions and consult your doctor before taking anything. Change in skin and skin sensation A temporary decrease in skin sensation may occur following liposculpture. This usually resolves over a period of time. Diminished or complete loss of skin sensation that does not totally resolve could potentially occur, but this is uncommon. Chronic pain Chronic pain and discomfort following liposculpture is unusual. Infection Infection is unusual following this type of surgery. Should an infection occur, treatment including antibiotics or additional surgery may be necessary. Although extremely rare, life-threatening infections such as toxic shock syndrome could occur after lipoplasty, regardless of the technology used.

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Table 23.5 (continued) Long-term effects Subsequent alterations in body contour may occur as a result of aging, weight loss or gain, pregnancy, or other circumstances not related to liposculpture with VASER. It is important to maintain lifestyle habits such as diet and exercise to maintain optimum body proportions. An increase in weight can result in disproportionate fatty deposits in areas not treated following lipoplasty. Pulmonary complications In extremely rare cases, fat droplets could become trapped in the lungs to create a possibly fatal complication called fat embolism. Pulmonary complications may also occur secondary to blood clots (pulmonary emboli) but this is extremely unlikely when a general anaesthetic is not used. Such complications would require hospitalisation and additional treatment. Scarring Although the incisions created during the LipoSelection procedure are very small and good healing is expected, abnormal scars may occur. Such scars may be enlarged or different in colour to surrounding tissue. Seroma This is a localised collection of fluid under the skin. Seromas are uncommon using VASER technology for lipoplasty, but should they occur, additional treatment or surgery may be required to promote drainage. Skin discolouration and/or swelling Although liposculpture with VASER typically reduces or eliminates the skin discolouration and swelling normally resulting from lipoplasty procedures, such could occur, and in rare situations, persist for extended periods of time. The incidence of permanent skin discolouration is rare. Skin contour irregularities As VASER ultrasound selectively targets fat cells, leaving other essential tissues intact, skin contour irregularities and depressions in the skin are unlikley but possible. Visible and palpable wrinkling of skin can occur, particularly when large quantities of fat cells are removed and/or skin is lacking in good elasticity. Post-operative skin contour irregularities could necessitate additional treatments including surgery. Lidocaine toxicity There is the possibility that large volumes of fluid containing local anaesthetic drugs and epinephrine that is injected into fat during the procedure may contribute to fluid overload or systemic reaction to these medications. Although uncommon, additional treatment including hospitalisation may be necessary. Ultrasound technology Risks associated with the use of ultrasound in lipoplasty treatments include the aforementioned and the following specific risks: Burns Ultrasonic energy may produce burns and tissue damage either at the incision site or in other areas if the probe touches the undersurface of the skin for prolonged periods of time. If burns occur, additonal treatment and surgery may be necessary. Probe fragmentation Ultrasonic energy produced within the probe may cause disintegration (fragmentation) of the surgical instrument. The occurrence and effect of this is unpredictable. If this should occur, additional treatment including surgery may be necessary. Unknown risks The long-term effect on tissue and organs of exposure to short-duration, high-intensity ultrasonic energy is unknown. The possibility exists that additional risk factors resulting from the use of ultrasound in VASER could potentially be discovered. Other While we have attempted to assist you in building realistic expectations for your liposculpture treatment, you may be disappointed with your surgical results. However infrequent, it may be necessary in your case to perform additional surgery to improve results. It is important to read the above information carefully and have all your questions answered before signing the consent on the next page. Patient Initials__________

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LIPOSCULPTURE WITH VASER INFORMED CONSENT Consent for Surgery/Procedure or Treatment I have received and read the following information sheet: Liposculpture with VASER Informed Consent. I understand that liposculpture using VASER is an elective surgical procedure to remove body fat from specific areas of the body. The procedure has been explained to me in a way that I understand. I have had the opportunity to ask questions and my questions have been answered. Alternative methods of treatment have been discussed with me. I acknowledge that no guarantee has been given by anyone as to the results I might obtain. Although a good result is expected, I understand that there are risks to the procedure or treatment proposed, as detailed in the preceeding information pages. I consent to the administration of such anaesthetics and anxiolytics considered necessary or advisable. I understand that all forms of anaesthesia involve risk and the possibility of complications, as outlined. For purposes of medical education, I consent to the admittance of observers to the operating room. I consent to the disposal of any tissue which may be removed. Having discussed the reasonable expectations of liposculpture with me and answered all of my questions to my satisfaction, I hereby authorise Dr Prendergast and such assistants as may be selected to perform liposculpture and any other procedure(s) that in their judgement may be necessary or advisable should unforeseen circumstances arise during surgery. With my signature below I hereby consent to having liposculpture with VASER and to the above. Patient Signature Date I, Dr Peter Prendergast, certify that I or a member of staff has discussed all of the above with the patient and have answered all questions regarding the liposculpture procedure. I believe the patient fully understands what I have explained and answered. Surgeon Signature Date

Table 23.6 Volumes of tumescent fluid required per body area Area Estimated volumes (mL) Lower abdomen

900–1,300

Upper abdomen

600–1,000

Flank

400–600 per side

Example A patient requiring liposculpture of upper and lower abdomen and flanks weighs 68 kg. An estimate of the volume of tumescent fluid required is made: Lower abdomen

1,200 mL

Upper abdomen

800 mL

Right flank

500 mL

Left flank

500 mL

Total

3,000 mL

The maximum lidocaine dose permitted (based on 45 mg/kg) is:68 × 45 = 3,060 mg

This lidocaine dose can be distributed safely in the total volume required (3,000 mL), i.e., 1,000 mg of lidocaine could safely be added to each litre of saline, giving a maximum dose of 3,000 mg if all tumescent fluid is used. In practice, 1,000 mg lidocaine per litre is rarely necessary, but can be useful for fibrous, sensitive areas such as the upper abdomen. In the above case, tumescent solution containing 1,000 mg/L lidocaine could be used for the upper abdomen, whereas solution with 800 mg/L would be sufficient for the lower abdomen and flanks. With 3,000 mL infiltrate, the total lidocaine in this scenario would be below the maximum allowed dose as follows:

Upper abdomen

800 mL of 1,000 mg/L lidocaine

Lower abdomen

200 mL of 1,000 mg/L + 800 mL of 800 mg/L lidocaine

Right flank

500 mL of 800 mg/L lidocaine

Left flank

500 mL of 800 mg/L lidocaine

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The total tumescent fluid infiltrated is 3,000 mL but the total lidocaine dose is reduced to 2,600 mg, well below the maximum allowable dose of 3,060 mg.

deposits. Once this is complete and the surgeon and patient are happy, the patient is asked to wait in a holding area to relax until brought to the operating room.

23.9 Premedication and Marking

23.10 Tumescent Technique

The patient is allowed a light breakfast on the morning of the procedure. Once consent forms are signed, the author administers 1 mg lorazepam and one solpadol tablet (paracetamol 500 mg, codeine 30 mg) routinely for mild anxiolytic and analgesic effects. These low doses are less likely to cause adverse side effects such as dizziness and nausea during the procedure. The patient then stands whilst markings are made on the skin using Sharpie® fine permanent skin markers. The author uses different colours to map out the plan for the procedure: blue or black in concentric circles represent areas for fat removal and sculpting, straight lines that radiate from these rings are areas for less aggressive fat removal or feathering, red markings represent areas of caution such as scars or areas where fat removal is to be avoided, and green markings represent proposed incision sites (Fig. 23.7). In practice, almost the entire abdomen and flanks can be sculpted as one aesthetic unit, and this is desirable, rather than simply marking out pockets of localised fatty

Tumescent anaesthesia for liposculpture on the awake patient must be sufficient and properly administered in order to eliminate pain and discomfort, provide adequate vasoconstriction, and stabilise tissues for fat removal. A homogenous fluid-filled fat compartment is also essential for UAL to transmit sound energy and reduce complications such as burns and seromas. After the surgeon scrubs and dons full sterile surgical attire, skin preparation is performed using betadine or chlorhexidine wash and the patient is covered using disposable sterile drapes. Small volumes of 1% lidocaine with 1:2,00,000 epinephrine are injected intradermally at the incision sites. Small 2–4 mm stab incisions are made using a number 11 blade. Meanwhile, the 1-L bags of tumescent fluid are warmed to 40°C in a warming bath to prevent hypothermia and reduce pain during infiltration [13]. The vasoconstricting properties of epinephrine in the solution are sufficient to overcome the theoretical inconvenience of vasodilatation using warmed fluid. The initial infiltration of the tumescent

a

Fig. 23.7 Pre-operative markings in a patient with multiple scars from an appendectomy, caesarian section, bilateral inguinal hernia repairs and laparoscopy. Red marker identifies scars or areas where liposculpture should be cautious or avoided

b

23 Liposculpture of the Abdomen in an Office-Based Practice

fluid using blunt cannulae can be painful for the patient, particularly in sensitive or fibrous areas such as the epigastrium, around the umbilicus or in the flanks. For the inexperienced liposuction surgeon, as well as the patient, this can be a source of considerable stress and may discourage the surgeon from infiltrating all fat layers completely and thoroughly. The use of sharp, large bore spinal needles to reduce pain during infiltration should be avoided due to the risk of bleeding or penetrating intraabdominal structures. These needles can also be painful themselves. The author uses a simple technique to overcome discomfort during the initial phase of infiltration, using a Mesorelle® multi-injector. Five 12 mm 30 gauge needles are mounted on the multi-injector, which is connected to the infiltration tubing through a Luer Lock (Fig. 23.8). Before infiltrating with the blunt cannula, 200–300 mL of tumescent fluid are injected transdermally into the superficial subcutaneous fat close to the dermis in sensitive areas. Tumescent fluid is delivered through the tubing with either a motor-driven pump at a slow infusion rate (<50 mL/min) or by using a three-way tap and 20 mL syringe, drawing fluid from the hanging bag and injecting it through the multi-injector without using the pump. Patients find the injections using 30 G needles to be almost painless and after 10 min, the subsequent infiltration using the blunt cannula is easily tolerated, even in tough fibrous areas. Tumescent infiltration should be slow initiallly (100 mL/min) and in the deep layers, and increased as tolerated to 200 mL/min and a

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continue through the more superficial layers of fat until the tissues are swollen and firm. The operating hand should move forwards and backwards slowly and deliberately to fill between fat lobules at every level, whilst the other hand palpates the tissue from the surface, always aware of the location of the tip of the cannula. After withdrawing the cannula, a suture is placed to stem the flow of fluid from the incision site to prevent a reduction in pressure in the fat compartment. The author sutures a port into the incision directly at this point to prepare for VAL. It is necessary to wait at least 25–30 min following the end of infiltration before continuing to allow complete diffusion of the tumescent fluid to all compartments within the subcutaneous tissues, including the intralobular compartments around the adipocytes. Since tumescence is a temporary state, a top-up immediately prior to emulsification or aspiration of fat might be necessary to reestablish the firmness and turgidity required to stabilise the tissues [14].

23.11 Operative Technique Using VASER The author employs third-generation ultrasound technology (VASER) to emulsify fat before it is gently aspirated. There are several advantages of the VASER system over traditional SAL, and significant

b

Fig. 23.8 (a) Mesorelle® multi-injector mounted with five 30G 12 mm needles and connected to infiltration tubing. (b) Subcutaneous injections prior to tumescent infiltration with a blunt cannula

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improvements upon previous ultrasound-based technologies in design and technique. 1. Solid metal probes are used to emulsify fat in an extra step before aspiration, thus preserving the fluid medium required to protect tissues from excessive ultrasound energy. 2. Probes are small in diameter (2.2, 2.9, 3.7 and 4.5 mm) and contain grooves at the distal ends in such an arrangement that ultrasound energy is delivered both from the tip and from the sides of the probe in varying ratios depending on whether a one, two, or three-grooved probe is used. The result is improved efficiency of emulsification of fatty tissues using less energy than would be required with previous devices. 3. Ultrasound energy delivered to the tissues is selective for lobules of fat bathed in tumescent solution, such that collateral damage to the tissue matrix, lymphatics, nerves, and vessels is minimised. This translates to an easier recovery for the patient with less bruising, swelling, and pain, particularly following liposculpture of the abdomen. 4. The VASER system allows pulsed or continuous delivery of ultrasound energy. Pulsed delivery, termed VASER mode, delivers approximately ten bursts of energy per second and reduces the absolute energy delivered to the tissues. This is useful for delicate areas or during superficial work to reduce complications such as burns or seromas. 5. The VASER system utilises suction cannulae with smaller port holes than standard liposuction cannulae of the same diameter. This feature reduces avulsion and trauma to tissues during the aspiration of emulsified fat. A small hole in the handpiece of the

suction cannulae also facilitates easy flow of aspirate through the tubing, even when the cannula is in the patient. This has been termed the VentX effect [15]. An appropriately sized and grooved VASER probe is selected depending on the volume of fat present and whether the tissues are soft or fibrous (Table 23.7). Although tissues in the lower abdomen are usually much softer than the upper abdomen, which tends to be fibrous, this can be “felt” during the infiltration phase of the procedure with the blunt cannula so that the appropriate probe for the degree of tissue tone can be selected. The author usually starts in the lower abdomen with the 3.7 mm three-ring probe using 80% energy in continuous mode. Ultrasound is delivered only with the probe inside the patient, who is informed that they will hear a squeaking noise, but should feel no discomfort or pain. Gentle but deliberate, long to-and-fro strokes are made with the operating hand like the bow movements of a cellist. Movements should be graceful and continuous with no torquing, which could conduct excessive heat through the skin port and result in a burn. Although the skin port protects the skin around the incision to some degree, wet towels folded twice should be placed adjacent to the port during ultrasound delivery to protect the skin from contact with the probe. The probe should be parallel to the skin and guided by the non-dominant hand. Some resistance is felt as the probe gently creates tunnels through the fat, but it should not stop the probe in its path or require grasping and pushing of the probe with the operating hand. If excessive resistance is encountered, energy is increased to 90%, or an alternative probe is selected. Deep and superficial fat are emulsified, leaving at least 1 cm of superficial fat to support the dermis and give smooth results. The entire lower

Table 23.7 Author’s preferred VASER probe selection according to volume of fat and density of tissues for abdominal liposculpture Density Volume Probe Mode Energy (%) Soft

Very large

4.5 mm (2 grooves)

Continuous

70–80

Soft

Medium–large

3.7 mm (3 grooves)

Continuous

70–80

Soft

Small

2.9 mm (3 grooves) or 3.7 mm (2 grooves)

Continuous or pulsed

70–80

Slightly fibrous

Medium–large

3.7 mm (2 grooves)

Continuous

80–90

Slightly fibrous

Small

2.9 mm (3 grooves) or 3.7 mm (1 groove)

Continuous

80–90

Very fibrous

Medium–large

3.7 mm (2 grooves) or 3.7 mm (1 groove)

Continuous

80–90

Very fibrous

Small

2.9 mm (3 grooves)

Continuous

80–90

23 Liposculpture of the Abdomen in an Office-Based Practice

abdomen can be treated through two small access incisions below the bikini line, in line vertically with the lateral border of rectus abdominis. The author continues emulsification until no resistance is encountered in the treatment area. This usually requires 60–70 s of ultrasound delivery in continuous mode per 100 mL of tumescent fluid infiltrated. To treat the upper abdomen, access incisions are placed either at the inframammary crease in line with the lower abdominal incisions, or at the level of the costal margin, which allows easy access to the fat over the ribs, as well as below the costal margin and above the umbilicus. If it is found that access is difficult during the procedure without levering the probes, no hesitation should be made to place extra incisions to ensure a complete treatment. Using long VASER probes, a criss-crossing maneuvre is made to emulsify fat on the ipsilateral and contralateral sides. This is important for smooth, even results. In addition to emulsifying all marked areas to a point of minimal or no resistance, feathering should be done by emulsifying to a lesser degree in border areas to create smooth transitions between contours. Once emulsification is complete, skin ports are removed and a suitably sized suction cannula is inserted. In general, smaller cannulae are less likely to create post-liposuction defects and irregularities. The author uses 3.7 and 3.0 mm VentX cannulae, which have port sizes smaller than those on 3.0 and 2.4 mm Mercedes cannulae, respectively. Aspiration of emulsified fat is easy and requires little force. The operating hand moves forwards and backwards radially like the spokes of a wheel while the other hand stabilises the skin over the tip of the cannula. As suction continues, the pinch test is performed intermittently to assess symmetry and reduction in thickness of the fat layer. The endpoint is reached when the desired amount of debulking and improvement in body contour has been achieved based on the pinch test and careful inspection from different vantage points in the operating room. Occasionally, if the aspirate becomes dry, bloody, or the patient begins to feel discomfort, further tumescence is required before completion of the procedure. Once an aesthetic unit is completed, the patient is repositioned, redraped, and tumescent infiltration recommences. The author considers the anterior abdomen as one aesthetic unit, and rarely treats just the lower or upper abdomen in isolation. It is usually appropriate to treat the flanks simultaneously to provide better body contouring. This can be achieved

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under tumescent local anaesthesia during the same procedure, with the patient in the supine position first, and then in the prone position for further contouring and blending of treatment areas. When all areas are treated, the abdomen is massaged or “milked” towards the incision sites to expel pools of residual tumescent fluid. Skin incisions are left open to drain. Sterile dressings are applied and a specially designed tight-fitting compression garment, such as a Marena ComfortWear® garment, is applied. The garment should be fitted properly with no creases to avoid indentations in the skin. The author does not use absorbent dressing or Reston foam padding underneath the compression garment. Instead, large disposable incontinence briefs are sufficient to absorb initial drainage through inferior incisions, and can be changed as required over the first few hours.

23.12 Post-Operative Care Immediately following the procedure, the patient rests in the office for an hour or two and is provided light nutrition. Once they feel well, and provided their vital signs are normal, they are allowed home accompanied by a friend or relative. The analgesic effects of the tumescent anaesthesia last several hours, after which simple analgesia is usually sufficient. Antibitoics, such as cephalexin, are continued for 5 days, and stronger analgesia, such as tramadol, is prescribed for 3 days, but is usually not required. The patient is advised to remove the compression garment after 24 h for washing and to change the dressings, which will be soiled. The compression garment is worn thereafter for 24 h a day for 2 weeks, and for 12 h a day for a further 2 weeks. A detailed post-operative instruction leaflet is given to the patient (Table 23.5). The patient is reviewed at 7 days, 6 weeks and 6 months following the procedure. Mild swelling, ecchymosis, and firmness of the skin and tissues during the healing process are normal, and can be ameliorated by a course of manual lymphatic drainage or Ender mologie™, starting 2 weeks after surgery, and continuing for up to 6 weeks. The patient is advised to avoid strenuous activity for 2 weeks. Although results following VAL can be appreciated as soon as 1 week following surgery (Figs. 23.9 and 23.10), the final result takes 4–6 months for complete skin retraction in the abdomen.

236 Fig. 23.9 (a) Pre-operative patient. (b) Eleven days post-operatively using VASER-assisted lipoplasty for the upper and lower abdomen

P. M. Prendergast

a

a

Fig. 23.10 (a) Pre-operative male patient. (b) Seven days post-operative after liposculpture under tumescent anaesthesia

b

b

23 Liposculpture of the Abdomen in an Office-Based Practice

23.13 Conclusions Sculpting the abdomen under tumescent local anaesthesia is safe and satisfying for both surgeon and patient. Excellent results can be achieved without the need for sedation or general anaesthesia in the office, and the patient benefits further from fewer complications and a quicker recovery, particularly if technology that requires less traumatic suction is employed, such as VASER third-generation ultrasound. As more office-based lipoplasty procedures are being performed all over the world, surgeons should be particularly mindful of the need to maintain high standards in all aspects of their health care delivery, by offering the best technology, using the safest and most effective techniques, in a safe environment, to those who are suitable and are likely to achieve a good outcome.

References 1. Flynn TC, Coleman WP III, Field LM, Klein JA, Hanke CW. History of liposuction. Dermatol Surg. 2000;26(6):515–20. 2. Fischer A, Fischer G. First surgical treatment for molding body’s cellulite with three 5 mm incisions. Bull Int Acad Cosmet Surg. 1976;3:35. 3. Joint American Academy of Dermatology/American Society of Dermatologic Surgery Liaison Committee. Current issues in dermatologic office-based surgery. J Am Acad Dermatol. 1999;41(4):624–34. 4. Klein JA. The tumescent technique for liposuction surgery. Am J Cosmet Surg. 1987;4:236–67.

237 5. Coldiron BM, Healy C, Bene NI. Office surgery incidents: what seven years of Florida data show us. Dermatol Surg. 2008;34(3):285–91. 6. Housman TS, Lawrence N, Mellen BG, George MN, Filippo JS, Cerveny KA, DeMarco M, Feldman SR, Fleischer AB. The safety of liposuction: results of a national survey. Dermatol Surg. 2002;28(11):971–8. 7. Coleman WP III, Hanke CW, Lillis P, Bernstein G, Narins R. Does the location of the surgery or the specialty of the physician affect malpractice claims in liposuction? Dermatol Surg. 1999;25:343–7. 8. Hanke CW, Lee MW, Bernstein G. The safety of dermatologic liposuction surgery. Dermatol Clin. 1990;8:563–8. 9. The American Society for Aesthetic Plastic Surgery. Cosmetic surgery national databank statistics. ASAPS; 2007. www.surgery.org. 10. Ostad A, Kageyama N, Moy RL. Tumescent anaesthesia with a lidocaine dose of 55mg/kg is safe for liposuction. Dermatol Surg. 1996;22(11):921–7. 11. Balkrishnan R, Hill A, Feldman SR, Graham GF. Efficacy, safety, and cost of office-based surgery: a multi-disciplinary perspective. Dermatol Surg. 2003;29(1):1–6. 12. Accreditation Association for Ambulatory Healthcare Incorporated. Accreditation guidebook for office-based surgery, 2008. www.aaahc.org. 13. Yang CH, Hsu HC, Shen SC, Juan WH, Hong HS, Chen CH. Warm and neutral tumescent anaesthetic solutions are essential factors for a less painful injection. Dermatol Surg. 2006;32(9):1119–22. 14. Sattler G, Sattler S. Physiodynamic concept of tumescence. In: Textbook of liposuction. Hanke CW, Sattler G, Sommer B, editors. UK: Informa Healthcare; 2007. p. 43–5. 15. Cimino WW. VASER-Assisted lipoplasty: technology and technique. In: Shiffman MA, Di Giuseppe A, editors. Liposuction principles and practice. Springer Verlag Berlin Heidelberg 2006. p. 239–44.

“Anchor-Line” Abdominoplasty: A Comprehensive Approach to Abdominal Wall Reconstruction and Body Contouring

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Paolo Persichetti, Pierfranco Simone, Annalisa Cogliandro, and Nicolò Scuderi

24.1 Introduction Abdominoplasty aims to reshape the abdominal wall by combining skin and subcutaneous tissue resection with musculo-aponeurotic reinforcement. The presence of a median or paramedian supraumbilical scar should always be considered in patients for whom an abdominoplasty is planned. In fact, advancement of the superior flap is very limited and leads to unfavorable aesthetic results, as the median scar resembles a cord under tension. A considerable number of these patients have supraumbilical scars consequent to bariatric surgery with massive weight loss. Simple transverse resection cannot guarantee adequate body contouring. The “anchor-line” abdominoplasty includes the median or paramedian supraumbilical scars (either vertical or short horizontal) in the resection and implies extensive abdominal wall excision by combining vertical and horizontal patterns. A final scar with an “anchor-line” shape is obtained [1].

24.2 History Weinhold [2] was probably the first author to perform an abdominoplasty involving horizontal and vertical incisions. Dufourmentel [3] and Galtier [4] also introduced techniques involving horizontal and vertical patterns. Castañares and Goethel [5] and Barraya and

P. Persichetti (*) Division of Plastic and Reconstructive Surgery, Organization of Bio-Medico University, Via Bertoloni 19, 00197 Rome, Italy e-mail: [email protected]

Dezeuze [6] described similar techniques in 1967. In this group, we can include the “fleur-de-lis abdominoplasty” [7] that was introduced more recently as an evolution of the Regnault’s modified W Castañares technique [8]. The “fleur-de-lis abdominoplasty” allows extensive resection in patients with massive weight loss, obesity associated with a panniculus and supraumbilical dermatochalasis, with or without multiple abdominal scarring. It includes a reduction of the mons pubis.

24.3 Patient Selection The selection of candidates for an abdominoplasty is an articulate process, which implies assessment of general and local parameters. The final step is the selection of a specific surgical technique. Patient’s age, food habits, alcohol intake, previous weight fluctuations, smoking, pregnancies are initially recorded. A thorough medical history includes general conditions: obesity, diabetes, pulmonary or cardiovascular disease, previous thromboembolic episodes, and metabolic syndrome. The latter is a new pathological entity, considered as a multiplex risk factor for cardiovascular disease (CD). The metabolic syndrome is defined by several clinical criteria such as abdominal obesity, atherogenic dyslipidemia, raised blood pressure, insulin resistance or glucose intolerance, a proinflammatory state and a prothrombotic state [9]. Consideration of every previous or ongoing local abdominal condition is of the utmost importance, especially with regard to surgery. Medications such as corticosteroids, immunosuppressives, and anticoagulants are noted. Allergies are recorded. Careful assessment of the motivation behind the request for surgery is carried out. Functional reasons

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Table 24.1 Functional and aesthetic reasons for abdominoplasty Functional reason Aesthetic reason Limitations in daily activities

Physical disproportion

Postural alterations

Disability to wear fitted garments

Back pain Skin rashes in the abdominal fold

are: limitations in daily activities, postural alterations, back pain, skin rashes in the abdominal fold. Aesthetic motivations include physical disproportion and disability to wear fitted garments. Oftentimes both functional and aesthetic reasons are reported (Table 24.1). The clinical abdominal evaluation is performed focussing the attention on multiple components. In fact, the form of the abdominal wall is given by the skeletal structure, the intraabdominal organs, the integrity of the aponeurotic and muscular system, the quantity and distribution of the fat, as well as the appearance and condition of the skin. The first stage of the abdominal examination is inspection, with the patient standing and in frontal view: assessment of shape, ratio between subcutaneous and deep fat, symmetry, masses, fat distribution, striae, extent and site of dermatochalasis, shape and position of umbilicus. Particular attention must be paid to scars: previous abdominal surgery must always raise suspicion of impaired skin vascular supply. In particular, scar position, length, width and retraction are accurately analyzed. The lateral view, in the upright position, allows evaluation of the lateral extent of the abdominal folds (Fig. 24.1). An easy way to assess musculo-aponeurotic system laxity is to have the patient bend over (diver’s test) (Fig. 24.2). Standardized photographic documentation is an integral part of the preoperative evaluation [10]. The patient is then examined in the supine position for palpation. Guarding, rigidity, or pain is noted and intraabdominal organs are evaluated. In particular, as far as the abdominal wall is concerned, attention is paid to thickness and distribution of the subcutaneous tissue, masses, hernias and rectus abdominis muscle diastasis. Useful maneuvers to assess hernias are to have the patient cough or hold his nose and mouth closed and blow forcibly. Muscle diastasis is better palpated by asking the patient to lift his head off the

Fig. 24.1 Lateral view, upright position

Fig. 24.2 Preoperative diver’s test

pillow and look at his toes. Skin redundancy is better assessed pinching the abdominal wall horizontally and vertically with the patient standing (Fig. 24.3). Percussion is the next step of the abdominal examination and is used to evaluate masses and to determine if abdominal distention is due to gas-filled bowels or accumulation of fluid. Auscultation for bowel sounds

24 “Anchor-Line” Abdominoplasty: A Comprehensive Approach to Abdominal Wall Reconstruction

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b

Fig. 24.3 Preoperative evaluation of skin redundancy: (a) horizontal pinching (b) vertical pinching

and bruits is the last step of the abdominal clinical examination. Preoperative laboratory tests are routinely obtained when selecting patients for an abdominoplasty, especially in patients with previous bariatric surgery, adequate control of their serum proteins and hydroelectrolytic balance is fundamental. ECG and Chest X-ray are routine preoperative investigations. Computerized tomographic scan or magnetic resonance imaging of the abdominal wall is carried out in all patients with primary or incisional hernias at rest and/or during straining. Pulmonary function studies are obtained in patients with primary or recurrent abdominal hernias or chronic obstructive pulmonary disease. In selected cases, hematologic, endocrinologic, or psychological consultations are requested. This type of selection allows identification of candidates for an abdominoplasty and in particular, based on the specific abdominal wall deformities, of the appropriate treatment. Key points are: 1. A median or paramedian supraumbilical scar implies significant concern when planning an abdominoplasty [11, 12]. The surgeon is faced with the problem of raising abdominal skin and subcutaneous tissue flaps, which may present impaired vascularization due to previous surgery. 2. Advancement of the superior flap, when performing a classical abdominoplasty without excision of the supraumbilical scar, is very limited and leads to unfavorable aesthetic results. In such cases, the median scar resembles a cord under tension.

3. Patients who have had bariatric surgery have a huge excess of abdominal skin. The anchor-line abdominoplasty offers the opportunity to overcome all these concerns: 1. Necrosis of the abdominal skin and subcutaneous flaps is unlikely, provided the lateral segmental vessels are preserved. Dissection is very limited in this procedure and concomitant liposuction to the lateral areas of the abdomen is generally discouraged, to avoid impairing the vascular supply to the abdominal wall [13, 14]. Liposuction is solely performed in selected cases with significant fat deposits in the flanks, and much caution is exercised in the execution of this procedure. 2. The anchor-line abdominoplasty implies resection of the median or paramedian supraumbilical scars (either vertical or short horizontal), thus preventing their unfavorable stretched appearance. 3. The upper component of the excision entails a wide area of the abdominal wall, and this is particularly useful in patients with extremely pendulous abdomens. The lateral dermolipectomy allows reduction of waist circumference and improvement of the antero-posterior silhouette. The vertical and horizontal approach is particularly advantageous whenever concomitant abdominal or gynaecological operations are needed, as it facilitates access to the abdominal cavity. This holds true also in case of recurrent incisional hernias. Each component plays a crucial role in determining specific abdominal wall deformities, which require appropriate treatment. Therefore, accurate patient selection is fundamental to plan the right surgical technique.

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24.4 Vascular Anatomy Huger [15] described the blood supply to the abdominal wall and divided it into three main zones (Huger’s zones I, II and III) (Fig. 24.4). The first zone corresponds to the mid part of the abdomen and is vascularized by the perforating branches of the superior epigastric artery and inferior epigastric artery, which anastomose within the rectus muscle fascia. The second zone corresponds to the hypogastrium and is nourished by the superficial iliac circumflex artery, the superficial epigastric artery and some perforating branches from the proximal segment of the inferior epigastric artery. The third zone includes the lateral areas of the abdomen and is supplied by the perforating branches from the diaphragmatic, intercostal and lumbar arteries. The third zone is responsible for the vascularization of the

a

Fig. 24.4 Blood supply to the abdominal wall. (a) Huger’s zones I, II, III (SSEA superficial superior epigastric artery; SCIA superficial circumflex iliac artery; SIEA superficial inferior epigastric

lateral cutaneous flaps advanced in the anchor-line abdominoplasty (Fig. 24.4); whenever these lateral segmental branches are spared, there is no increased risk of skin necrosis at the crossing of the vertical and horizontal incisions.

24.5 Surgical Technique Bowel preparation with enemas is carried out the day before surgery. Foley catheter is positioned preoperatively. Elastic stockings are applied to legs to prevent venous stasis and low-dose heparin is administered for deep venous thrombosis prophylaxis. Several leading authorities, including the 2006 National Quality Forum (NQF), American College of Chest Physicians (ACCP), and American Society of Colon & Rectal Surgeons (ACRS), endorse the use of prophylaxis against DVT

b

artery). (b) The lateral segmental perforators responsible the vascularization of the flaps advanced in the abdominoplasty

24 “Anchor-Line” Abdominoplasty: A Comprehensive Approach to Abdominal Wall Reconstruction

(deep venous thromboembolism) for surgery patients [16] (Table 24.2). Marking of the surgical incisions consists of the midline drawn from the xyphoid to the pubic symphysis with the patient in the upright position. With the patient supine, a lower horizontal ellipsis plus an upper vertical medial triangle, which entails the supraumbilical scars, are marked (Fig. 24.5). The upper components of the elliptical drawing run obliquely downward beneath the umbilicus that is different from the conventional design. In this way, the final horizontal scars

are placed as low as possible, in the natural suprapubic fold. The width of the upper triangle is easily established by gently pinching the abdominal wall transversally, with the patient supine, and advancing the lateral flaps so as to obtain the new abdominal silhouette. No excess tension must be exerted so as to avoid pubic hair line elevation. The patient’s hips should be placed over the hinge brake of the operating table for flexion during the operation in order to release tension when performing the sutures.

Table 24.2 Guidelines for DVT prophylaxis Trends that may reduce DVT risk 2004 American College of Chest in general surgery patients: Physicians (ACCP) guidelines recommend:

2006 National Quality Forum (NQF)/ Surgical Care Improvement Project (SCIP) performance measures outlined for patients undergoing abdominal surgery are:

− More rapid mobilization

− Prophylaxis of DVT following abdominal surgerya,b

− Surgery patients with recommended venous thromboembolism (VTE) prophylaxis ordered

− Greater use of thromboprophylaxis

− Higher-risk general surgery patients (those undergoing nonmajor surgery who are >60 years of age or have additional risk factors, or patients undergoing major surgery who are >40 years of age or have additional risk factors): recommend LDUH (5,000 U tid) or LMWH (>3,400 U daily) (both Grade 1A)

− Surgery patients who received appropriate VTE prophylaxis within 24 h prior to surgery to 24 h after surgery

− Other advances in perioperative care

− High-risk general surgery patients with multiple risk factors: recommend pharmacologic methods (i.e., LDUH tid or LMWH > 3,400 U daily) combined with the use of GCS and/or IPC (Grade 1C+) − Selected high-risk general surgery patients, including those who have undergone major cancer surgery: suggest posthospital discharge prophylaxis with LMWH (Grade 2A)

Trends that may increase dvt risk in general surgery patients: − Performance of more extensive operative procedures in older and sicker patients − Use of preoperative chemotherapy − Shorter lengths of stay in the hospital, leading to shorter durations of prophylaxis Excerpted from the 7th ACCP Conference on antithrombotic and thrombolytic therapy. Abdominal surgery was considered as a part of general surgery recommendations LDUH low-dose unfractionated heparin; LMWH low-molecular-weight heparin; GCS graduated compression stockings; IPC intermittent pneumatic compression a

b

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Fig. 24.5 Preoperative marking

Incisions are performed along the preoperative drawing and an “en-bloc” resection of skin and subcutaneous tissue is carried out. The umbilicus is resected in a triangular shape, with the base placed superiorly, isolating and preserving its stalk, which is left attached to the abdominal fascia.

P. Persichetti et al.

The lateral flaps are elevated through sharp dissection in a prefascial plane in order to mobilize the flaps sparing the lateral musculocutaneous perforators, and being careful not to impair the vascular supply (Huger’s zone III). Use of conventional electric cutting current is discouraged, given the increased risk of seroma associated with this procedure, as observed in other sites [17]. Ultrasound devices or new electrocautery devices with limited thermal damage can be a valid alternative. Plication of the rectus sheath is then performed; in most cases it is vertical and sometimes vertical and horizontal depending on the myoaponeurotic laxity (Fig. 24.6). Reinforcement of the abdominal muscolo-aponeurotic layer may imply medial advancement of muscolofascial flaps from the oblique muscles of both sides. In these cases, the fascia is incised along the anterior axillary lines and the muscles are split, preserving the underlying intercostal vessels, allowing medial advancement of the flaps. The oblique muscles are fixed medially with bilateral paramedian plications, which are performed in addition to the medial one. Plications are carried out with an inverted nonabsorbable suture such as Prolene 1–0. In case of recurrent abdominal incisional or inguinal hernias, a Prolene mesh is placed in a preperitoneal position. Sometimes the mesh is applied onto the deep rectus muscle fascia, because of peritoneal impairment caused by previous surgery (Fig. 24.7). The umbilicus, previously cut out in a triangular shape, with a superior base, is fixed to the aponeurosis.

Fig. 24.6 After “en bloc” dermolipectomy. (a) Before plication of rectus and oblique muscle fascia. (b) After plication

24 “Anchor-Line” Abdominoplasty: A Comprehensive Approach to Abdominal Wall Reconstruction

a

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b

Fig. 24.7 (a) Epigastric incisional hernia. (b) Suprapubic incisional hernia

The lateral dermoadipose flaps are advanced and approximated medially and two oblique incisions are carried out in the midline, in the umbilicus anatomical position. A “Y”-shaped recipient site results, and the navel is sutured into it. A very natural umbilicus shape is obtained. Two suction drains are always placed, one in a supraumbilical position and the other in a lower position, beneath the umbilicus. Before advancing the abdominal flaps and starting the sutures, the operating table is flexed 30° to release tension on the sutures. Subcutaneous approximation is attained with absorbable polyglycolic acid sutures, followed by a running subcuticular nylon suture. The abdomen is padded with a cotton–wool bandage. An elastic pressure dressing is applied all over the area. Patients stay in bed for 48 h postoperatively, wearing elastic stockings till they are ambulated for thromboembolic prophylaxis. They are carefully instructed to mobilize their lower extremities in bed under a nurse’s supervision and antibiotics (cephalosporins) are administered until drains are removed. A full blood count is requested the day after surgery. Postoperative temporary ileus is frequent and patients are nil by mouth till bowel canalization is ascertained. A girdle is worn for 1.5 months; the first 2 weeks it is worn night and day. The “anchor-line” abdominoplasty is often associated with other extraperitoneal or intraperitoneal operations,

mainly, inguinal hernioplasty or cholecystectomy. The association with other surgeries must take into account the higher risk of postoperative complications, which depend on the type of combined operations. Whenever the umbilicus is lost during previous surgery, a neo-omphaloplasty is performed, marking a 2 cm diameter circle at the new navel site. An equatorial incision is then performed obtaining two flaps. The lower flap is defatted and sutured to the underlying fascia. The wound heals by secondary intention, yielding a very natural umbilical scar.

24.6 Complications Early complications observed following an anchorline abdominoplasty are considered as minor when they do not require surgical revision: suture abscess/ granuloma, minor wound dehiscence, minor skin slough can be treated with local dressings to obtain healing by secondary intention. Innovative wound care, with active dressings, is available to assist in the healing process and provide excellent exudate management. Seroma formation following abdominoplasty has a statistically higher incidence in overweight or obese patients [18]. Quilting sutures have been shown to decrease the rate of seromas in a recently published

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study. In a retrospective study, Kim et al. [19] concluded that liposuction of the flanks in concert with abdominoplasty does not increase the risk of seroma formation. Seroma is easily assessed with ultrasound and is generally treated with syringe aspiration and elastic pressure dressing in the out-patient clinic. The main early major complications, following an anchor-line abdominoplasty, are skin necrosis and loss of the umbilicus. Skin necrosis generally occurs at the crossing of the vertical and horizontal incisions. Once the necrotic area is well-demarcated, surgical debridement is performed and, depending on the extent of the defect, reconstruction is attained through local flap advancement or skin grafting. New undermining of the

a1

b1

Fig. 24.8 (a1,2) Preoperative view. (b1,2) Three months postoperatively

abdominal flaps allows further medial advancement, which generally results in a longer horizontal scar. Loss of umbilicus requires neo-omphaloplasty, as previously described. Postoperative hematoma can be a major complication in the days following surgery and its early recognition is extremely important. On clinical examination, the amount of blood drained, local swelling and ecchymosis as well as symptoms of anemia reveal an ongoing blood collection. Ultrasonographic examination is an effective method for early recognition of such postoperative hematomas, and it should be carried out as soon as clinical symptoms appear. Haematoma surgical

a2

b2

24 “Anchor-Line” Abdominoplasty: A Comprehensive Approach to Abdominal Wall Reconstruction

evacuation is mandatory, as well as identification and sealing of bleeders. Blood transfusion is requested based on the haemoglobin level. Infection can be a severe complication, especially if caused by multiresistant bacteria and if a mesh was placed. A sample should always be sent for microbiological examination to select specific antibiotics. In severe cases, local debridement is necessary; vacuum therapy offers a valid option but in the most severe cases, mesh removal is necessary. The most devastating early complication of abdominoplasty is pulmonary embolus, which seems to be related to the severity of plication of the rectus fascia, which can cause intraabdominal hypertension [20– 22]. The increased intraabdominal pressure causes stasis of the venous circulation and predisposes to deep venous thrombosis (DVT). However, deep vein thrombophlebitis and pulmonary embolus seem to be rare complications. Long-term complications include scar asymmetry, hypertrophic scarring, umbilical malposition, elevation of the pubic escutcheon, painful neuromas, and dog-ears [23]. Surgical revision depends on the patient’s preferences and severity of the defect. Comorbid factors play a significant role. Patients who smoke or have diabetes, hypertension, or asthma have significantly higher complication rates. Postoperative anemia is to be expected in patients with malabsorption following bariatric surgery. Obesity is yet another wellknown risk factor for wound complications in abdominoplasty. Obesity at the time of abdominoplasty has a profound influence on the wound complication rate following surgery, regardless of any previous weight reduction surgery [24]. In a recent study, the largest series of local and systemic complication rates was reported and compared with those of previously published abdominoplasty surveys [25]. This study underlined that, despite more extensive abdominal contouring techniques and the association of liposuction, the local and systemic complication rates coincided with previously published data (Fig. 24.8).

24.7 Conclusions In the vast majority of patients who are candidates for an abdominoplasty and present with supraumbilical

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median or paramedian scars, especially in case of concomitant intraabdominal procedures, an anchor-line abdominoplasty should always be considered.

References 1. Persichetti P, Simone P, Scuderi N. Anchor-line abdominoplasty: a comprehensive approach to abdominal wall reconstruction and body contouring. Plast Reconstr Surg. 2005; 116(1):289–94. 2. Weinhold S. Bauchdeckenplastik. Zentralbl Für Gynäk. 1909;38:1332. 3. Dufourmentel C, Mouly R. Chirurgie plastique. Paris: Flammarion; 1959. p. 381–9. 4. Galtier M. Obésité de la paroi abdominale. Presse Méd. 1962;70:135–6. 5. Castañares S, Goethel JA. Abdominal lipectomy: a modification in technique. Plast Reconstr Surg. 1967;40(4):378–83. 6. Barraya L, Dezeuze J. Chirurgie abdominale, réparation pariétales et dermolipectomies. Nouvel ombilic. Mem Acad Chir (Paris). 1967;93(15):473–9. 7. Dellon AL. Fleur-de-lis abdominoplasty. Aesthetic Plast Surg. 1985;9(1):27–32. 8. Regnault P. Abdominoplasty by the “W” technique. Plast Reconstr Surg. 1975;55(3):265–74. 9. Grundy SM, Brewer HB Jr, Cleeman JI, Smith SC Jr, Lenfant C. American Heart Association, National Heart, Lung, and Blood Institute. Definition of metabolic syndrome: Report of the National Heart, Lung, and Blood Institute/ American Heart Association conference on scientific issues related to definition. Circulation. 2004;109(3):433–8. 10. Persichetti P, Simone P, Langella M, Marangi GF, Carusi C. Digital photography in plastic surgery: how to achieve reasonable standardization outside a photographic studio. Aesthetic Plast Surg. 2007;31(2):194–200. 11. Cardoso de Castro C, Salema R, Atias P, Aboudib JH Jr. T abdominoplasty to remove multiple scars from the abdomen. Ann Plast Surg. 1984;12(4):369–73. 12. de Castro CC, Costa Aboudib JH Jr, Salema R, Gradel J, Braga L. How to deal with abdominoplasty in an abdomen with a scar. Aesthetic Plast Surg. 1993;17(1):67–71. 13. Matarasso A. Liposuction as an adjunct to a full abdominoplasty revisited. Plast Reconstr Surg. 2000;106(5):1197–202. 14. Dillerud E. Abdominoplasty combined with liposuction (letter). Ann Plast Surg. 1991;27(2):182–6. 15. Huger WE Jr. The anatomical rationale for abdominal lipectomy. Am Surg. 1979;45(9):612–7. 16. Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, Ray JG. Prevention of venous thromboembolism: the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 2004;126(3 Suppl):338–400S. 17. Porter KA, O’Connor S, Rimm E, Lopez M. Electrocautery as a factor in seroma formation following mastectomy. Am J Surg. 1998;176(1):8–11. 18. Nahas FX, Ferreira LM, Ghelfond C. Does quilting suture prevent seroma in abdominoplasty?. Plast Reconstr Surg. 2007;119(3):1060–4; discussion 1065–6.

248 19. Kim J, Stevenson TR. Abdominoplasty, liposuction of the flanks, and obesity: analyzing risk factors for seroma formation. Plast Reconstr Surg. 2006;117(3):773–9; discussion 780–1. 20. Schein M, Wittmann DH, Aprahamian CC, Condon RE. The abdominal compartment syndrome: the physiological and clinical consequences of elevated intraabdominal pressure. J Am Coll Surg. 1995;180(6):745–53. 21. Ivatury RR, Diebel L, Porter JM, Simon RJ. Intraabdominal hypertension and the abdominal compartment syndrome. Surg Clin North Am. 1997;77(4):783–800. 22. Sugrue M. Intra-abdominal pressure: time for clinical practice guidelines? Intensive Care Med. 2002;28(4):389–91.

P. Persichetti et al. 23. Chaouat M, Levan P, Lalanne B, Buisson T, Nicolau P, Mimoun M. Abdominal dermolipectomies: early postoperative complications and long-term unfavorable results. Plast Reconstr Surg. 2000;106(7):1614–8; discussion 1619–23. 24. Rogliani M, Silvi E, Labardi L, Maggiulli F, Cervelli V. Obese and nonobese patients: complications of abdominoplasty. Ann Plast Surg. 2006;57(3):336–8. 25. Matarasso A, Swift RW, Rankin M. Abdominoplasty and abdominal contour surgery: a national plastic surgery survey. Plast Reconstr Surg. 2006;117(6):1797–808.

Circular Lipectomy with Lateral Thigh–Buttock Lift

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Héctor J. Morales Gracia

25.1 Introduction Patients with body contour deformities are among the challenges that plastic surgeons most frequently face. These body contour deformities vary from patient to patient in number, intensity, and anatomical location depending on racial and genetic factors, and these are worsened with overweight and even more with obesity. These patients usually have tried different weightreduction methods, including diets, reductive massages, amphetamines, exercise, etc. Nevertheless, the majority do not succeed and they fall into a vicious cycle that only increases the problem. Those who succeed in losing weight end up with skin and soft tissue laxity that creates problems. Some of these patients believe that liposuction is magical, thinking that it will solve all their contour deformities. Therefore, it is vital that plastic surgeons inform their patients about the limitations of liposuction, the risks of a radical liposuction, and the need for an appropriate surgery. Most patients present a number of body contour deformities that cannot be corrected in one single surgical stage. Some will require three or more surgical stages. For these reasons, I decided to create a treatment program that combines several body contour techniques without increasing the surgical risk. With this program, it is possible to change the patient’s silhouette (body contour), helping them to recover their self-esteem and break the vicious obesity cycle [1].

H. J. Morales Gracia Belisario Domínguez 2501, Colonia Obispado, Monterrey, Nuevo León, CP 64060, México e-mail: [email protected]

The obesity and morbid obesity rate has increased all over the world in the last decade, and so has the bariatric surgery and consequently, the number of postbariatric or massive weight loss patients who successfully have lost weight and recurred (needed, asked for) to plastic surgery. Initially in post-bariatric plastic surgery, the procedures were merely paniculectomies, cutting out the skin excess, careless of the resultant scar placing, ignoring the body aesthetic units and symmetry, without improving body contouring and shaping and yet the patients were satisfied. There was no experience in this kind of patients, but later, different plastic surgeons started to create new procedures and sometimes modified preexistent procedures to improve them, observing all the principles of the aesthetic plastic surgery, placing the scars following the aesthetic units of the body, getting the best possible symmetry, shape, and volume to obtain a nice silhouette. The post-bariatric surgery patient is a much more difficult patient than the moderately overweight patient in order to get an aesthetic result. To perform the surgery, they must be weight stable; that can be achieved in approximately between 12 and 18 months after bariatric surgery. They must also be in good nutritional shape. When they come to the plastic surgeon, some of them have lost a lot of the fat tissue; in this case, the skin and subcutaneous tissue are very thin and the fixation mechanisms of the connective tissues to the muscular fascia have excessive laxity, which makes it easy to evaluate the amount of skin resection using the pinch manoeuvre, and easy to control bleeding, but without fat it is almost impossible to get a nice female body shape and in a couple of months, the tissues that were tightened get loose, the tissues lose elasticity and due to elasticity loss, have excessive laxity. That is why we often see cases of circular lipectomies in post-bariatric patients with bad located asymmetrical scars with a complete

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lack of female silhouette, no volume at the gluteal area and some with residual skin excess in the abdomen. The asymmetrical and/or misplaced scars could be due to either bad planning or displacement of the scar because the fixation sutures did not hold the tissues that were extremely lax and weak and could be even worse if there is still residual weight on the legs or buttocks. That is why in this case, we must plan properly following the aesthetic units of the body and place as many fixation sutures as possible and we must team up with the bariatric surgeons and nutritional assistance staff to assure patient’s weight and nutritional stability prior to cosmetic surgery in order to succeed. One of the advantages of the stable post-bariatric patient is that the skin becomes very thin so they usually tend to form less conspicuous, almost invisible scars.

H. J. M. Gracia

25.2 Objectives with Circular Lipectomy There are several objectives that we seek to achieve with this Circular Lipectomy: 1. To lift, and to improve the shape, size, and skin texture of the gluteus, making them look round and youthful (Fig. 25.1). 2. To lift the lateral thigh, eliminating cellulite by tightening the skin (Fig. 25.2). 3. To eliminate redundant flank tissue (Fig. 25.3). 4. To lessen the amount and size of (and sometimes eliminate) the middle and lower back adipose cutaneous folds, therefore reducing waist size (Fig. 25.4).

Fig. 25.1 The lift corrects the ptosis and improves the shape, size, and skin texture of the gluteus, making then appear round and youthful

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Fig. 25.2 The lift improves the silhouette and eliminates cellulite by tightening the skin of the lateral thigh

5. To reduce the redundant skin and fat of the abdomen and to tighten the rectus abdominis and external oblique muscles when needed, thus improving the abdomen and waist shape (Fig. 25.5). 6. To break the vicious cycle of obesity. 7. To leave a single circular scar that can be hidden with a thong and that may be planned and placed according to the patient’s dressing habits and of course respecting the aesthetic units of the body (Fig. 25.6).

25.3 Indications This surgery is indicated in thin, normal, and little overweight patients with loose and redundant skin and subcutaneous tissue and even in patients with moderate obesity and obesity (Fig. 25.7). It can also be performed only to lift the buttocks to improve their size, shape and eliminate cellulite without doing the abdominoplasty (Fig. 25.8). The author frequently combines this surgery with breast surgery, either mastopexy or

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Fig. 25.3 Circular lipectomy eliminates redundant flank tissue

breast augmentation, but can also be combined with brachioplasty if needed. In postbariatric patients, numbering the areas to be corrected and making a surgical plan is mandatory in order to reduce the number of surgical stages within safety limits.

25.4 Pre-Operative Markings For pre-operative markings, the patient stands while the trochanteric area that needs liposuction is outlined. The supragluteal and lateral supragluteal areas (flanks) that will be resected are marked starting with the lower

marking line at the posterior midline, 3–5 cm above the intergluteal crease. A convex line lightly ascendant is traced until it reaches the gluteal midline and then extends caudally following the line of the inferior edge of the lateral supragluteal fat pad (love handles) until it reaches the upper edge of the lateral gluteal recess. The contralateral side is marked in the same way, forming a seagull–wing shape line (Fig. 25.9). The upper marking line is marked at the midline, 2 or 3 cm above the expected or desired suture line. It starts at the midline, usually 5–7 cm above the inferior edge of the resection with lightly ascending curved line extended laterally just over the lateral supragluteal fat deposit (flanks).

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Fig. 25.4 Circular lipectomy lessens the amount and size (sometimes eliminates) of the middle and lower back adipose cutaneous fonds

It is important to consider that the further an incision is from the midline, the more lax the subcutaneous tissue and its superficial fascia system are [2]. The expected suture line at the lateral aspect of the flanks will be located 5–7 cm below the upper limit of resection. Once both lines are marked, the vertical distance of midline is 5–7 cm and of the lateral aspect of the flanks is 14–25 cm (Fig. 25.9). The pinching maneuver on the flank facilitates marking on the thin patients [3]. The abdominoplasty is then marked conventionally. A horizontal line of 10–12 cm, located just above the pubic hairline, is traced, extended laterally, and following an ascending line parallel to the inguinal crease. The upper margin is a curved line with its upper end located above the umbilicus (at the lowest), depending on the case, and extended laterally until it meets the inferior margin line. The posterior and anterior marking lines are then joined in the most convenient way for each case.

25.5 Surgical Technique An intravenous line is set, and the anaesthesiologist administers light intravenous sedation with 50 mg/kg of mydazolam, 1 mg/kg of fentanest, 1 g of cephalotine

every 6 h, 50 mg of ranitidine every 12 h, and 5,000 U of subcutaneous heparin. The epidural catheter is introduced in a lateral decubitus position at the L2–3 level and in cases in which breast surgery will also be performed, a second epidural catheter is introduced at T6–7 level. A Foley catheter is set and the patient is made prone. The surgery starts with the trochanteric dry liposuction of the deep fat. If liposuction is not needed, the cannula is used to undermine and free the trochanteric area to facilitate the lift using a 4-mm cannula through a small, oblique 7 mm incision located at the inferior posterior edge of the trochanteric markings, being careful not to damage or compromise the integrity of the superficial fascia system and subcutaneous tissue of the upper edge of the lateral thigh flap because they are going to be used for closure. The resection of the supragluteal and lateral supragluteal tissue starts dividing (cut the flap in two) (Fig. 25.10) the flap at the posterior midline to facilitate the undermining and the resection, then the incision is made on or following the superior or upper marking line and then the incision of the lower or on the lower or inferior marking line is made both starting from medial to lateral. The whole thickness of the subcutaneous tissue is resected, exposing the fascia thoracolumbalis in the mid lower back

254 Fig. 25.5 The abdomen and waist shape are nicely improved

H. J. M. Gracia

25 Circular Lipectomy with Lateral Thigh–Buttock Lift Fig. 25.6 The Scar is placed at the limits of the body’s aesthetic units and can be hidden by a thong

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Fig. 25.7 Circular lipectomy in a 35-year-old obese patient who refused bariatric surgery has significantly improved buttocks and abdomen

area and laterally, the aponeurosis of the latissimus dorsi and external oblique muscles [4]. The caudal limit of the undermining is just to the level of the inferior line of the markings. Once the undermining and resection are completed, the lower flap is manually pulled up to confirm that the resection has been

adequate and to establish the vector of the lifting at several points and marking them the way we like it (Fig. 25.11). In moderately obese patients, it is difficult to establish, by using the pinch maneuver, the amount of tissue to be resected; a partial resection is made to facilitate the undermining and also to establish the

25 Circular Lipectomy with Lateral Thigh–Buttock Lift

Fig. 25.8 The size, shape, uneven aspects, and cellulite of the buttocks are totally corrected by the lift

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H. J. M. Gracia UPPER ANTERIOR AND POSTERIOR MARKING LINES

LOWER ANTERIOR AND POSTERIOR MARKING LINES

HORIZONTAL SUPRA PUBIC MARKING LINE

TROCHANTERIC AREA (SADDLE BAGS)

OBLIQUE PARANGUINAL ASCENDING MARKING LINE

LATERAL SUPRA GLUTEAL AREA OR FLANK (LOVE HANDLES)

RESULTANT SCAR

IDEAL SILHOUETTE LINE

UPPER MARKING LINE LOWER MARKING LINE

INTER GLUTEAL CREASE

GLUTEAL MIDLINE

LATERAL GLUTEAL RECESS

TROCHANTERIC LIPOSUCTION INCISION

Fig. 25.9 Pre-operative markings are done immediately before surgery with the patient standing

definitive level of the resection. In most patients, the tissue resection is greater than the initial marking because the flap displacement increases once the tissue is resected, facilitating an overlapping maneuver of the upper over the lower flap allowing a more precise, complementary resection. This is especially important at the flanks because an insufficient resection will not correct the cellulite or the contour deformities. When the resection is excessive, the wound closure will be difficult and the tension on the suture may result in dehiscence, or widening of the scar. Once the resection is completed, a combined maneuver is performed that shifts the upper and lower flaps to define and mark the traction axis of the lateral thigh and gluteal lift (Fig. 25.11). The gluteal flap is pulled up over the fascia thoracolumbalis, the aponeurosis of the latissimus dorsi, and external oblique muscles to mark traction and fixation suture line (Fig. 25.12). The wound closure starts with zero monofilament Prolene sutures, to fix mid line, taking enough subcutaneous tissue, with its superficial fascial system, at mid line on the inferior flap and then enough tissue of the aponeurosis of the fascia thoracolumbalis at the midline. As many of these sutures (every cm) as necessary are placed on each side following the traction-fixation suture line in order to pull up the flap

and reduce tension on the subcutaneous and sub dermal sutures, favouring better scar quality. A 2.5-mm external diameter perforated tube is placed as suction drainage. The subcutaneous tissue is sutured with zero Prolene, taking enough subcutaneous tissue, with its superficial fascia system, on both flaps and then taking some of the aponeurosis of the underlying muscles. Ten to twelve of these sutures are paced on each side. The subdermal layer is then closed with 3–0 Monocryl inverted sutures and there is no need for intradermal suture. The posterior suturing is finished leaving a dog ear on each side before moving the patient to the supine position (Fig. 25.13). The abdominoplasty begins with the skin resection as marked. The rectus abdominis muscle is plicated (Fig. 25.14) as is the external oblique muscle when needed. The wound is closed in two layers and suction drainages are left. At the end of the surgery, the patients wear a compressive girdle with shoulder straps to suspend the buttocks during ambulation. The patients spend one night at the clinic and receive autologous blood if needed [5, 6]. They start walking the next morning and are discharged at noon. They are examined on the sixth post-operative day when the drains and umbilicus stitches are removed. Examination is continued weekly for the first month, and then monthly for a year [1].

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Fig. 25.10 Cutting the supragluteal flap in two at the midline facilitates the undermining and resection

25.6 Complications Over the past 10 years, circular lipectomy has been performed with lateral thigh and buttock lift in over 100 patients. No major complications have occurred. All the patients had a fast recovery, beginning

ambulation the morning after the surgery, wearing the compressive girdle with gluteal suspension. Some patients indicated pain in the lumbar area, but it did not prevent them from walking. It was easier for the most obese patients to walk because of their decrease in weight and reduced circumference, due to the

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Fig. 25.12 Gluteal flap pull up maneuver over the fascia thoracolumbalis and muscles to mark traction and fixation suture line

Fig. 25.11 Overlapping maneuver allows a more precise complementary resection

elimination of excess skin and fat folds. Their heart rate and blood pressure decreased after surgery. The body contour deformities involved were corrected in all the patients, with very good aesthetic results. The average fat volume obtained by liposuction was 400 g.

The resected tissue weight varied from 1.3 to 15 kg with an average of 3.6 kg Twentynine patients had abdominal seroma. In ten patients, the seroma extended to the flank (or it was isolate formed at the flank and back) and six patients presented seroma leakage through the wound at the posterior midline. This problem was spontaneously corrected during the first 3–4 weeks. Seroma leakage through the wound has been prevented by placing thin suction drain tubes on the back. There were two cases of partial dehiscence, one was 7 cm-long and the other was 5 cm-long. One of the dehiscence cases was on the flank – site of maximum tension – and the other was in the supragluteal area. There were three cases of micro-dehiscence at the posterior midline,

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Fig. 25.13 Posterior suture end laterally leaving dogears

resulting from difficulty in suturing the tip of the upper flap and /or favoured by posterior seroma draining through. Therefore, the incision design was changed to eliminate the tip of the seagull-wing flap (Fig. 25.9) and place posterior drains. In the last 60 cases, there has been no complication other than few abdominal seroma. Excellent results were achieved on non-obese patients who had thin torsos, producing an ideal silhouette (Figs. 25.15 and 25.16). In the moderately obese patients, the correction was also very good, significantly improving the silhouette at the waist, the gluteus, and lateral thigh. The ideal silhouette was not obtained in patients with other body contour deformities that were left untreated, such as the internal thighs, the upper back, the trunk, and the arms. The resulting scar was located at the limits of the aesthetic units and could be covered by thongs and bikinis in most of the cases. In six patients, the scar could not be covered by a thong, requiring normal underwear or bikinis,

Fig. 25.14 Rectus abdominis muscle plication significantly improves the abdominal silhouette

because of scar widening or asymmetry. Four patients presented unilateral widening of the scar at the flanks, caused by dehiscence in one case but in absence of skin dehiscence, in the remaining three cases (Fig. 25.17). In four patients, the scar was high, two presented asymmetry of the supragluteal scar. The wide scars at the flanks that were not preceded by dehiscence were probably due to technical failure because this area of maximum tension requires meticulous suturing. It is also possible that liposuction of the neighbouring area compromised the integrity of the superficial fascial system, producing subcutaneous dehiscence. I found that the scars were less conspicuous in non-obese patients than in obese patients. In all

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Fig. 25.15 Excellent results in non-obese patients with thin torso

the cases, the results were greater than patient’s expectations. During the first 2 months, the gluteal shape and projection on the lateral view is very poor and the buttocks look flat, but around the fourth month, the area becomes round and youthful (Fig. 25.18). The results were consistently good.

25.7 Discussion The circular lipectomy with lateral thigh and buttock lift is based on previous experiences of several

surgeons, [2, 3, 7–17]. The circular lipectomy of Gonzàlez Ulloa was designed to eliminate the redundant skin and fat tissues of the abdomen, flanks, and lower back, but it did not improve the lateral thighs and buttocks contour or lift them either. The resultant scar was higher than that left by the author’s procedure, requiring compensation triangles that left vertical scars. Liposuction [7, 13, 14], together with the body contour surgery techniques of Baroudi, advanced the treatment of body contour deformities [6, 10–12]. The different combinations proposed by Baroudi have similar incisions, but the posterior ones are lower and the ones of the abdomen are different [6]. Lockwood used

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Fig. 25.16 Ideal silhouette is obtained with circular lipectomy in mild overweight patients

incisions on the lower body lift that are similar to those we use, but lower and with different design and marking of the area of resection [17]. His results are outstanding but require several stages. Also, he does not perform this procedure on moderately obese patients. With the circular lipectomy, it is possible to achieve several objectives in one stage: 1. The gluteus is lifted and its size and shape is improved. 2. The lateral thigh is lifted, improving the contour and tightening the skin, eliminating cellulite.

3. The number and size of adipose cutaneous folds of the lower and middle back are decreased, improving the waist silhouette. 4. Redundant flank tissue is eliminated. 5. Excessive abdominal skin and fat are eliminated. 6. The rectus abdominis muscle is plicated, improving the waistline and abdominal silhouette. 7. The circumferences of the abdomen, waist, hips, and thighs are significantly decreased. 8. The only scar left can be placed according to the patient’s dressing habits and can be covered by a thong in most cases [1].

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Fig. 25.17 Scar widening at the flank in the absence of dehiscence

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c

b

a

c

Fig. 25.18 (a) Flat gluteal shape and projection at 1 month after surgery. (b) Three months after surgery with buttocks starting to appear better. (c) One year after surgery with round and youthful buttocks

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References 1. Baroudi R, Keppke EM, Tozzi-Neto F. Abdominoplasty. Plast Reconstr Surg. 1974;54(2):161–8. 2. Baroudi R. Body sculpturing. Clin Plast Surg. 1984; 11(3):419–43. 3. Baroudi R. Lipolysis combined with conventional Surgery. In: Hetter GP, editor. Lipolysis: the theory and practice of blunt suction lipectomy. Boston: Little Brown; 1984. 4. Baroudi R. Body contouring surgery. Clin Plast Surg. 1989; 16(21):263–77. 5. Gonzalez Ulloa M. Circular lipectomy with transposition of the umbilicus and aponeurolytic technique. Cirugìa 1959; 27:394–409. 6. González Ulloa M. Belt lipectomy. Br J Plast Surg. 1960; 13:179–86. 7. Illouz YG. Illouz`s technique of body contouring by liposis. Clin Plast Surg. 1984;11(3):409–17. 8. Illouz YG. Surgical remodeling of the silhouette by aspiration liposis or selective lipectomy. Aesthetic Plast Surg. 1985;9(1):7–21.

H. J. M. Gracia 9. Illouz YG, De Villers YT. Body sculpturing by lipoplasty. New York: Churchill Livingstone; 1989. 10. Couch N, Laks H, Pilon RN. Autotransfusion in three variations. Arch Surg. 1974;108(1):121–2. 11. Lockwood TE. Fascial anchoring technique in medial thigh lifts. Plast Reconstr Surg. 1988;82(2):299–304. 12. Lockwood TE. Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast Reconstr Surg. 1991; 87(6):1009–18. 13. Lockwood TE. Transverse flank-thigh-buttock lift with superficial fascial suspension. Plast Reconstr Surg. 1991; 87(6):1019–27. 14. Lockwood T. Lower body lift with superficial fascial system suspension. Plast Reconstr Surg. 1993;92(6):1123–5. 15. Morales Gracia HJ. Circular lipectomy with lateral thighbuttock lift. Aesthetic Plast Surg. 2003;27(1):50–7. 16. Newman MM, Hamstra R, Block M. Use of banked autologous blood and elective surgery. J Am Med Assoc. 1971; 218(6):861–3. 17. Testut L, Jacobs O. Tratado de anatomía topográfica. Barcelona: Salvat Editores SA; 1952.

Prevention and Management of Abdominoplasty Complications

26

Melvin A. Shiffman

26.1 Introduction Complications following abdominoplasty can occur at any time with any patient despite adequate surgical technique and patient care. These problems may cause patient discomfort, delay recovery, require further surgery, or threaten the patient’s survival. The surgeon should be aware of the possible complications, their prevention, their timely diagnosis, and their treatment. The possible risks and complications must be discussed with the patient prior to surgery.

26.2 Complications 26.2.1 Asymmetry If care is not taken in the initial marking prior to surgery, asymmetry may result. The midline should be marked above the umbilicus and in the area of the pubis. If there is a very fatty abdominal wall, the midline at the level of the pubis can be located either by visualizing the anterior junction of the vulva or carefully spreading the pubic hair to find the direction of the hairs that diverge to each side at the midline. The transverse lower abdominal incision line should be marked preoperatively so that the distance from the midline is equal on each side. The height of the ends of the lateral extensions should be equidistant from some measurable point superiorly or inferiorly, such as the

M. A. Shiffman 17501 Chatham Drive, Tustin, CA 92780-2302, USA e-mail: [email protected]

anterior superior tubercle or the level of the top of the ilium. The amount of skin excised is determined by firm traction on the skin flap at an equidistant point on each side from the midline of the flap. This will prevent excessive tension on one side of the flap compared to the other. Care must be taken to center the umbilicus to prevent asymmetry involving the umbilicus. Excessive fat or skin can be surgically excised to correct asymmetry. Fat can also be liposuctioned in areas of excess.

26.2.2 Bleeding (Bruising, Hematoma, Exsanguination) The presence of bruising following any surgical procedure is accepted as a known consequence of the procedure [1–3]. When a swelling filled with blood appears in the abdominal wall shortly after surgery, the surgeon must make a decision as to careful observation or some form of drainage. When a hematoma first appears, the clot can be aspirated only with great difficulty. Over time (a few days), the fibrin precipitates and the remaining fluid can be more easily aspirated with a needle. If the hematoma is not aspirated, the serosanguinous fluid in the pocket will slowly become typical serous fluid and thus a pseudocyst. When the hematoma is increasing in size, surgery should be seriously considered to ligate the bleeder surgically by exploring the wound and emptying the clot. Mohammad [3] reported a 9% incidence of hematoma. Bleeding from the wound is easier to monitor than hidden bleeding. Compression dressings, bed rest, and ice packs sometimes will control the bleeding. If there

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is persistent bleeding, surgical exploration is essential. The wound is opened, any hematoma evacuated, and the bleeder(s) ligated or electrocoagulated. The wound may be closed with or without drainage but it is safer with catheter or penrose drainage. The presence of orthostatic hypotension should be a warning that there may be inadequate fluid replacement or excessive blood loss. Fluid should be replaced if the hypotensive episodes persist. If there is no prolonged response, then there is probably excessive blood loss even if there is no apparent bleeding from the wound or expanding hematoma. Immediate Hemoglobin (Hgb) and Hematocrit (HCT) should be obtained and if there is a significant drop from the preoperative studies, then replacement of fluids should be rapid with volume expanders such as Hespan or albumin. A 20% drop in Hgb or HCT is reason enough to consider blood replacement since these studies do not equilibrate for 24–48 h. Admission to a hospital emergency room may be necessary to monitor the patient over a period of time in order to determine if blood replacement is necessary.

26.2.3 Dehiscence Dehiscence following abdominoplasty usually occurs at the tightest point of the abdominal incision closure. This point is the center of the flap at the attachment in the region of the pubis. The area darkens and necrosis occurs followed by disruption of the closure, sometimes with the wound pulling apart. The tight closure elongates the vessels resulting in spasm and clotting of the vessels, which is followed by necrosis and disruption of the wound. Usually the wound does not pull far apart because the sutures lateral to the disrupted area hold the wound together [1, 4]. Other contributory causes include smoking, poorly controlled diabetes mellitus, underlying hematoma or seroma, and too much activity by the patient. Many surgeons close the wound tightly with the patient bent tilting the chest and legs toward each other. The surgeon then expects the patient to remain in that position for several weeks even while walking around. Compliance with these instructions is usually poor since it is virtually impossible to maintain this position for any length of time, especially if the patient has a history of back problems.

M. A. Shiffman

Treatment for dehiscence should be conservative allowing the wound to slowly slough the necrotic tissue and the wound should heal by secondary intention if the wound cannot be sutured closed because of excessive tension. The necrotic tissue can be debrided at appropriate intervals of time. Usually the scar will contract sufficiently to form a slightly widened scar that can be revised if necessary (if the patient is dissatisfied with the appearance).

26.2.4 Dog-Ears The closure of the transverse lower abdominal wound is started with a suture in the midline to properly position the new umbilicus. The wound should then be closed starting laterally on each side to give a flattened appearance to the most lateral regions of the wound. If there is excessive fatty tissue in the region where dog ears usually form, this tissue should be excised prior to the closure. Many times, small dogears will resolve within 3 months without treatment. When there are persistent dogears for more than 3 months, these can be excised under local anesthesia, usually in an elliptical form. Very large dogears and fullness in the area can be treated by liposuction as well as excision.

26.2.5 Edema, Persistent When edema is persistent, over 3 months, and does not respond to conservative measures such as compression, liposuction with tumescent solution should be considered. Too much liposuction may result in damage to the skin or indentations. Therefore, the liposuction should be conservative. At the same time, there should be a determination as to whether there is persistent edema or just too much residual fat.

26.2.6 Infection, Sepsis Wound infection is a known consequence of any clean surgery, occurring in 1% of patients in an outpatient or office surgical center and 3% in a hospital. It is not

26 Prevention and Management of Abdominoplasty Complications

unusual for slight erythema to occur around the sutures without actual significant infection. If significant wound erythema occurs while the patient is on antibiotics, the dosage may be increased or the antibiotic changed. The wound should be watched very carefully for progression of the infection that may require intravenous antibiotics that can be given as an outpatient of in the hospital. Infections not responding to antibiotics may require consultation with an infectious disease specialist and may indicate early necrotizing fasciitis or may evolve into toxic shock syndrome that can be fatal. Complete blood count (CBC) should be obtained as well as wound, where possible, and blood cultures [1]. Uncontrolled infection can be life threatening if sepsis occurs. This may be indicated by fever, elevated white count, and lethargy. Prompt treatment with appropriate intravenous antibiotics is essential.

26.2.7 Necrosis Necrosis is more likely to occur if the patient is a smoker, if concomitant abdominal liposuction is performed, or if there has been prior extensive liposuction to the abdominal wall. Smokers may say they will stop smoking but there are some who will continue to smoke despite all the admonitions. There is nothing that can be done if the patient does not stop smoking completely. The necrosis will progress to its fullest extent, not only in the lower abdomen, but also at times in the periumbilical area and upper abdomen [1, 2, 4]. Poorly controlled diabetes mellitus, very tight wound closure, underlying hematoma or seroma, and infection may contribute to the cause and extent of the necrosis. If the patient has a prior transverse upper abdominal scar (i.e., cholecystectomy, gastrectomy, splenectomy), the triangle formed by the scar, the midline, and the tightly pulled abdominal skin flap is susceptible to necrosis unless enough space is left between the old scar and the transverse closure line to allow vascularity to the triangle. It is helpful to place less tension on the flap closure so that stretching the vessels and thromboses are not added to the problem. Sometimes, the use of a different type of resection may be necessary to prevent necrosis. This usually means the addition of a vertical midline scar [5]. The best treatment is observation with debridement as needed and allowing the wound to heal by secondary

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intention. Placing skin grafts in a granulating abdominal wound will shorten the healing time but will not allow the wound to contract enough to decrease the extent of scarring. It is surprising how small the scar can be after complete healing and contraction even if the whole lower abdominal wall has been involved with necrosis. Scar revision is usually necessary for wide or irregular scars.

26.2.8 Necrotizing Fasciitis Necrotizing fasciitis is a result of infection from Streptococcus or mixed infection, frequently with anaerobic organisms. The infection results in thrombosis of the subcutaneous vessels, including vessels entering the fascia and underlying muscles. The tissues become necrotic and require debridement as well as proper antibiotics. Cultures of the tissues may reveal the offending organism(s). The wound should then be allowed to granulate and can be skin grafted when all the necrotic tissue has been removed and granulations are present.

26.2.9 Need for Further Surgery There are a variety of reasons for further surgery being necessary following abdominoplasty. These include asymmetry, irregularities, dogears, necrosis, inadequate skin resection, significant scar (hypertrophic or keloid), umbilical stenosis, or excessive fat requiring liposuction. If a patient has excessive fat prior to the abdominoplasty and the fat is not liposuctioned at the same procedure, the patient should be informed about the probable future need for liposuction before surgery.

26.2.10 Perforation of Intraabdominal Viscus It is possible to perforate the bowel when repairing an umbilical hernia or ventral hernia at the same time as performing the abdominoplasty by not opening the hernia sac to observe for attached bowel or placing the

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sutures superficially only in well-exposed fascia. Closing the midline fascia in a patient with a very loose abdominal wall may require sutures at the lateral edge of the rectus. This is an area consisting only of fascia and peritoneum millimeters in depth where suturing can readily perforate into the abdominal cavity. It might be more appropriate to consider lateral sutures in the external oblique aponeurosis first before central repair so that the central sutures may not need to be placed so far laterally. Any patient complaining of more postoperative abdominal pain than the usual patient or persistent severe pain should be observed very carefully and at appropriate short intervals of time to rule out perforation of a viscus. Abdominal X-ray series may be indicated and possibly, observation in the hospital. If a perforation is diagnosed, immediate surgical intervention is indicated. Preoperative antibiotics should be started. The abdomen should be carefully explored for possible multiple perforations and any observed bowel perforations should be closed after thorough irrigation of the abdominal cavity. Early intervention may prevent a severe infectious process.

M. A. Shiffman

26.2.13 Scarring (Widened, Thickened, Hypertrophic, Keloid) Wide scars are frequent following abdominoplasty because of the need for a tight closure to get a flat abdomen. When the skin loosens after 6 months, it is possible to resect the scar in order to make it thinner [2]. Certain individuals are prone to get hypertrophic scars although this is unpredictable. Hypertrophic scars may resolve without treatment. Keloid scars occur in 15% of blacks, Asiatics, and Hispanics. There are a variety of treatments available, usually used in combination. Recurrence of keloids is common.

26.2.14 Sensory Loss

Patients should be forewarned that weight gain after abdominoplasty could result in recurrent fatty abdomen with panniculus that might require another surgical procedure. Pregnancy after abdominoplasty is a risk for causing loose skin, stretching the muscles and the midline, and striae. This may result in the need for repeat abdominoplasty.

Loss of sensation in the abdominal wall is more common when liposuction is performed at the same time as abdominoplasty. This sensory change is usually temporary and resolves without treatment. Injury to the lateral femoral cutaneous nerve has been reported [1, 6]. This can result in permanent sensory loss along the anterior, lateral, and posterior thigh. It is possible to explore and reanastamose a transected nerve, if the nerve ends can be found and a large section of the nerve has not been removed. This type of surgery must be performed in a timely manner in order to have any success. Usually the sensory loss is not in areas that will interfere with normal activity and patients may become used to the sensory loss over a long period of time.

26.2.12 Recurrent Protrusion of Abdominal Wall

26.2.15 Seroma

Some patients have very lax abdominal wall muscles and there is a tendency for recurrent protrusion after a seemingly adequate fascial repair. This can be improved with repeat closure of the abdominal wall fascia in the midline with the combination of lateral wall (external oblique aponeurosis) tightening. This repair can also be performed for the patient who has recurrent protrusion from loosened or disrupted sutures.

The use of drains following abdominoplasty usually prevents the accumulation of blood but may not prevent seroma formation. The large flap with an empty space extending from xyphoid to pubis is readily filled with serous fluid with patient movement that results in the rubbing together of raw tissues. If there is a palpable fluid collection, this can be aspirated and compressed to allow the tissues to seal. If aspiration does

26.2.11 Recurrent Panniculus

26 Prevention and Management of Abdominoplasty Complications

not resolve the problem, injecting room air to fill the cavity after fluid aspiration will almost always result in sealing the cavity. Introduction of air may have to be repeated if there is a larger cavity. This method is less traumatic than excision of the pseudocyst [1–3, 7, 8].

26.2.16 Skin Overhanging Scar If enough skin is not resected in abdominoplasty or the transverse lower abdominal scar becomes adherent to the underlying fascia, there may be a visible overlap of the skin over the scar. This may require revision by resecting the excess skin and/or freeing up the skin scar attachment to the deeper tissue.

26.2.17 Thromboembolism Patients who undergo surgery are at risk for venous thromboembolic complications. This is especially critical in the cosmetic surgery patient who, having an elective procedure, would not expect to have the morbidity or mortality associated with thromboembolic disease. The cosmetic surgeon must be aware of the possibility of thromboembolism in every patient and should take a careful history to disclose predisposing risk factors. The surgeon should also be aware of the clinical manifestations of pulmonary embolus in order to make a timely diagnosis.

26.3 Risk Factors Minor surgery <30 min in patients over 40 years of age without additional risk factors and uncomplicated surgery in patients under 40 years of age without additional risk factors are in the low risk category. General surgery in patients over 40 years of age lasting >30 min and patients under 40 years on oral contraceptives are in the moderate risk category [9]. High risk category would be major surgery in patients over 40 years of age with recent history of deep-vein thrombosis or pulmonary embolism, extensive pelvic of abdominal surgery for malignancy, and major orthopedic surgery of the lower extremities.

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Predisposing risk factors include age over 50 years, malignancy, obesity, prior history of thromboembolism, varicose veins, recent operative procedures, and thrombophilia. These risks are further modified by duration and type of anesthesia, preoperative and postoperative immobilization, level of hydration, and the presence of sepsis [10]. Medical problems associated with increased risk include acute myocardial infarction, stroke, and immobilization [11]. Estrogen therapy and pregnancy are common risk factors while uncommon factors include lupus anticoagulant, nephrotic syndrome, inflammatory bowel disease, polycythemia vera, persistent thrombocytosis, paroxysmal nocturnal hemoglobinuria, and inherited factors such as antithrombin III deficiency, protein C deficiency, protein S deficiency, plasminogen activator deficiency, elevated plasminogen activator inhibitor, and homocystinuria [12]. Superficial calf vein thrombosis, proximal deepvein thrombosis, and fatal pulmonary embolus increase in incidence as the risk category increases from low to high.

26.4 Clinical Manifestations Superficial thrombophlebitis (an inflamed vein) appears as a red, tender cord. Deep-vein thrombosis may be associated with pain at rest or only during exercise with edema distal to the obstructed vein. The first manifestation can be pulmonary embolism. There may be tenderness in the extremity and the temperature of the skin may be increased. Increased resistance or pain on voluntary dorsiflexion of the foot (Homan’s sign) and/or tenderness of the calf on palpation is useful diagnostic criteria. Pulmonary embolism is usually manifested by one of three clinical patterns. (1) onset of sudden dyspnea with tachypnea and no other symptoms; (2) sudden pleuritic chest pain and dyspnea associated with findings of pleural effusion or lung consolidation; and (3) sudden apprehension, chest discomfort, and dyspnea with findings of cor pulmonale and systemic hypotension. The symptoms occasionally consist of fever, arrhythmias, or refractory congestive heart failure.

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26.5 Diagnosis Deep-vein thrombosis is best diagnosed with duplex ultrasonography, which combines pulsed gated Doppler evaluation of blood flow with real-time ultrasound imaging. Other diagnostic tests include X-ray venography, radionucleide venography, radioisotope-labeled fibrinogen, ultrasonography, and impedance plethysmography. Liquid crystal thermography detects increases in skin temperature and is a useful adjunct to ultrasonography or impedance plethysmography. Ventilation–perfusion (VP scan) lung scan is a safe, sensitive means of diagnosing pulmonary embolism. Isotope pulmonary perfusion scan (Q scan) is more specific with inclusion of the isotope ventilation scan (V scan). The definitive diagnosis can be made by pulmonary arteriography but VP scan can give a high degree of certainty. Arterial blood gas typically shows reduction in PaO2 and PaCO2, while electrocardiogram will show tachycardia but is best used for ruling out myocardial infarction. Chest X-ray may show basilar atelectasis, infiltrates, pleural effusion, or cardiac dilatation.

26.6 Prophylactic Treatment Low-risk general surgical patients may be treated with graduated compression stockings applied during surgery, early ambulation, and adequate hydration [13]. Keeping the knees flexed on pillows during surgery and avoiding local compression on any areas of the legs are helpful. All patients are treated the same if there are any low risk factors. The type of surgery does not matter as long as general anesthesia or intravenous sedation is given. Compression stockings (20– 30 mm support hose is adequate) are applied in the operating room and ambulation is begun when the patient is awake and capable of ambulating with assistance. When the patient is ambulating on a regular basis during the day, the compression stockings can be removed. For moderate risk patients, low-dose heparin (5,000 units 2 h before surgery and then every 8–12 h until ambulatory), low molecular weight heparin (LMWH), dextran, or aspirin is recommended. Alternatively, graduated compression stockings or intermittent pneumatic compression started during surgery, used continuously

M. A. Shiffman

until ambulatory, or a combination of both is recommended [10]. All high risk patients should be treated with lowdose heparin or LMWH, and combined pharmacologic and mechanical methods. Dextran can result in cardiac overload and high dose aspirin (1,000–1,500 mg/day) has limited efficacy in preventing deep-vein thrombosis. In cosmetic surgery, the use of aspirin or heparin may result in postoperative bleeding. The best prophylaxis for low risk cosmetic surgery patients would appear to be mechanical methods, including knee compression stockings and early ambulation. For low risk patients, the knees should be slightly flexed and extremity compression avoided [14].

26.6.1 Hereditary Hypercoagulable States Patients with a family history of thrombosis, earlyonset or recurring thrombosis, thrombosis at unusual sites, or warfarin-induced skin necrosis should be evaluated for possible underlying inherited hypercoagulable disorders. Antithrombin III (AT-III) is a heparin cofactor that allows heparin to inactivate primarily factor IIa but also factors IXa, Xa, XIa, and XIIa [15]. A deficiency in AT-III predisposes to thrombosis by allowing uncontrolled activity of many of the coagulation factors. Endothelial surfaces have receptors called thrombomodulin that function as anticoagulants because of the ability to neutralize thrombin. The thrombin– thrombomodulin complex activates protein C, a vitamin K-dependent factor that is facilitated by protein S, another vitamin K-dependent factor. Activated proteins C and S metabolize activated factors V and VIII that results in downregulating the coagulation system. Patients with protein C deficiency may have recurrent episodes of superficial thrombophlebitis as well as thromboembolism [16]. Patients with protein S deficiency experience more arterial thromboembolism including stroke [17]. Deficiency in protein C or S may present as neonatal purpura fulminans in the newborn or skin necrosis in adults treated with warfarin, a drug known to cause a sudden fall in protein C or S. Venous thromboembolism occurs in one out of every thousand people with activated protein C resistance

26 Prevention and Management of Abdominoplasty Complications

(APC-R) responsible for up to 64% of the cases. APC-R is due to a single point mutation in the FV gene for clotting factor V. This mutated FV may be referred to as factor V Leiden (FVL), FV:Q506 allele, or APC-gene and is less efficiently degraded by APC. A hypercoagulable state results from impairment of the inactivation of factor V by activated protein C. This creates a lifelong increased risk of thrombosis and thromboembolism. Within the intact vessel, thrombin binds to thrombomodulin on the endothelial cell acting as an anticoagulant bay activating the protein C system. Activated protein C (APC), potentiated by cofactor protein S, downregulates the activity of the coagulation system (limits clot formation) by cleaving and inhibiting factors V (FV) and VIII [18–20]. APC testing can be performed with DNA genotyping. This can differentiate acquired from inherited APC-R. Approximately 10% of patients with APC-R phenotype lack the FV mutation (genotype) and the diagnosis of APC-R in these patients will be missed [21]. The combination of phenotype and genotype information aids in establishing prophylactic and therapeutic guidelines. Asymptomatic patients with APC-R who have never had a thromboembolic event, as well as their family members, should receive counseling regarding the implications of the diagnosis and information concerning the signs and symptoms of venous Thromboembolism [22]. Short-term prophylaxis with heparin should be considered when there are high risk circumstances encountered such as immobilization, surgery, trauma, or obstetrical procedures. After a thrombotic event, these patients need extended anticoagulation, balancing the risk of bleeding against the risk of recurrence when therapy is discontinued. Empirical treatment is for at least 1 year after two episodes of thromboembolism and life-long treatment after three episodes [23].

26.6.2 Toxic Shock Syndrome Toxic shock syndrome has been reported in breast augmentation [24–26]. The syndrome is caused by the exotoxins (superantigens) secreted with infection from Staphylococcus aureus and group A Streptococci [27]. Knowledge of the criteria for diagnosis is important in

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order to treat this potentially fatal disease. These include [27]: 1. Fever (>102°) 2. Rash (diffuse, macular erythroderma) 3. Desquamation (1–2 weeks after onset, especially of palms and sole) 4. Hypotension 5. Involvement of three or more organ systems: (a) Gastrointestinal (vomiting, diarrhea at onset) (b) Muscular (myalgia, elevated CPK) (c) Mucous membrane (conjunctiva, oropharynx) (d) Renal (BUN or creatinine >2 times normal) (e) Hepatic (bilirubin, SGOT, SGPT >2 times normal) (f) Hematologic (platelets <1,00,000) 6. Negative results on the following studies (if obtained) (a) Blood, throat or cerebral spinal fluid (CSF) cultures (b) Serologic tests for Rocky Mountain Spotted Fever, Leptospirosis, measles Treatment consists of surgical debridement for necrosis, antibiotics, circulatory and respiratory care, anticoagulant therapy for disseminated intravascular coagulation, and immunoglobulin [28]. Experimental approaches have included use of antitumor necrosis factor monoclonal antibodies and plasmapheresis.

26.6.3 Umbilical Stenosis The advent of a contracting scar around the umbilicus following abdominoplasty is not rare. There have been different methods proposed for doing the umbilical reconstruction during abdominoplasty in order to prevent stenosis. The umbilical stenosis may result in chronic inflammation and drainage that the patient needs to have addressed. At the same time, a stenosed umbilicus is not a normal looking umbilicus. Reconstruction of the stenosis can be surgically performed.

26.6.4 Umbilicus, Off Center or Loss The umbilicus should be evaluated for deviation from the centerline preoperatively. If deviation is present,

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then this should be pointed out to the patient, discussed with the patient, and recorded in the medical record. The deviation may need to be adjusted at the time of surgery. Imbrication of the fascia next to the umbilical stalk on the side opposite the deviation will result in centering the umbilicus. The centerline of the abdomen must be marked preoperatively. The umbilicus should be brought through the abdominal wall at the appropriate height and in the marked midline. A deviated umbilicus can cause the patient distress and result in litigation. When performing a modified abdominoplasty without release of the umbilicus, there will usually be deviation of the umbilicus inferiorly from removal of the excess skin. The patient must be informed of this problem preoperatively since the lowered umbilicus may not look normal, especially in a bathing suit. The normal umbilicus is at the level of the iliac crests. When the umbilical stalk is denuded of all the fat during abdominoplasty, the blood supply should not be disturbed since it comes through the underlying fascia. However, if a full abdominoplasty is performed following a modified abdominoplasty, where the base of the umbilicus has been transected and the umbilicus lowered, the blood supply may not be sufficient and necrosis of the umbilicus may occur. The physician should be forewarned in a patient who has had a prior abdominoplasty or tummy tuck to look for this possible problem by obtaining the prior surgeon’s records. The smoker is a major source of necrosis following abdominoplasty, and this may affect the umbilicus or the periumbilical region. Needless to say, the patient must stop smoking at least 2 weeks prior to surgery and for 2 weeks after surgery. There still remains the problem of the patient who says smoking will be stopped but in actuality, the patient continues to smoke. When this information is divulged after surgery to the surgeon or medical staff, there may be difficulties getting the patient to stop smoking even when necrosis is severe. The medical record should be excruciatingly complete with every conversation, phone call, and recommendation.

26.7 Discussion The combination of liposuction with abdominoplasty is associated with an increase in the risks and complications.

M. A. Shiffman

Fat embolism syndrome has been reported [29] as well as an increased incidence of thromboembolism. Necrosis is more common, possibly because of injury to the cutaneous vascular system. Matarasso warns about the problem with liposuction of the mid upper abdomen at the same time as performing abdominoplasty. Benvenuti [30] reported an increased incidence of inguinal hernias following abdominoplasty. Obesity has been associated with increased complications following abdominoplasty, 80% in obese and 33% in nonobese patients [31]. Postoperatively, the surgeon should check the patient at appropriate intervals of time depending on the extent of surgery, patient age, and patient. Awareness of the early symptoms or physical findings of a complication is essential in order to make a timely diagnosis. Proper studies should be obtained and treatment begun as soon as possible in order to avoid a dangerous or life threatening problem. If a diagnosis of a complication is difficult for the attending surgeon to make, early consultation should be obtained. If the surgeon intends to leave the area for any reason, the patient should be informed and adequate medical coverage obtained. This should be a surgeon who is experienced in performing the same surgery as performed on the patient. Any important or critical patient problem must be relayed to the covering physician and records made available when necessary.

References 1. Van Uchelen JH, Werker PM, Kon M. Complications in abdominoplasty in 86 patients. Plast Reconstr Surg. 2001;107(7):1869–73. 2. Pollock H, Pollock T. Progressive tension sutures: a technique to reduce local complications in abdominoplasty. Plast Reconstr Surg. 2000;105(7):2583–6. 3. Mohammad JA, Warnke PH, Stavraky W. Ultrasound in the diagnosis and management of fluid collection complications following abdominoplasty. Ann Plast Surg. 1998;41(5): 498–502. 4. Fenn CH, Butler PE. Abdominoplasty wound-healing complications: assisted closure using foam suction dressing. Br J Plast Surg. 2001;54(4):348–51. 5. Shiffman MA. The complicated abdominoplasty: upper abdominal scars. Am J Cosmet Surg. 1994;11(1):43–6. 6. Floros C, Davis PK. Complications and long-term results following abdominoplasty: a retrospective study. Br J Plast Surg. 1001;44(3):190–4. 7. Hafezi F, Nouhi AH. Abdominoplasty and seroma. Ann Plast Surg. 2002;48(1):109–10.

26 Prevention and Management of Abdominoplasty Complications 8. Zecha PJ, Missotten FE. Pseudocyst formation after abdominoplasty – extravasation of Morel-Lavalee. Br J Plast Surg. 1999;52(6):500–2. 9. Nicolaides AN, Arcelus J, Belcaro G, Bergqvist D, Borris LC, Buller HR, Caprini JA, Christopoulos D, Clark-Pearson D, Clement D, et al. European consensus statement of the prevention of venous thromboembolism. Int Angiol. 1992; 11:151. 10. Bick RL, Haas SK. International consensus recommendations: summary statement and additional suggested guidelines. Med Clin N Am. 1998;82(3):613–33. 11. Clement DI, Gheeraert P, Buysere M, Medical patients. In: Bergquist D, Comerota AJ, Nicolaides AN, editors. Prevention of venous thromboembolism. London: MedOrion; 1994. p. 319. 12. Senior RM. Pulmonary embolism. In: Wyngaarden JB, Smith LH Jr, Bennett JC, editors. Cecil textbook of medicine. Philadelphia: WB Saunders; 1992. p. 421–8. 13. Anonymous. Prevention of venous thromboembolism. International consensus statement: guideline according to scientific evidence. Int Angiol. 1997;16:3. 14. McDevitt NB. Deep-vein thrombosis prophylaxis. Plast Reconstr Surg. 1999;104(6):1923–8. 15. Alving BM. The hypercoagulable states. Hosp Pract. 1993; 28(2):109–21. 16. Bovill EG, Bauer KA, Dickerman JD, Callas P, West B. The clinical spectrum of heterozygous protein C deficiency in a large New England kindred. Blood 1989;73(3):712–7. 17. Engesser L, Broekman AW, Briet E, Brommer EJ, Bertina RM. Hereditary protein S deficiency: clinical manifestations. Ann Intern Med. 1987;106(5):677–82. 18. Dahlback B. New molecular insights into the genetics of thrombophilia. Resistance to activated protein C caused by Arg506 to GLn mutation in factor V as a pathogenic risk factor for venous thrombosis. Thromb Haemost. 1995;74(1): 139–48. 19. Zoller B, Hillarp A, Dahlback B. Activated protein C resistance due to a common factor V gene mutation is a major

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risk factor for venous thrombosis. Annu Rev Med. 1997; 48:45–58. 20. Svensson PJ, Dahlback B. Resistance to activated protein C as a basis for venous thrombosis. N Engl J Med. 1994; 330(8):517–22. 21. Bertina RM, Koeleman BP, Koster T, Rosendaal FR, Dirven RJ, de Ronde H, van der Velden PA, Reitsma PH. Mutation in blood coagulation factor V associated with resistance to activated protein C. Nature 1994;369(6475):64–7. 22. Bridgen ML. The hypercoagulable state. Who, how, and when to test and treat. Postgrad Med. 1997;101(5):249–67. 23. Ginsberg JS. Management of venous thromboembolism. N Engl J Med. 1996;335(24):1816–28. 24. Olesen LL, Ejlertsen T, Nielsen T. Toxic shock syndrome following insertion of breast prostheses. Br J Surg. 1991;78(5):585–6. 25. Poblete JV, Rodgers JA, Wolfort FG. Toxic shock syndrome as a complication of breast prostheses. Plast Reconstr Surg. 1995;96(7):1702–8. 26. Walker LE, Breiner MJ, Goodman CM. Toxic shock syndrome after explantation of breast implants: a case report and review of the literature. Plast Reconstr Surg. 1997;99(3):875–9. 27. Neifert MR, Seacat JM, Jobe WE. Lactation failure due to inadequate glandular development of the breast. Pediatrics 1985;76(5):823–8. 28. Georgiade NG, Serafin D, Barwick W. Late development of hematoma around a breast implant. Plast Reconstr Surg. 1979;64(5):708–10. 29. Scroggins C, Barson PK. Fat embolism syndrome in a case of abdominal lipectomy with liposuction. Md Med J. 1999;48(3):116–8. 30. Benvenuti D. Increased incidence of inguinal hernias following abdominoplasty. Plast Reconstr Surg. 1999;103(6): 1798. 31. Vastine VL, Morgan RF, Williams GS, Gampper TJ, Drake DB, Knox LK, Lin KY. Wound complications of abdominoplasty in obese patients. Ann Plast Surg. 1999;42(1):34–9.

Mastopexy with Extended Chest Wall-Based Flap After Massive Weight Loss

27

Luiz Haroldo Pereira and Aris Sterodimas

27.1 Introduction

a

Morbid obesity in the United States has reached startling proportions, with serious physical and psychosocial ramifications. In parallel, bariatric surgery has been increasingly utilized as a method of treatment. As a result, obese patients undergo massive weight loss (MWL), and the resulting skin excess can lead to both functional problems and profound dissatisfaction with their appearance. This appears to be having an impact on the rate of body contouring surgery for the correction of skin excess after the enormous weight reduction [1]. Reconstruction of breast and upper-body deformities in MWL patients presents specific challenges to the plastic surgeon [2]. Typical breast characteristics of patients who have undergone MWL are a breast that is very ptotic, laterally displaced, with a flat upper pole presenting significant skin laxity, and an unstable mound, with loss of volume and form (Fig. 27.1) [3]. This deformity can be treated by traditional reduction, silicone implant augmentation alone or combined with mastopexy. Regardless of the technique, the breasts usually do not maintain their projection [4]. In the recent years, new techniques have been described in order to maintain breast shape following MWL [5, 6]. The technique that the authors are outlining is versatile for restoring a long lasting aesthetic and youthful breast shape in the patient who has lost a massive amount of weight.

b

L. H. Pereira (*) Luiz Haroldo Clinic, 45/206 Rua Xavier da Silveira, Rio de Janeiro 22061-010, Brazil e-mail: [email protected]

Fig. 27.1 (a) Preoperative front view of a 42-year-old woman with ptotic breasts after massive weight loss (MWL). (b) Preoper ative lateral view of a 42-year-old woman with ptotic breasts after MWL

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_27, © Springer-Verlag Berlin Heidelberg 2010

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27.2 Surgical Technique 1. Preoperative sedation in the surgical suite is administered. Anesthesia consists of intravenous sedation and epidural anesthesia. The patient is placed in supine position with the arms spread out. 2. A classic Pitanguy breast reduction technique is marked. The Pitanguy point, or point A, is determined by placing the index finger of one hand at the sub mammary fold and the other along the midclavicular line. By pinching the skin on either side of the nipple, excess skin and parenchyma is estimated and points B and C are demarcated. The last two landmarks, D and E, will define the medial and lateral extension of the incision. Transfer of the markings is made in the contralateral breast (Fig. 27.2). 3. Injection of normal saline wetting solution containing 1: 500000 of adrenaline is done. 4. Maneuver of Schwartzman is performed within the area marked. The whole area of the superior pedicle is deepithelialized and the lateral dermoglandular pedicle is then incised vertically down toward the chest wall. 5. The inferior dermoglandular pedicle is incised horizontally 1 cm below the areola position, down toward the chest wall, with no undermining. The flap length should be approximately 7–8 cm and 7–8 cm wide. The flap is extended laterally 2–3 cm above the inframammary fold, in order to include its lateral extension. After marking the flap, lateral and medial incisions should be made away from the

Fig. 27.2 Pitanguy technique markings for breast mastopexy

Fig. 27.3 Preparation of the extended chest wall-based flap

perforating vessels of the fourth and fifth intercostals spaces (Fig. 27.3). 6. The lower portion of the flap is dissected meticulously down to the original inframammary fold according to the premarked design. 7. The cranial breast tissue is undermined up to the second intercostal space, detaching the gland from the pectoralis major fascia (Fig. 27.4).

Fig. 27.4 Undermining of the cranial breast tissue

27 Mastopexy with Extended Chest Wall-Based Flap After Massive Weight Loss

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8. Once the dermoglandular flap is created, the excess skin and parenchyma is resected, depending on the size and shape desired. 9. A bipedicled muscle sling is created out of the pectoralis major and the tissue flap is passed through the sling. The muscle sling must be partially dissected, leaving 1/3 of the pectoralis muscle attached to the thoracic wall. The extended chest wall-based flap should be accommodated below the muscle sling and its lateral extension needs to be flipped with the dermis side down (Figs. 27.5 and 27.6). Its position is secured by a

Fig. 27.7 Closure of the breast in two layers

continuous 2–0 Mononylon suture on the lateral and medial sides of the flap. 10. The lateral and medial breast tissue pillars then are sewn together and the points B and C are brought together. The new position of the areola is marked. 11. Finally, the skin is closed in two layers (Fig. 27.7). 12. Immediate postoperative dressing is done. Fig. 27.5 Schematic of the extended chest wall-based flap accommodated below the muscle sling, with its lateral extension flipped with the dermis side down

27.3 Patient Selection Candidates are patients whose weight loss has been stabilized for more than a year. In the author’s series, ten patients were included that were operated on between January 2005 until December 2007. Age distribution of patients ranged from 26 to 65 years, with a mean of 38.9 years. All the patients have been followed up for a minimum of 1 year.

27.4 Cases

Fig. 27.6 Extended chest wall-based flap with its lateral extension fixed on the superior portion of the breast

A 49-year-old female was seen because she was highly concerned about the aesthetic appearance of her breasts. On examination, the patient had ptotic breasts with significant skin laxity and loss of breast volume and form (Fig. 27.8). The patient had undergone bariatric surgery on March 2004.

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a1

b1

a2

b2

Fig. 27.8 (a1, 2) Preoperative 49-year-old woman with ptotic breasts after MWL. (b1, 2) Twenty four months postoperative after mastopexy with extended chest wall-based flap

She lost 35 kg and she had maintained her weight stable for 2 years. On November 2006, she underwent mastopexy with extended chest wall-based flap. The follow-up for the patient has been 24 months with no complications and a satisfactory aesthetic result. A 61-year-old woman was seen with laterally displaced ptotic breasts, presenting significant skin laxity with loss of breast volume and form (Fig. 27.9). She had undergone bariatric surgery on November 2002. She lost 27 kg and she had maintained her weight stable for 2 years. On September 2005, she underwent mastopexy with extended chest wall-based flap. The

follow-up for the patient has been 36 months with no complications and a satisfactory aesthetic result.

27.5 Complications One patient suffered an early complication of hematoma formation, which had to be evacuated. One patient had a late complication of formation of hypertophic scar. Temporary decreased areolar sensibility for about 3 months was noted in two patients.

27 Mastopexy with Extended Chest Wall-Based Flap After Massive Weight Loss

a1

b1

a2

b2

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Fig. 27.9 (a1, 2) Preoperative 61-year-old woman with ptotic breasts after MWL. (b1, 2) Thirty Six months postoperative after mastopexy with extended chest wall-based flap

27.6 Discussion One of the major problems of breast contouring after MWL is the difficulty in achieving an adequate and durable breast shape [7]. In addition to significant breast ptosis and loss of breast volume, bariatric patients also have excessive lateral axillary and posterior truncal tissue [2]. With the growing demand for MWL breast contouring, new techniques based on old principles have been presented. A wise-pattern mastopexy with a pedicled

fasciocutaneous flap based on the intercostal artery perforators (ICAP) to correct breast ptosis has been described, to restore breast volume, and to eliminate redundant upper truncal tissue [2]. The superomedial pedicle is a well-vascularized pedicle that allows for glandular plication of the lower pole and autoaugmentation of the upper pole once rotated [3]. The spiral flap reshaping technique has been described by Hurwitz et al. [4]. This lift is a reverse abdominoplasty that ends along the inframammary fold incision of the Wise pattern mastopexy and continues laterally to along the

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back roll. Excess tissue from the epigastrium and lateral back roll is deepithelialized and used for breast autoaugmentation. These flap extensions of the central breast pedicle are spiraled around the breast for augmentation, shaping, and suspension. Ribeiro [8, 9] was the first to describe the use of inferior pedicle in reduction mamoplasties. Daniel [10] complemented the Ribeiros’ technique by creating a flap pedicled on the thoracic wall and fixing it beneath a strip of pectoralis muscle under the new nipple position. This flap acts as an autogenous flap that fills the superior pole of the breast. Graf et al. [7] presented recently their experience with a new mammaplasty technique using an extended chest wall-based flap associated with a loop of pectoralis muscle for patients after MWL. Mastopexy is virtually always required in the female MWL patient, and breast augmentation is often an important adjunct to breast-lifting procedures in selected cases [11]. Most of the MWL patients prefer not to have silicone implants added to their body, when they learn of the long-term malposition problems [4]. The authors’ technique focuses on glandular shaping through autoaugmentation using the extended wall pedicled flap and buried under the bipedicled pectoralis muscle flap. In MWL patients, harvesting the chest wall-based flap with its lateral extension provides supple tissue for breast augmentation, while simultaneously improves the lateral breast contour that is frequently affected by skin excess. This technique auto augments the upper pole, narrows the wide breast, provides an internal sling to secure long-term breast projection, and redefines and secures the inframammary fold. Harvesting of the bipedicled pectoralis flap without total sacrifice of the underlying muscle eases postoperative recovery and reduces donor site morbidity. There is also the possibility of using this technique in combination with a subpectoral implant in the cases that there is severe ptosis and flacidity of the breast that cannot be repaired by the use of the extended chest wall-based flap. In patients with significant ptosis who desire additional augmentation by means of implant insertion, it might be safer to stage implant placement until a later procedure [3]. In the authors’ series, all the patients were treated by performing mastopexy with the extended chest wall-based flap, without using a breast implant. Despite the disadvantages of a lengthy scar and the need for extensive intraoperative tailoring, which usually increase the operative time, this

L. H. Pereira and A. Sterodimas

operation carries an extremely high rate of patient satisfaction. One of the challenges that the plastic surgeon has to face is the possibility of recurrent ptosis even though sophisticated mastopexy techniques have been developed. A certain degree of recurrent ptosis in MWL patient is expected and the patient should be informed about this possibility. The ideal technique for breast contouring after MWL has not yet been found. With the growing demand for MWL breast contouring, new techniques based on old principles will undoubtedly become more popular as we continue to search for better ways to manage this relatively new and growing area in our specialty [12].

27.7 Conclusions Mastopexy with extended chest wall-based flap after MWL is a safe, simple, and versatile technique that achieves excellent suspension of breast parenchyma with upper pole fullness and long-standing contour. It requires though pectoralis major flap harvesting. As the number of patients undergoing bariatric surgery is increasing, it is expected that there will be an increase in the number of patients presenting to plastic surgery offices for breast contouring after weight loss. It is imperative that plastic surgeons are prepared to treat this category of patients requesting breast reshaping.

References 1. Sterodimas A, Radwanski HN, Pitanguy I. Body contouring after weight loss. Plast Cosm Surg. 2005;18:10–3. 2. Kwei S, Borud LJ, Lee BT. Mastopexy with autologous augmentation after massive weight loss: the intercostal artery perforator (ICAP) flap. Ann Plast Surg. 2006;57(4):361–5. 3. Losken A, Holtz DJ. Versatility of the superomedial pedicle in managing the massive weight loss breast: the rotationadvancement technique. Plast Reconstr Surg. 2007;120(4): 1060–8. 4. Hurwitz DJ, Agha-Mohammadi S. Postbariatric surgery breast reshaping: the spiral flap. Ann Plast Surg. 2006; 56(5):481–6; discussion 486. 5. Lockwood T. Reduction mammaplasty and mastopexy with superficial fascial system suspension. Plast Reconstr Surg. 1999;103(5):1411–20.

27 Mastopexy with Extended Chest Wall-Based Flap After Massive Weight Loss 6. Graf R, Biggs TM. In search of better shape in mastopexy and reduction mammoplasty. Plast Reconstr Surg. 2002; 110(1):309–17; discussion 318–22. 7. Graf RM, Mansur AE, Tenius FP, Ono MC, Romano GG, Cruz GA. Mastopexy after massive weight loss: extended chest wall-based flap associated with a loop of pectoralis muscle. Aesthetic Plast Surg. 2008;32(2):371–4. 8. Ribeiro L. A new technique for reduction mammaplasty. Plast Reconstr Surg. 1975;55(3):330–4. 9. Ribeiro L, Accorsi A Jr, Buss A, Marcal-Pessoa M. Creation and evolution of 30 years of the inferior pedicle in reduction mammaplasties. Plast Reconstr Surg. 2002;110(3):960–70.

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10. Daniel MJB. Mammaplasty with pectoral muscle flap. Presented at the 64th American Annual Scientific Meeting, Montreal: 1995. 11. Hamdi M, Van Landuyt K, Blondeel P, Hijjawi JB, Roche N, Monstrey S. Autologous breast augmentation with the lateral intercostal artery perforator flap in massive weight loss patients. J Plast Reconstr Aesthetic Surg. 2009;62(1): 65–70. 12. Mitchell JE, Crosby RD, Ertelt TW, Marino JM, Sarwer DB, Thompson JK, Lancaster KL, Simonich H, Howell LM. The desire for body contouring surgery after bariatric surgery. Obes Surg. 2008;18(10):1308–12.

Part Extremities

IV

28

Brachioplasty: How to Choose the Correct Procedure A. Chasby Sacks

28.1 Introduction There are multiple reasons that women - or in a few cases, men - will seek correction of the appearance of their upper arms. Some of the causes may be due to fluctuations in size, as in weight gain, but are seen more commonly following huge weight loss, where the skin has been stretched out and cannot return to its previous tone. Changes in the quality of the skin associated with progressing age and even heredity can also cause the upper arms to have a drooping or sagging appearance. Unfortunately, although exercise may improve the underlying muscle tone, it cannot tighten up the excess skin that has lost elasticity. If there are fat deposits in the upper arm without skin laxity, then exercise accompanied by some weight loss may be helpful in reducing the underlying fat and thus improving the appearance. Changes in the incision length and position, combined with small cannula liposuction have led to decreased risk of complications as well as increasing the types of upper arm deformity that can be successfully corrected by surgery. A systematic approach to brachioplasty, combined with a solid knowledge of the different options available, will help to ensure the best possible result.

28.2 Patient Consultation Basic questions such as age, height, and weight are of course mandatory, but more detailed questioning

A. C. Sacks Arizona Cosmetic Surgery, 4202 North 32nd Street, Suite F, Phoenix, AZ 85018, USA e-mail: [email protected]

regarding weight gain and weight loss patterns will be helpful in assessing the cause of the upper arm problems. Has the patient gained and lost weight on multiple occasions? What was the patient’s maximum weight ever? When was that? What is the least amount that the patient has weighed in the last 5–10 years? Is the patient planning to lose more weight? How much? How realistic is this goal? Would she need to lose all the goal weight first before having the proposed surgery? Does the patient’s mother have similar problems?

28.3 General Questions for the Patient 1. Why does the patient want the surgery? What are the patient’s expectations? 2. Are there any significant medical conditions, drug allergies and/or smoking? The patient has to stop smoking at least 2 weeks prior to surgery. Does the patient have diabetes or hypertension and are they under good medical control? Is there a cardiac history? Has the patient been cleared for surgery? Are there any other medical conditions of note? 3. Current medications, vitamins, herbal preparations, alcohol, and drugs. Is the patient taking any blood thinning substances?

28.4 Patient Consultation Different options available to discuss with the patient:

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28.4.1 Diet and or Exercise In some patients who may not have loose skin and who may have recently experienced generalized weight gain, causing some bulging in the upper arm, weight loss with or without exercise may be sufficient to improve the patient’s appearance.

A. C. Sacks

tightening of the epidermis. Newer lasers have also been used in a similar way to heat up the dermal collagen without damaging the skin and also promote skin tightening. A newer method uses laser-assisted liposuction to dissolve the fat internally. This dissolved fat is then suctioned out of the treated areas. This method is also said to tighten the skin more than using regular liposuction alone.

28.4.2 Liposuction Some patients with normal body weight have a genetic predisposition to deposit fat in the upper arms. These patients would probably respond to liposuction alone, without any skin removal. Those patients with good skin tone but with significant fat deposits in the upper arm are candidates for liposuction alone. The cannulas used for upper arm liposuction must be small in order to obtain a smoother appearance to the skin, and removing the fat closer to the surface promotes some skin retraction as well. However, care must be taken not to let the cannula opening sit against the undersurface of the skin, or contour deformities may result. It is preferable to place small incisions for the cannula at the medial and lateral ends of the antecubital fold and at the superior and inferior ends of the axillary fold. Using smaller cannulas is advised. The cannula is inserted through the medial incision at the elbow and the superior axillary end for the medial portion of the upper arm liposuction. Then use the lateral end of the antecubital fold and inferior end of the axilla for the liposuction of the postero-lateral areas. Note that it is seldom necessary to liposuction the anterior or bicipital area anterior to the bicipital groove, or if doing so, this must be done very conservatively. The area of the forearm just distal to the olecranon often contains fat and this area may need to be liposuctioned as a separate area. Ultrasonic-assisted liposuction has been advocated by some surgeons to obtain more skin retraction but care must be taken around the medial elbow area to avoid damage to the Ulna nerve. Some of the newer modalities such as radiofrequency devices used to help tighten skin, do so by generating electrical energy. This heats up the dermis at a relatively low level, thus promoting collagen reorganization with some resultant

28.4.3 Short Scar Surgery Some patients have most of their skin laxity in the proximal portion of the upper arm and they may be the candidates for a shorter horizontal scar with or without an excision of skin in the axillary area. Female patients especially, are interested in keeping the horizontal portion of the scar as short as possible in order to feel comfortable wearing sleeveless or short- sleeve tops or dresses. This method would be used when isolated skin excess is present in the proximal ½–1/3 of the upper arm. In a few patients, it may be possible to slightly tighten proximal skin laxity with an axillary skin excision alone (Fig. 28.1).

28.4.4 Short Horizontal Scar Combined with Axillary Skin Excision Another aspect of providing a short horizontal scar is to combine this horizontal scar with vertical excision of axillary skin, thus tightening the upper arm skin, especially the proximal portion. Adding this procedure has some other advantages; some or all of the sweat glands are removed with the skin specimen as well as hair follicles and so perspiration may no longer be a problem and shaving the axilla, may not be necessary. When the vertical axillary excision is combined with the horizontal elliptical excision, the distal portion of the vertical excision is shorter than the proximal portion, and so in closing the incisions, the posterior edge of the axilla is shortened, thus correcting or improving loose axillary skin (Fig. 28.2).

28 Brachioplasty: How to Choose the Correct Procedure

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a

b

b

c

Fig. 28.1 It may be possible to slightly tighten proximal skin laxity with an axillary skin excision alone

Fig. 28.2 When the vertical axillary excision is combined with the horizontal elliptical excision, the distal portion of the vertical excision is shorter than the proximal portion, and so in closing the incisions, the posterior edge of the axilla is shortened thus correcting or improving loose axillary skin

28.4.5 Long Horizontal Scar When the skin laxity is found along the entire length of the upper arm, then an excision of skin starting at the elbow and ending at the axilla is required. If the skin excision is designed with the bicipital groove at the center of its long axis, then the scar will be lying in the bicipital groove (Fig. 28.3). Some surgeons feel that placing the resultant scar along the posterior border of the upper arm may provide for the least noticeable scar (Fig. 28.4). If the axillary skin is loose, then the surgical excision is extended into the axilla to include this excess. Indeed, in some extreme weight loss patients, the skin excision may help to tighten the antero-lateral chest wall, as well. The most important aspect of the discussion about the various procedures available to the patient is to address the nature and extent of the resultant scarring and that revisions may be necessary. This aspect of the discussion is extremely important!

Fig. 28.3 If the skin excision is designed with the bicipital groove at the center of its long axis, then the scar will be lying in the bicipital groove

28.5 Patient Assessment Patients should be examined in just their under-wear, so that the entire arm and axillary area can be examined. Patients should be examined with their forearms

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a

b

c

Fig. 28.4 Some surgeons believe that placing the resultant scar along the posterior border of the upper arm may provide for the least noticeable scar. (a) Bicipital groove scar compared to posterior border scar. (b) Preoperative. (c) Postoperative

vertical and upper arms horizontal. Preoperative and postoperative photographs must also be taken in this position. It is important to examine the patient completely to ascertain whether the deformity is genetic or acquired and whether the patient is generally overweight or just has isolated deposits of fat in the upper arm area. In this way, the options of weight loss vs. liposuction can be correctly assessed. Does the axilla have excess fat and/or skin? Patients, who have issues in these areas, may expect them to be corrected during surgery as part of the brachioplasty procedure, and so this area must be discussed. Gently pull and pinch the upper arm skin to assess the fat content and the extent of skin laxity. Examine the axilla in the same way. The method to assess, which procedure to use include (modified from Sacks [1] grading system):

Fig. 28.5 Axillary excision only

1. If there is 1–1.5 cm of fat excess in the upper arm by pinch test but with good skin tone, then liposuction alone can be considered. 2. If the axillary skin has more than 2–3 cm of excess, then axillary skin excision should be considered. 3. If the upper arm skin has more than 2–3 cm of excess then a horizontal excision is necessary. 4. If the upper arm skin has more than 3 cm of excess skin, then a long excision from the elbow is probably necessary. 5. If the upper arm has more than 5 cm excess skin, then an axillary excision as well as horizontal resection is needed. This is done so that more of the proximal portion of the skin excess can be excised. With the added axillary excision, the pattern does not have to narrow at this area, as it needs to with horizontal skin excision only (Figs. 28.3 and 28.5). Larger amounts of skin excess in the upper arm are usually accompanied by axillary skin excess as well. 6. Sometimes the skin of the axilla and antero-lateral chest skin is so loose that the excision needs to be extended into the superior portion of the axilla as a full ellipse but occasionally, only an inferior skin resection is required in the axilla (Fig. 28.6). As would be expected, these longer scars would probably heal with contractures and it may be important to design some releasing Z-plasties into the incision in the axilla (Fig. 28.7).

28.6 Other Surgical Considerations 1. In order to accurately align the horizontal incision, apposing vertical marks along the upper and lower borders of the pattern, should be placed when

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tends to run in close proximity to the intermuscular septum. Injury to the nerve may result in parasthesia or complex regional pain syndrome, requiring treatment with hand therapy and/or Gabapentin for weeks and in some cases, for months. 5. Lockwood [2] believes that anchoring the superficial fascia of the arm to the axillary fascia decreases the incidence of recurrence and difficulties with scarring. 6. Closed suction drainage in full extent brachioplasties. Fig. 28.6 The skin of the axilla and antero-lateral chest skin is so loose that the excision needs to be extended into the superior portion of the axilla as a full ellipse, but occasionally, only an inferior skin resection is required in the axilla

28.7 Postoperative Management Closed suction drains are used until drainage has decreased to less than 25–30 mL. The arms are circumferentially wrapped with nonadhesive foam with compression either with garments or wrapping to try to reduce postoperative swelling. Elevation of the arms on pillows is helpful and comfortable for the patient. When the foam is removed at 1–2 weeks, the suture line is supported by paper tape and wrapping for an additional few weeks. Silicone sheeting can also help to improve the scarring. Patients can resume activity and exercise in progressive increments starting at 2–3 weeks, varying with the extent of their procedure.

Fig. 28.7 Longer scars would probably heal with contractures and it may be important to design some releasing Z-plasties into the incision in the axilla

doing the preoperative marking to facilitate closure (Figs. 28.1 and 28.5). 2. No undermining of the flaps is necessary unless closure cannot be obtained. Liposuction of the edges with a small cannula, to reduce skin tension, would be preferable to maintain a better blood supply to the edges, than aggressive undermining. 3. Important: Remove less skin first if you are not sure about the ability to close without excess tension! 4. Do not excise the skin and fat too deeply. It would be safer to perform open liposuction on excess fat to avoid damage to lymphatics and the medial antebrachial cutaneous nerve. This nerve has on occasion been damaged during brachioplasty, especially when deeper resections are performed. The nerve

28.8 Complications of Brachioplasty and Management Complications

Management

Minor (most) Seromas

Multiple aspirations

Hypertrophic scarring

Massage, silicone gel sheeting

Cellulitis

Oral antibiotics

Wound dehiscence

Local wound care

Subcutaneous abscess

Incision and drainage

Major (few) Nerve damage

Gabapentin, hand physiotherapy

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In a study on complications of brachioplasty by Knoetgen [3] on 40 patients, there were no complications in patients who underwent simultaneous liposuction and brachioplasty. This seems to suggest some beneficial use of adding liposuction to brachioplasty and it is probably related to lessening of closure tension. Gentle, small cannula liposuction can be of great assistance to facilitate skin closure in some brachioplasty procedures, especially when there is skin tension.

28.9 Discussion Through the years, thanks to newer technologies and techniques, brachioplasty has evolved into a useful item in the cosmetic surgeon’s armamentarium. Pleasing results can be obtained with fewer complications than previously experienced, provided that the surgeon has assessed the patient completely and has a good working knowledge of all the various treatment options now available.

A. C. Sacks

References 1. Sacks AC. Grading system simplifies brachioplasty decisions. Cosmet Surg Times. 2003. 2. Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96:912. 3. Knoetgen J, Moran SL. Long-term outcomes and complications associated with brachioplasty: a retrospective and cadaveric study. Plast Reconstr Surg. 2006;117:2219.

Additional References 1. Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg. 1998;102:545. 2. Appelt EA, Janis JE, Rohrich RJ. An algorithmic approach to upper arm contouring. Plast Reconstr Surg. 2006; 118:237.

Brachioplasty: A Body-Contouring Challenge

29

James G. Hoehn, Sumeet N. Makhijani, and Jerome D. Chao

29.1 Introduction Upper arm rejuvenation remains a challenge to the aesthetic surgeon. Yearly, since 2000, the American Society of Plastic Surgeons has reported a steady increase in the number of brachioplasties performed for aesthetic and postbariatric body contouring patients. Between 2000 and 2008, the number of brachioplasties increased by 40–59% [1]. Increased upper-arm cutaneous volume secondary to obesity, lipodystrophy, aging, or massive weight reduction can be cumbersome and unsightly for the patient to say nothing about the interference with the patient’s comfort and clothing selection. While most of the recent literature has focused on the massiveweight-loss patient [2–7], this chapter will concentrate on the principles of aesthetic brachioplasty.

29.2 History of Surgical Technique and Development The evolution of aesthetic brachioplasty has been frustrated by the compromises which must be made between aesthetic desires and the necessary presence of telltale or unsightly scars in highly visible locations. Various surgeons have proposed a spectrum of preoperative markings, incisions, and closure techniques, as well as various flap designs, to minimize the

J. G. Hoehn (*) Division of Plastic Surgery, Albany Medical College, 25 Hackett Blvd, MC133, Albany, NY 12208, USA e-mail: [email protected]

undesirable sequelae [2, 5, 6, 8–13]. Recently, the addition of liposuction (traditional, ultrasonic- or power-assisted methods) has expanded the therapeutic options available to the surgeon to improve contours without external scars and has sparked interest in upper-arm rejuvenation both clinically and in the literature [14–17]. Correa-Iturraspe and Fernandez described the first aesthetic brachioplasty in 1954 [18]. It was not until almost 20 years later that Pitanguy revisited the subject and introduced the concept of the inner arms and the lateral chest/axillary area as a single aesthetic unit. He felt that the indications for surgical correction should be limited to patients with lipodystrophy and specifically those who had undergone large volumes of weight loss resulting in significant skin laxity. Pitanguy further described the use of a sinuous line incision traversing the entire aesthetic unit. This incision extended from the inner biceps to the posterior axillary line and inframammary fold with posterior subcutaneous dissection and careful “flap” advancement and rotation to allow a “tension-free” closure to produce, hopefully, acceptable scarring (Fig. 29.1). Pitanguy was the first to focus attention on the problem of unsatisfactory brachial scars [19]. Glanz and Gonzalez-Ulloa attempted to quantitatively define the aging process in the upper arm to further understand the aesthetic changes in the upper extremity. By using radiographs, they measured the ratio of soft tissue superior and inferior to the humerus in the upper arm at the midhumeral line. This ratio was termed the “Hoyer coefficient.” They showed that this measurement increased progressively with age from 1:1.0 at 10 years of age to 1:2.2 at 70 years of age, with the greatest incremental changes occurring after the age of 50 years. Additionally, they described the aging posterior elbow skin wrinkling resulting from adipose

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294 Fig. 29.1 Pitanguy’s use of a sinuous line incision traversing the entire aesthetic unit with the incision extended from the inner biceps to the posterior axillary line and inframammary fold with posterior subcutaneous dissection and careful “flap” advancement and rotation to allow a “tension-free” closure to produce acceptable scarring. Left: Preoperative excision. Right: Postoperative closure

J. G. Hoehn et al.

Pre-op

Post-op Closure

Excised skin

tissue absorption, increased cornification, and increased pigmentation [20]. Next, various surgeons focused on perfecting the preoperative markings, surgical techniques, and postoperative care to improve aesthetic outcomes. Baroudi emphasized the creation of a tension-free closure with the use of an incision two fingerbreadths above the bicipital groove combined with an elliptical skin excision (Fig. 29.2) [12]. Guerrerosantos felt that careful patient selection was just as important as good surgical technique in avoiding postoperative problems. Skin flaccidity of the inferior–posterior border of the upper arm provided his primary indication for brachioplasty. Guerrerosantos described his incision, which included a Z-plasty in the axilla to prevent scar retraction and subsequent hypertrophy (Fig. 29.3). He also recognized that preservation of the longitudinally oriented

venous and lymphatic circulations was important to diminishing postoperative fluid collections and persistent soft-tissue edema [21]. Juri described a quadrangular flap with a medial subcutaneous advancement combined with a modified “T” closure to minimize “dog-ear” formation and axillary banding (Fig. 29.4). This technique stressed the reduction of a greater amount of tissue in the upper 1/3 of the arm, where it is usually most pronounced, but taking care not to produce excessive narrowing in the middle 1/3 of the arm [22]. Others have described L-shaped and W-shaped incisions to address these concerns [13]. Although these incisions may minimize scar contraction, they, of necessity, extend the incision further in the longitudinal dimensions and potentially make the scar more visible. Frequently, the aesthetic surgeon is required to design a flap closure to deal with

Post-op Closure

Pre-op

Fig. 29.2 Baroudi emphasized the creation of a tension-free closure with the use of an incision two fingerbreadths above the bicipital groove combined with an elliptical skin excision. Left: Preoperative showing area of proposed deepithelialized skin. Right: Postoperative closure

De-epithelialized skin

Bicipital groove

29 Brachioplasty: A Body-Contouring Challenge Fig. 29.3 Guerrerosantos’s incision included a Z-plasty in the axilla to prevent scar retraction and subsequent hypertrophy. Left: Showing proposed Z-plasty and deepithelialized area. Right: Postoperative closure

295

Post-op Closure

Pre-op Z-plasty De-epithelialized skin

Bicipital groove

Post-op Closure

Pre-op

Fig. 29.4 Juri’s quadrangular flap with a medial subcutaneous advancement combined with a modified “T” closure to minimize “dog-ear” formation and axillary banding. Left: Preoperative showing proposed area of deepithelialized skin. Right: Postoperative closure

De-epithelialized skin

excessive skin based on his knowledge and creativity as applied to local conditions. Regnault also attempted to accommodate for the inequality of fat distribution in the upper arm by designing a V-shaped excision with the distal incision ending in a sharp angle (Fig. 29.5). Her proximal incision was separated by maximum width to ensure adequate excision of tissue in the upper third of the arm accepting a minimal “dog-ear” deformation. Closure was accomplished by either a “fishtail” or “double-triangular” excision in the depth of the axilla to prevent retraction. She also recognized that the length of the incision could be limited when employing this technique for a “minimal” brachioplasty (known as a minibrachioplasty, which can be used with liposuction as needed) when fat deposits and

expanded skin are localized to the upper 1/3 of the arm [23]. Goddio introduced a technique involving deepithelialization of the posterior flap of skin and subcutaneous tissue and burying the posterior flap beneath the anterior flap [24]. The goal was to minimize the longitudinal depression frequently found over the major vessels by creating a firmer and more youthful contour. This technique has the potential benefit of improved fixation of tissues, which should produce an improved scar. The next major advancement, which enhanced the selection of techniques to treat upper arm skin laxity, was the introduction of a classification of patients according to the degree of degenerative changes apparent in the upper extremity and the adjacent chest wall.

296 Fig. 29.5 Regnault attempted to accommodate for the inequality of fat distribution in the upper arm by designing a V-shaped excision with the distal incision ending in a sharp angle. Left: Preoperative showing proposed area of deepithelialized skin. Right: Postoperative closure

J. G. Hoehn et al.

Post-op Closure

Pre-op

De-epithelialized skin

In 1995, Lockwood emphasized the importance of the superficial fascial system (SFS) in all aspects of body contouring surgery [25, 26]. The SFS provides anchoring support and, thus, contour development in all areas of the body. This SFS extends from the axilla to the elbow as a horizontal sheet, which is attached to the bony skeleton by vertical fascial septae. In turn, these vertical fascial septae compartmentalize the fat in the subcutaneous planes. In the axilla, the SFS is adherent to the clavipectoral fascia, which creates a sling effect suspending the soft tissues of the posteromedial arm. Lockwood believed that significant laxity of this fascia produced the significant posterior positioning of the redundant soft tissues. Thus, Lockwood’s approach to

a

Fig. 29.6 The “pinch test” to determine degree of skin laxity

body contouring in any location is to place anchoring sutures to resuspend and anchor the SFS to achieve the desired contours and to reduce tension on all levels of the incision, which should lead to improved wound healing and better scars. The addition of liposuction to the surgeon’s armamentarium expanded the dimensions of upper arm recontouring. The “pinch test” can be used as a selection criterion in selecting patients and areas, which would benefit from liposuction. (Fig. 29.6). In patients with mild contour deformities (usually younger age groups), liposuction may be sufficient to achieve the desired results with minimal scars. However, in patients with moderate-to-severe skin laxity (usually the older

b

29 Brachioplasty: A Body-Contouring Challenge

age groups and postbariatric surgery patients), liposuction can actually make the contour deformity worse by removing subcutaneous fat, leaving only redundant unsupported skin. In such cases, liposuction must be followed by skin resection. Gilliland and Lyos described circumferential paraaxillary superficial tumescent liposuction [14, 15]. They proposed that circumferential liposuction enhanced skin retraction in the upper arm. Lillis [16] noted good skin retraction in patients with good skin tone and skin quality even with large-volume liposuction. He believed that the upper arm skin has enhanced properties such as elasticity similar to the upper–inner medial thigh skin. Most body contour surgeons agree that individual patient assessment and selection is critical to allow dependence on skin retraction alone for the end result [14–16]. Currently, most aesthetic surgeons focus on the integration of liposuction and surgical excision in their quest to achieve the optimal aesthetic result with minimal postoperative problems and complications (Table 29.1). Several authors more recently have proposed “limited incision” brachioplasty techniques [8–10]. The success of these techniques relies on first selecting the appropriate candidate, usually one who has proximal

Table 29.1 Early brachioplasty techniques Reference

Technique

Correa-Iturraspe and Fernandez [18]

First aesthetic brachioplasty

Pitanguy [19]

Sinuous incision

Baroudi [29]

Elliptic incision with vertical markers

Guerrerosantos [21]

Z-plasty axilla

Juri et al. [22]

Quadrangular flap with T-closure

Borges [13]

W-plasty

Regnault [23]

V-shaped incision with axilla triangle flaps

Goddio [24]

Deepithelization of the posterior flap

Lockwood [25]

Superficial fascial system

Teimourian and Malekzadeh [27]

Classification

Gilliland and Lyos [14, 15]

Circumferential para-axillary superficial tumescent

297

third upper extremity skin excess. In combination with liposuction, the focus of minibrachioplasty procedures is primarily on the axilla and proximal portion of the upper arm, with incisions and removal of excess skin centered in these anatomic areas.

29.3 Classification Teimourian and Malekzadeh proposed a classification of four groups of patients based on the severity of lipodystrophy and estimated amount of skin laxity and used such a classification to plan their operations [27]. This classification allowed a modern integration of available aesthetic surgical techniques and individual patient skin and soft-tissue deformities. Group 1 included those patients with minimal to moderate subcutaneous fat, minimal skin laxity, and good skin turgor (elasticity). Their recommended treatment focused on circumferential liposuction, allowing postoperative skin contraction to resolve the problem of mild skin laxity. Group 2 represented patients with a generalized increase in subcutaneous fat and moderate skin laxity. These patients benefited from circumferential liposuction with an axillary skin excision (Fig. 29.7). Group 3 patients presented with generalized obesity and extensive skin laxity. The recommended treatment for this group advanced to a T-shaped skin excision and closure pattern in the axilla. It was stated that circumferential liposuction alone would leave significant skin ptosis and contour irregularities not managed well by anticipated skin contraction. Group 4 patients had minimal subcutaneous fat and extensive skin laxity and required skin excision and recontouring (Fig. 29.8). El Kahtib more recently proposed a new classification scheme grading brachial ptosis based on the distance from the brachial sulcus to the lowermost border of the pendulous skin [28]. In doing so, he then offered the preferred treatment based on this evaluation. For stage 1, which consisted of minimal adipose tissue with no ptosis, circumferential liposuction was the treatment of choice. Stage 2 was subdivided into 2a (moderate adipose tissue with grade 1 ptosis, defined as <5 cm) and 2b (severe adipose tissue with grade 2 ptosis, defined as 5–10 cm), with stage 2a treated by staged circumferential liposuction. Stages 2b and 3 (severe adipose tissue deposit with grade 3 ptosis, defined as >10 cm) were both treated with liposuction

298 Fig. 29.7 Group 2 represents patients with a generalized increase in subcutaneous fat and moderate skin laxity. These patients benefited from circumferential liposuction with an axillary skin excision. Left: Preoperative showing area of deepithelialization. Right: Postoperative closure

J. G. Hoehn et al.

Pre-op

Post-op Closure

De-epithelialized skin

Pre-op

Fig. 29.8 Group 4 patients have minimal subcutaneous fat and extensive skin laxity and require skin excision and recontouring. Left: Preoperative showing area of deepithelialization. Right: Postoperative closure

Post-op Closure

De-epithelialized skin

and short scar brachioplasty. Stage 4, defined as minimal or no adipose tissue with grade 3 ptosis, was best treated by traditional brachioplasty according to the author.

29.4 Surgical Anatomy The anatomy discussed in this chapter is reflective of the arm, which is defined as the upper arm as opposed to the lower arm (forearm), which is below the cubital crease at the elbow. This anatomy, however, out of necessity, will encompass the depths of the axilla and the adjacent chest wall, which will play a role in the satisfactory management of the redundant upper arm.

The upper extent of the surgical field for brachioplasty begins with the axilla as defined by the anterior and posterior axillary lines. The axilla can be loosely described as a truncated cone with its apex directed superomedially toward the root of the neck. The inferior border of the “cone” extends a variable distance inferiorly onto the lateral chest wall. The anterior limit of the axilla is formed by the flare of the pectoralis major muscle and, in the female, the axillary skin fold extension of the breast. The posterior extension of the axilla becomes confluent with the medial skin of the arm and the inferior border is limited by the posterior axillary line. The arm begins at the lateral extension of the insertion of the pectoralis major muscle and extends to the medial and lateral malleoli of the elbow joint, which are joined by the cubital flexion creases.

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The selection of patients and the recommendation for treatment depends on a thorough knowledge of the normal anatomy and the abnormal anatomy. The superficial anatomy of the upper arm and axilla, the skin and subcutaneous tissue, is straightforward. Knowledge of the SFS and its distribution is necessary to understand and execute several current techniques of brachioplasty. However, the deeper structures of the arm and axilla are vital and understanding their locations and relationships is of utmost importance (Fig. 29.9).

a

29.4.1 Vascular Anatomy The first deep structures encountered in the upper arm are the components of the venous system. The superficial layer is diffuse and without a consistent pattern of distribution. Anticipation of their presence will avoid injury, which will lead to obstructed venous drainage contributing to postoperative upper extremity edema. The cephalic and basilic veins are readily identified at the antebrachium as they pass beneath the brachial aponeurosis [29]. Major

Axillary fascia

Medial Arm

Superficial axillary lymph nodes Cephalic v. Brachial fascia

Basilic v.

Medial brachial cutaneous n. Intercostobrachial n.

Medial antebrachial n. Skin laxity

Thoracoepigastric v.

b

Superficial Fascial System (SFS) of the Medial Arm

Clavipectoral fascia

SFS

Deep axillary fascia

Fig. 29.9 (a) Superficial nerves in the field of a brachioplasty. (b) Superficial fascial system of the medial arm

Elbow zone of adherence

300

arterial vessels are more superficial in the axilla proper and the surgeon should be constantly aware of their location in his surgical field. Beyond the upper 1/3 of the humerus, the major vascular structures should pass to a deeper plane and be beneath the surgical field.

J. G. Hoehn et al.

soft tissue creates either an aesthetically pleasing feature such as a dimple or an unaesthetically pleasing depression known as peau d’orange or cellulite [25].

29.5 Patient Selection 29.4.2 Lymphatic Anatomy The surgeon should attempt to preserve the major lymphatic channels, which are predictably coursing with the major venous structures. Lymph nodes are found with increasing frequency as the axilla is approached, but with longitudinal dissection techniques, few should be functionally disturbed. Proper management of lymphatic structures should minimize postoperative seromas and persistent postoperative edema.

29.4.3 Nerve Anatomy Longitudinal dissection techniques should minimize potential injury to nerve structures. However, several sensory cutaneous nerves (intercostobrachial, medial antebrachial and medial brachial cutaneous nerves) are variably located in the medial subcutaneous tissue and may be vulnerable to surgical injury. Currently, protection of the sensory nerves is accomplished by dissection of each nerve.

Primary indications for upper-arm rejuvenation are changes in the skin tone, muscle tone, and location of fat deposits, which may occur independently or in various combinations. As shown by Glanz and GonzalezUlloa, this may be from aging, gravitational effects, and/or extensive sun exposure [20]. Genetic predispositions and large weight fluctuations may have a significant effect on premature upper-arm aging. All candidates for elective, aesthetic surgery require a thorough history and physical examination to uncover those few patients who are inappropriate candidates because of medical or psychosocial problems. Con current medical problems, such as hypertension, insulin-dependent diabetes, or atherosclerotic vascular disease, will require further evaluation and control by an appropriate consultant prior to surgery. Knowledge of the metabolic issues, which are sequelae of bariatric surgery, is required to operate on this group of patients without significant complications. Uncovering the occasional patient who is poorly motivated and/or psychologically unstable will prevent undesirable outcomes.

29.6 Surgical Techniques 29.4.4 Fascial Anatomy The soft tissue of the arm is separated into superficial and deep compartments by fascial planes. Lockwood has studied the SFS in detail and has described the brachial component as, “a dynamic fascial sling that gains its strength from attachments to the clavipectoral and axillary fascia” [25]. The superficial fascia of the medial arm is securely anchored to the deep axillary fascia in the depth of the axilla (Fig. 29.9). The superficial fascia is also secured at the narrowing curves in what are known as zones of adherence at the elbow and the wrist [26, 30]. The SFS extends to the skin through a system of vertical septae known as the retinaculae cutis. A discrepancy in the vertical height of the septae and the surrounding

The basic surgical techniques and the multiple variations described to manage contour deformities in the arm reflect the wide variation of anatomical presentations with which the surgeon must deal. Many of the techniques should be in the armamentarium of the surgeon to allow tailoring of the surgical procedure to the specific anatomy presented by the patient. The following represents the techniques routinely applied by the authors with mention of the occasional variation employed to solve a particular presentation of axillary or elbow skin. Liposuction, whether standard, ultrasonic assisted, or power assisted, may be added to any of the surgical excision techniques to enhance the final result. It should be the unusual presentation in which liposuction may be used alone.

29 Brachioplasty: A Body-Contouring Challenge

Surgical brachioplasty is a viable option for upperarm contouring in the appropriately selected patient. Most candidates present with a significant redundancy of skin, which drapes inferiorly with the shoulder abducted and the elbow supinated. This redundancy will not be gracefully solved without resection of the redundant skin. The resultant scars, although visible in certain clothing styles, are acceptable trade-offs for the renewed arm contours. Although many variations of the basic surgical resection exist, the basic surgical technique of the senior authors will be used to present the general concepts. Although brachioplasty is frequently combined with other procedures, the remainder of this presentation will focus on the procedure as an isolated entity.

29.6.1 Preoperative Planning After the general medical issues have been assessed and the suitability of the patient for brachioplasty determined, the surgeon and the patient should discuss the conduct of the procedure in detail. The prospective patient should be very aware of the scars and their potential for untoward hypertrophic healing. The positioning of the axillary and the arm scars should be candidly described and documented in the patient record. Photographs are taken in the standard anterior views and may include preliminary preoperative markings to document that this information was communicated with the patient (Fig. 29.10).

Fig. 29.10 Standard anterior preoperative views

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29.6.2 Site of Service and Anesthesia Brachioplasty can usually be accomplished on an outpatient basis in an ambulatory surgery center or office surgical suite setting. Typically, general anesthesia is employed and laryngeal mask airway (LMA) is a convenient choice. However, frequently, brachioplasty is performed in conjunction with other body contouring procedures and in these cases, general endotracheal intubation anesthesia is the technique of choice.

29.6.3 Preoperative Preparation On the evening prior to surgery, the patient is instructed to shower with an antibacterial soap at length and, in the case of a female patient, instructed to perform her own axillary hair care. On the morning of surgery, the patient is asked to disrobe to the waist completely with underwear in place.

29.6.4 Preoperative Marking With the patient in the erect position, the arms are abducted to 90°, the elbow and forearm completely supinated, and the elbow flexed 90° (Fig. 29.11). A “pinch test” is performed to determine the degree of

Fig. 29.11 Patient arm position for preoperative marking

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skin laxity (Fig. 29.6). Visualization of the anticipated results while gently overlapping the lax tissues with the thumb and forefinger may also assist in planning the markings. Particular attention should be paid to the ultimate contour of the inferior border of the forearm. Care must also be taken to ensure that the upper-arm contouring is not so severe as to leave the patient with a disproportionately large forearm. A conservative resection of the upper arm skin and fat may result in a more pleasing rejuvenation to the entire arm by preserving an appropriate proportionality between the arm and forearm. If significant laxity persists at the level of the elbow, then the resection may be extended across the joint. However, because of the visibility of potentially unsightly scars, this extension should be the exception rather that the rule. Having said that, the surgeon should not be afraid to extend the incision if necessary to achieve a drastically improved contour. It is convenient to envision the planning and marking of the excess skin as two ellipses – one running horizontally centered along the midaxial line of the upper arm and the other crossing the axilla at almost 90° (Fig. 29.12). The extent of the axillary ellipse will

Fig. 29.12 Horizontally based ellipse of the arm continuing into the axilla

J. G. Hoehn et al.

Fig. 29.13 Markings of the horizontal ellipse to place the incision in an aesthetically pleasing location

vary in concert with the volume of the skin to be resected from the upper arm. The larger horizontal ellipse is marked positioning the resulting scar to be in a line parallel with the interbrachial groove (Fig. 29.13). This scar is well hidden on the innermost surface of the arm. A common pitfall here is the tendency to place the incision directly in the groove. The final scar will be too far inferior and will be visible from the posterior in sleeveless clothing. The incision ideally should be placed approximately two fingerbreadths (~3 cm) above a line drawn on the bicipital sulcus. This maneuver will locate the final scar in the center of the inner surface of the arm affording the maximum visual protection. The majority of patients with substantial upper arm laxity also have redundant tissue in the axilla and adjacent breast and inferior shoulder regions. A longitudinal ellipse performed alone may result in undesirable axillary fullness. In such patients, the longitudinal elliptical incision is connected in the axilla to a nearly vertical ellipse to solve this problem. This surgical planning permits a greater amount of tissue to be resected in the axilla perpendicular to the upper arm. Both sides of this vertical ellipse may be adjusted in an anterior–posterior direction to allow adoption of this plan to most patient presentations. This maneuver removes a larger portion of the hair-bearing axillary skin that many female patients view as an added benefit. Various authors have presented methods to deal with the inferior limb of the vertical elliptical incision such as Z-plasties, W-plasties, and S-shaped incisions [13, 19, 22]. The surgeon’s preference can be used to adapt the skin markings to the skin laxity presentations.

29 Brachioplasty: A Body-Contouring Challenge

After all markings are made, the patient should be viewed both anteriorly and posteriorly, with the arms at the sides, to be sure that the visibility of the final scars will be minimal in sleeveless clothing. Once satisfactory markings have been made, the patient may be placed on the operating table. For skin antiseptic, the author’s preference is Betadine followed by alcohol. However, care must be taken not to erase any markings.

29.6.5 Dissection The incision of the skin and subcutaneous tissues typically begins with the transverse ellipse and penetrates just through the dermis and the subcutaneous fat. Hemostasis is controlled by ligature and cautery, with bipolar cautery preferred over monopolar cautery. The structures, which will be required later to perform suspension of the SFS are noted. The inferior margin is undermined by blunt and sharp dissection. This inferior/ posterior flap can be intermittently advanced to determine the preliminary results. When the dissection is sufficient to achieve the contour rejuvenation, a secondary incision is made in the center of the advanced flap. Two or more additional such incisions can be made as required to allow sequential excision and approximation. This sequential method of excision allows for a more predictable result. Another common pitfall, which occurs at this time, is to overresect the horizontal ellipse as the average arm is not completely void of tissue medially. During the dissection, most often the cephalic vein and sensory cutaneous nerves will be encountered. These structures can often be preserved. However, small branches, particularly those entering the skin, can be sacrificed. If necessary, the cephalic vein can be tied off and sacrificed. At this point, a subcutaneous fascial suspension, as described by Lockwood, is performed [25, 26]. The posteromedial soft tissues can be suspended by creating a sturdy fascial sling. First, the axillary artery, axillary vein, and trunks of the brachial plexus are identified beginning one fingerbreadth medial to the axillary vein, and then four or five sutures are placed in the axillary fascia. These anchoring sutures are then secured into the SFS from the anterior and posterior aspects. At this time, if a vertical elliptical excision is used, this resection is carried out at the same depth as the dissection in the upper arm. This maneuver frequently allows sufficient advancement of tissues from posterior

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to anterior by accounting for the redundant tissues generated by the advancement in the upper arm dissection. Tissue rearrangement is occasionally required to achieve a satisfactory tissue contour in the concavity of the axillary hollow.

29.6.6 Wound Closure Once these suspensions are performed, then the surgeon’s attention is directed to closing the wound. A single suction drain may or may not be placed based on the surgeon’s discretion. The remainder of the wound is closed with deep dermal absorbable and intracuticular nonabsorbable removable sutures supplemented with dermal adhesive or steri-strips. Another alternative for skin closure includes barbed suture devices, obviating the need to use deep dermal sutures. Bulky gauze fluffs and an elastic wrap from the metacarpophalangeal joint level of the hand to the shoulder are used for control of postoperative edema control.

29.6.7 Liposuction An individualized selection of techniques (surgical brachioplasty with or without fascial suspension and with or without liposuction) will produce optimal results. However, in our hands, as in others, liposuction, when used alone to recontour the upper arm, results have been variable. The list of common postoperative complaints includes tissue sagging, skin wrinkling, and persistent seroma formation [7, 13]. Although these problems still exist, compulsive postoperative care with compression dressings and frequent follow-up to deal with seromas has increased overall patient satisfaction. Modern techniques of liposuction for brachio plasty have added a circumferential approach. The circumferential para-axillary superficial tumescent was introduced by Gilliland to describe a rigorous liposuction technique for difficult cases [14, 15]. Upper arm tissue is evaluated by the “pinch test” (Fig. 29.6). Special attention is paid to the anteromedial portion of the arm. This area is especially sensitive to wrinkling and may be best treated by tunneling alone. If the skin here is less that 6 mm by the “pinch test”, then even minimal tunneling is used. Posterolateral areas are generally less emphasized and satisfactory results are achieved.

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Generally, 500–1,000 mL of tumescent solution (1,000 mg lidocaine in 1 L of lactated Ringers solution – epinephrine is no longer used) is injected and approximately 500–600 mL of aspirate from each arm is taken. Access skin incisions are made above the medial epicondyle of the elbow and the posterior and anterior aspects of the axilla. If required, a secondary incision may be made in the mid-posterolateral upper arm. Suction is performed circumferentially in a superficial plane 4–7 mm beneath the skin. If the “pinch test” demonstrates a thickness over 12 mm, then conservative liposuction may be performed at a deeper level with a 2.4 or 3.0-mm cannula. The intent is to create a consistent pattern of circumferential scarring that will contract evenly around the circumference of the upper arm. If skin laxity exists but the patient is unwilling to accept the scarring, which accompanies a surgical brachioplasty, then a technique of abrading the deep surface of the dermis with a serrated cannula (3 mm Gilliland or 8 mm Becker cannula) has been used without suction to promote skin contraction. No cases of lymphedema were reported, but, again, postoperative care must be attentive. If desired, drains are typically placed for 2–3 days. However, seroma rates for this procedure were reported to be as high as 34%. Such seromas should be managed aggressively and early to avoid persistent problems. Painful bands of scar tissue and nodules of tissue necrosis were noted and treated with local massage and 0.2% triamcinolone injections [17]. Patients insisting on liposuction alone must understand that a satisfactory outcome requires postoperative compliance. Extensive liposuction in the upper arm may sound like an attractive alternative to the scars of brachioplasty, but the limitations, complications, and potentially protracted postoperative course needs to be thoroughly understood by the patient and documented by the surgeon. The desired contour rejuvenation of surgical brachioplasty is rarely achieved with liposuction alone.

29.6.8 Postoperative Care Each of the described procedures for brachioplasty will benefit from rigorous follow-up evaluation and care beginning at 48 h. Intraoperatively placed compressive

J. G. Hoehn et al.

dressings are the surgeon’s choice. For long-term compression, elastic wraps and commercial compression garments designed for upper-arm use are available and add considerably to the surgical outcome. Follow-up office visits for wound inspection and care occur as often as necessary, but at least weekly after the 48-h visit. Any drains placed are typically removed after 72 h but should be maintained as long as significant drainage persists. The early detection of postoperative fluid collections will speed wound healing. Removal of the nonabsorbable intracutaneous sutures occurs anytime after 14 days, but steri-strips may be continued for scar control for a longer period. Postoperative scar massage with appropriate scar softening agents is useful.

29.7 Complications and Their Management Brachioplasty as a procedure is troubled with potential complications. This procedure is sought for aesthetics and, therefore, in the appreciation of a result by the patient, even a subtle change can change a satisfactory result into an undesirable one.

29.7.1 Scar Visibility The upper arm is a highly visible area and a discrete inner arm scar with a smooth contour optimizes the aesthetic outcome. An unsightly scar will result from a malpositioned incision or a hypertrophic scar. The ideal incision should be contained within the area defined by the brachial groove posteriorly and extending 3 cm anterior to the brachial groove. Outside this area, the scar may be visible to even the untrained eye in a short-sleeve or sleeveless garment.

29.7.2 Scar Hypertrophy Hypertrophic scarring can be seen with poor surgical technique in wound closure, poor skin quality, or excessive tension in skin closure. Skin tension may also produce wound dehiscence or superficial skin necrosis.

29 Brachioplasty: A Body-Contouring Challenge

Abnormal tension can result from overresection of the skin and subcutaneous tissue or abnormal excessive fluid or blood collection present in the postoperative wound. Additionally, a longitudinal incision, which does not disrupt venous or lymphatic drainage, is very helpful in diminishing postoperative fluid collection. As has been stated, when a collection of fluid is found, it should be evacuated immediately with a large needle and syringe aspiration, followed by compression.

29.7.3 Contour Irregularities Suction-assisted lipectomy with brachioplasty increases the possibility for contour irregularities. Lillis stresses the importance of reducing trauma to the subdermis [16]. During surgical resection, incomplete release of the SFS may also create a contour deformity [25, 26]. The overresection of the proximal third of the upper arm or overresection of the upper arm as compared with the forearm will produce an obvious deformity. It is also critical to achieve symmetry between both arms. The careful preoperative marking of both arms with the patient positioned as noted above will minimize asymmetries in the postoperative result.

29.7.4 Skin Resection Finally, with significant skin laxity, there will often be a redundancy of tissue at the medial condyle of the elbow and the anterior axillary line. This may be compensated for in the closure with a medial adjustment of the skin flaps toward the center of the incision to work out the excess tissue (“dog-ear”). Similarly, in the axilla, care must be taken not to resect the redundant tissue into the axilla with a straight closure to prevent postoperative cutaneous banding.

29.7.5 Nerve Injury Attention to preserving underlying sensory nerves must be made during brachioplasty. Knoetgen and Moran reviewed the complications from brachioplasty at the Mayo Clinic over a 16-year period. Five percent

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of their study group of 40 patients developed an injury to the medial antebrachial cutaneous nerve during the procedure. They also noted in the cadaveric portion of their study that this nerve penetrates the deep fascia of the forearm at 14 cm proximal to the medial epicondyle [31].

29.8 Conclusions Upper-arm rejuvenation has undergone an evolution to create an aesthetically optimal outcome in a procedure fraught with complications. The importance of fascial suspension, as described by Lockwood, was critical in reducing postoperative scar complications [25, 26]. Additional, nonsurgical brachioplasty with liposuction has minimized scarring in very carefully selected patients. Brachioplasty can be a rewarding surgical procedure in appropriately selected patients combined with meticulous surgical technique and rigorous postoperative care. We describe our techniques, which have provided reproducible results with optimal aesthetic outcomes for patient who desire rejuvenation of the upper arm.

References 1. American Society of Plastic Surgeons. 2000/2007/2008 National Plastic Surgery Statistics. Available at http://www. plasticsurgery.org/Media/stats/2008-cosmetic-reconstructive-plastic-surgery-minimally-invasive-statistics.pdf. Accessed 8 Apr 2009. 2. Pascal JF, Le Louarn C. Brachioplasty. Aesthetic Plast Surg. 2005;29(5):423–9. 3. Aly A, Pace D, Cram A. Brachioplasty in the patient with massive weight loss. Aesthetic Surg J. 2006;26(1):76–84. 4. Cannistra C, Valero R, Benelli C, Marmuse JP. Brachioplasty after massive weight loss: a simple algorithm for surgical plane. Aesthetic Plast Surg. 2007;31(1):6–9. 5. Migliori FC, Ghiglione M, D’Alessandro G, Serra Cervetti GG. Brachioplasty after bariatric surgery: personal technique. Obes Surg. 2008;18(9):1165–9. 6. Hurwitz DJ, Holland SW. The L brachioplasty: an innovative approach to correct excess tissue of the upper arm, axilla, and lateral chest. Plast Reconstr Surg. 2006;117(2): 403–11. 7. 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(2):595–603.

306 8. Abramson DL. Minibrachioplasty: minimizing scars while maximizing results. Plast Reconstr Surg. 2004;114(6): 1631–4. 9. Reed LS, Hyman JB. Minimal incision brachioplasty: refining transaxillary arm rejuvenation. Aesthetic Surg J. 2007; 27(4):433–41. 10. Trussler AP, Rohrich RJ. Limited incision medial brachioplasty: technical refinements in upper arm contouring. Plast Reconstr Surg. 2008;121(1):305–7. 11. Chandawarkar RY, Lewis JM. ‘Fish-incision’ brachioplasty. J Plast Reconstr Aesthet Surg. 2006;59(5):521–5. 12. Baroudi R. Dermatolipectomy of the upper arm. Clin Plast Surg. 1975;2:485–94. 13. Borges A. W-plastic dermolipectomy to correct “Bat-Wing” deformity. Ann Plast Surg. 1982;9(6):498–501. 14. Gilliland M, Lyos A. CAST liposuction of the arm improves aesthetic results. Aesthetic Plast Surg. 1997;21(4):225–9. 15. Gilliland M, Lyos A. CAST liposuction: an alternative to brachioplasty. Aesthetic Plast Surg. 1997;21(6):398–402. 16. Lillis P. Liposuction of the arms. Dermatol Clin. 1999;17(4): 783–97. 17. Vogt P. Brachial suction-assisted lipoplasty and brachioplasty. Aesthetic Plast Surg. 2001;21(2):164–7. 18. Correa-Iturraspe M, Fernandez J. Dermolipectomia braquial. Prensa Med Argent. 1954;34:2432–4. 19. Pitanguy I. Correction of lipodystrophy of the lateral thoracic aspect and inner side of the arm and elbow dermosenescence. Clin Plast Surg. 1975;2:477–83.

J. G. Hoehn et al. 20. Glanz S, Gonzalez-Ullon M. Aesthetic surgery of the arm part I. Aesthetic Plast Surg. 1981;5(1):1–17. 21. Guerrerosantos J. Brachioplasty. Aesthetic Plast Surg. 1979; 3:1–14. 22. Juri J, Juri C, Elias J. Arm dermolipectomy with a quadrangular flap and “T” closure. Plast Reconstr Surg. 1979;64(4):521–5. 23. Regnault P. Brachioplasty, axilloplasty, and preaxilloplasty. Aesthetic Plast Surg. 1983;7(1):31–6. 24. Goddio A. A new technique for brachioplasty. Plast Reconstr Surg. 1989;84(1):85–91. 25. Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96(4):912–20. 26. Lockwood T. Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast Reconstr Surg. 1991; 87(6):1009–18. 27. Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg. 1998;102(2):545–51. 28. El Khatib HA. Classification of brachial ptosis: strategy for treatment. Plast Reconstr Surg. 2007;119(4):1337–42. 29. Baroudi R, Vogt P. Brachioplasty and brachial suction-assisted lipectomy. In: Cohen M, editor. Mastery of plastic and reconstructive surgery. Boston: Little Brown; 1994. p. 2219–36. 30. de Souza Pinto E, Erazo P, Matsuda C, Regazzini DV, Burgo DS, Acosta HA, do Amaral AG. Brachioplasty technique with the use of molds. Plast Reconstr Surg. 2000;105(5):1854–60. 31. Moran SL, Knoetgen J. Long-term outcomes and complications associated with brachioplasty: a retrospective review and cadaveric study. Plast Reconstr Surg. 2006;117(7):2219–23.

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“Fish-Incision” Brachioplasty Rajiv Y. Chandawarkar

30.1 Introduction Redundant skin and soft tissue on the upper arms occurs commonly following massive weight loss. Patients suffer enormously from a deformity that is readily visible and not easily hidden. First described by Correa-Iturraspe and Fernandez [1], brachioplasty is a surgical procedure that directly addresses this deformity. In 2007 alone, the ASAPS reported that 21,870 brachioplasties were performed, a sevenfold increase over the period of ten years. Several surgical techniques to achieve arm rejuvenation have been described (Table 30.1). All of these procedures seek to achieve the following common goals: excision of skin and soft tissue, reposition the skin flaps to improve the upper arm contour, and minimize the scar. In patients with a large volume of upper arm skin and fat, the usual demarcations and landmarks are difficult to identify since the traditional bony and skin surface markings are altered due to laxity and fat. Preoperatively, the planning of the surgical procedure is critical and complex. Operatively, the placement of scars and amount of resection plays an important role in determining the outcome. Lastly, in terms of patient satisfaction, two issues continue to be problematic: the length and visibility of the scar; and the anatomy of the axillary fold. Poor contour correction, webbing of the axilla, and widened, visible scars often require revision surgery.

R. Y. Chandawarkar Department of Surgery, Division of Plastic Surgery, University of Connecticut School of Medicine, Farmington, CT 06030, USA e-mail: [email protected]

The “Fish” incision brachioplasty addresses these concerns and offers some unique advantages over other techniques [2]. The principles of the surgery, salient operative steps including preoperative marking, incisions, flaps, and potential postoperative complications are discussed. Preoperative markings are based upon careful mathematical measurements of the deformity. The incision used is in the shape of a fish and is specially designed to address the problems discussed above. The position of the final scar on the posterior aspect of the arm is more hidden when the person is animating. Mathematical measurements, anatomic marking, and conduct of the operation have been described in detail. The “fish-incision” brachioplasty provides a usable, simple method that is easy to follow and optimizes aesthetic results.

30.2 Presentation and Patient Selection Typically, patients present with a large “bat-wingshaped” lax tissue that extends from the olecranon process to the axillary fold (Fig. 30.1). In some cases, this laxity extends across to the lateral portion of the thorax as well. Ideally, the selected surgical procedure must remove excess with a hidden scar, resulting in a well-contoured arm and a normal appearing axilla. Widening scars and axillary webbing affect the cosmetic outcome. The Fish Incision technique involves a series of steps that ensure a better surgical outcome by offsetting two major concerns: the position of the longitudinal scar and the axillary webbing. Preoperative marking the incisions is based on actual measurements instead of relying on anatomic landmarks alone. Designing the

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_30, © Springer-Verlag Berlin Heidelberg 2010

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Table 30.1 Developments in brachioplasty techniques Investigator Operative methods Posse

Elliptical incision [3]

Correa-Iturraspe and Fernandez

Aesthetic brachioplasty [1]

Pitanguy

S- incision [4]

Franco and Rebello

L-incision [5]

Juri et al.

Quadrangular flap and T-closure [6]

Borges

W-plasty [7]

Goddio

Deepithelization and repositioning [8]

Lockwood

Fascial suspension [9]

Gilliland

Circumferential para-axillary superficial tumescent (CAST) liposuction [10]

Hallock

Simultaneous mammoplasty thoracoplasty and brachioplasty [11]

Regnault

Axilloplasty [12]

Strauch et al.

Sinusoidal incision [13]

Pinto et al.

Molds [14]

Temourian et al.

Classification [15]

Fig. 30.1 Patients present with a large “bat-wing-shaped” lax tissue that extends from the olecranon process to the axillary fold

incision and meticulous closure enhances the aesthetic result, leading to a better contour correction. It is important to emphasize here that the most appropriate patient for the “Fish-incision” brachioplasty is the one that does not have additional laxity on the thorax. For those patients, the incisions would have to be extended onto the lateral thorax. In the ideal patient for a Fish Incision brachioplasty, the bat wing is restricted to the arm. This selection is important or else the deformity on the thorax will remain unaddressed.

30.3 Preoperative Marking This remains the most important step for success of any type of brachioplasty – and cannot be underestimated. Preferably sufficient time must be set aside preoperatively so that it can be performed perfectly. Typically, this marking takes about 15–20 min and could potentially be performed the day prior to the surgery so that photo-documentation can be incorporated as well. Steps for preoperative marking that are based upon mathematics and anatomic landmarks are easier to follow than using anatomic landmarks alone. Typically, severe laxity of soft tissues of the arm is disorienting in terms of defining the appropriate anatomic location of incisions and flaps. Anatomic landmarks are blurred, and bony points that could serve as surface markers are heavily padded with fat and soft tissue. The steps for preoperative marking described below provide usable guidelines to address these problems. Step 1: Mid-lateral line: The lateral portion of the arm is usually less affected by the fat deposition and skin excess. With the patient in the standing position, and the arms by the side of the body, a line is drawn in the mid lateral plane of the arm, connecting the deltoid tubercle and the lateral tubercle of the elbow. This simple step is easy since these specific landmarks are well preserved even in patients with severe arm laxity. Using an adjustable height sitting stool with wheels makes this marking much more convenient for the surgeon who can perform the markings without excessive bending – it spares your back. Step 2: Mark the longitudinal axis of the “Fish incision”: The guiding principle for marking this axis preoperatively is that the final resting position of the scar must lie postero-medially, well posterior to the groove on the inner arm, between the biceps and the triceps muscle (medial groove). This placement ensures that the scar does not lie in the easily visible portion of the arm while the patient animates. In order to define the axis, the following method is applied (Fig. 30.2). First, measure the circumference of the arm at the widest by asking the patient to abduct the arm to 90°. Then, using the mid lateral line as a frame of reference, a point two-thirds the circumference anteriorly is marked as the axis-point of the fish incision. A straight line at this point along the long axis of the arm is drawn. Usually, this line lies approximately 3–4 cm posterior to the medial groove. This axis will place the final scar in its

30 “Fish-Incision” Brachioplasty

a

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c

A2 BODY

TAIL

Longitudinal Axis

45

P2

2/3 Anterior

1/3 Posterior

Body

e roov ial G Med Tail

is

l Ax

dina

gitu

Lon

b

Fig. 30.2 (a) Diagrammatic representation of the marking. Note that the axis of scar is behind the medial groove. (b, c) Markings (extra markings of the axes have been erased for simplicity) [2]

resting position well posterior to the mid-bicipital groove, making it much less conspicuous during daily routine activities. Step 3: Marking the “Fish-incision” and planning the axillary tail: All these markings are performed with the patient’s arm abducted initially to 90 and later to 180°. Adding a full-length mirror allows the patient to participate in this process as well. With the patient standing with her arms abducted, the excess skin and soft tissue fold is allowed to hang freely. The maximum laxity of the arm (measured at its widest portion) is held between index fingers of both hands on each side of the laxity. These points on the arm represent the widest portion of the body of the fish

and are designated A1 and P1 for anterior and posterior, respectively (Fig. 30.2). Step 4: Using a simple correction factor that is absolutely essential in the “width” measurement – since it accounts for the inherent thickness of the skin flaps themselves and subsequently allows for tension-free closure of the wound at the widest margin. If it is not taken into consideration, wound closure places undue tension on the incision. This correction factor reduces the tension on the scar, reducing in turn the widening of the scar. In addition, this measure improves the aesthetic contour by prevention of a depression in the scar axis. The correction factor generates two new points A2 and P2, which are merely additions of the thickness of

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the skin measured by pinching the skin itself (recorded as “F”). The new points A2 and P2 mark the widest portions of the body of the fish incision (Fig. 30.2). The length of the incision depends upon the longitudinal extent of laxity and can be easily judged when the patient abducts the arm to 90° angle. In most patients, it extends from the axilla to the olecranon process. The tail of the incision is at the level of the axillary fold – the line joining the lateral border of the pectoralis major and the anterior border of the latissimus muscle transgressing the axillary hollow. This distance measured is recorded as “T”. From the anterior and posterior limits, an angle of 45° is marked and a line measuring 2/3 (T) is marked anteriorly and 1/3 (T) is marked posteriorly (Fig. 30.2). This completes the marking of the fishtail. An easily curved ellipse is marked joining the distal most point of the laxity on the arm and the ends of the fishtail, including in its course the previously marked points A2 and P2. The marking of the fish incision is now complete and surgical excision is performed – making intraoperative modifications only if necessary. Excised specimens are shown (Fig. 30.3). In order to optimize contour, the patient is examined in both supine and sitting position intraoperatively by flexing the operating table to a sitting position. This allows for modifications to be made

Fig. 30.3 Specimen

R. Y. Chandawarkar

immediately if necessary. Closure of the wound requires specific attention. Briefly, there are two support systems that help the skin and soft tissue in the arm to retain their shape. These include: (A) the superficial fascial system that extends from the axilla to the elbow and encases the subcutaneous fat. This fat is connected to the posteromedial fascial system of the arm that forms the clavipectoral and axillary fascia; and (B) the musculoaponeutotic layer that invests the arm muscles. Meticulous closure in three layers: fascial layer using 2.0 Vicryl interrupted suture; numerous subdermal sutures using 3.0 Monocryl buried interrupted sutures and skin closed with 3.0 Monocryl subcuticular sutures. This multilayered closure is essential for optimal scars. The suturing as well as allowances for the skin thickness reduced the tension on the skin edges and reduces scar widening. A multi-perforated tube suction drain is placed in the subcutaneous space and the arm is bandaged using Ace wrap. We avoid using Kerlex gauze bandages since they lack expansibility and in patients that develop postoperative tissue edema, may cause undue compression. The Ace-wrap bandages are kept for 3 weeks during which time the patient is asked not to lift weights more than 5 lbs and avoid any strenuous activity. Postoperative results (Fig. 30.4) reveal a favorable aesthetic and functional outcome, with desired reduction in arm volume, optimal placement of the scar and complete lack of axillary webbing. All the figures shown emphasize the lack of axillary webbing and very importantly, the low visibility of the scar while animation in most positions (Fig. 30.4). There are several methods that aim to explain preand intraoperative steps for brachioplasty. The Fish incision brachioplasty provides a framework for planning this procedure for patients who do not need extension of the incision onto the chest wall. The operative steps detailed here provide mathematical guidelines as well as allow individual tailoring as additional modifications to the central plan. It is based upon simple principles and can be easily applied. The modifications of the surgical technique described here seek to resolve some common problems associated with brachioplasty. Using these techniques allows accurate preoperative planning and a clear, easy-to-understand method for marking surgical incisions.

30 “Fish-Incision” Brachioplasty Fig. 30.4 Postoperative results reveal a favorable aesthetic and functional outcome, with desired reduction in arm volume, optimal placement of the scar, and complete lack of axillary webbing (a1-3). Also note that the scar is not visible in the position of routine activity (since it is located posteromedially). (b1-3, c). Only seen in position shown in d

311

a1

a2

a3

b1

b2

It must be emphasized that no single technique fits all. One must be flexible and allow modifications based upon individual patient needs. The fish incision not only corrects the contour effectively but also accounts for the anatomic location of the final scars, the appearance and function of the axillary

b3

scarring, the prevention of webbing, and measures to prevent widening scars. The location of the final scar (posteromedially placed instead of the traditional mid-seam) is an important consideration for movement and animation since they are much less visible.

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c

d

Fig. 30.4 (continued)

R. Y. Chandawarkar

References 1. Correa-Iturraspe M, Fernandez JC. Dermatolipectomia braquial. Prensa Med Argent. 1954;41(34):2432–6. 2. Chandawarkar RY, Lewis JM. ‘Fish-incision’ brachioplasty. JPRAS. 2006;59(5):521–5. 3. Posse P. Cirurgia estetica. Buenos Aires: Athenue, 1943. p. 1046. 4. Pitanguy I. Abdominal lipectomy. Clin Plast Surg. 1975; 2(3):401–10. 5. Franco TR. Cirurgia estetica. Rio De Janeiro: Athenue, 1977. p. 336. 6. Juri J, Juri C, Elias JC. Arm dermolipectomy with a quadrangular flap and “T” closure. Plast Reconstr Surg. 1979; 64(4):521–5. 7. Borges AF. W-plastic dermolipectomy to correct “bat-wing” deformity. Ann Plast Surg. 1982;9(5):498–501. 8. Goddio AS. A new technique for brachioplasty. Plast Reconstr Surg. 1989;84(1):85–91. 9. Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96(4):912–20. 10. Gilliland MD, Lyos AT. CAST liposuction: an alternative to brachioplasty. Aesthetic Plast Surg. 1997;21(6):398–402. 11. Hallock GG, Altobelli JA. Simultaneous brachioplasty, thoracoplasty, and mammoplasty. Aesthetic Plast Surg. 1985; 9(3):233–5. 12. Regnault P. Brachioplasty, axilloplasty, and preaxilloplasty. Aesthetic Plast Surg. 1983;7(1):31–6. 13. Strauch B, Greenspun D, Levine J, Baum T. A technique of brachioplasty. Plast Reconstr Surg. 2004;113(3):1044–8; discussion 1049. 14. de Souza Pinto EB, Erazo PJ, Matsuda CA, Regazzini DV, Burgos DS, Acosta HA, do Amaral AG. Brachioplasty technique with the use of molds. Plast Reconstr Surg. 2000;105(5):1854–60; discussion 1861–5. 15. Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg. 1998;102(2):545–51; discussion 552–3.

Brachioplasty Technique with Molds Combined to Vaser Assisted Lipomyosculpture

31

Ewaldo Bolivar de Souza Pinto and Pablo S. Frizzera Delboni

31.1 Introduction At the beginning of the twenty-first century, fashion is no longer as rigid as it was in the past. Currently, more practical and free-formed clothes show parts of the body that were previously hidden. With today’s styles, the fact that obesity and aging lead to aesthetic disarrangement of the body is a greater cause for concern cosmetically. With regard to the arms in particular, lipodystrophy, loss of muscular mass, and skin laxity are the results of such disharmony and present an increase in the inferior curve of the arm. Many solutions have been proposed to prevent and correct brachial dystrophy, from noninvasive procedures such as diet and exercise to surgical techniques such as liposuction and dermolipectomy (Table 31.1) [1–10]. The unsatisfactory results of the surgical techniques are due to poor surgical indications, incorrect localization of the scar, skin quality, and fat over resection, causing impaired venous and lymphatic circulation and insufficient correction of deformity. A three-degree classification is presented according to subcutaneous cellular tissue, skin laxity, and weight loss. The procedure and technique, as determined by individual cases, tries to achieve a better brachial contour by using an italic double S-shape acrylic mold for a symmetrical bilateral marking, resulting in precise and good quality scarring. The VASER-assisted lipomyosculpture technique, whether associated or not with brachioplasty, helps us to prevent lymphatics,

E. B. de Souza Pinto (*) Plastic Surgery Department, Santa Cecilia University – UNISANTA, São Paulo, Brazil e-mail: [email protected]

vessels and nerves damaging while we are able to reduce the arm volume, and give a better tissue mobilization, obtaining a better aesthetic result with minimal complications.

31.2 Anatomy A better knowledge of the anatomy allows to prevent lymphatics, vessels and nerves damaging, and keep good vascularization of the edges of the wound, helping to reduce the two main problems of brachioplasties: effusions and bad scarring. At the medial part of the arm is located a round prominence with a sulcus on each side (bicipital). The inner sulcus, which is more evident and extends from the axillary region to the elbow’s crease region and the external sulcus is of less importance. The arm presents the following layers: skin, subcutaneous cellular tissue, aponeurosis, muscles, and skeleton. The skin on the inner side of the arm presents thinner and more flexible and hairfree features compared with that on the external side, and is more affected by loss of elasticity from aging. The amount of fat present may vary according to the individual’s biotype, age, and sex. There are two basic skin support and fat systems: first is the superficial fascial system that extends from the axilla to the elbow and encases the subcutaneous fat. This superficial system is connected to the posteromedial fascial system of the arm that forms the clavipectoral and axillary fasciae. The posteromedial system is the second and most important support system and extends from the clavicle to the axillary fascia down and over the major pectoralis muscle. Gravity, aging, and weight fluctuations cause loss and/or weakening on the connections of the

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Table 31.1 History of brachioplasty technique Reference

Technique

Posse [6]

Elliptical incision

Correa-Iturraspe and Fernandez [2]

Published the first aesthetic brachioplasty techinique

Clarkson and Jeff [3]

Curved suprascapular and infrascapular incision with downward and upward concavity

Pitanguy [7]

S-shaped incision

Franco and Rebello [9]

L-shaped incision

Juri et al. [4]

Quadrangular flap and T-closure

Borges [1]

W-plasty incision

Teimourian [10]

Classification

Goddio [3]

Deepithelialization of the posterior flap, repositioned to create a bicipital sulcus

nerves are present. Passing through the superficial plane are the cephalic vein and the basilic distal portion; the superficial lymphatic net, of major importance in draining the upper limb; and the nerve branches of the cutaneous medial brachial (an important sensible nerve), superior lateral, anterior of the forearm, medial of the forearm, and lateral supraclavicular areas. Every dissection could lead to local or generalized effusions. A large lymphoedema of the whole arm can occur in case of axillary dissection. However, the most frequent problem is the lesion of the other lymphatics leading to local seromas, which are bad for healing.

31.3 Clinical Evaluation

Lockwood [11]

Suspension of the fascial system

Marquez and Abramo [5]

Treatment of brachia, axillary, and elbow segments

arm’s support system, resulting in a ptosis of the posteromedial structures [11]. We can quantify the loss of the arm support through the Hoyer Coefficient [12], which on X-ray film indicates a relation between the thickness of the soft parts over and under the humerus. This procedure shows an increase on the lower curve of the arm in relation to the person’s age. Under the fascia, the aponeurotic layer that encases the brachial aponeurosis and the musculature can be seen, showing a superficial plane (deltoid and brachial biceps muscles) and a deep layer (tracheobrachial, anterior brachial, and long supinator muscles). Important structures pass through this region: on the deep plane the axillary artery, ulnar, and basilic veins and lymphatic branches sharing the same names and nervous bundles as the ulnar, radial, and medial

All patients are examined in supine position with arms abducted at a 90° angle in relation to the body. The amount of fat tissue (subcutaneous cellular tissue) and degree of skin flaccidity are evaluated in relation to body weight. From these data, a classification was established (Table 31.2) to group the findings and offer a better treatment. Group I. Group I includes patients with localized brachial fat, good skin quality with no laxity, and no history of body weight changes. Patients with these characteristics may benefit from arm liposuction to treat the lipodystrophy because of their good skin retraction. Group II. Group II includes patients with fat excess and a moderate degree of skin laxity usually associated with overweight. For this group of patients is indicated brachioplasty associated with liposuction. Group III. Group III includes patients with massive weight loss presenting a thin fat tissue, severe brachial ptosis, and poor skin quality. Brachioplasty only is indicated in cases such as these. Preoperatively, the bicipital diameter on the midpoint of the arm (half the distance between the elbow and shoulder) was first measured, and then the bicipital

Table 31.2 Clinical classification Group

Skin laxity

Fat

Weight

Treatment

I

Good

Localized

Normal

Lipomiosculpture

II

Moderate

Moderate

Over

Brachioplasty and lipomiosculpture

III

Poor

Minimal

Massive loss

Brachioplasty

31 Brachioplasty Technique with Molds Combined to Vaser Assisted Lipomyosculpture

height (the lower bicipital curvature) at the same place was determined.

31.3.1 Molds The molds are made of acrylic in three sizes: small, medium, and large, with widths of 2.5, 4.5, and 6 cm, respectively. Any alterations in the amount of skin to be resected are generally made in regard to width. The mold is designed in an italic double S-shape with a branch to support the marking. When using the same mold on both arms, similar markings must be made to attain an identical result without irregular scarring (Fig. 31.1) [13]. Molds are sterilized with ethylene oxide before the procedure is begun. The cost of the molds is minimal, and they can be selected according to degree of skin flaccidity and amount of tissue to be resected.

Fig. 31.1 Italic double S-shape acrylic molds. L large; M medium; S small

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31.3.2 VASER-assisted Lipomyosculpture Lipomyosculpture is a new technique of lipoplasty, development of which was based on the morphohistological analysis of fat tissue. It combines a new body contouring technology, the VASER, with a new liposuction technique where cannulas and probes are only passed in the same direction as the muscular fibers underneath instead of the more traditional cross tunneling (Fig. 31.2) [14]. The technique addresses both the superficial and deep layers of the subcutaneous tissue in the search for skin retraction and harmonious fat removal. The preoperative markings are considered essential for the success of liposuction. They must be done with the patient placed supine with arms abduced in a 90° angle. The markings are done according to the muscle fibers underlying each area. It is especially important to draw with different colors the limits of the muscles and the direction of their fibers so as to define the placement of the skin incisions and guide the movement of the cannulas intraoperatively. We use an iodopovidone solution for antisepsis. Both layers of the subcutaneous tissue should be infiltrated with appropriate amounts of wetting solution with the tumescent technique (1:5,00,000 epinephrine/solution ratio). The VASER device (Fig. 31.2) is first used to pretreat fat. Access incisions 3–4 mm in length are made in the boundaries of the marked areas and skin protectors are placed to prevent the skin from injury. The deep layer is approached to diminish local fat deposits and the superficial layer is treated in a careful manner, to get some skin retraction and refinement with the aim of avoiding irregularities. Once the probe is introduced through the port, simple axial back-and-forth movements are done in the same direction as the muscle fibers underneath the treated area and without levering to the sides or up and down. After emulsification of the target localized fat deposits, aspiration can be carried out by suction-assisted lipoplasty. Once again it is important to follow the direction of the muscle fibers of the area. Performing the movements in such a way enhances the body contour, featuring the shape of the muscles with more pleasant and attractive results and fewer irregularities. There is also better skin retraction, probably due to stimulation caused by the muscle contraction in the same direction.

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Fig. 31.2 (Above) VASER. (Below) VASER cannulas

31.4 Surgical Technique One of the biggest advantages of this technique concerns the anesthesia. When performed as an isolated procedure, the brachioplasty technique may be done with local anesthesia; if associated with lipomyosculpture or any other procedure, low-flow general anesthesia can be used. For group I patients (lipodystrophy with good skin quality), the surgical procedure consists of a tumescent infiltration of the treatment areas, followed by lipomyosculpture underneath the area of the resec tion. Two incisions are made to achieve a complete access to the area: one located on the arm joint with the axillary crease; and the other located above the medial epicondyle of the humerus. After fat fragmentation/emulsification with VASER, perforated tip cannulas 3–4 mm in size were used to make tunnels in the superficial plane. For refinement, a 4 mm Robles

cannula is used to obtain better contour and skin retraction. The incisions are sutured with a 6–0 monofilament nylon thread. A tubular elastic garment is put into place and changed once a week for a 1-month period, after which it was replaced with a longsleeved cotton blouse, for compression, for 45 days (Fig. 31.3). For group II (moderate lipodystrophy and skin flaccidity), the lipomyosculpture procedure as described for group I was followed. The mold is chosen only after clinical observation. The mold’s straight side is placed on the axilla, then, the italic double S-shape is placed in a downward and transverse direction, with the mold’s convex side adapting to the medium third of the arm and ending approximately 4–5 cm of the humerus inner epicondyle (Fig. 31.4). Marking is done bilaterally with the same mold. The marked area is infiltrated with the standard solution as previously described. The skin and

31 Brachioplasty Technique with Molds Combined to Vaser Assisted Lipomyosculpture

317

Fig. 31.3 40-year-old patient. (Above) preoperative and (below) postoperative

subcutaneous cellular tissue are incised up to the arm’s superficial fascia plane. The detachment is performed toward the cranio-caudal area with skin flap resection (Fig. 31.5). After rigorous hemostasis, closure begins, with the approximation of the flaps and no undermining. Subdermal stitches are done with 4–0 monofilament nylon thread, followed by intradermic suture with 5–0 nylon thread and, on the skin, continuous suture with 6–0 poliglecaprone 25. After suture, any fat accumulation observed on the medial face of the arm is removed by using superficial liposuction, avoiding the detached area. An aspiration drain is left for 24 h. Hypoallergenic tape and a tubular elastic garment are used for dressing, which is changed every week during a month-long period, after which it is replaced by a long-sleeved elastic blouse used as a compression for 45 days (Fig. 31.6). For group III patients (major flaccidity and massive weight loss), brachioplasty is performed as described previously but with larger molds (Fig. 31.7).

Fig. 31.4 (Above) Patient is being marked with an acrylic mold. (Center) Patient with unilateral marking. (Below) Patient with bilateral marking

31.5 Complications The two main problems concerning brachioplasties are effusions and bad scarring. Group I patients generally presents excellent aesthetic results with fine contour of the upper extremity, obtaining great fat reduction and good skin retraction. Edema, when it occurs, is transitory and lasts for

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Fig. 31.5 Intraoperative views: (above, left) skin and subcutaneous cellular tissue resection; (above, right) flap ready for closure; (center, left) deep anchoring point of the flap; (center, right)

complete closure with final scarring symmetrical in italic S-shape; (below) dressing

approximately 30 days; no persistent edema is commonly observed. Patients in groups II and III usually show a harmonious brachial contour, with symmetrical and discreet scarring that is hidden by the bicipital sulcus. As in other surgical procedures, scarring is more visible

during the first 2 months, and at the end of the first year, it becomes very thin, of normal pigmentation, and completely hidden by the bicipital sulcus. The lower brachial curvature shows great improvement at 60 days postoperative, with the diminishing of 4 cm on average, and 3 cm from the brachial diameter.

31 Brachioplasty Technique with Molds Combined to Vaser Assisted Lipomyosculpture

319

Fig. 31.6 Posterior views of 44-year-old patient (group II). (Above) preoperative and (below) postoperative

Fig. 31.7 Patient in group III, 56-years-old (above, left) front view with torso, preoperative; (above, right) front view with torso, postoperative; (below, left) detailed front view, preoperative; (below, right) detailed front view, postoperative

320

The authors had two cases of hypertrophic scarring in group II patients, probably because of high tension over the suture. Other possible complications common after any surgical procedure, such as seroma, hematoma, necrosis, and suture dehiscence have not occurred with the authors’ cases.

31.6 Discussion Before surgery decide which technique is better to correct brachial dystrophy. Each patient must be submitted to complete clinical examination that will evaluate the amount of subcutaneous cellular tissue, skin laxity, and weight loss in the past years. The patient requiring brachial contour procedure must receive specified treatment according to this evaluation to avoid unsatisfactory results. Lipomyosculpture is a very useful procedure for patients with different degrees of lipodystrophy, as well as for minor imperfections of the lower third of the arm. It helps to prevent lymphatics, vessels and nerves damaging while we are able to reduce the arm volume, and gives a better tissue mobilization, obtaining a better aesthetic result with minimal complications. The use of the acrylic mold for marking made it easier to perform bilateral, symmetrical incisions resulting in minimal, localized (bicipital sulcus) scarring. The use of the molds also helps to reduce surgical time and consequent morbidity. Another important fact regarding scarring quality with this technique is that minimal skin and subcutaneous cellular tissue resection was necessary with the use of the molds. Only the exact amount of skin was resected to correct the brachial contour and ensure good incision closure without tension of the surgical wound, preventing hypertrophic irregularities and “dog-ears.” Two cases of hypertrophic scars occurred when the authors started using this technique, probably from high tension over the scarred area.

31.7 Conclusions The use of molds in plastic surgery is controversial because of differences in patient characteristics. The

E. B. de Souza Pinto and P. S. F. Delboni

variable-sized molds enable us to adapt the surgical expectations regarding the degree of lipodystrophy, skin flaccidity, and weight loss to the patient’s individual needs. Each patient with arm lipodystrophy will have a specific surgical indication according to our classification of brachioplasty. Both brachioplasty with molds and lipomyosculpture with VASER, combined or as an isolated procedure, are demonstrated to be good options for treating arm deformities. The italic double S acrylic molds made it easier to achieve minimal, symmetrical, bilateral and localized scarring with reducing surgical time and morbidity. Lipomyosculpture with VASER helped preventing important arm structures from injury, reducing the complications rate with a very good aesthetic outcome.

References 1. Borges AF. W-plastic dermolipectomy to correct “batwing” deformity. Ann Plast Surg. 1982;9:498. 2. Correa-Iturraspe M, Fernandez JC. Dermolipectomia braquial. Prensa Med Argent. 1954;41:2432. 3. Goddio AS. A new technique for brachioplasty. Plast Reconstr Surg. 1989;84:85. 4. Juri J, Juri C, Elias JC. Arm dermolipectomy with a quadrangular flap and “T” closure. Plast Reconstr Surg. 1979;64: 521. 5. Marquez BE, Abramo A. Dermolipectomia braquial (braquioplastia). Rev Soc Bras Cir Plást Estét Reconstr. 1996;11:1. 6. Posse P. Cirurgia estética, Buenos Aires: Atheneu, 1943. p. 1046. 7. Pitanguy I. Abdominal lipectomy. Clin Plast Surg. 1975; 2:401. 8. Clarkson P, Jeff J. The contribution of plastic surgery to the treatment of obesity. In: Gibson T, editor. Modern trends in plastic surgery, 2nd series. Washington: Butterworths; 1996. p. 315. 9. Franco T, Rebello C. Cirurgia estética. Rio de Janeiro: Atheneu, 1977. p. 336. 10. Teimourian B. Suction lipectomy and body sculpturing. St. Louis: Mosby, 1987. p. 163–72. 11. Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96:912. 12. Glanz S, Gonzalez-Ulloa M. Aesthetic surgery of the arm: Part I. Aesthetic Plast Surg. 1981;59:1. 13. de Souza Pinto EB. Brachioplasty technique with the use of molds. Plast Reconstr Surg. 2000;105:1854. 14. de Souza Pinto EB. Lipomioplasty with VASER: a new approach to body contouring. Innov Plast Aesthet Surg. 2008:433–42.

Limited Incision Medial Brachioplasty

32

Andrew P. Trussler and Rod J. Rohrich

32.1 Introduction Upper arm contouring has evolved to offer effective and safe procedures to a diverse patient population [1]. Aesthetic brachioplasty was first described in 1954 by Correa-Iturraspe and Fernandez [2]. The drawback to a classic brachioplasty has always been the longitudinal scar burden placed on the inner arm. In order to decrease the visibility of the scar, different longitudinal incision positions have been described, though none of which conceal the scars with the arms abducted in short-sleeved garments. The inspiration for a limited incision brachioplasty was likely the description of the local excision of axillary hidradenitis suppurativa with primary closure in 1972 [3]. This demonstrated that a significant excision of tissue in the area could be resected and the scars were well tolerated and concealed in the axilla. This procedure in the treatment of hidradenitis obviated the need for skin grafting, though the goal in the aesthetic application is to obviate longitudinal scar extending from the elbow to the axilla. Systematic preoperative evaluation of the upper extremity with categorization of the deformity has led to progressive approaches to arm contouring [4–6]. These procedures range from liposuction only to combined extended brachioplasty and lateral chest wall excisions. Changes in the location of incisions, and the combination of liposuction with superficial excision has A. P. Trussler (*) Department of Plastic Surgery, University of Texas Southwestern, 1801 Inwood Road, Dallas, TX 75390–9132, USA e-mail: [email protected]

led to decreased risk to underlying nerves and lymphatics with improved scarring and decreased postoperative edema [7, 8] The limited incision medial brachioplasty highlights the evolution of upper arm contouring because it combines the use of liposuction with a wellcamouflaged area of excision to deliver a refined contour with minimal scarring to the select patient.

32.2 Patient Selection The limited incision medial brachioplasty offers a straightforward arm-lift procedure that minimizes patient morbidity and downtime. This procedure has specific applications and in no way does it take the place of a full brachioplasty; however, it can be applied to well-selected groups of both the cosmetic and the massive weight loss patients. Ideal patients for this procedure have moderate amounts of proximal third upper extremity skin excess and moderate upper extremity and axillary lipodystrophy. Skin quality and tone should be excellent for this limited procedure.

32.3 Examination The patients should be evaluated in the upright position with the amount of lipodystrophy initially determined. This can be performed with a pinch test along the entire upper arm. The thickness of the tissue (>1.5 cm) or amount of deflation in the massive weight loss patient determines the amount and the location of liposuction. The inner elbow should be evaluated as a

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separate sub-unit for liposuction; as should the axillary area and upper lateral thorax. This should be done with a pinch test to predetermine the exact area and relative volume of liposuction. In the massive weight loss patient, an upper extremity without full deflation would be ideal for this limited procedure as the amount of liposuction and skin excision can be tailored to the appearance of the entire arm, avoiding a skeletonized upper arm with large forearms. Skin quality and quantity should be evaluated. Skin quality in the nonmassive weight loss patient should be relatively normal with adequate tone and intact contractile properties. The massive weight loss patient may have stigmata of permanent skin damage with striae and thinning of the upper arm skin. In this circumstance, a limited procedure should be avoided, as early recurrence of the deformity would be predictable. Skin excess should be located in the proximal third of the upper arm, which is the focal point of the excisional area. The vertical limit of the excision is 3–5 cm from the axilla to the upper arm.

32.4 Markings Patients are marked in the upright position with the anterior and posterior limits of the axillary incision marked in the axillary skin crease with the arm at the side of the patient, as this is the position of the arm at repose. By limiting the incision to these points, the incision is hidden within the axilla. The arm is then abducted to 90° and the two points are connected in the axillary fold, delineating the final position of the scar and most medial incision. Using medial traction on the upper medial arm skin, the amount of skin excision is marked in an elliptical fashion. This usually measures 3–5 cm in vertical distance at the most central point. The areas of liposuction are marked within the medial arm, elbow, and axilla with the arm in the abducted position. The bicipital groove is marked as the most anterior point of arm liposuction. The medial elbow is marked separately, as this will be an area to be suctioned with standard liposuction. The axilla should be marked as a separate sub-unit to blend the upper arm and axilla to contour the bra strap area.

A. P. Trussler and R. J. Rohrich

32.5 Procedure The procedure is performed with the patient in the supine position under general anesthesia. The limited incision medial brachioplasty can be performed as a single procedure or combined with other contouring procedures. The arms are prepped into the operative field with the peripheral intravenous (IV) preferably, but not absolutely in the lower extremity, and the hands and forearms covered with a surgical stockinette. The arm is supported by an assistant while the areas for liposuction are infiltrated using a superwet technique with a solution of 1 L of lactated Ringers, 30 mL of 1% Lidocaine and 1 ampule of 1:1,000 epinephrine. The arm is accessed via a 1 cm radial incision in the elbow. A separate incision in the lateral chest may be required if axillary liposuction is to be performed. Approximately 200–500 mL of lipoaspirate is retrieved from the both the arm and axilla, depending on the amount of lipodystrophy present. Ultrasonic-assisted liposuction (UAL) is utilized in the arm and axilla using long radial strokes. The UAL settings are 50% in a nonpulsed mode. The middle fat layer is targeted with a 3.7–4.6-mm liposuction cannula. The end point for UAL in all areas is time and decreased stroke resistance. UAL is then followed by standard liposuction using exaggerated long strokes to prevent contour deformities. Superficial standard liposuction is performed at the elbow with a 3.0–3.7-mm Lambros cannula. UAL is not recommended around the medial elbow secondary to the close proximity of the ulnar nerve. After completion of the liposuction portion of the procedure, an incision is made in the medial axillary skin fold previously marked in the patient. This is carried to the subcutaneous layer of the inner arm to preserve the underlying structures, including lymphatics and nerves. The liposuction plane will be visualized and the skin is undermined after the lateral incision is made and connected to form an elliptical area of resection. A deeper plane is excised posteriorly to aid in the final contour of the incision. The medial incision is undermined for 1 cm in the subcutaneous plane to assist the closure. After irrigation of the incision with antibiotic irrigation and confirmation of hemostasis, the closure is approximated,

32 Limited Incision Medial Brachioplasty

with staples anteriorly and posteriorly advancing any excess centrally. Pleating in the incision should be kept to a minimum. If pleating occurs, it may be addressed with a vertical wedge excision to remove the excess redundancy. The closure is performed in a layered fashion with 3–0 Vicryl® suture (Ethicon, Inc. Somerville, NJ) interrupted sutures in the deep dermis, 4–0 PDS® suture (Ethicon, Inc. Somerville, NJ) running subcuticular suture, and the skin reapproximated and dressed with Dermabond® (Ethicon, Inc. Somerville, NJ). The liposuction ports are closed with a single 5–0 fast-absorbing suture. No drains are used in this procedure.

32.6 Postoperative Care The limited incision medial brachioplasty can be performed as an isolated procedure or combined with other body contouring procedures. It can be performed as an outpatient procedure, but should be performed in an approved, accredited operating room environment. Antibiotics are administered perioperatively and continued for 3 days postoperatively. The patient is placed in a long arm surgical garment after the operation. This provides compression to the areas of liposuction; which is maintained for 3 weeks. Topifoam® (Lysonix, Inc. Carpenteria, CA) is placed under the garment onto the areas of liposuction and is maintained for 48 h. The patient may shower 2 days after the procedure when the Topifoam® (Lysonix, Inc. Carpenteria, CA) is removed. The use of Dermabond® (Ethicon, Inc. Somerville, NJ) reduces the amount of wound drainage and enables early showering. Patient activity is not limited after surgery with early ambulation encouraged, though abduction of the arms is limited to less than 90° for 3 weeks postoperatively.

32.7 Modifications A vertical dart may be incorporated into the limited incision medial brachioplasty if the area of excess

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includes focal horizontal excess combined with vertical excess. This maneuver refines the outcome as it may eliminate central pleating in the incision, though it adds a “T” incision to the procedure. A “pursestring” closure has been described to eliminate the “T” incision [9]. This converts the crescent excision pattern to that of an oval. The redundancy and pleating though may be excessive and revision procedures may be necessary to smooth the contour of the scar. The areas of liposuction may be modified to address the focal areas of lipodystrophy within the sub-units of the upper-extremity: elbow, upper arm, and axilla/ lateral chest wall.

32.8 Complications The complication rate in the limited incision medial brachioplasty is decreased secondary to the short incision and superficial excision plane. Wound infections and small areas of incision dehiscence are the most common complications. These are usually treated conservatively with oral antibiotics and local wound care; and do not necessitate reoperation. Lymphoceles have rarely occurred postoperatively and usually can be opened, marsupialized, and packed with gauze in the office setting. These usually resolve shortly after opening the cavity. Nerve injury, hypertrophic scarring, major wound complications and lymphedema have not been observed with this procedure.

32.9 Conclusions The limited incision medial brachioplasty can be applied to a diverse, select patient population with excellent results and limited morbidity (Figs. 32.1 and 32.2). This procedure is a continuum of the current refinements in upper extremity contouring surgery, and highlights the importance of careful preoperative analysis and categorization, with safe, reliable surgical procedures.

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Fig. 32.1 Left: Preoperative 45-year-old female with diffuse upper arm lipodystrophy, limited skin excess, and excellent fascial support. Right: One year postoperative after UAL of the upper arm with a limited incision brachioplasty

Fig. 32.2 Left: 38-year-old with diffuse though limited upper arm lipodystrophy with moderate skin excess and moderate fascial support. Right: One year postoperative after UAL of the upper arm with a limited incision brachioplasty

32 Limited Incision Medial Brachioplasty

References 1. Trussler AP, Rohrich RJ. Limited incision medial brachioplasty: technical refinements in upper arm contouring. Plast Reconstr Surg. 2008;121(1):305–7. 2. Correa-Iturraspe M, Fernandez JC. Dermolipectomia braquial. Prensa Med Argent. 1954;41(34):2432–6. 3. Pollock WJ, Virnelli FR, Ryan RF. Axillary hidradenitis suppurativa: a simple and effective surgical technique. Plast Reconstr Surg. 1972;49(1):22–7. 4. Appelt EA, Janis JE, Rohrich RJ. An algorithmic approach to upper arm contouring. Plast Reconstr Surg. 2006; 118(1): 237–46.

325 5. Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg. 1998;102(2):545. 6. Pinto E, Erazo PJ, Matsuda CA, Regazzini DV, Burgos DS, Acosta HAP, do Amaral AG. Brachioplasty technique with the use of molds. Plast Reconstr Surg. 2000;105(5):1854. 7. Knoetgen J III, Moran SL. Long-term outcomes and complications associated with brachioplasty: a retrospective and cadaveric study. Plast Reconstr Surg. 2006;117(7): 2219–23. 8. Pascal JF, Le Louarn C. Brachioplasty. Aesthetic Plast Surg. 2005;29(5):423–9. 9. Reed LS, Hyman JB. Minimal incision brachioplasty: refining transaxillary arm rejuvenation. Aesthet Surg J. 2007; 27(4):443–1.

Augmentation Brachioplasty with Cohesive Silicone Gel Implants

33

Gal Moreira Dini and Lydia Massako Ferreria

33.1 Introduction Acquired and congenital body contour deformities may lead to low self-esteem and negative self-image. The use of fat transplants harvested from the abdomen and buttocks became a common practice among surgeons after the work of Lexer [1] was published. However, complications such as high reabsorption rate of fat, chronic drainage, calcification, and presence of a visible scar at the donor site had discouraged its use. The use of alloplastic materials in the repair of body contour deformities has been the subject of research for centuries. Different substances have been injected percutaneously such as paraffin, and more recently, in the beginning of the 1960s, liquid silicone. Complications resulting from the use of paraffin and silicone include the presence of nodules and embolism. Prosthesis implantation was the next step in the evolution of methods. The first authors to describe a prosthesis implantation technique for breast augmentation were Cronin and Gerow [2]. Various types of prostheses have been devised since that time [3–6]. Presently, implants of various shapes and sizes, and of different outer shell and filler materials are available in the market. There are smooth and textured silicone shell prostheses, polyurethane-coated implants, and double- or triple-lumen implants. With regard to the filler material, there are implants filled with saline solution, natural oils, and silicone gel. In the 1980s, there was an intense debate about the eventual association between the risk of systemic

G. M. Dini (*) Department of Plastic Surgery, Universidade Federale de São Paulo, Escola Paulista de Medicina, São Paulo, Brazil e-mail: [email protected]

diseases, such as cancer and autoimmune diseases, and silicone implants. The lack of scientific evidence on the safety of these implants raised concerns among the general public, resulting in a large number of lawsuits. Later, several studies have proved the absence of risks associated with implants [7–9] other than those normally involved in any surgical procedure. Capsule contracture is the most common complication related to silicone implants. The literature shows that there is a decreased incidence of capsule contracture when the implant is protected by muscles, probably because of the constant massaging action of the muscle on the implant [10]. The search for a better body contour has motivated persons to exercise regularly to increase muscle mass in the arms and legs. In a study performed by the author on ten adult female cadavers, in the Division of Anatomy at the Federal University of São Paulo (UNIFESP-EPM), Brazil (unpublished data), it was verified that the average size of the short head of the biceps was 20 cm in length, 3 cm in width, and 1.7 cm in height. Based on these measurements, an implant consisting of a silicone elastomer envelope filled with silicone gel (similar to that used in breast prostheses) was designed to enhance the appearance of the biceps muscle.

33.2 Surgical Technique The procedure is performed under local anesthesia (axillary brachial plexus block) and sedation (midazolam). Both arms are extended at 90° to the trunk and maintained in this position during the entire surgical procedure. The outline of the biceps muscle is traced on the skin. A 3-cm incision is made through the skin and subcutaneous tissue in the axilla, exposing the fascia of

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the biceps brachii muscle. The fascia is opened (Figs. 33.1 and 33.2), and a tunnel is created into the short head of the biceps muscle (Fig. 33.3) with a Langenbeck

retractor. Hemostasis is verified using a 4-mm rigid endoscope (Fig. 33.4) and the silicone implant is inserted (Fig. 33.5). The aponeurosis is closed with a

Fig. 33.1 Visualization of the fascia of the biceps brachii muscle

Fig. 33.4 Verification of hemostasis using a video endoscope

Fig. 33.2 Opening of fascia of the biceps brachii muscle

Fig. 33.3 Evulsion of the short head of the biceps muscle

Fig. 33.5 Insertion of the silicone implant

Fig. 33.6 Wound closure

33 Augmentation Brachioplasty with Cohesive Silicone Gel Implants

2–0 absorbable suture, and the skin with a 4–0 absorbable suture (Fig. 33.6). At this point, liposuction of the posterior arm is performed. A small amount of skin may be resected for a better aesthetic result.

33.3 Discussion The anatomy of this region favors the surgical approach since there are no vascular or nerve structures in the incision or dissection path nor under or over the muscle that may be damaged by the compression exerted by the implant. This technique may be used in selected cases of hypoplasia of the biceps brachii muscle, either associated or not associated with a low degree of flaccidity of the posterior upper arm [11]. The volume

increase in the anterior upper arm stretches the skin of the posterior upper arm (Figs. 33.7–33.8). The use of instruments for image enhancement that offer a direct visualization of the detached planes allows precise dissection and safe hemostasis [12, 13]. The elastic property of the fascia covering the muscle allows easy placement of the implant. Standard implants are fusiform in shape since asymmetrical implants that were tried first had a tendency to roll laterally. No postoperative complications, such as edema of the forearm and relevant pain, have been reported. Patients are able to return to their normal activities in less than a week. Patients who underwent this surgical procedure reported improvement in quality of life when assessed with appropriate tools (Rosenberg’s self-esteem scale/ UNIFESP-EPM and Short Form-36 health survey questionnaire (Brazilian versions)) [14]. Improvements in

a

b

Fig. 33.7 (a) Preoperative. (b) Postoperative

a

Fig. 33.8 (a) Preoperative. (b) Postoperative

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b

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self-esteem, vitality, role emotional, social functioning, and mental health have been observed after treatment.

33.4 Conclusions This technique can be an important addition to the therapeutic arsenal of the plastic surgeon.

References 1. Lexer E. Freie Fettransplantation. Dtsch Wochenschr. 1910;36:640. 2. Cronin T, Gerow F. Augmentation mammaplasty-a new “natural feel” prosthesis. In: Transactions of the Third International Congress of Plastic Surgeons. Amsterdam: Excerpta Medica; 1964. p. 41–9. 3. Bartels RJ, O’Malley JE, Douglas WM, Wilson RG. An unusual use of the Cronin breast prosthesis. Case report. Plast Recosntr Surg. 1969;44(5):500. 4. Glicenstein J. “Advantages” and inconveniences. Apropos of breast implants. Ann Chir Plast Esthet. 1992;37(4):353–5. 5. Montellano L. Calf augmentation. Ann Plast Surg. 1991; 27(5):429–38.

G. M. Dini and L. M. Ferreria 6. Vergara R, Marcos M. Intramuscular gluteal implants. Aesthetic Plast Surg. 1996;20(3):259–62. 7. Berner I, Gaubitz M, Jackisch C, Pfeiderer B. Comparative examination of complaints of patients with breast cancer with and without silicone implants. Eur J Obstet Gynecol Reprod Biol. 2002;102(1):61–6. 8. Brown SL, Duggirala HJ, Pennello G. An association of silicone-gel breast implant rupture and fibromyalgia. Curr Rheumatol Rep. 2002;4(4):193–298. 9. Cash TF, Duel LA, Perkins LL. Women’s paychosocial outcomes of breast augmentation with silicone gel-filled implants: a 2-year prospective study. Plast Recosntr Surg. 2002;109(6):2112–21. 10. Lemperle G, Kostka K. Calf augmentation with new solid silicone implants. Aesthetic Plast Surg. 1993;17(3): 233–7. 11. Dini GM, Ferreria LM. Augmentation brachioplasty. Plast Reconstr Surg. 2006;117(6):2109–11. 12. Beer GM, Kompatscher P. Endoscopic plastic surgery: the endoscopic evaluation of implants after breast augmentation. Aesthetic Plast Surg. 1995;19(4):353–9. 13. Price CI, Eaves FF III, Nahai F, Jones G, Bostwick J III. Endoscopic transaxillary supbectoral breast augmentation. Plast Reconstr Surg. 1994;94(5):612–9. 14. Ciconelli RM, Soarez PC, Kowalski CC, Ferraz MB. The Brazilian Portuguese version of the Work Productivity and Activity impairmentL General Health (WPAI-GH) Questionaire. Sao Paulo Med J. 2006;124(6):325–32.

Long-Term Outcomes and Complications After Brachioplasty

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James Knoetgen III

34.1 Introduction

34.2 Technique

Brachioplasty has traditionally been an unpopular procedure in plastic surgery because of the poor scarring and complications. Because of the increased popularity of bariatric surgery in recent years, plastic surgeons are caring for more massive weight loss patients, and as a result, upper arm contouring has become increasingly popular. Brachioplasty is an upper arm contouring procedure which includes skin excision from the upper arm and was first described 75 years ago [1]. Since that description, there have been a large number of technique papers in the plastic surgery literature [2–18]. American Society of Plastic Surgery (ASPS) data reveal that the popularity of brachioplasty has increased dramatically in recent years. There was a 4,059% increase in the number of brachioplasties performed between 2000 and 2008 [19]. A variety of procedures have been described to treat the upper arms, covering the spectrum from liposuction to large upper arm skin excisions which extend onto the lateral torso. Traditional brachioplasty results in a long longitudinal scar extending from the axilla to the elbow. This scarring is typically displeasing, which limited the popularity of this procedure and encouraged the use of upper arm liposuction and the development of limited incision or mini-brachioplasty techniques. The introduction of upper arm pathology classification systems has significantly helped the plastic surgeon in selecting the appropriate procedure for the patient with upper arm contouring needs.

Prior to choosing the appropriate brachioplasty procedure for the patient, the plastic surgeon must first accurately classify the type and degree of upper arm pathology. While there have been many advances and evolutions in brachioplasty surgical technique, perhaps the most significant contribution to brachioplasty surgery in recent years has been the development of upper arm classification systems [20, 21]. Appelt et al. [20] classify upper arm pathology by the amount of excess skin and fat, and location of skin excess. Their classification system can be summarized as follows:

J. Knoetgen III Private Practice, 20296, Bakersfield, CA, 93390-0296, USA e-mail: [email protected]

Type I: excess upper arm fat with good skin tone Type II: moderate skin laxity with minimal excess fat Type II A: proximal upper arm skin redundancy only Type II B: skin redundancy of entire upper arm Type II C: skin redundancy extends onto lateral chest wall Type III: lipodystrophy and redundant skin of the arm The authors proposed a treatment algorithm for determining the best procedure for each type of upper arm pathology. Regardless of which classification system is used, it is important for the plastic surgeon to determine the amount of lipodystrophy of the upper arm, the amount and location of excess skin, and the quality of the skin before planning surgery. Liposuction alone can be successful in patients with upper arm lipodystrophy, minimal or no redundant skin, and good skin quality. Many surgeons advocate ultrasound-assisted liposuction to improve skin retraction [22]. Arms with mild-to-moderate skin excess and lipodystrophy may respond to a limited incision or mini-brachioplasty technique with or without the use

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of adjuvant liposuction. Patients with significant skin excess and/or poor skin quality require a full brachioplasty. If skin excess extends onto the trunk, as is often seen in the massive weight loss patient, an extended brachioplasty is often required. Complication and revision rates are included in the preoperative discussions with brachioplasty patients when informed consent is obtained. The risks, benefits, alternatives, hopeful outcomes, and potential complications of brachioplasty are thoroughly explained in detail prior to surgery. As with all plastic surgery techniques, proper patient selection is vital. The plastic surgeon must establish that the patient has realistic expectations, and expected outcomes should be explained to the patient in detail. The standard brachioplasty technique focuses on the removal of skin and subcutaneous fat from the upper medial arm. While the details of brachioplasty techniques vary among surgeons, the majority of surgeons attempt to place the scar in the brachial sulcus. It is thought that this location will best hide the brachioplasty scar, which is often lengthy and unattractive, especially in the massive weight loss patient. Some surgeons have suggested placing the incision in a more posterior location [16, 17]. The resultant scar may be less visible. Markings are performed with the patient upright, elbow flexed at 90°, and the shoulder abducted at 90°. The bicipital groove is marked, and the planned skin excision is marked around the bicipital groove. For a full brachioplasty, the skin excision generally extends from the axilla to the elbow. If skin laxity extends into the axilla or onto the trunk, excision can be extended to these areas. It is always safer to underresect skin rather than overresect, and several techniques are helpful in accomplishing this. The intraoperative use of Pitanguy forceps is very helpful in making decisions about the amount of skin to be resected. Alternatively, as the surgeon elevates the flap of upper arm skin to be resected, the flap can be divided in several places with interval incisions to ensure an appropriate amount of skin resection. It is advisable to approximate wound edges immediately after skin resection with surgical staples or towel clips to facilitate wound closure. It is prudent to interrupt a scar that crosses the axilla with a Z or W plasty to prevent a contracture. Skin excision rarely extends past the elbow. Liposuction is sometimes combined with the skin excision, and when performed, should be limited to superficial and medium-depth fat. Likewise, it is imperative to keep surgical dissection

J. Knoetgen III

superficial to avoid injury to deeper structures. Injury to the medial antebrachial cutaneous nerve (MACN) was reported in 5% in one series [23] and can result in long-term paresthesia. The superficial fascia of the arm is then sutured to the clavipectoral fascia. The wound is closed in layers with absorbable suture over a closedsuction drain. Sterile dressings and a compressive wrap are applied. A variety of limited incision or mini-brachioplasties have been described [18, 22]. Trussler and Rohrich describe a technique for patients with moderate amounts of proximal third upper arm skin excess and moderate upper extremity and axillary lipodystrophy. The authors emphasize the importance of systematic preoperative evaluation and categorization of the deformity before planning the procedure. A vertical scar is placed in the axillary sulcus and debulking of the arm is performed with ultrasound-assisted liposuction. While limited incision brachioplasties cannot replace the standard brachioplasty, if performed in the right patient population, it can minimize patient morbidity and recovery. Postoperatively, compressive garments or wraps are helpful in treating edema and ecchymosis. Careful postoperative care is important to assess for seromas, hematomas, nerve injury, poor scarring, and other complications.

34.3 Complications Complications cited in the literature include poor scarring, edema, wound infection or suture abscess, lymphocele, wound dehiscence, distal seroma, under resection, and paresthesias/dysesthesias secondary to nerve injury. Despite these reports, there are few peer reviewed long-term brachioplasty outcome studies, so complications and complication rates are poorly understood. Gusenoff et al. [24] reported a prospective study of 101 patients who underwent brachioplasty. All patients were massive weight loss patients and 96% had concomitant body contouring procedures. They report a brachioplasty complication rate of 36% and a total revision rate of 4%. Arm liposuction, in addition to brachioplasty, was noted to increase complications. Knoetgen and Moran [23] reported a retrospective review of 40 patients and a cadaveric study of brachioplasty anatomy. Seventy six percent were massive

34 Long-Term Outcomes and Complications After Brachioplasty

weight loss patients. The overall complication rate was 25%. Complications noted were seroma (10% of patients), hypertrophic scarring (10%), cellulitis (7.5%), wound dehiscence (7.5%), subcutaneous abscess (2.5%), and nerve injury (5%). Patients with nerve injury had symptoms which persisted beyond 1 year. Surgical revisions were performed in 12.5% of patients, and included skin resections as well as liposuction alone. A cadaveric study was performed to study upper arm anatomy in relation to the typical brachioplasty excision, particularly the course of the nerves. The courses of the MACN and the medial brachial cutaneous nerve (MBCN) were studied. The MACN and MBCN were present in all ten cadaver specimens. The course of the MACN was variable after exiting the deep fascia, but tended to run in close proximity to the intramuscular septum (Fig. 34.1). The average distance at which the nerve penetrated the deep fascia was variable, but averaged 15 cm proximal to the medial epicondyle (range 8–21 cm). The nerve did divide into an anterior and posterior branch after exiting the deep fascia. The posterior branch consistently terminated in branches at the level of the medial epicondyle, while the anterior branch coursed more distal to supply portions of the anterior proximal forearm. The nerve did not consistently run with the basilic vein, and in three specimens, the nerve was found greater than 5 cm anterior to the basilic vein within the mid arm. Anatomic dissections noted that the MACN becomes a superficial structure at an average distance of 15 cm proximal to the medial epicondyle, and is therefore, at risk of injury during brachioplasty surgery. At the point

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Fig. 34.2 The MACN, adjacent to the basilic vein, travels superficial to the deep brachial fascia of the upper arm where it is at risk of injury during brachioplasty

where the MACN exited the deep fascia, it was considered a superficial structure, and thus, at risk during brachioplasty procedures when the superior skin incision is placed near the intermuscular septum (Fig. 34.2). The MBCN consistently ran posterior to the basilic vein and was encountered during the inferior portion of the skin resection in all cadavers. The nerve passed medial and posterior to the ulnar nerve at the mid portion of the forearm giving terminal braches at the level of the medial epicondyle. This structure would be at risk in incisions centered more posterior to the medial intermuscular septum. The important conclusion from this study is that both nerves run superficial to the deep fascia, which strongly supports the assertion that brachioplasty dissections should be performed as superficially as possible.

34.4 Discussion

Fig. 34.1 Medial upper arm. Forceps point to the medial antebrachial cutaneous nerve (MACN) as it pierces the deep brachial fascia to become a superficial structure in the upper arm

The frequency of brachioplasty procedures continues to rise. However, despite this increase, there are few studies which have attempted to examine the complication rates associated with this procedure. Previous reports in the literature have sited complications such as poor scarring, edema, wound infection or suture abscess, lymphocele, wound dehiscence, distal seroma, and under resection. Because of the historical unpopularity of brachioplasty, some authors have suggested liposuction of the upper extremity alone as an alternative to brachioplasty [25]. This technique can be effective in patients with minimal or no excess skin and

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with good skin quality. Others have suggested that the use of short scar or mini-brachioplasty to minimize scarring; suggesting the incidence of hypertrophic or unsightly scarring is high in this patient population. Patients with lipodystrophy and moderate skin excess may benefit from a combination of liposuction and a limited incision brachioplasty. While brachioplasty techniques vary among surgeons, several basic tenets should be followed to minimize complications while maximizing aesthetic results. These tenets include: (1) Careful preoperative classification of upper arm pathology and an algorithmic approach to surgical planning, (2) appropriate, yet conservative, skin resection with the intraoperative use of Pitanguy forceps or other technique to control the degree of skin resection, (3) judicious use of liposuction when combined with brachioplasty and perhaps the use of ultrasound-assisted liposuction to improve skin retraction, (4) the use of a z-plasty when crossing the axilla, (5) superficial dissection and liposuction to avoid injury to deep structures such as nerves, (6) suturing of the superficial fascia to the clavipectoral fascia and a layered wound closure over closed-suction drains, and (7) light compressive dressings postoperatively for at least 7 days. To improve scarring, treatment with early silicone gel sheeting in patients with a history of poor scaring or at the first sign of hypertrophic scarring or keloid is helpful. Perhaps the most distressing complication associated with brachioplasty is nerve injury. Injury to the MACN has been reported most frequently in relation to cubital tunnel surgery, where the nerve is often injured as the terminal branches pass anterior to the medial epicondyle. Injury to the nerve in this location may lead to the development of painful neuromas [26, 27]. The anatomy of the MACN has been described in several papers [26–29]. The MACN arises from the brachial plexus, emerges from the axilla, travels medial to the brachial artery, and lies adjacent to the basilic vein, but its course with the basilic vein is variable. The nerve pierces the deep fascia to become subcutaneous in the distal or midbrachium. The nerve then divides into an anterior and posterior branch at an average distance of 14.5 cm from the medial epicondyle. However, no specific anatomic landmark has been consistently attributed to the location at which the nerve pierces the deep fascia to become a superficial structure. Therefore, the MACN is consistently present in the deep plane of dissection for the standard brachioplasty

J. Knoetgen III

technique. Thus, it may be potentially injured during skin and fat resection. If injured, the patient is at risk of developing dysesthesia, and possibly a complex regional pain syndrome. While injury to other major structures (i.e., ulnar, median nerves) has not been reported in the literature, complications such as these are theoretically possible during brachioplasty. These structures are deep upper arm structures that exist beneath the brachial fascia, and if a brachioplasty technique penetrates the deep fascia, especially in the area of the intermuscular septum, injury to median and ulnar nerves is a possibility. The posterior brachioplasty approach could still potentially injure one of the posterior crossing branches of the MACN. Subcutaneous crossing branches of the posterior branch of the MACN near the elbow have been described by Lowe et al. [27]. Injury to the posterior branch can result in a painful neuroma and paresthesia of the elbow pad. In addition, with more posterior dissections, surgeons must be aware of the course of the MBCN running posterior to the ulnar nerve and basilic vein. Regardless of which brachioplasty technique a surgeon chooses, the course of the MACN should be understood and considered during design of the skin resection. It is advisable to preserve a cuff of at least 1 cm of fat on the deep (brachial) fascia of the upper arm to help prevent the possibility of nerve injury during dissection. This technique would also prevent injury to deeper structures, such as the median and ulnar nerves.

34.5 Conclusions Upper arm contouring has evolved from one surgical procedure to a variety of procedures which can treat a wide variety of upper arm pathologies. Brachioplasty has become increasingly popular, especially in the massive weight loss population. Accurate preoperative evaluation is imperative before establishing a surgical plan. Informed consent, emphasizing potential complications and revisions, must be discussed with patients preoperatively. Surgical procedures should be based on the patient’s specific anatomic abnormality. While arms with lipodystrophy, minimal excess skin, and good skin quality can be treated with liposuction alone, patients with significant amounts of excess skin and

34 Long-Term Outcomes and Complications After Brachioplasty

poor quality skin require skin excisions which may extend onto the torso. Regardless of which surgical technique is used, dissections should be superficial to avoid injury to deeper structures such as nerves and lymphatics. While brachioplasty can be performed with a low incidence of major complications, patient and surgeon should be aware of the possible risks associated with this procedure. Excellent aesthetic results and minimal morbidity can be accomplished with careful preoperative analysis and safe procedures.

References 1. Thorek M. Esthetic surgery of pendulous breast, abdomen and arms in the female. Ill Med J. 1930;58:48. 2. Correa-Iturraspe M, Fernandez JC. Dermolipectomia braquial. Prensa Med Argent. 1954;41(34):2432–6. 3. Lewis JR. Atlas of aesthetic surgery. Boston: Little Brown; 1973. 4. McCraw LH Jr. Surgical rehabilitation after massive weight reduction: case report. Plast Reconstr Surg. 1974;53(3): 349–52. 5. Baroudi R. Dermatolipectomy of the upper arm. Clin Plast Surg. 1975;2(4):485. 6. Pitanguy I. Correction of lipodystrophy of the lateral thoracic aspect and inner side of the arm and elbow dermosenescence. Clin Plast Surg. 1975;2(3):477–83. 7. Guerrerosantos J. Brachioplasty. Aesthetic Plast Surg. 1979; 3:1. 8. Juri J, Juri C, Elias JC. Arm dermoplipectomy with a quadrangular flap and T closure. Plast Reconstr Surg. 1979; 64(4):521–5. 9. Borges AF. W-plastic dermolipectomy to correct bat-wing deformity. Ann Plast Surg. 1982;9(6):498–501. 10. Regnault P. Brachioplasty, axilloplasty, and pre-axilloplasty. Aesthetic Plast Surg. 1983;7(1):31–6. 11. Goddio AS. A new technique for brachioplasty. Plast Reconstr Surg. 1989;84(1):85–91. 12. Vogt PA, Baroudi R. Mastery of plastic and reconstructive surgery. Boston: Little Brown; 1994.

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13. Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96(4):912–20. 14. de Souza Pinto EB, Erazo PJ, Matsuda CA, Regazzini DV, Burgos DS, Acosta HA, do Amaral AG. Brachioplasty technique with the use of molds. Plast Reconstr Surg. 2000; 105(5):1854–60. 15. Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg. 1998;102(2):545–51. 16. Strauch B, Greenspun D, Levine J, Baum T. A technique of brachioplasty. Plast Reconstr Surg. 2004;113(3):1044–8. 17. Aly A, Soliman S, Cram A. Brachioplasty in the massive weight loss patient. Clin Plast Surg. 2008;35(1):141–7. 18. Abramson DL. Minibrachioplasty: minimizing scars while maximizing results. Plast Reconstr Surg. 2004;114(6):1631–4. 19. http://www.plasticsurgery.org/Media/stats/2008-cosmeticreconstructive-plastic-surgery-minimally-invasive-statistics. pdf. Accessed 1 Feb 2009. 20. Appelt EA, Janis JE, Rohrich RJ. An algorithmic approach to upper arm contouring. Plast Reconstr Surg. 2006; 118(1):237–46. 21. El Khatib HA. Classification of brachial ptosis: strategy for treatment. Plast Reconstr Surg. 2007;119(4):1337–42. 22. Trussler AP, Rohrich RJ. Limited incision medical brachioplasty: technical refinements in upper arm contouring. Plast Reconstr Surg. 2008;121(1):305–7. 23. Knoetgen J III, Moran SL. Long-term outcomes and complications associated with brachioplasty: a retrospective review and cadaveric study. Plast Reconstr Surg. 2006;117(7): 2219–23. 24. 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(2):595–603. 25. Gilliland MD, Lyos AT. CAST liposuction: an alternative to brachioplasty. Aesthetic Plast Surg. 1997;21(6):398–402. 26. Dellon AL, MacKinnon SE. Injury to the medial antebrachial cutaneous nerve during cubital tunnel surgery. J Hand Surg Br. 1985;10(1):33–6. 27. Lowe JB, Maggi SP, MacKinnon SE. The position of crossing branches of the medial antebrachial cutaneous nerve during cubital tunnel surgery in humans. Plast Reconstr Surg. 2004;114(3):692–6. 28. Masear VR, Meyer RD, Pichora DR. Surgical anatomy of the medial antebrachial cutaneous nerve. J Hand Surg Am. 1989;14(2 Pt 1):267–71. 29. Race CM, Saldana MJ. Anatomic course of the medial cutaneous nerves of the arm. J Hand Surg Am. 1991;16(1): 48–52.

Lymphoscintigraphy: Evaluation of the Lymphatic System

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Cristina Hachul Moreno, Aline Rodrigues Bragatto, Américo Helene, Carlos Alberto Malheiros, and Henrique Jorge Guedes Neto

35.1 Introduction The lymphatic system can be studied by various methods, invasive or noninvasive. Among the invasive methods, conventional lymphography consists of the injection of a radioopaque contrast into the previously dissected and cannulated lymphatic vessel, providing images of the anatomy of the lymphatic vessels and lymph nodes, but without much information as to their function [1–3]. Computerized tomography and magnetic resonance also provide anatomical visualization, in a noninvasive manner, but also leave much to be desired as to the functional part; they show details of the size and architecture of lymph nodes, but do not provide the dynamic study of the lymphatic vessels [4]. Lymphoscintigraphy was introduced as a diagnostic tool in 1953 by Sherman and Ter-Pergossian, who did experimental studies on rabbits, injecting colloidal radioactive gold into their paws and parametrium, enabling them to evaluate the regional lymphatic and lymph node passages. In 1955, Hultborn, Larsson, and Ragnhult utilized the same radiopharmaceutical, colloidal gold, but this time in vivo in five lower limbs, measuring the radiation with a counter at different sites, evaluating the time of appearance of the radioactivity. Sage and Gozun described the same technique in normal dogs,

C. H. Moreno (*) Rua Vergueiro, 1353 cj 407, Paraiso, CEP 04101-000, São Paulo, Brazil e-mail: [email protected]

concluding in 1958 that the described method was capable of graphically demonstrating the lymphatic vessels and lymph nodes, serving as a pilot for other physiological studies and evaluations of some diseases. Interest in lymphoscintigraphy led to the perfecting of the same, which occurred with the improvements in the images obtained on the scintigram and with the better distribution of the size of the particles utilized, facilitating their removal from the tissues studied, confirmed by Seiki et al. in 1968 by means of the analysis of the clearance rate of albumin marked with iodine 131, showing that it could be used as a lymphatic flux indicator under normal conditions. In 1965, Harper et al. published studies with technetium-99m, revealing the versatile characteristics of this radiopharmaceutical, indicating it as their radioisotope of choice because of its favorable physical conditions of a very low rate of deposition in tissues and rapid urinary excretion, as compared to colloidal gold. In 1982, Henze et al. after the publishing of various papers, which studied the best substance to mark technetium-99m, utilized dextran instead of the previously used agents, which presented limitations due to a low migration from the injection site and the unknown effect of phagocytosis to remove marked particles. Dextran, a polysaccharide utilized as a substitute for plasma, whose drainage from the interstices occurs only through lymphatic capillaries, presented excellent stability when marked with technetium-99m and began to be used in the lymphoscitigraphic exams. Lymphoscintigraphy studies the lymphatic system by making use of radioactive agents injected in the

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interstices, which are absorbed and transported in the lymphatic circulation, establishing images of the anatomy and functional analyses. This occurs because the transport of macromolecules, coupled with the radioactive compound, depends on their absorption, which in turn reveals details of the flow, the accumulation in lymph nodes, and other parameters. It presents elevated sensitivity and specificity in the study of lymphatic vessels, making it the exam of choice for the evaluation of the same [2, 6]. The radiopharmaceuticals utilized in the exam present variations, and many studies describe the search for the ideal agent for the performance of lymphoscintigraphy. Even so, all of them, when compared with the contrast used in lymphography, present low rates of direct damage to the lymphatic system and systemic complications, thus demonstrating superiority in relation to the lymphographic exam [6, 7] The lymphoscintigraphic study is of rapid execution. It is noninvasive and well tolerated by the patients, even the pediatric ones, and can be considered the exam of choice for lymphatic drainage evaluation [8]. As it is easily performed, it has a fundamental role in the follow-up in therapeutic, medicinal, and surgical interventions in the treatment of lower-limb edemas [1, 3, 6, 8–11]. The diagnosis of lymphatic alterations can be observed with an accuracy rate of approximately 93%. It also permits one to distinguish purely venous edema of the lymphedema and can analyze anatomical abnormalities in the lymphatic system, such as lymphoceles or lymphangiectases with reflux [1].

35.2 Technique The exam consists of the subcutaneous administration of a radiopharmaceutical in the first interdigital space of both lower limbs, or both upper limbs each of which receives 3mCi of human albumin marked with technetium-99m (99mTc-SAH) serum, in a volume of 0.2 mL. The images were acquired in the Elsint Apex SP-6 gamma chamber of a detector equipped with a lowenergy and high-resolution collimator, scanning from the thorax to the feet. These images were made at 15, 30, 60, and 180 min after the injection of the radiopharmaceutical, with the patient in frontal incidence.

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The images of the foot, leg, and thigh on both sides, or hand, elbow and axillary region on both side stored in a digital file or on radiological film, were evaluated by doctors in the Department of Nuclear Medicine. The interpretation of the images involved the evaluation of the injection sites, number and size of the lymphatic vessels, lymph node chains, presence of collateral vessels or dermal reflux, crossover uptake by lymph nodes, and the evaluation of hepatic uptake. The following were considered abnormalities: • Impermeability of the lymphatic passages • Delay in the drainage of the radiopharmaceutical • Progression asymmetry in the lymph between limbs (temporal and qualitative) • Nonidentification of inguinal, or pelvic, lymph nodes, (or a small number of the same) in lower limbs and nonidentification of axilar lymphnodes, (or a small number of the same) in upper limbs • Presence of dermal reflux, lymphorrhagia or lymphorrhea • Predominant drainage by collateral lymphatic channels Normal lymphoscintigraphy: Image at 15, 30, 60, and 180 min. Normal lymphoscintigraphy presents symmetrical uptake in the larger lymph nodes, at the same speed, but with lymphoceles identified in the distal part of the thighs (Figs. 35.1–35.3). Altered lymphoscintigraphy: 1. Discrete deficit in lymphatic drainage in the right lower limb, noting the smaller uptake in the right inguinal lymph nodes, as compared to the left lower limb lymph nodes at 30 and 60 min (Fig. 35.4). 2. Moderate deficit, with smaller uptake in the right lower limb inguinal lymph nodes at 15, 30, and 60 min (Fig. 35.5). 3. Accentuated deficit in lymphatic drainage in the left lower limb, in addition to the visualization of lymphoceles in the distal part of the right and left thighs (Figs. 35.6–35.7).

35.3 Discussion It is not a simple task to make a differential clinical diagnosis of lymphedemas, mainly in their initial phase. In this way, advances in the study of lymphatic vessels have permitted earlier and more precise

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Fig. 35.1 Normal lymphoscintigraphy: Image at 15, 30, 60, and 180 min

Fig. 35.2 Normal lymphoscintigraphy presents symmetrical uptake in the larger lymph nodes, at the same speed, but with lymphoceles identified in the distal part of the thighs

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Fig. 35.3 Discrete deficit in lymphatic drainage in the right lower limb, noting the smaller uptake in the right inguinal lymph nodes, as compared to the left lower limb lymph nodes at 30 and 60 min

diagnoses [12]. Lymphography permits an adequate anatomical analysis of lymphatic vessels and lymph nodes, with little information as to the functional

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dynamics of the lymphatic system. It is difficult to execute and it is believed that the contrast used can destroy some lymphatic vessels during the performance [3]. The computerized tomography and the nuclear magnetic resonance also provide adequate information about the anatomy of the lymphatic vessels in the study of lower limb edemas. Furthermore, they provide information about differential diagnoses in relation to hematomas, cysts, and associated diseases, which justify the occurrence of the edema, however the dynamic analysis of lymphatic drainage is precarious [3, 4]. Lymphoscintigraphy is a very slightly invasive exam and is well tolerated even by pediatric patients. It is technically easy to perform, making use of the infiltration of a radiopharmaceutical into the interdigital spaces of both feet or hands. The drainage of the radiopharmaceutical by the lymphatic vessels is studied by means of imaging exams done at determined times, and the analysis of these evaluates the lymphatic drainage in an adequate manner. In most clinical situations, this technique permits a rapidly analyzed diagnosis, with results in as little as 3 h [1–3, 8, 13]. The effective use of lymphoscintigraphy requires an adequate knowledge of physiopathology and of the influence of technical parameters, such as the adequate selection of a radiopharmaceutical, image capturing time and physical activity of the patient following the injection of the radioactive product [13]. The analysis of the interpretation of the captured images following the injection of the radiopharmaceutical follows a specific study standard to determine the final result as altered or normal, by means of the analysis of the images surrounding the injection site of the radiopharmaceutical, the number and size of lymphatic vessels, the lymph node chains (number and distribution), the presence of collateral vessels or dermal reflux, crossed filling of larger lymph nodes (crossover), and hepatic uptake [1, 13, 14]. There are controversies in the literature as to the best manner to interpret the findings of the lymphoscintigraphy, as each author employs his or her own technique, different radioisotopes and different image acquisition times and curve plotting, making use or not of physical exercise. This analysis determines the transport of lymph, as well as identifying its anatomy. For example, the appearance of the radiopharmaceutical in

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Fig. 35.4 Moderate deficit, with smaller uptake in the right lower limb inguinal lymph nodes at 15, 30, and 60 min

the larger lymph nodes, combined with a decrease in the number of smaller lymph node chains, in relation to the expected anatomy, provides the information of a reduced lymphatic transport, always related to the contrast injection time [1, 13]. There is already a consensus in the literature on the normal and abnormal lymphoscintigraphical standards for the lower limbs, which included some cases of

upper limbs, the study of which was mainly developed in our midst by Neto in 2002 [15], concluding normal and abnormal qualitative lymphoscintigraphic standards for the arm and forearm, evaluating the lymphatic vessels, visualization of the lymph nodes, dermal reflux, collateral circulation and axillary uptake in patients with lymphedema following the surgical treatment for breast cancer.

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Fig. 35.5 Accentuated deficit in lymphatic drainage in the left lower limb, in addition to the visualization of lymphoceles in the distal part of the right and left thighs

This visual interpretation of the radiopharmaceutical uptake, associated with the estimated time of appearance of the colloid in the regional lymph nodes, provided information on the normal or abnormal lymphatic drainage, with a specificity of 100% and a

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sensitivity of 92% in the studies of Gloviczki et al. in 1989 [1], which analyzed 190 lymphoscintigraphies. Therefore, the peripheral lymphatic vessels can now be visualized as easily as the arteries and veins. The determining factor is lymphoscintigraphy, which allows for a rapid evaluation, and can be utilized before and after clinical and surgical treatments, in the follow-up of patients with lymphedema and lipedema, as a diagnostic complement to the physical exam and to evaluate the efficacy of drugs, surgical procedures, and complementary methods for the treatment of lymphatic drainage [2, 4, 9, 10, 16–19]. Perez [20] studied the effect of sequential intermittent pneumatic compression on the lymphedema of the lower limbs using lymphoscintigraphic evaluation with dextran marked with technetium, arriving at conclusions compatible with the literature of effective reduction in the circumference of the limbs studied, albeit without alteration in the transport of the radioisotope, by means of quantitative and qualitative lymphoscintigraphic analyses. Said method presents elevated rates of sensitivity and specificity when compared with lymphography or computerized tomography, among others, being the exam of choice for the evaluation of lymphatic drainage [14]. This is an exam that is habitually performed on patients to be submitted to thighplasties or brachioplasties. Depending on the outcome of the exam preoperatively, the patient is authorized or not to have the surgical procedure. Hence, the preoperative analysis is of significant importance, because if it demonstrates an alteration, the patient must then be evaluated by a vascular surgeon, followed by a joint decision to define or not the surgical conduct, once again demonstrating multidisciplinary treatment. In the same way, the postoperative follow-up is also fundamental in the identification of clinical alterations and the definition of the adequate treatment [21]. The decision to perform this exam postoperatively has the purpose of enabling the evaluation the lymphatic drainage following the surgical procedure and to study if this procedure alters it or not. A study was performed by the authors and it was observed from the case results that the surgical procedure determines alteration in the lymphatic drainage in a statistically significant manner, but no major clinical signs, such as

35 Lymphoscintigraphy: Evaluation of the Lymphatic System Fig. 35.6 Normal lymphoscintigraphy of upper limbs

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Fig. 35.7 Accentuated defict in lymphatic drainage in both arms, with lymphocele in both elbows, and collateral lymphatic channels on the left forearm

lymphedema, have been observed in the outpatient follow-up [21]. The edema present in the postoperative period underwent a gradual reduction, becoming minimal or absent in this period of 6 months, leading us to believe this was the best moment in the postoperative for lymphoscintigraphic analysis. Other studies are underway along the same research lines, analyzing lymphatic drainage following other surgical procedures, such as liposuction, for example, in the ex-obese or others. In the same way, the effect of the brachioplasty on lymphatic drainage of the upper limbs can be studied, with the knowledge that the lymphoscintigraphic exam is the gold standard and that the

ex-obese have an increasing prevalence, according to the world literature.

References 1. Gloviczki P, Calcagno D, Schirger A, Pairolero PC, Cherry Kj, Hallett JW, Wahner HW. Noninvasive evaluation of the swollen extremity: experiences with 190 lymphoscintigraphic examinations. J Vasc Surg. 1989;9(5):683–9; discussion 690. 2. Cestari SC, Petri V, Castiglioni ML, Lederman H. Linfedemas dos membros inferiores: estudo linfocintilográfico. Rev Assoc Med Brasil. 1994;40(2):93–100.

35 Lymphoscintigraphy: Evaluation of the Lymphatic System 3. Khan O, Maharaj P, Rampaul R, Archibald A, Naipaul R, Loutan N. Lymphoscintigraphic evaluation of chronic lower limb edema. West Indian Med J. 2003;52(2):136–9. 4. Williams WH, Witte CL, Witte MH, McNeill GC. Radionuclide lymphangioscintigraphy in the evaluation of peripheral lymphedema. Clin Nucl Med. 2000;25(6): 451–64. 5. Sherman AI, Ter-Pogossian M. Lymph-node concentration of radioactive colloidal gold following interstitial injection. Cancer 1953;6(6):1238–40. 6. Hung JC, Wiseman GA, Wahner HW, Mullan BP, Taggart TR, Dunn WL. Filtered technetium-99m-sulfur colloid evaluated for lymphoscintigraphy. J Nucl Med. 1995;36(10): 1895–901. 7. Wahl RL, Liebert M, Wilson BS, Petry NA. Radiolabeled antibodies, albumin and antimony sulfide colloid: comparison as lymphoscintigraphic agents. Int J Rad Appl Instrum B. 1998;15:243–50. 8. Bellini C, Arioni C, Mazzella M, Campisi C, Taddei G, Boccardo F, Serra G. Lymphoscintigraphic evaluation of congenital lymphedema of the newborn. Clin Nucl Med. 2002;27(5):383–4. 9. Yeh SD, Morse MJ, Grando R, Kleinert EL, Whitmore WF Jr. Lymphoscintigraphic studies of lymphatic drainage from the testes. Clin Nucl Med.1986;11(12):823–7. 10. Richards TB, McBiles M, Collins PS. An easy method for diagnosis of lymphedema. Ann Vasc Surg.1990;4(3): 255–59. 11. Ercocen AR, Yilmaz S, Can Z, Berk F, Kir M, Yenidunya S, Edali N, Ozbek MR. The effects of tissue expansion on skin lymph flow and lymphatics: an experimental study in rabbits. Scand J Plast Reconstr Surg Hand Surg. 1998; 32(4):353–8. 12. Guedes Neto HJ. Diagnóstico e tratamento de linfedema periférico. Rev Cir Vasc Angiol. 1996;12:62–5.

345 13. Szuba A, Shin WS, Strauss HW, Rockson S. The third circulation: radionuclide lymphoscintigraphy in the evaluation of lymphedema. J Nucl Med. 2003;44:43–57. 14. Ter SE, Alavi A, Kim CK, Merli G. Lymphoscintigraphy. A reliable test for the diagnosis of lymphedema. Clin Nucl Med. 1993;18(8):646–54. 15. Guedes Neto HJ. Estudo linfocintilográfico qualitativo dos membros superiores de pacientes com linfedema secundário a tratamento cirúrgico para câncer de mama. Tese (Doutorado). São Paulo: Faculdade de Ciências Médicas da Santa Casa de São Paulo; 2002. 16. Brautigam P, Vanscheidt W, Foldi E, Krause T, Moser E. The importance of the subfascial lymphatics in the diagnoses of the limb edema: investigations with semiquantitative lymphoscintigraphy. Angiology 1993;44(6):464–70. 17. Bilancini S, Lucchi M, Tucci S, Eleuteri P. Functional lymphatic alterations in patients suffering from lipedema. Angiology 1995;46(4):333–9. 18. Howarth DM. Increased lymphoscintigraphic flow pattern in the lower extremity under evaluation for lymphedema. Mayo Clin Proc. 1997;72(5):423–9. 19. Bourgeois P, Leduc O, Leduc A. Imaging techniques in the management and prevention of posttherapeutic upper limb edemas. Cancer 1998;83(12 suppl American):2805–13. 20. Perez MCJ. Compressão pneumática intermitente seqüencial no linfedema dos membros inferiores:avaliação linfocintilográfica com Dextran marcado com tecnécio 99m. Tese (Doutorado). São Paulo, UNIFESP; 1997. 21. Moreno CH, Guedes Neto HJ, Junior AH, Malheiros CA. Thighplasty after bariatric surgery: evaluation of lymphatic drainage in lower extremities. Obes Surg. 2008; 18(9): 1160–4.

Medial Thigh Lift and Declive: Inner Thigh Lift Without Using Colle’s Fascia1

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Daniele Spirito

36.1 Introduction The medial thigh aesthetic deformity frequently presents a challenging problem to the plastic surgeon. Skin laxity in the medial thigh area is the earliest sign of aging in the thighs and is one of the first signs of ptosis of the body. The skin of the medial thigh area is thin, and therefore, not elastic resulting in early relaxation with age, and does not respond well to liposuction due to poor retraction. By the age of 40 years in most patients, actual or potential laxity of the medial thigh tissue can lead to disappointing result after liposuction alone. Laxity of the medial thigh area may occur at an early age in patients with a history of obesity during childhood or early adulthood or in patients with the familial trait of thin, lax skin. The classic medial thigh lift has been plagued with persistent problems, such as inferior migration and widening of the scar, lateral traction deformity of the vulva, and early recurrence of the ptosis. In an attempt to limit untoward results, the medial thigh lift was modified to allow anchoring of the inferior skin flap to the tough, inelastic deep layer of the superficial fascia of the perineum. More long-lasting and effective results were achieved while applying Colles’ fascia as the central anchor for the medial thigh lift. This procedure decreased the risk of complications being

1

commonly associated with the classic skin-suspension medial thigh lift. Since the fascial anchoring technique for medial thigh lift was originally described in 1987 by Lockwood [1] (Fig. 36.1), numerous technical refinements have been developed to provide enhanced safety, predictability, and aesthetic. The surgical principles of the medial thigh lift have evolved to allow a more accurate patient selection, individualized operative planning, and standardized surgical techniques. Significant actual or potential laxity of the medial thigh tissue remains the standard indication for medial thigh lift today. Liposuction of the moderate to severe fat deposits of the medial thighs often leads to skin relaxation, especially after the age of 35. Moderate to severe skin laxity requires thigh lifting along with liposuction of any medial thigh fat deposits. In less severe cases of skin laxity, a more limited medial thigh lift may provide optimal thigh contours and skin tightening with improved aging potential in the region. The medial thigh lift design has changed significantly in the last 10 years due to a better understanding

pecial acknowledgment to Ted Lockwood† and Ricardo S Baroudi for the studies on the “anchoring system” and on the “adhesion sutures,” respectively

D. Spirito Via delle Baleniere, 107/b, 00121, Rome-Ostia, Italy e-mail: [email protected]

Fig. 36.1 Ted Lockwood

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of thigh aesthetic deformities. The majority of the skin laxity in this area occurs at the juncture of the anterior and medial thighs; the standard surgical resection pattern has rotated anteriorly allowing the entire procedure to be performed in the supine position. Lockwood basically reinvented the lower body lift by redefining the nature of suspension of the deeper tissue of the abdomen and flank. The lower body lift extends the tummy tuck incision completely around the lower torso. This allows resuspension of the lateral and anterior thighs along with the traditional tummy tuck improvements. The concept has been expanded upon to include additional lifts such as those of the inner thigh (medial thigh lift). The traditional lower body lift targeted the upper thighs as well as the buttocks and abdomen. For the large volume weight loss patient, this operation is ideal to remove the redundant skin that frequently “hangs” around the lower torso. This type of operation requires 5–8 h “all at once” and postoperative supervision is strongly advised. An accurate reconstruction of the inguino-crural fold can really improve and stabilize the contour of the inner thigh surface. The anchorage of the medial thigh skin to a deep and strong structure, i.e., the superficial perineal fascia, allows a correction that is anatomically better. The perineal fascia, described for the first time in 1811 by Colles [2], defines and anchors the inguino-crural fold. Unfortunately, it was not successful in all cases. It works well reducing the scar broadness, and avoids external genitalia distortion and scar descent when no excess skin resection is removed. Tension in the suture should not exist. These problems may become evident a few months after surgery; if these procedures are not followed, patients complain about these. The patient should be made aware that the final result is restricted to the upper third of the thigh only. Patients regularly take the skin of the upper thigh in both hands and stretch/pull the skin upwards, and ask the surgeon to obtain a similar result to this. Presently, there is no surgical technique available that can yield this result except for: (a) The Vertical Dermo Cruro Lipectomy is the technique referred to as “DECLIVE” (in Italian language: DErmo Cruro LIpectomia VErticale which in Latin means something that moves downward) technique, scar migration can be avoided so we can lift tightly. (b) The “adhesion sutures of Baroudi” improves the results.

D. Spirito

The Declive technique represents a contribution to the dynamics of the thigh lift. With a “sacrifice of skin” of a triangular portion of the perivulvar area, a “vertical scar” is achieved that will stop its displacement downward. The routine use of the Baroudi’s (Fig. 36.2) sutures to avoid the “dead space” is useful in the thigh lift because of this morphodynamic area. The incision should not extend into the posterior buttock fold.

36.2 Marking Preoperative markings are made in standing position with the knees apart. The extent of medial thigh fat deposits is marked and an estimate of the amount of skin redundancy is determined (Fig. 36.3). The actual skin resection has become more conservative over the years, averaging 5–7 cm of stretched skin at the anterior medial corner of the thigh. The Declive technique plus the adhesion sutures provide an additional lift. More conservative resection has decreased wound complications from over resection while still providing consistent contour improvements. Initially the patient is placed in the lithotomy position, and the natural perineal crease is marked as it extends into the posterior infrabuttocks crease. Traction on medial thigh tissue is placed at different points along the natural perineal crease to mark the point at which traction will not affect the position of the vaginal labia. Usually this corresponds to the origin of the gracilis muscle.

36.3 Technique After anesthesia is established, a foley catheter is inserted, and the patient remains in the frog-leg position, with the hips flexed 20–30°. Stockinettes are placed to the knees, so the thighs can be repositioned during the surgery. The excision of the redundant tissue and the subsequent repair is performed with the knees shoulder-width apart (rather than semi-frog leg) to avoid undercorrection. The thigh can be abducted for exposure as needed. Initial deep liposuction with epinephrine solution is followed by skin-only incision along superior resection line. Posteriorly, the perineal thigh crease incision should not extend into the buttocks fold as Lockwood suggested. Anteriorly, the incision will leave the crease

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Fig. 36.2 Baroudi 1989

Fig. 36.3 Marking of declive

at the origin of the adductor longus muscle (pubic tubercle) and extend vertically along the lateral border of the mons pubis after the excision of the triangular of the skin of the Declive technique. A more youthful narrowed pubic hair pattern should be selected. After skin incision, undermining of the inferior flap posterior to the pubic tubercle is performed superficial to the adductor muscle fascia. This direct undermining usually extend 4–6 cm beyond the planned line of resection. Cannulas undermining more distally may be helpful for laxity problems extending to the knee. Anterior to the pubic tubercle, care is taken to leave the soft tissue bundle coursing between the mons pubis, and the femoral triangle preserves the external pudendal blood and lymphatic vessels, reducing the risk of lymphatic complications. Blunt dissections through this soft tissue bundle at the mons pubic exposes Scarpa’s fascia or muscular fascia, either of which was used for anchoring of the thigh flap in the pubic region according to Lockwood’s technique. Once flap undermining is completed, the Colles’ fascia roll is identified. It is very important not to overdissect

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this fascia because, like all superficial fasciae, it tends to be somewhat vague and indistinct on gross examination. Attempts to overly define this fascia will lead to disruption of the connections between Colles’ fascia and the periosteum of the ischio-pubic ramous. Digital dissection using a dry gauze sponge most reliably preserves Colles’ fascial anatomy. Push superiorly, the adductor muscles until the tendinous muscle origins are seen and the bony ischio-pubic ramus is palpated at the fingertip. Retracting the skin and the superficial fat of the vulva medially will expose the Colles’ fascial roll at the deepest and most lateral aspect of the vulvar soft tissues. Scarpa’s fascia is used as the anchor anteriorly and the buttock-fold SFS is used as the anchor posteriorly. Blunt dissection throughout the soft tissue bundle at the mons pubis exposes Scarpa’s fascia or muscular fascia, either of which can be used for anchoring of the thigh flap in the pubic region. Failure to do this will lead to unaesthetic widening of the mons pubic. Skin is repaired with 3–0 nylon subdermal sutures and interrupted 3–0 absorbable monofilament skin suture. “Good” dressings are applied. Anchoring sutures into Colles’ fascia are not needed because of the vertical manner of the Declive. In addition, Scarpa’s fascia is used as the anchor anteriorly and the buttock-fold SPS posteriorly. Baroudi sutures are used for the total area undermined. They consist of isolated absorbable material that fixates two dissected cutaneous or noncutaneous surfaces during the surgery. The extension of the “dead space” is reduced when the sutures are applied with up to 2 cm distance between them. Drains are generally not used; there is no space to introduce them after the adhesion stitches. Of course, the “good” dressing (for a week) is important.

D. Spirito

presence, location, and severity of excess skin and fat in the thigh. Based on the degree of excess skin and fat, liposuction alone, a transverse medial thigh incision, or a vertical medial thigh incision (Declive) should be made to correct the deformity. Care must be taken to preserve the soft tissue between the mons pubis and the femoral triangle to prevent postoperative lymphedema. To prevent recurrence of thigh ptosis, the Declive technique plus the adhesion sutures is the solution. In medicine and surgery, the subcutaneous tissue and superficial tissue have always been secondary and the subject was always left to interested anatomists and dermatologists. They were mainly interested in using the external tissue of the hernia in the groin area as described by Camper and Scarpa. The subcutaneous tissue was always considered an “appendage” when considering diseases of the layers of the skin. The anatomist Sterzi [3] (Fig. 36.4) was the first to discover the structure and function of this organ and its systematic distribution throughout the body (with few exceptions) a subcutaneous layer subdivided as follows: 1. A superficial layer of skin comprised fibrous septi vertically arranged between the superficial layer, deep layer, and fat deposits 2. A thin superficial layer where the fibrous septi are apparent on both sides 3. A deep layer of fibrous septi that present in a disorderly manner, vertical, connected, and held together by the superficial layer and fat deposits 4. A deep layer of muscle tissue Sterzi categorized his observations: 1. Different regions of the body 2. Individual differences (obese/thin)

36.4 Complications Complications include delayed would healing (3%), scar widening (0.5%), transient lymphocele (0.3%), and pubic hair dislocation (31%). No infection in spite of the area because we suggest to the patients to wash with betadine soap very often, and never scar migration.

36.5 Discussion Aesthetic rejuvenation of the thigh begins with complete history and physical examination to determine the

Fig. 36.4 Giuseppe Sterzi 1876–1919

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3. Sexual differences 4. Age difference His description in 1910 was extremely detailed and there still exists today (rare in real life) a text with reference to the subcutaneous tissue. Nevertheless, the argument over the years has never sparked much interest. Even in the eighties and nineties the majority of surgeons were not even aware that the area existed. This was also included in Bibbia’s text/book called Anglo-Saxon Grey’s Anatomy. With Mitz and Perone’s publication [4] on the superficial layers of the skin named SMAS (superficial musculo aponeurotic system) by them, the superficial tissue became the leading protagonist of facial plastic surgery. They then followed the work of Stuzin et al. [5], Jost and Levet [6], Hamra [7], and others (Table 36.1). It was Micheli-Pellegrini [8] who contributed to history the work of the incredible Sterzi. It was Spirito (Fig. 36.5) in 1980–5 who had the insight

Table 36.1 Contributors to the medial thigh lift Lewis 1957 reported an operation in which he treated medial thigh excess, due to massive weight loss with a combine one stage vertical and horizontal skin excision Pitanguy 1964 used a buttock fold and a medial thigh incision only Baroudi 1989 described a flanc excision to slim and tighten the hip flank area Lockwood 1987 and 1991 (new concept) anchors the deep closure to SFS Spirito 1995 sacrifices the skin of the perivulvar area and anchors with not absorbable stitches directly on derma (Declive technique) Spirito 2007 introduce the adhesion stitches of Baroudi to Declive to improve the results

Fig. 36.6 Declive procedure. Left: preoperative with markings. Right: postoperative

Fig. 36.5 Daniele Spirito

to underline the importance of the layers of the skin with an article titled “Il lifting, da Skoog a Jost.” Markmann followed by Lockwood published their works on the system of the superficial layers of the body as well as articles defining the fat and adhesion zones. This revolutionized the technique of liposuction and by using the new surgery techniques studied by Sattler et al. [9], was more careful in not destroying the superficial layers of the skin. Lockwood also published his studies on abdominoplasty and lifting of the middle leg region and the superficial skin layers.

352 Fig. 36.7 Declive procedure. (a) Preoperative patient. (b) Marking declive and abdominoplasty. (c) Postoperative

D. Spirito

a

b

c

Nava et al. [10] reported his studies on the superficial system in the breast region that is so important in reconstruction.

36.6 Conclusions The vertical dermo cruro lipectomy (Declive) is the only technique to guarantee against the possibility of scar migration. The result goes from good to excellent, but always with satisfaction (Figs. 36.6 and 36.7).

5. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg. 1992;89(3): 441–9. 6. Jost G, Levet Y. Parotid fascia and face lifting: a critical evaluation of the SMAS concept. Plast Reconstr Surg. 1984; 74(1):42–51. 7. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg. 1992;90(1):1–13. 8. Micheli-Pellegrini V. Surgical anatomy and dynamics on face lifts. Facial Plast Surg. 1992;8(1):1–10. 9. Sattler G, Sommer B, Bergfeld D, Sattler S. Tumescent liposuction in Germany: history and new trends and techniques. Dermatol Surg. 1999;25(3):221–3. 10. Nava M, Quattrone P, Riggio E. Focus on the breast fascial system: a new approach for inframammary fold reconstruction. Plast Reconstr Surg. 1998;102(4):1034–45.

References 1. Lockwood TE. Fascial anchoring technique in medial thigh lifts. Plast Reconstr Surg. 1988;82(2):299–304. 2. Colles A. A treatise on surgical anatomy. Dublin: Gilbert & Hodges; 1811. 3. Sterzi G. Il tessuto Sottocutaneo (Tela Subcutanea). Florence: Niccolai; 1910. 4. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg. 1976;58(1):80–8.

Further Reading 1. Aston SJ. Buttocks and thighs. In: Rees TD, editor. Aesthetic plastic surgery. Philadelphia: WB Saunders; 1980. p. 1039–66. 2. Baroudi R. Body sculpturing. Clin Plast Surg. 1984;11(3): 419–43. 3. Baroudi R, Carvalho CGS. Lifting of the inner third of the thigh; an analysis of immediate and mediate results. Cir

36 Medial Thigh Lift and Declive: Inner Thigh Lift Without Using Colle’s Fascia1 Plast Iber Lat Am. 1981;7:275; abstracted in Plast Reconstr Surg. 1981;74:160. 4. Baroudi R. Thigh lift and buttock lift. In: Courtiss EH, editor. Aesthetic surgery: trouble how to avoid it and how to treat it. St Louis: CV Mosby; 1978. p. 223–31. 5. Baroudi R, Moraes M. Philosophy, technical principles, selection and indication in body contour surgery. Aesthetic Plast Surg. 1991;15(1):1–18. 6. Baroudi R. Body contour surgery. Clin Plast Surg. 1989; 16(2):263–77. 7. Baroudi R. Flankplasty. In: Hetter GP, editor. Lipoplasty: the theory and practice of blunt suction lipectomy. Boston: Little Brown; 1990. p. 399–416. 8. Baroudi R, Ferreira CAA. Seroma: how to avoid it and how to solve it. Aesthet Surg J. 1998;18:439–41. 9. Baroudi R., De Almeida FR. Adhesion stitches to avoid and to treat seroma. In: Eisenmann-Klein M, Neuhann-Lornz C, editors. Innovations in plastic and aesthetic surgery. New York: Springer; 2008. 10. Clemente C. Gray’s anatomy of the human body. 30th ed. Philadelphia: Lea & Febiger; 1985. 11. Ducourtioux JL. Technique et indications des dermolipectomies crurales. Ann Chir Plast. 1972;17(3):204–11. 12. Farina R, Baroudi R, Golcman B, De Castro O. Lipodistrofia pelvi-crural tipo calcas de montaria. Hospital (Rio J). 1960; 57:717–22. 13. Farina R, Baroudi R, Golcman B, De Castro O. Ridingtrousers like type of pelvicrural lidpodystrophy (trochanteris lipomatosis). Br J Plast Surg. 1960;13:174–8. 14. Hodgkinson DJ. Medial thighplasty, prevention of scar migration, and labial flattening. Aesthetic Plast Surg. 1989; 13(2):111–4. 15. Hoffman S, Simon BE. Experiences with the Pitanguy method of correction of trochanteric lipodystrophy. Plast Reconstr Surg. 1975;55(5):551–8. 16. Illouz YJ, Dradour JC. Combined procedures: the thighs and the buttocks. In: Illouz YG, de Villers,YT, editors. Body contouring by lipoplasty. New York: Churchill Livingstone; 1989. p. 340–52. 17. Leitner DW, Sherwood RC. Inguinal lymphocele as a complication of thighplasty. Plast Reconstr Surg. 1983;72(6): 878–81. 18. Lewis JR. Surgery of the hips, buttocks and thighs. In: Goldwin RM, editor. Long term results in plastic and reconstructive surgery. Boston: Little Brown; 1980. p. 784–9. 19. Lewis JR Jr. Correction of ptosis of the thigh. The thigh lift. Plast Reconstr Surg. 1966;37(6):494–8. 20. Lewis JR Jr. The thigh lift. J Int Coll Surg. 1957;27(3): 330–4. 21. Lockwood TE. Medial thighplasty. In: Hetter GP, editor. Lipoplasty: the theory and practice of blunt suction lipectomy. Boston: Little Brown; 1990. p. 375–83.

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22. Lockwood TE. Superficial Fascial System (SFS) of the trunk and the extremities. A new concept. Plast Reconstr Surg. 1991;87(6):1009–18. 23. Lockwood TE. Transverse flank, thigh, buttock lift with superficial fascial suspension. Plast Reconstr Surg. 1991; 87(6):1019–27. 24. Lockwood TE. Lower body lift and medial thigh lift. In: Aly A, editor. Body contouring after massive weight loss. St. Louis: Quality Medical Publishing; 2006. 25. Loeb R. Narrowing of the mons pubis during thigh lift. Ann Plast Surg. 1979;2:290. 26. Pitanguy I. Aesthetic plastic surgery of head and body. New York: Springer; 1981. p. 129–53. 27. Pitanguy I. Aesthetic plastic surgery of the upper and lower limbs. Aesthetic Plast Surg. 1980;4:363–72. 28. Pitanguy I. Technique for trunk and thigh reductions. In: Huston J, editor. Transactions of the fifth international congress of plastic surgeons. Melbourne: Butterworths; 1971. p. 1204–10. 29. Pitman GH. Liposuction and aesthetic surgery. St Louis: Quality Medical Publishing; 1993. 30. Planas J. The “Crural Meloplasty” for lifting of the thigh. Clin Plast Surg. 1975;2(3):495. 31. Posse RP. Chirurgia esthetica. Cited In Pitanguy I (Ed), Aesthetic plastic surgery of the upper and lower limbs. Aesthetic Plast Surg. 1980;4:363–72. 32. Salmon M. Arteries of the skin. Paris: Masson & Cie; 1936. (First English Edition edited by Taylor GI, Tempest MN. Translated by Hueston P, Cuthbertson A, Tempest MN, New York: Churchill Livingstone; 1988). 33. Schulz RC, Feinberg LA. Medial thigh lift. Ann Plast Surg. 1979;2:404–10. 34. Shaer WD. Gluteal and thigh reduction: reclassification, critical review and improved technique for primary collection. Aesthetic Plast Surg. 1984;8(3):165–72. 35. Shaer WD. Gluteal and thigh reduction: reclassification, critical review and improved technique for primary correction. Aesthetic Plast Surg. 1984;8(3):165–72. 36. Spirito D. The medial thigh lift and the declive. 14th Congress Isaps. Sao Paulo Brazil: 1997. 37. Spirito D. The medial thigh lift and the DE.C.LI.VE. Aesthetic Plast Surg. 1998;22(4):298–300. 38. Spirito D. The declive and adhesion stiches according with Baroudi. 56th Italian Congress of Plastic and Reconstructive Surgery, 2007. 39. Vilain R, Dardour JC. Aesthetic surgery of the medial thigh. Ann Plast Surg. 1986;17(3):176–83. 40. Vilain R, Dardour JC. Aesthetic surgery of medial thigh. Ann Plast Surg. 1986;17(3):176–83. 41. Zook EG. The massive weight loss patient. Clin Plast Surg. 1975;2(3):457–66.

Spiral Lift: Medial and Lateral Thigh Lift with Buttock Lift and Augmentation

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Sadri O. Sozer, Francisco J. Agullo, and Humberto Palladino

37.1 Introduction Developments in surgical techniques allow safe and efficient surgical correction of contour deformities [1]. The trunk, buttocks, and thighs represent areas of increased patient interest and surgical technique modification. Consequently, familiarity with the presentation and effective treatment of these contour alterations has become increasingly important [2, 3]. Patients with a “pear” or “guitar” shaped body contour deformity comprising lipodystrophy and excess skin in the thighs, buttock, and waist, with abdominal sparing, are not frequently encountered, but represent a surgical challenge. These patients often present with additional trochanteric lipodystrophy and ptosis of the buttocks. This condition may consist of pure fat deposits or excess skin with or without fat accumulation. The development of these contour alterations can be accredited to the lack of exercise, body weight variations, and genetics. These deformities are very difficult to correct with diet and exercise alone. Liposuction can offer an improvement in select cases, but is usually insufficient, and overaggressive liposuction of the thighs can result in complications. Traditionally, these patients have been treated with a combination of liposuction, flankplasty, belt lipectomies, lower body lifts, and/or medial thigh lifts. Baroudi described an upper inner

S. O. Sozer (*) Department of Surgery, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso, TX 79905, USA e-mail: [email protected]

thigh lift and flankplasty with optional lipoplasty as an alternative method for performing a medial, anterior, and lateral thigh lift at the same time [4]. This “extended flankplasty,” along with some modifications accompanied by a buttock lift and autologous augmentation with a dermal fat flap [5], is a good option for the deformities described. This “spiral lift” can be accomplished with a single spiral incision easily concealed by underwear resulting in the removal of excess tissue as well as reconfiguration of a natural silhouette (Fig. 37.1) [6].

37.2 Technique 37.2.1 Preoperative Markings Preoperative markings are a crucial component to a successful surgery and to achieving desired results. Patients are marked preoperatively in standing and prone positions (Fig. 37.2). The thigh is abducted while the patient is in prone position in order to assess lateral mobility and extent of lateral resection. Symmetry of the incisions is later evaluated with the patient standing. A line is drawn starting at the lateral portion of the inferior gluteal fold, extending medially to the upper inner thigh, proceeding interiorly and anteriorly through the pudendal region, moving along the inguinal line through the anterior iliac spine to the posterior iliac crest, above the buttocks, and to the sacrum. At the sacrum, the line from the contralateral side is joined forming a V. The pinch method is utilized to estimate

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Fig. 37.1 Tissue excised extends from the inner inside crease of the buttocks, along the inguinal crease and anterior iliac spine, spiraling above the buttocks and meeting the contralateral incision at the sacrum

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Fig. 37.2 Preoperative markings. Tissue to be excised is marked in red ink, the dermal fat flaps are marked in dark blue ink, and areas of liposuction marked with blue concentric circles

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Fig. 37.3 (a) Creation of an autologous buttock augmentation flap. Tissue to be excised is in purple and the deepithelialized flaps in red. The flap is dissected down to the fascia at an oblique angle undermining the inferior border, rotated caudally 180° into the pocket, and anchored to the fascia with suture. The

remaining buttock skin is pulled to cover the flap. (b) Dissection of the buttock flap with a consistent pedicle including muscle fibers from gluteus muscle to achieve better mobility without blood supply compromise. (c) Development of the gluteal pocket to accommodate the rotated flap

the amount of possible skin resection. The areas of liposuction are marked in the traditional manner, with emphasis on the sacrum, supragluteal area, trochanteric region, and anterior and medial thighs. A dermal fat flap originating in the medial half of the supragluteal tissue marked for excision is designed (Figs. 37.2 and 37.3). The size of the flap is individualized according to the patient’s buttocks contour and desired augmentation.

37.3 Surgical Technique The patient is placed in the prone position under general anesthesia with legs abducted to expose the medial thigh and to maximize lateral resection. Traditional deep and superficial liposuction of the marked areas is performed after the subcutaneous tissue is infiltrated with tumescent solution consisting of 1 L of Hartmann

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solution with 1 mg of epinephrine and 10 mL of 1% lidocaine. The wedge excision of the inferior gluteal fold and posterior portion of the medial thigh is accomplished and left for completion once the patient is rotated to the supine position. Skin and subcutaneous tissue are excised down to the gluteus maximus fascia and connective tissue of the ischial tuberosity. The inferior edge of the wedge excision is then anchored in a cephalad and medial direction to the periosteal connective tissue surrounding the ischial tuberosity and gluteus maximus fascia with 2–0 polydioxanone (PDS). The objective is to lift the posterior thigh and shorten and elevate the inferior gluteal fold. The skin and subcutaneous tissues are then closed in layers. The marked supragluteal and flank wedges of skin are resected down to the fascia and the gluteal flaps are deepithelialized (Fig. 37.3). The inferior border of the flap is dissected at an oblique angle so that the base of the flap lies more inferior to allow for greater caudal mobility. The superior, medial, and lateral borders are dissected in a plane perpendicular to the underlying fascia including some muscle fibers from the gluteus maximus into the pedicle of the flap (Fig. 37.3). A pocket is then created for insertion of the flap by undermining the buttock skin and subcutaneous tissue caudally in the plane above the fascia, extending it to a sufficient length to reach the inferior gluteal crease (Fig. 37.3). The superior aspect of the flap is then detached in an intramuscular plane inferiorly until the flap can be rotated caudally 180° into the pocket and anchored to the fascia with polyglactin 910 (3/0 Vicryl) suture. The remaining buttock skin is then pulled superiorly over the flap and a drain is placed in each side. The lateral thigh is undermined inferiorly deep to the superficial fascial system using a Lockwood retractor. The superficial fascial system is then approximated with polyglactin 910 (0 Vicryl), and the skin and subcutaneous tissue are closed in a layered fashion. At this point, the patient is turned to the supine position with the legs abducted to expose the medial thighs. Liposuction is performed where necessary as previously described. Thereafter, resection of a crescent of redundant skin and fat at the superior medial

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thigh spiraling from the flank toward the infragluteal fold is made, thereby joining the previous flank and infragluteal excision sites. The Lockwood retractor is used for limited undermining of the anterior and lateral thigh in an inferior fashion deep to the superficial fascial system. The medial thigh is not undermined. The inferior margin of the incision is then suspended superiorly from the superficial fascial system to the superficial perineal (Colles’) fascia medially, inguinal ligament anteriorly, and periosteum of the anterior superior iliac spine laterally with PDS. The superior and inferior edges are then approximated in a layered fashion with subdermic running absorbable polyglactin 910 (3/0 Vicryl) and subcutaneous running absorbable poliglecaprone 25 (4/0 Monocryl).

37.4 Complications The procedure is performed at an outpatient surgery center under general anesthesia with 23-h postoperative observation. Operative time ranges from three and a half to four and a half hours. Total resection weight ranges from 2.3 to 3.7 kg (2.6 kg average), with an average volume of fat obtained by liposuction of 5,200 mL (5,000–7,000 mL). Mean operative blood loss is 220 mL (125–295 mL). Sequential compression devices and fractioned heparin are used for deep venous thrombosis prophylaxis before and after the procedure until the patient begins ambulation. Patients are continuously monitored during their stay, and intra and postoperative prophylactic antibiotics are used. Seroma and hematoma are usually prevented with meticulous surgical technique and drains, but if they occur, evacuation is required. Wound dehiscence or delayed wound healing are caused by technical errors in approximating the superficial fascial system or excessive tension during the closure. Visible scars are prevented by careful preoperative markings within the location of underwear. Inferior scar migration, labial separation, and early recurrence of ptosis are avoided by anchoring of the inferior skin flap to the tough, inelastic deep layer of the superficial

37 Spiral Lift: Medial and Lateral Thigh Lift with Buttock Lift and Augmentation

perineal fascia medially, inguinal ligament superiorly, and periosteum of the anterior superior iliac spine laterally. In the authors’ experience with more than one hundred autoprosthesis buttock augmentations, there have been no instances of necrosis of the buttock dermal fat flap. Flap viability is corroborated by incising the most distal portion of the flap to check for adequate blood flow. Incorporating muscle in the superior undermined portion of the flap allows for a greater number of perforators to the flap.

37.5 Discussion Body contouring has continued to increase in popularity, as have the alternatives and procedures to address deformities. The trunk, buttocks, and thighs represent areas of increased patient interest and surgical technique modification. Consequently, familiarity with the presentation and effective treatment of these patients has become increasingly important [2, 3, 7]. The “pear” or “guitar” shaped body contour is an unaesthetic appearance that may cause much frustration for the patient and surgeon when encountered. The summation of deformities is very difficult to correct with diet and exercise alone. Liposuction can offer an improvement in patients that present with fat deposits without skin excess or laxity, but it is usually insufficient. More aggressive liposuction to correct these areas can result in untoward results and complications (Fig. 37.5). Traditionally, these patients have been treated with a combination of liposuction, flankplasty, belt lipectomies, lower body lifts, and/or medial thigh lifts [8–12]. Baroudi described an upper inner thigh lift and flankplasty with optional lipoplasty as an alternative method for performing a medial, anterior, and lateral thigh lift with a buttock lift [4, 7, 13]. Our modifications to the procedure include superficial fascial anchoring to the Colles’ fascia, inguinal ligament, and anterior superior iliac spine, aggressive liposuction, lateral and anterior thigh lift with

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undermining and high lateral tension, and a buttock lift with autoprosthesis augmentation using a dermal fat flap [5, 9, 10]. Anchoring of the inferior skin flap to the tough, inelastic deep layer of the superficial perineal fascia medially, inguinal ligament superiorly, and periosteum of the anterior superior iliac spine laterally has reduced inferior scar migration, labial separation, and early recurrence of ptosis [9]. The aggressive liposuction of the thigh is possible since it is done in combination with the circumferential thigh lift, thereby avoiding contour irregularities. The buttock lift is complemented with buttock augmentation to avoid a flattened buttocks contour after an aggressive resection of excess skin and subcutaneous tissue in the supragluteal region [5]. In contrast to gluteal flaps previously described [14–18], maximal projection of the buttocks is achieved at midlevel, which is aesthetically ideal [19]. By combining these techniques, the overall result is improved, since it not only relies on excision and lifting, but also includes a volumetric enhancement that leads to an improved and natural silhouette (Figs. 37.4–37.6).

37.6 Conclusions The spiral lift effectively addresses the “pear” or “guitar” shaped body contour deformity. The high satisfaction rate, the ease of concealing the incision with clothing, and the low complication rate suggest that this is a reliable and versatile technique. The procedure results in significant improved body contour and firmness of the skin in the medial and lateral thigh, trochanteric area, and gluteal region. The gluteal sulcus becomes less evident, the buttock mass is elevated, and the maximum projection is achieved at midlevel of the buttock. The scars are considered acceptable to the patients in respect to the procedure and easily concealed by a bikini-type bathing suit. The low complication rate, easily concealed scar, and high degree of contour correction contribute to a high patient and surgeon satisfaction rate.

360 Fig. 37.4 (a) Posterior and (b) Anterior preoperative and postoperative views after spiral lift. Note the improvement in the waist, buttock contour, and thigh circumference

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37 Spiral Lift: Medial and Lateral Thigh Lift with Buttock Lift and Augmentation Fig. 37.5 (a) Lateral and (b) three-quarter preoperative and postoperative views. Patient with previous overaggressive liposuction of lateral thighs with marked skin dimpling successfully corrected with the spiral lift

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362 Fig. 37.6 (a) Anterior, (b) lateral, and (c) posterior view of preoperative and postoperative photographs of a spiral lift

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37 Spiral Lift: Medial and Lateral Thigh Lift with Buttock Lift and Augmentation Fig. 37.6 (continued)

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References 1. Pitanguy I. Evaluation of body contouring surgery today: a 30-year perspective. Plast Reconstr Surg. 2000;105(4): 1499–514. 2. Aly A, Cram A, Heddens C. Truncal body contouring surgery in the massive weight loss patient. Clin Plast Surg. 2004; 31(4):611–24. 3. Cardenas-Camarena L. Various surgical techniques for improving body contour. Aesthetic Plast Surg. 2005;29(6): 446–55. 4. Baroudi R. Body contour surgery. Clin Plast Surg. 1989; 16(2):263–77. 5. Sozer SO, Agullo FJ, Wolf C. Autoprosthesis buttock augmentation during lower body lift. Aesthetic Plast Surg. 2005; 29(3):133–7. 6. Sozer SO, Agullo FJ, Palladino H. Spiral lift: medial and lateral thigh lift with buttock lift and augmentation. Aesthetic Plast Surg. 2008;32(1):120–5. 7. Baroudi R. Flankplasty: a specific treatment to improve body contouring. Ann Plast Surg. 1991;27(5): 404–20. 8. Farina R, Baroudi R, Golcman B, Castro O. Riding trouserslike type pelvicrural lypodystrophy. Br J Plast Surg. 1960; 13:174–8. 9. Lockwood TE. Fascial anchoring technique in medial thigh lifts. Plast Reconstr Surg. 1988;82(2):299–304.

10. Lockwood TE. Transverse flank-thigh-buttock lift with superficial fascial suspension. Plast Reconstr Surg. 1991; 87(6):1019–27. 11. Pitanguy I. Trochanteric lipodystrophy. Plast Reconstr Surg. 1964;34:280–6. 12. Schultz RC, Feinberg LA. Medial thigh lift. Ann Plast Surg. 1979;2(5):404–10. 13. Baroudi R. Contouring the hip and the abdomen. Clin Plast Surg. 1996;23(4):551–72. 14. Gonzalez M, Guerrerosantos J. Deep planed torso-abdominoplasty combined with buttocks pexy. Aesthetic Plast Surg. 1997;21(4):245–53. 15. Guerrerosantos J. Secondary hip-buttock-thigh plasty. Clin Plast Surg. 1984;11(3):491–503. 16. Pascal JF, Le Louarn C. Remodeling bodylift with high lateral tension. Aesthetic Plast Surg. 2002;26(3):223–30. 17. Pitanguy I. Surgical reduction of the abdomen, thighs and buttocks. Surg Clin North Am. 1971;51(2):479–89. 18. Regnault P, Daniel R. Secondary thigh-buttock deformities after classical techniques: prevention and treatment. Clin Plast Surg. 1984;11(3):505–16. 19. Cuenca-Guerra R, Lugo-Beltran I. Beautiful buttocks: characteristics and surgical techniques. Clin Past Surg. 2006; 33(3):321–32.

A Novel Treatment Option for Thigh Lymphoceles Complicating Medial Thigh Lifting Procedures

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Wayne K. Stadelmann

38.1 The Nature of Lymphatic Fluid Lymphatic fluid is a transudate derived from the ultrafiltration of blood across the endothelial layer of blood vessels. This fluid is devoid of cellular elements containing neither red blood cells nor platelets, yet it is rich in lymphocytes [1]. Lymph has high protein levels, but contains relatively small quantities of clotting factors [2]. The lack of platelets and clotting proteins predisposes cut lymphatic channels to leak and drain lymphatic fluid for hours to days after the channels are transected. Trying to seal transected lymphatics using electrocautery alone is relatively ineffective as the electrically induced thermal trauma cannot initiate a clotting cascade. Ideally, if lymphatic channels are cut, they should be sealed either with ligatures or hemoclips to prevent a postoperative leak from occurring. Most lymphatic channels are quite small and contain clear to yellow-tinged fluid, making their identification difficult intraoperatively. Once transected, lymph will flow passively into any adjoining potential space resulting in a sterile protein-rich fluid collection termed a lymphocele (Fig. 38.1). A lymphocele will enlarge until the pressure exerted by the accumulating lymphatic fluid equals the pressure exerted by the surrounding tissues. This is typically on the order of 10 mmHg pressure [1]. If the skin integrity over a lymphocele is violated, the flow of lymph will be externalized and lymphorrhea will occur (Fig. 38.2). Lymphatic fluid is a very good bacterial culture medium as it is protein-rich, has a high concentration of glucose, and is warm. Correspondingly,

Fig. 38.1 A well-established left groin lymphocele that is firm, protuberant, and uncomfortable for the patient

infections are always a concern with lymphoceles and the risk for infection becomes more acute with the development of lymphorrhea. Lymph production and lymph flow are dependent on blood flow, blood pressure, protein status, and muscle activity, and may range between 4 and 900 mL/kg/h [1]. Exercise will increase lymph production between 5 and 15 times above baseline levels. Lymphatic leaks are made more likely by several contributing factors such as prior radiation exposure to the lymphatic bed being operated upon, systemic steroid use, anticoagulation, infection, hematoma formation, and diuretic use [2].

38.2 Procedures at Risk for Groin Lymphocele Formation W. K. Stadelmann 248 Pleasant Street, Pillsbury Medical Office Building, Suite 201, Concord, NH 03301, USA e-mail: [email protected]

In the groin, oblique incisions place the lymphatic channels at risk for trauma, especially if the incisions

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is created which can subsequently passively fill with lymphatic fluid. With early ambulation and activity, the lymphocele may enlarge precipitously. Once formed, lymphoceles that fail to resolve spontaneously are notoriously difficult to treat and pose a constant threat of infection, as well as compromised patient satisfaction.

38.3 Treatment Options for Lymphoceles and Lymphorrhea The majority of lymphoceles will resolve spontaneously using external compression and extremity edema control. For refractory lymphatic fluid collections, numerous surgical as well as nonoperative methods have been used, all of which have a recurrence rate of up to 50% [6]. While not exhaustive in its scope, the following is a listing of the most commonly used treatments:

Fig. 38.2 Lymphorrhea originating from a lymphocele that has developed a sinus tract with the overlying skin. The risk of infection is elevated when the lymphatic collection communicates with the groin skin and native bacterial organisms

transverse the deep fascia above the femoral triangle. Any procedure performed in this area runs the risk of inadvertently damaging the underlying lymphatics. Lymphoceles have been reported with groin lymph node biopsies, vascular access for cardio-pulmonary bypass procedures, arterial revascularizations, saphenous vein manipulation and harvest, as well with medial thigh lift procedures [2–5]. Postoperative seroma formation has been documented in up to 19% of thigh lift procedures [5]. An early report of a lymphocele following an elective thigh lift was published in 1983 by Leitner and Sherwood [2]. Lymphoceles accompanying groin and pelvic lymphadenectomies have been reported to occur between 3 and 49% [2]. Medial thigh lift procedures often encroach upon the femoral triangle and even if the deep fascia is not violated, multiple small lymphatic channels may be transected. With a medial thigh lift operation, often a large potential space

1. Observation with leg elevation and edema control with compression garments and reduced physical activity has been shown to be successful in 70% of thigh lymphoceles [7]. Muscle activity is known to increase the production of lymphatic fluid from 5 to 15 times above baseline lymph production [8]. Therefore, by keeping the extremity at rest and providing edema control, lymph production and the associated increase in the lymphatic pressure head at the lymphocele can be minimized. Once a lymphocele has been well established, however, reducing the rate of lymph production may reduce the size of the fluid collection, but the potential space will persist only to fill time and time again. 2. Serial percutaneous aspirations and compression along with edema control. This method is potential curative when the lymphocele is young and the lining has not yet matured. Aspiration may also cause hemorrhage within the cavity, which may serve as an irritant promoting the formation of adhesions with subsequent obliteration of the potential space into which lymphatic fluid may accumulate. Aspirations may also introduce bacteria into the sterile fluid-filled space resulting in an abscess with the predictable consequences of loss of contour, depression of the local tissues, pain, fibrosis, and excessive scar formation.

38 A Novel Treatment Option for Thigh Lymphoceles Complicating Medial Thigh Lifting Procedures

3. Percutaneous aspiration and simultaneous instillation of sclerosing agents. Numerous agents have been used as sclerosants to attempt to cause an intense inflammatory response within the lining of the lymphocele and promote adhesions between the walls of the cavity. These agents have included talc, alcohols, bleomycin, tetracycline, ampicillin, doxycycline, and providone–iodine [9–13]. Success rates are variable and often multiple treatment sessions are needed. 4. Percutaneous placement of a closed system drainage catheters [14–16]. Drains can be used as a sole treatment option or in combination with sclerosants. Once again success rates are variable. 5. Operative approaches are mainly limited to direct exploration of the lymphocele with damaged lymphatic channel obliteration using ligatures. Visualizing the transected lymphatics is often very difficult, especially if the lymphocele lining is resected at the same time as the initial exploration. Surgical dogma has maintained that the lining of a lymphocele should be removed at the time of surgical exploration [2]. Direct physiological support for this practice is not well documented. The lining of a lymphocele is similar in texture to the fibrous capsule surrounding breast implants and lacks a true distinct epithelial lining. When a breast implant explantation is performed and a new implant is not inserted, a formal capsulectomy may not be performed and some residual capsule may be left behind. The capsule eventually is reabsorbed and obliterates. The same phenomenon occurs with a lymphocele lining, provided that the production of lymphatic fluid is stopped and the potential space incorporated by the lymphocele is obliterated. Additionally, and more importantly, the lining of the lymphocele directly overlays undamaged lymphatic channels as will be discussed below. If the lining is removed, these fine lymphatics may be transected and may then contribute to the high recurrence rates (up to 50%) traditionally seen with open operative treatment approaches [17]. 6. Operative treatment using muscle flaps such as the sartorius and rectus femoris muscles to obliterate the potential space occupied by the lymphocele [18–20]. This technique is particularly useful if the lining of the lymphocele has been removed and the resultant dead space cannot be obliterated using direct suturing. Muscle flaps do require more local dissection that can result in contour irregularity, which would not be desirable when dealing with a complication

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Fig. 38.3 A groin lymphocele that has been treated with a prior operative drainage, lining excision, and a rectus femoris flap. The lymphocele has recurred despite this relatively extensive operation. The lateral thigh is also depressed over the muscle donor site, which became more obvious when the patient was standing upright

resulting from a cosmetic procedure (Fig. 38.3). Muscle flaps are also associated with a small but real risk of bleeding and hematoma formation. 7. Operative treatment using lymphatic mapping and direct surgical ligation of leaking lymphatics. Several authors have written about using vital dyes to identify the leaking lymphatics that are responsible for the formation of lymphoceles [3, 5, 6, 16, 17]. The use of lymphatic mapping provides a relatively easy, safe, and effective method to identify and ligate leaking lymphatic channels. As described below, this technique has little associated morbidity.

38.4 Rational for Using Intraoperative Lymphatic Mapping with Blue Dye Lymphatic mapping using various dyes has been performed for many years [21]. While Patent Blue V and Evan’s blue have been used for lymphatic mapping, the dye most commonly used today is 1% isosulfan blue

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Fig. 38.4 Isosulfan blue dye has been used for sentinel lymph node mapping and harvesting for nearly 20 years. As seen here in a breast cancer case, the dye imparts a brilliant blue hue that is seen migrating away from the injection site through the dermal lymphatics. Isosulfan blue dye is relatively safe, but on rare occasions, it does create a mild powder blue-colored tattoo that may take over a year to resolve and may be permanent

[22]. Over the past two decades, isosulfan blue dye has emerged as a reliable, safe, and easy-to-use agent that has few side effects and an allergic reaction incidence of about 1% (Fig. 38.4) [23–27]. This dye is watersoluble, has a deep azure color, is selectively absorbed by lymphatic channels, has rapid transit time of about 10 cm/min, and has little extravasation beyond the lymphatic system making its use clean and precise [28]. Isosulfan blue is currently used for the sentinel node evaluation in patients with cutaneous malignancies such as melanoma, squamous cell carcinoma, Merkel cell carcinoma, as well as breast cancer and several other visceral malignancies [29–33]. Isosulfan blue dye has also been used before to assist in the intraoperative identification of leaking lymphatics for treating lymphoceles [3, 6, 16, 17]. Although the dye is not considered to be permanent, a prolonged blue hue at the injection site, especially in the lower extremities, back area, and the breast, has been reported. The possibility of permanent tattooing with the blue dye should, therefore, be discussed with the patient preoperatively.

38.5 Operative Technique for Treating Groin Lymphoceles Prior to treating a refractory groin lymphocele, no special imaging studies are needed in the absence of

W. K. Stadelmann

Fig. 38.5 In this patient, the groin lymphocele was secondary to an arterial bypass procedure. A preoperative duplex ultrasound scan was done to confirm that a pseudoaneurysm was not present

known trauma to the femoral area. If a firm mass exists, examination with a stethoscope should be performed to identify any bruits. A duplex ultrasound may be obtained if there is even the remote chance of a pseudoaneurysm or an arteriovenous fistula being present (Fig. 38.5). If these studies are positive, a vascular surgery consultation should be considered and/or contingency plans be made to deal with sudden arterial hemorrhage intraoperatively. Prior to prepping out the groin, 1% isosulfan blue dye is injected intradermally in the ankle area in four locations placed equidistantly around the extremity (Fig. 38.6). The rationale for this maneuver is to identify the cutaneous region corresponding to the leaking lymphatic. This is essentially a sentinel node mapping procedure done in reverse. With a lymphocele, the lymphatic vessels that are leaking need to be identified by the blue dye that is injected intradermally. The dermal drainage patterns cannot, however, be determined by random injection of blue dye. For example, the leaking lymphatic may drain a cutaneous distribution over the posterior leg. Blue dye injected into the anterior leg would not travel to the groin via the lymphatics that are damaged, and therefore, the leaking lymphatics would not stain blue and would defy detection. The blue dye should be injected in all four quadrants of the extremity, so that the draining blue dye will have the greatest likelihood of being transported to the lymphocele by the leaking lymphatic channel. After the dye is injected, the extremity is elevated and massaged to promote the more rapid transit of the dye

38 A Novel Treatment Option for Thigh Lymphoceles Complicating Medial Thigh Lifting Procedures

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a

b

Fig. 38.7 The typical lymphocele, if not infected, contains clear to yellow-tinged fluid under relatively low pressure. Here a large lymphocele is being drained prior to cavity exploration

Fig. 38.6 (a) Distal leg intradermal injections of the blue dye are done in at least four quadrants to capture any lymphatics that may be contributing to the lymphatic leak. The blue dye can be seen streaming through the dermal lymphatics toward the groin which is located to the left of the image. Point A represents the medial malleolus. (b) Another patient undergoing an extremity blue dye injection. Note the rapid uptake of the dye within the dermal lymphatics after the dye was injected intradermally

through the dermal lymphatics. The groin is then prepped and draped. Depending on the incision used to perform the medial thigh lift, an incision is made directly over the lymphocele. During the subcutaneous dissection, any blue staining lymphatics should be controlled with ligatures or hemoclips. Once the lymphocele is encountered, the anterior surface is incised and the contained fluid is evacuated (Fig. 38.7). The cavity lining is then carefully inspected for blue dye emerging from the offending lymphatic leak(s) (Fig. 38.8). The rate of dye emergence is dependent on the size of the lymphatic and also on the amount of time that has transpired since the time of injection. Often, the site of emergence is tiny and seems almost inconsequential (Fig. 38.9). Remembering that the patient is at rest with no active muscle contractions while anesthetized will help put the minimal flow volumes in perspective. Small leaks at rest can be much more voluminous when the patient

is ambulating and physically active. If no blue dye is seen, the injection site is massaged through the sterile drapes and the leg is elevated. Rarely is further injection of dye required, but this should be contemplated if absolutely no dye is seen to emerge after about 20–30 min. The leaking lymphatics may be multiple and a thorough search for any blue staining needs to be done to minimize any possible recurrence. At this time, the lining of the lymphocele may be seen to overlay multiple blue staining lymphatics that are beautifully demonstrated with this technique. These lymphatics are directly deep to the lining and are at risk for being transected if the lining is excised. This is the main reason why the lymphocele lining is not removed. The leaking lymphatics are now oversewn with figure-of-eight 4–0 monofilament absorbable sutures. The cessation of leaking blue dye provides immediate confirmation that the lymph leak has been successfully treated. Next, the lymphocele is closed by imbricating the lining with multiple layers of the figure-of-eight monofilament sutures. The lining of mature lymphoceles is quite tough and holds sutures very well (Fig. 38.10). This is the second reason to not resect the lining. If the lining is removed, the space created is lined by subcutaneous fat that does hold sutures well, especially if they are placed under tension. Usually the imbrication is done closing the cavity with multiple layers that completely obliterate the cavity, so completely that a drain is rarely used (Fig. 38.11).

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W. K. Stadelmann

a

b

Fig. 38.9 An almost imperceptible leak causing a mere blush of blue dye to emerge. Despite waiting for almost 30 min, no other sites were seen to drain any blue fluid. The leaking lymphatic was oversewn and the capsule imbricated in multiple layers using a monofilament suture. No drain was used. An uncomplicated recovery followed with complete resolution of the lymphocele

a

Fig. 38.8 (a) In this patient, the lymphocele has been drained and fillet open after blue dye was injected into the ipsilateral distal extremity. Blue dye was seen to emerge immediately from two separate locations. Also, note the faint blue hue to the left of the superior leaking site. This represents subcapsular lymphatics that would be at risk for transection if the capsule was resected. (b) In this melanoma patient, the blue dye is seen traveling through the subcutaneous lymphatics. The blue dye is spectacular to observe

b

38.6 Postoperative Care The postoperative regimen is intended to reduce lymph production. By using compressive toe to thigh dressings, leg elevation, and relative extremity inactivity for 3–4 days postoperatively, the production of lymph is minimized. Exercise has been shown to increase the production of lymphatic fluid by as much as 5–15 times above baseline. Decreasing the production of lymph would seem to be a logical goal to minimize any pressure on the ligated lymphatics. Dry gauze dressings are placed over the incision every 12 h

Fig. 38.10 (a) A typical mature lymphocele. The lining is thick and fibrous and holds sutures extremely well. To the left near the army-navy retractor, the capsule has been transected and the surrounding fat can be seen. The fat is not able to hold sutures nearly as well and complete obliteration of the cavity is often difficult if the lining is resected. (b) Another lymphocele cavity with the thick capsule in situ

38 A Novel Treatment Option for Thigh Lymphoceles Complicating Medial Thigh Lifting Procedures Fig. 38.11 (a) The preoperative appearance of a 50-year-old woman with a groin lymphocele. (b) The same patient after the lymphocele was treated with lymphatic mapping, lymphatic ligation, and cavity obliteration with multiple layers using monofilament sutures. Full recovery was about 4 weeks postoperatively. The contour is normal and the scarring is quite acceptable

a

after the incision is wiped with a provolone iodine moistened gauze pad. Provolone iodine dressings are performed for 3–4 days postoperatively to reduce surface bacterial contamination. This regimen is admittedly empiric; however, it makes physiologic sense and has been associated with neither recurrent lymphoceles nor postoperative infections. After about 4 days, a gradual return to “normal” activity is allowed. I caution my patients to use common sense and refrain from working out or taking long walks for about 2 weeks. After this time, the repair should be healed well enough to allow resumption in the preoperative activity level.

38.7 Risks and Complications The main risks associated with the described technique are the ½% risk of blue dye associated anaphylactic reaction, blue staining of the skin at the injection site, bleeding, hematoma, infection, and the chance that the lymphocele may recur. I have performed over 25 lymphocele repair procedures with a 0% recurrence rate and no major bleeding or infectious complications. For the novice, the failure rate will likely be higher at first, especially if the surgeon is not familiar with sentinel node mapping techniques. It may prove prudent to refer the rare patient with this complication to a plastic surgeon who frequently does melanoma cases. It might also be a good idea to send along a copy of this chapter as well.

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b

38.8 Conclusions A simple, safe, effective, and cosmetically acceptable method has been described to treat postoperative groin lymphoceles accompanying medial thigh lift procedures. This technique incorporates blue dye lymphatic mapping technology, direct visual identification and ligation of leaking lymphatics, maintenance of the lymphocele lining, and obliterating the lymphocele space with multiple layers of imbricating monofilament sutures. An empiric postoperative treatment regimen was also presented that is designed to minimize lymphatic flow and reduce surface colonization.

References 1. Eckert R, Randall D, editors. Animal physiology mechanisms and adaptations. 2nd ed. New York: WH Freeman; 1983. p. 579–80. 2. Leitner DW, Sherwood RC. Inguinal lymphocele as a complication of thighplasty. Plast Reconstr Surg. 1983;72(6): 878–81. 3. Stadelmann WK. Intra-operative lymphatic mapping to treat groin lymphorrhea complicating an elective medial thigh lift. Ann Plast Surg. 2002;48(2):205–8. 4. Lockwood TE. Lower body lift with superficial fascial system suspension. Plast Reconstr Surg. 1993;92(6):1112–22. 5. Candiani P, Campiglio GL, Signorini M. Fascio-fascial suspension technique in medial thigh lifts. Aesthetic Plast Surg. 1995;19(2):137–40. 6. Stadelmann WK, Tobin GR. Successful treatment of 19 consecutive groin lymphoceles with the assistance of intraoperative lymphatic mapping. Plast Reconstr Surg. 2002;109(4): 1274–80.

372 7. Mori N. Clinical and experimental studies on the so-called lymphocyst which develops after radical hysterectomy in cancer of the uterine cervix. J Jpn Obstet Gynecol Soc. 1955; 2:178. 8. Guyton AC. Textbook of medical physiology. 5th ed. Philadelphia: Saunders; 1976. p. 370–3. 9. Cannon L, Walker AJ. Sclerotherapy of a wound lymphocele using tetracycline. Eur J Vasc Endovasc Surg. 1997;14(6): 505. 10. Seelig MH, Klingler PJ, Oldenburg WA. Treatment of postoperative cervical chylous lymphocele by percutaneous sclerosis with povidone-iodine. J Vasc Surg. 1998;27(6): 1148–51. 11. Zuckerman DA, Yaeger TD. Percutaneous ethanol sclerotherapy of postoperative lymphoceles. AJR Amer J Roentgenol. 1997;169(2):433–7. 12. Kerlan RK Jr, LaBerge JM, Gordon RL, Ring EJ. Bleomycin sclerosis of pelvic lymphoceles. J Vasc Interv Radiol. 1997; 8(5):885–7. 13. Folk JJ, Musa AG. Management of persistent lymphocele by sclerotherapy with doxycycline. Eur J Obstet Gynecol Reprod Biol. 1995;60(2):191–3. 14. Hoffman MS, Mark JE, Cavanagh D. A management scheme for postoperative lymphocysts. Gynecol Oncol. 1995;56(2): 262–5. 15. Kwaan JH, Bernstein JM, Connolly JE. Management of lymph fistula in the groin after arterial reconstruction. Arch Surg. 1979;114(12):1416–8. 16. Schanzer H, Skladany M. Treatment of lymphorrhea by early selective lymphatic ligation. Surgical Rounds. 1999: 542–5. 17. Weaver FA, Yellin AE. Management of postoperative lymphatic leaks by use of isosulfan blue. Letter to the editor. J Vasc Surg. 1991;14(4):566–7. 18. Goldstein JA, Janu P, Fields B. Rectus femoris flap repair of recalcitrant inguinal lymphoceles after heart transplantation. J Heart Lung Transplant. 1994;13(3):549–53. 19. Roberts JR, Walters GK, Zenilman ME, Jones CE. Groin lymphorrhea complicating revascularization involving the femoral vessels. Am J Surg. 1993;165(3):341–4. 20. Soots G, Mikati A, Warembourg H Jr, Watel A, Noblet D. Treatment of lymphorrhea with exposed or infected vascular prosthetic grafts in the groin using sartorious myoplasty. J Cardiovasc Surg (Torino). 1988;29(1):42–5. 21. Morton DL, Wen D-R, Wong JH, Economou JS, Cagle LA, Strom FK, Foshag LJ, Cochran AJ. Technical details of intraoperative lymphatic mapping for early stage melanoma. Arch Surg. 1992;127(4):392–9.

W. K. Stadelmann 22. Reintgen DS, Rapaport DP, Tanabe KK, Ross MI. Lymphatic mapping and sentinel lymphadenectomy. In: Balch CM, editor. Cutaneous melanoma. 3rd ed. St. Louis: Quality Medical Publishing; 1998. p. 227–44. 23. Cimmino VM, Brown AC, Szocik JF, Pass HA, Moline S, De SK, Domino EF. Allergic reactions to isosulfan blue during sentinel node biopsy-a common event. Surgery 2001; 130(3):439–42. 24. Komenaka IK, Bauer VP, Schnabel FR, Horowitz E, Joseph KA, Ditkoff BA, El-Tamer MB. Allergic reactions to isosulfan blue dye in sentinel lymph node mapping. Breast J. 2005; 11(1):70–2. 25. Raut CP, Hunt KK, Akins JS, Daley MD, Ross MI, Singletary SE, Marshall GD Jr, et al. Incidence of anaphylactoid reactions to isosulfan blue dye during breast carcinoma lymphatic mapping in patients treated with preoperative prophylaxis. Cancer. 2005;104(4):692–9. 26. Montgomery LL, Thorne AC, Van Zee KJ, Fey J, Heerdt AS, Gemignani MN, Port E, Petrek J, Cody HS III, Borgen PI. Isosulfan blue dye reactions during sentinel lymph node mapping for breast cancer. Anesth Analg. 2002;95(2): 385–8. 27. Leong SPL, Donegan E, Heffernon W, Dean S, Katz JA. Adverse reactions to isosulfan blue during selective sentinel lymph node dissection in melanoma. Ann Surg Oncol. 2000; 7(5):361–6. 28. Nathanson SD, Nelson L, Karvelis KC. Rates of flow of 99m-labled human serum albumin from peripheral injection sites to sentinel lymph nodes. Ann Surg Oncol. 1996;3(4): 329–35. 29. Stadelmann WK, Javaheri S, Cruse CW, Reintgen DS. The use of sentinel lymphadenectomy in squamous cell carcinoma of the wrist. a case report. J Hand Surg Am. 1997;22(4):726–31. 30. Javaheri S, Cruse CW, Stadelmann WK, Reintgen DS. Sentinel node excision for the diagnosis of metastatic neuroendocrine carcinoma of the skin: a case report. Ann Plast Surg. 1997;39(3):299–302. 31. Messina JL, Reintgen DS, Cruse CW, Rappaport DP, Berman C, Fenske NA, Glass LF. Selective lymphadenectomy in patients with merkel cell (cutaneous neuroendocrine) carcinoma. Ann Surg Oncol. 1997;4(5):389–95. 32. Albertini JJ, Lyman GH, Cox C, Yeatman T, Balducci L, Ku N, Shivers S, et al. Lymphatic mapping and sentinel node biopsy in the patient with breast cancer. JAMA. 1996;276(22): 1818–22. 33. Reintgen DS, Albertini J, Miliotes G, Berman C, Cruse CW, Fenske N, Glass F, et al. The Accurate staging and modern day treatment of malignant melanoma. Cancer Res. 1995; 4:183–97.

Fat Augmentation of Buttocks and Legs

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Lina Valero de Pedroza

39.1 History Surgical techniques to enhance buttocks’ or calves’ volume have consisted of placement of silicone implants below the gluteus maximus muscle in the buttocks or over the internal gemellus muscle for calves. Those surgical techniques with placement of silicone implants were performed by the author; however, they were inconvenient because they had the following consequences: 1. Very painful within the twenty postoperative days. 2. Very poor aesthetic results. 3. Permanent and/or long-term disabilities that consisted of persistent pain when in the sitting position or whenever wearing heels. Fat transfer was used by the author to obtain optimal aesthetic results, reduce the recovery period, reduce the side effects, and avoid physical or aesthetic complications. Extensively related uses of small quantities of fat tissue were described in the medical literature since 1893 to correct defects in soft tissues.

39.2 Technique 1. Fat retrieval is from any anatomical area below the neck that is good to retrieve fat tissue. There are major areas of concentration of volume such as the arms, back, abdomen, hips, knees, and buttocks.

L. Valero de Pedroza Clínica La Font, Carrera 16, No 86A–32, Bogotá, DC, Colombia e-mail: [email protected]

2. Tumescence with 1,000 mL saline containing 1 mL epinephrine is performed in any area used as a donor site. Five to ten minutes before harvesting are required to achieve maximum hemostasis and obtain clean tissue. 3. Liposuction is performed with a mixture of ultrasonic-assisted liposuction and traditional liposuction at low pressure with machine. The use of ultrasound-assisted liposuction was from September 1997 to the present time. From 1991 to 1997, machine suction was performed at low pressure. 4. The fat tissue graft is placed in sterile glass flasks that have been vapor sterilized. An amount of 1–3 L and more is kept sterile for about 15–25 min with no contact with air until decantation of the cells is done. 5. After the natural separation of the fat has occurred with the fat cells rising to the surface and the tumescent liquid on the bottom of the flasks, the harvested tissue is ready to be transferred to a sterile syringe. 6. For large volumes, a 60-mL syringe is used, and for small volumes, a 10-mL syringe is used to inject the graft.

39.3 Materials 1. Cannulas from 3 to 5 mm are used to harvest tissue. If tissue is retrieved with a 3-mm cannula, injection of the graft is performed with a 3-mm cannula. 2. Blunt cannulas to harvest and blunt cannulas to graft are used. 3. Suction machine at low pressure 350 mm Hg is used to preserve the integrity of the cells that could be disrupted under high vacuum pressure.

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L. Valero de Pedroza

4. Syringe suction is recommended for small amounts of fat tissue transplant. 5. Centrifugation of a small amount of fat tissue to be transplanted over the face and hands is recommended in order to obtain a more precise quality of graft free of liquid and avoid unnecessary edema. 6. No washing or exposing to the air is the main purpose in managing the graft to preserve its viability and preventing its contamination, as a priority.

39.4 Fat as a Tissue Filler Fat tissue has three of its characteristics that make it the ideal tissue filler: (1) It is composed of cells that have the property to be hypertrophic; (2) It is composed of cells able to grow in volume, and at the same time, it is a hyperplasic tissue; and (3) It has a large amount of cells, able to grow in volume (hyperplasic nature). These properties make it the ideal “Soufflé” to fill a depressed or deformed anatomical area.

a

39.5 Placement of the Fat Graft The nature of human anatomy places fat tissue under the skin surface and over the muscular structure. Intraperitonealy, it covers all the abdominal organs and structures and we find a large amount of fat cushion denominated “Epiplon.” The author sculpts the normal anatomy of the human body by reshaping and relocating fat tissue. The initial goals were based on enhancing the volume of buttocks, ankles, and calves for beautification. The graft was placed under the skin following the normal anatomic growth and existence of the fat tissue. The author has found fat of great help as a total body tissue filler to reconstruct body deformities from traumatic, congenital, or iatrogenic origin. It produces excellent results in cosmetic enhancement, is a long-term survival tissue, is well tolerated, and has low risks if the graft is adequately manipulated (preventing its contamination and preserving the survival of its cells while harvesting it) (Figs. 39.1–39.4).

b

Fig. 39.1 (a) Preoperative 58-year-old female with aging process of the buttocks with wrinkles and loss of volume. (b) Eight months postoperative after 300 mL of fat transfer to each side

39 Fat Augmentation of Buttocks and Legs

a1

375

a2

Fig. 39.2 (a1, 2) Preoperative 28-year-old female requesting increased volume of buttocks. (b1, 2) One year following fat retrieval from abdomen, waist, and hips, and transfer of 300 mL of fat to each buttock

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b1

b2

Fig. 39.2 (continued)

39.6 Synopsis of Technique (a) Materials 1. 3–5 mm cannulas 2. Syringe suction 3. Machine suction low pressure 4. 3–5 mm cannulas blunt for injection 5. Tumescence with 1,000 mL saline and 1 mg epinephrine 6. Sterile glass 1,000 mL flasks

(b) Donor site areas 1. Arms 2. Back 3. Hips 4. Abdomen 5. Buttocks 6. Knees (c) Methods 1. Traditional suction machine 2. Syringe suction

39 Fat Augmentation of Buttocks and Legs Fig. 39.3 (a) Preoperative 27-year-old male with agenesis of gemellus muscle of the right leg. (b) Seven years after 350 mL fat graft over the agenetic musculature of the right leg

a

3. Ultrasound-assisted liposuction 4. Centrifugation for small amounts of fat transplant tissue (for face and hands) (d) Recipient areas 1. Buttocks 2. Hips 3. Muscular atrophies in legs, arms, ankles (e) Manipulation of the graft 1. No washing 2. Natural decantation 15–25 min in the sterile glass flasks 3. Storage for 30–45 min with no air contact 4. Direct liposuction from patients, to flasks, to sterile syringes, to patient again as a graft (f) Amount of fat volume transplanted Area amount Each buttock 240–700 mL Each leg 150–400 mL

377

b

Each ankle 120–280 mL Each hip 300–750 mL

39.7 Qualities of Fat Transplant 1. It is an autologous tissue 2. Hyperplasic tissue (large number of cells) 3. Each fat cell has an hypertrophic capacity to grow in volume (the “soufflé” effect) 4. Normal to the touch 5. No side effects if manipulated sterile 6. Easy handling 7. Long lasting – permanent in life 8. No functional changes 9. It is a fat cells graft, not a fat (liquid) or oil injection

378 Fig. 39.4 (a1, 2) Preoperative 72-year-old male with “skinny” legs. (b1, 2) Two and one half years after 300 mL fat transfer to each calf and ankle

L. Valero de Pedroza

a1

a2

39 Fat Augmentation of Buttocks and Legs

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39.8 Complications

39.9 Conclusions

In the author’s cases there were a few slight complications varying from skin vesicles from the skin tape, redness without injection, edema of the ankles for 20 days postoperatively, and one case of erysipelas occurred from trauma that was treated with penicillin and without losing the fat transplant volume injected over the legs.

The author recommends fat transfer to all patients for reconstructive and cosmetic purposes because of the clinical results and satisfaction of the patients, after a long term follow-up during the 16 years making use of this technique.

Lower Leg Augmentation with Combined Calf-Tibial Implant

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Afshin Farzadmehr and Robert A. Gutstein1

40.1 Introduction Augmentation of the calves has been performed for over 25 years. Patients seeking this procedure have underdeveloped lower legs that make them self-conscious and their calves are source of embarrassment. This is even more true when the underdevelopment or atrophy is associated with asymmetry, congenital deformity (tibial torsion, pes planus, genu valgus) traumatic nerve injury or disease (polio). In some people exercise would not help in building the musculature in the calves. Calf augmentation with implant has been performed by placing a subfascial silicone implant from a transverse incision in the popliteal crease in a plane dissected between the gastrocnemius fascia and the muscle. Usually either medial and/or lateral gastrocnemius is augmented with the medial one being a larger size. In patients who have lower legs that are also thin from calf to the ankle, just performing the calf augmentation alone would exaggerate the deformity. In 2003, Gutstein [1] developed an implant to address the deficiency of contour of the lower leg and calves combined via an implant that would have a rodlike structure extending from the lenticular implant inferiorly. He had operated in over 40 patients successfully of varied ages with a variety of presenting conditions. The majority had generalized (congenital) hypoplasia and hypoplasia with tibial torsion. There were also patients with polio, direct trauma, club foot,

1

trauma with nerve damage, and burn scars. They all had one thing in common, which was either “I will not wear shorts” or “I will not wear short skirts.” Among these patients, there were those who had previous calf augmentation and wanted to exchange the medial implant with one with extended calf-tibial implant. It was noted that sufficient pliable tissue is necessary, but it was possible to achieve distention and safe implantation with extensive but mature scars present.

40.2 Implant The implant is a one piece, molded, soft, solid silicone structure with proximal portion similar to the Aiache lenticular implant and a rod extension from the inferomedial border of the gastrocnemius to just above medial malleolus (Fig. 40.1). The rod extension’ length varies from 12 to 20 cm depending on the length of patient’ leg. The rod portion is 2.5 cm wide and projects 1.3 cm feathering at the distal end. The proximal portion of the implant corresponds to Aiache 3, 4, 5 implant and the choice is based on the patient’s input regarding the bulk and definition of the calf and with consideration of tissue distensibility. During consultation, measurements of the lengths of the medial and lateral heads of the gastrocnemius, as well as the length between the inferior border of the medial belly of the gastrocnemius and the malleolus

Posthumously for Robert A Gutstein.

A. Farzadmehr (*) Plastic Surgery Center of Beverly Hills, 1125 South Beverly Drive, Suite 600, Los Angeles, CA 90035, USA e-mail: [email protected]

Fig. 40.1 Gutstein implant

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are taken. With these measurements, the implant can be ordered through Hanson Medical (US Patent no. USD478,988S). The implant is solid silicone with durometer of 4.5–5.0.

A. Farzadmehr and R. A. Gutstein

a

40.3 Technique Based on patient’s preference, this procedure could be performed under local, dissociative twilight, or general anesthesia. The patient is placed in prone position and the ankles elevated slightly. Local anesthesia is injected, usually 0.5% lidocaine with epinephrine into the incision line and as a field block for the calf and the medial leg. A 4-cm incision is marked at the popliteal crease 3 cm medial to the midline of the leg and 1 cm lateral to that point. The incision is carried through the superficial fascia to the thin fascial covering adherent to the gastrocnemius muscle. At this level, the subfascial pocket is made. A bridge is allowed to remain containing the lesser saphenous-sural nerve bundle if both heads of the muscle are to be augmented. The medial head is only augmented in cases of tibial torsion, especially in women. Blunt dissection is performed in this plane using blunt scissors, middle finger, and a flat cannula (which also instills Marcaine), and finally the long paddle or spade to the inferior border of gastrocnemius fascia. The long, straight, ribbon retractor with a hole drilled near each end is passed into the medial compartment to enter the subfascial plane of soleus. A piece of umbilical tape is passed through the proximal hole in the instrument and the tape is tied over the implant so that the implant tip is on the metal “sled.” The ribbon metal retractor sled is advanced to just above the medial malleolus. Palpation delineates the instrument and a vertical incision of 2 cm is made over it, 2 cm proximal to the malleolus. The incision is spread and the ribbon dissector exposed (Fig. 40.2). The tibialis posterior tendon should be posterior to this area and the greater saphenous vein anterior to the exit point. The hole in the distal end of the sled is helpful in retrieving it with a curved hemostat. The ribbon retractor is pulled through and the implant extension follows. The umbilical tape is removed, a slight distal dissection of the subfascial pocket is made, and the end of the implant is seated. Then, 4–0 nylon is used to approximate the fascia, 4–0 Vicryl is used to approximate the subcutaneous tissue, and the skin is closed with subcuticular 4–0 Prolene. If the lateral gastrocnemius compartment is to be augmented, an appropriate sized Aiache implant is positioned in the lateral subfascial pocket.

b

Fig. 40.2 The ribbon retractor is passed from the incision at the popliteal crease to the area 2 cm proximal to the medial malleolus

The popliteal incision is repaired with 4–0 nylon, 3–0 or 4–0 Vicryl, and 4–0 subcuticular Prolene. If the patient will not be available for suture removal in 10–14 days because of geographic consideration, 4–0 polydioxanone or Monocryl is used. Xeroform gauze, 4 × 4 gauze, paper tape, and 65-in. Ace wraps are used for dressing. The legs should be elevated as much as possible for the first 2 days, with limited ambulation. Ace wraps are continued for another week. Use of an elevated heel is helpful in the early postoperative period. Lower body exercises may commence in 4 weeks. Ancillary procedures such as liposuction of fat or AlloDerm grafting are useful at times to complete the contour correction at the knees or ankles. Over time and with experience, the leg extension rod has been made longer, feathering it to slide over the proximal slope of the malleolus, which eliminates any gap in contour. Also, a longer, 18-in. metal sled has been used in taller patients so that an intermediate incision is no longer necessary.

40.4 Discussion The patients who underwent this procedure to enhance the entire thin and/or curved medial lower leg have all expressed great pleasure with their augmentation (Figs. 40.3–40.6). There have been no limitation of motion, no malposition, and no athletic restrictions.

40 Lower Leg Augmentation with Combined Calf-Tibial Implant Fig. 40.3 (Left) Preoperative. (Right) Postoperative

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384 Fig. 40.4 (Left) Preoperative. (Right) Postoperative

A. Farzadmehr and R. A. Gutstein

40 Lower Leg Augmentation with Combined Calf-Tibial Implant Fig. 40.5 (Left) Preoperative. (Right) Postoperative

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386 Fig. 40.6 (Left) Preoperative. (Right) Postoperative

Reference 1. Gutstein RA. Augmentation of the lower leg a new combined calf-tibial implant. Plast Reconstr Surg. 2006;117(3): 817-216

A. Farzadmehr and R. A. Gutstein

Part Liposuction

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William W. Cimino

41.1 Introduction Safe and effective use of ultrasonic instrumentation for lipoplasty requires an understanding of both the technology and associated surgical methods that differ significantly in many ways from the basic tools and methods of suction-assisted lipoplasty. The basic physics and tissue interactions for ultrasound-assisted lipoplasty, the benefits of the proper use of this technology and complications associated with its improper use will be discussed.

41.2 Basic Physics Over the past decade and a half, there have been three distinct generations of ultrasonic instrumentation for lipoplasty introduced to the market. In each subse quent generation, there have been design changes that improved the safety, efficacy, and usability of the equipment. In the following section, the basic physics of ultrasonic instrumentation is explained and used to describe the differences in each of the three generations of ultrasonic instrumentation for lipoplasty. Firstgeneration ultrasonic instrumentation is represented by the SMEI Sculpture technology, second-generation by the Mentor Contour Genesis and Lysonix 2000/3000 technologies, and third-generation by the Sound Surgical VASER technology, respectively. Ultrasonic surgery is the use of metal probes vibrating at low ultrasonic frequencies (20–60 kHz) to

W. W. Cimino 578 W. Sagebrush Ct., Louisville, CO 80027, USA e-mail: [email protected]

achieve a desired surgical effect in tissues. The probe design, the frequency of vibration, and the surgical technique, all play a role. To be clear, it is the vibrating metal tip of the probe interacting with the tissue that is of concern; not sonic radiation or some other mysterious phenomenon. It is complex, but understandable. Ultrasonic surgical instruments are in common use as dental descalers (from the 1950s to 1960s), for phacoemulsification (from the 1960s to 1970s), for neurosurgery (from the mid 1970s), for laparoscopic surgery (from the 1980s to 1990s), and for lipoplasty. Firstgeneration ultrasonic lipoplasty devices arrived in the late 1980s and early 1990s, second-and third-generation devices in the mid 1990s and the early 2000s, respectively. The basic ultrasonic surgery system has an electronic generator that interacts with an ultrasonic handpiece. The ultrasonic handpiece has an ultrasonic motor, most often composed of PZT crystals that convert electrical energy into vibratory motion. The vibratory motion is passed to a probe that vibrates in resonance with the handpiece. The electronic circuits in the generator maintain the vibration at the selected resonant frequency and adjust the amplitude of the vibration based on the controls on the generator. Vibration frequencies for ultrasonic systems for lipoplasty range from 22 to 36 kHz. There is no significant difference in the tissue effect across this frequency range; it simply alters the lengths of the resonant pieces by changing the wavelength of the vibration. Because the devices must resonate, the lengths are multiples of 0.5 wavelength. The ultrasonic probe and handpiece vibrate longitudinally at the designed resonant frequency. This means that standing waves are established in the probe and handpiece such that the tip of the probe experiences maximum longitudinal motion, on the order of a

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p eak-to-peak displacement of a few thousandths of an inch, barely visible to the naked eye. The amplitude is a function of the vibration frequency and the amplitude setting. It is important to understand that the vibration is not “lateral,” i.e., transverse to the long axis of the probe. When transverse vibration occurs, as it sometimes can with smaller diameter or longer probes, it has a very strong audible “zing.” Such a vibration can easily fracture the ultrasonic probe because the probe was not designed to accommodate bending stresses. It is also important to visualize the standing waves in the probe as opposed to a single back and forth motion of the entire probe. A reciprocating powered cannula device moves the cannula back and forth as a solid unit. Ultrasonic probes vibrate with the standing waves and thus achieve the ability to concentrate energy at the tip of the probe. The peak-topeak vibration amplitudes and probe dimensions for the various first, second, and third generation ultrasonic devices for lipoplasty have been summarized [1]. The available vibration amplitudes for the various devices are actually of little consequence. What matters is the available power at the tip of the device, which does scale with amplitude, but is also a function of frequency. Thus, lower amplitudes and higher frequencies can achieve the same level of power as higher amplitudes and lower frequencies. Electrical power into the generator or amplitude of vibration is a not useful indicator of actual power for effecting tissues. Power deposited in tissues is a function of the generator setting, and also a strong function of the “coupling” between the tip of the probe and the

tissues. A vibrating tip that is pressed strongly into the tissue will couple significantly more energy to the tissue than the same tip that is gently touching the same tissue. Furthermore, the design and shape of the vibrating tip will strongly influence the measure of power that is coupled to the tissue and the point on the tip where the energy will be concentrated. Thus, what is needed is a measure of the maximum acoustic power that could be coupled from a probe with a specific design and a selected amplitude of vibration. This information has been measured and reported [1]. In short, a water bath was used as a repeatable and reliable way to assess the power available from ultrasonic devices. Water is a very effective medium to assess power because it is a consistent and strong coupling agent. The data show that first and second-generation ultrasonic devices, when run in the range of clinically effective amplitudes, deliver between 20 and 30 W of power to the water bath. The third generation devices typically deliver 10–15 watts of power to the water bath; generally 50% of the power of the earlier generation devices. However, the thirdgeneration devices deliver the reduced overall power with much greater efficiency [1]. The measure of the efficiency developed was the energy per unit active volume at the tip, where the active volume of the tip can be determined by measurements of the tip geometry. This measured data showed that the design of the tip greatly influences the efficiency of the coupling. First and second-generation devices possess efficiencies in the range of 100–175 mJ/mm3 in the clinically usable amplitude range, whereas the third-generation technology has efficiencies in the range of 175–250 mJ/mm3.

Fig. 41.1 Different lipoplasty probe designs. From the left: second-generation 5 mm hollow, second-generation 5 mm golf-tee hollow, third-generation 4.5 mm three ring solid, first-

generation 4 mm solid, third-generation 3.7 mm three-ring solid, third-generation 2.9 mm three-ring solid, and third-generation 2.2 mm two-ring solid

41 Ultrasound-Assisted Lipoplasty: Basic Physics, Tissue Interactions, and Related Results/Complications

In summary, third generation technology was able to roughly double the efficiency while cutting the power applied in half. There are a variety of probe designs (Fig. 41.1) that can be used to explain this result. The probe on the left is a 5-mm probe with two aspiration holes and a relatively flat front surface. The majority of the frontal surface is active on this probe. Thus, when the probe is pressed strongly into the tissues, there is strong coupling of the ultrasonic energy from the face of the probe. The second probe from the left is a golf-tee design, having a concave surface at the front of the tip. The active area for this probe is inside the concave recess and will not contact the tissue unless the tissue is pulled into the recess with suction or the probe is pressed strongly into a tissue area. Thus, the useful active area for this probe design is actually quite small. The outside ring around the outside diameter of the probe will act as an ultrasonic knife when vibrating, which will be discussed later. The energy density along the outside ring is very high, resulting in the cutting action. The fourth probe from the left is a smooth hemispherical tip. This style is from the firstgeneration UAL technology. This active area for this probe is actually only a small portion in the center of the hemispherical dome. The efficiency of such a design is very low and the energy intensity is very high at the active area. The ringed or grooved probes are from the thirdgeneration technology. The grooves act to increase the active area for each probe and the small flat disc at the center of the hemispherical end increases the useful active area of the tip portion. This probe design has significantly decreased energy density due to the distribution of the total energy delivered by the probe across a much greater area. The efficiency of this style of probe is much greater than first or second-generation designs. The impact of the grooves can be examined and quantified (Fig. 41.2). The efficiency of each probe can be measured by the number of rings on the probe as well as the distribution of the energy around the vibrating tip. The grooves have surfaces that are perpendicular to the vibratory motion. More grooves have more surfaces and hence more coupling. Table 41.1 shows the relative partitioning of the energy for the four probes. Note that as the number of grooves increases, more and more energy, on a percentage basis, is coupled from the sides of the probe tip and less is coupled

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Fig. 41.2 Four identical probes except for the number of rings Table 41.1 Relative partitioning of energy based on the number of rings Probe Front Side (%) Tissue (%) 3.7–0

100

0

Extreme fiber

3.7–1

65

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3.7–2

55

45

Moderate

3.7–3

42

58

Soft

from the front surface of the tip. Thus, a probe with more grooves will not glide so well in fibrous tissue and is more suited to softer tissues. A probe with fewer grooves will have more energy at the front of the tip and will thus penetrate fibrous tissues better. The extent or reach of the energy from the surface of the probe is a common question and concern. While some energy does radiate away from the tip, such energy is excessively weak and not capable of tissue disruption. The very long wavelength (on the order of 5 cm) means that the energy quickly passes through any tissues and does not concentrate or focus at distal locations. The active energy is associated with the zone very near to the metal vibrating tip. Experiments with tissues, tissue phantoms, fingers, and other media can be used to show that the effective zone around a vibrating tip is limited to approximately 0.5 mm from the surface of the tip. If the tissue is outside of this distance, then generally, it will not be impacted in any way. Therefore, the effective use of an ultrasonically vibrating probe requires that the probe tip be placed in contact with all the targeted tissues. It is not analogous

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to an “air brush” or some other device that has an effect at a distance. Pulsed delivery of energy further reduces the average energy but maintains peak energy densities. This is analogous to the techniques used to calm the thermal delivery in continuous wave lasers. Short bursts of intense (peak) energy achieve the desired effect but limit the overall thermal energy deposition. The duration of the pulse must be short enough and the number of pulses per second must be large enough to achieve the desired effect. Less than about ten pulses per second results in nonsignificant differences relative to continuous wave.

41.3 Tissue Interactions The interaction between the tip of the ultrasonic probe and the tissue is a complex function of three different phenomena and is further strongly influenced by the technique of the surgeon. The three basic tissue interactions are (1) cavitation, (2) thermal, and (3) mechanical. The cavitation theory was the original theory that was advanced for the interaction between the ultrasonic device and the fatty tissue. The theory holds that the ultrasonic energy at the tip of the probe induces an acoustic field that causes gases dissolved in the tissue and fluids to accumulate in bubbles which are then acoustically driven to grow in size until they become unstable at which time they implode. The implosion is a violent process that releases energy in the form of shock waves and heat. The implosion actually releases only a very small amount of energy per bubble because the bubbles are very small. The net energy is the sum of the many bubbles that are being generated by the ultrasonic energy at the tip of the probe. The cavitation bubbles exist as a “beard” around the tip of the ultrasonic probe, seemingly attached to the probe surface and extending no more than a millimeter therefrom. The bubbles exist at profile changes in the tip, not along the smooth surfaces parallel to the axis of vibration. There is significant energy present in these zones of cavitation bubbles; no doubt it is enough to damage or lyse adipose cells. However, the question remains as to whether or not this is the primary interaction with tissue. For example, one can examine the interaction between the ultrasonic probe and tissue which is

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submerged in degassed water that has a significantly increased cavitation threshold. The tissue can still be easily fragmented/emulsified by the device, even though much of the cavitation has been suppressed. One can also reduce the amplitude of the device until cavitation is either greatly reduced or not present, and then apply the device to submerged tissue. While slower, the fragmentation/emulsification process is still observable. Further still, one can excise a sample of fatty tissue, say from an abdomen, with no infused fluid, and apply the device directly in an open-air environment. The fatty tissue will still dissolve or fragment quickly. Thus, while cavitation may be present, it is not the predominant tissue interaction. A thermal theory has been advanced. This theory holds that ultrasonic energy essentially “melts” the adipose tissue. Certainly, it is possible to generate heat with an ultrasonic probe device. However, this is the opposite of the surgical and treatment objectives. The addition of copious amounts of wetting solution and proper probe motion will ensure that no significant heat is generated. Some small amount of heat will always be generated by a high-frequency vibrating probe. However, the amount and distribution of the thermal energy can be easily controlled and managed such that the fragmentation/emulsification process can occur without untoward thermal effects. The amount of heat generation has been measured and quantified [1]. The mechanical theory holds that when the rapidly moving metal tip of the ultrasonic probe encounters the tissue, it creates high-energy vibration-induced impact and flow conditions that fragment/emulsify the adipose tissue. High and low pressures, rapid acoustic streaming, and impacts with fast-moving metal surfaces, individually and in combination, are enough to fragment/emulsify the tissue [2, 3]. All of the three types of interaction are likely to be present in most situations, to varying degrees. The design of the instrumentation and the technique used by the surgeon will influence how much of each interaction is present. With regard to the design, probes that are run at excessive amplitudes, or which have smooth overall shapes, are inefficient and will result in more thermal energy deposition and less mechanical fragmentation. Probes with flat or concave front surfaces will generate excessive cavitational energy that ultimately converts into thermal energy and also have very high energy densities along these surfaces. Mechanical efficiency is optimized by probe designs

41 Ultrasound-Assisted Lipoplasty: Basic Physics, Tissue Interactions, and Related Results/Complications

with many surfaces perpendicular to the axis of vibration and the elimination of sharp edges. With regard to the surgical technique, use of sufficient wetting solution and consistent probe movement will eliminate thermal issues. The vibrating tip should not be strongly pressed into any tissue as this removes the protective fluid and strongly couples the ultrasonic energy to the tissue, resulting in a strong thermal energy deposition (end-hit). Large diameter probes should be avoided as they possess excessive vibrational energy and require significant “pushing” to get through the tissue unless the amplitude is turned way up, again resulting in excessive vibrational energy applied to the tissues.

41.4 Results of the Physics and Tissue Interactions This section focuses on results enabled by the use of ultrasonic instrumentation from the perspective of the physics and tissue interactions. Results based on before and after pictures from lipoplasty surgeries are widely available elsewhere. With proper design and surgical technique, the mechanical tissue interaction discussed above can be made to dominate the tissue interactions. The advantage of such a combination is that the ultrasonic energy can be made to be tissue selective. The basis for the tissue selectivity is the “strength” of the various tissues relative to the “strength” of the ultrasonic energy [2, 3]. As the tissue strength increases, the effect of the ultrasonic energy decreases (Fig. 41.3). The ultrasonic energy level can be adjusted so that tissues with

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lower strengths are fragmented/emulsified (fatty tissues), while tissues with higher strengths are relatively undamaged. This is the key to success with ultrasonic instrumentation. Whereas suction-assisted avulsive trauma is not selective (anything pulled into the suction port is torn and removed), properly designed ultrasonic instrumentation can be tissue selective. This phenomenon is the basis for the use of ultrasonic energy in the neurosurgery field where similar type ultrasonic devices are used to fragment and aspirate brain tumor tissue while sparing as much nervous tissue and vascular tissue as possible. In fact, this phenomenon was the genesis of the application of ultrasonic energy to the lipoplasty procedure. When done properly, ultrasound-assisted lipoplasty fragments the adipose tissue and creates a soft emulsion (Fig. 41.4). Figure 41.4 shows the soft emulsion in an abdominoplasty sample where an incision has been placed to reveal the emulsified tissues, subsequent to the application of the ultrasonic energy. The collagen structures, vessels, and nervous tissue are spared (Fig. 41.5). Because the emulsified tissue/fluids can be more easily removed with less avulsive trauma than with traditional suction-assisted lipoplasty, more of the tissue matrix can be spared. The body thus experiences less tissue trauma than if the visible tissue matrix was extensively torn, resulting in faster healing, smoother results, and less pain. Further, the reduced tissue matrix trauma results in significantly reduced blood loss as has been shown when comparing the use of third-generation technology to suction-assisted lipoplasty in the back [4]. This study found 6–7 times less blood in the aspirate for the third-generation technology vs. SAL.

Fat

Increasing fragmentation

Muscle

Collagen Bone

Fig. 41.3 The effect of increasing tissue strength on fragmentation rate

Increasing tissue strength

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a

b Fig. 41.4 Soft emulsified tissue and fluids subsequent to the application of ultrasonic energy

Because the ultrasonic instrumentation is less traumatic to the tissue matrix, it can be used to enhance skin retraction in lipoplasty. Skin retraction is maximized when the superficial fatty layer is “thinned” (to 1 cm below the underside of the dermis) but minimally traumatized, meaning that the connective tissue and vas cular structure in this superficial layer remain as undamaged as possible. If this superficial layer is thinned with suction-assisted lipoplasty devices, the result is that the structures in this layer are torn or removed, leaving the skin less attached to the lower layers. The skin therefore does not experience the contractive loading of the connective tissue and tends to settle on the lower layers and scar/heal in place with very little contraction. Alternatively, if the superficial layer can be successfully “defatted” resulting in a volume reduction in the superficial layer but leaving the majority of the tissue matrix intact, then the skin will settle/heal subject to the elastic loading generated during the healing process to eliminate volume. There are two keys to successful defatting of the superficial layer: (1) the technology and technique used must result in minimal trauma to all tissues except the adipose cells; and (2) the technology and technique used must be applied uniformly and evenly in the superficial layer. The objective of proper application of ultrasonic energy to the lipoplasty procedure is to reduce avulsive trauma to the tissue matrix, which thereby promotes smoother results with more skin retraction, faster healing, less bleeding, and less pain. These results can be produced only with proper and appropriate application of ultrasonic energy. Early generation UAL devices had many design characteristics that precluded the

c

Fig. 41.5 Examples of spared collagen structures, vessels, and nerve tissue (a–c)

achievement of these objectives as described above in Basic Physics and below in Complications.

41.5 Complications Complications may be related directly to the design and use of ultrasonic instrumentation for lipoplasty. Complications related to surgical error or judgment for lipoplasty surgery or patient specific situations are not discussed.

41 Ultrasound-Assisted Lipoplasty: Basic Physics, Tissue Interactions, and Related Results/Complications

Complications can be lumped into two general categories: (1) “pilot error” which are complications due to a surgeon’s lack of knowledge concerning (a) proper use of the ultrasonic instrumentation, (b) tissue effects, (c) surgical endpoints, (d) energy delivery; and (2) ultra sonic instrumentation design issues that result in excessive energy delivery or inefficient energy delivery. Pilot error issues can be described as “technique issues” and the design issues can be described as “technology issues.” By far, the largest concern and most frequent complication can be described as “skin burns.” This type of complication is most often a “pilot error,” but can also be related to the design.

41.5.1 Burns at the Incision Site An ultrasonically vibrating probe will create heat through friction when pressed into the skin. The single most important factor is called “coupling.” In short, this refers to how hard the vibrating probe is pressed or torqued into the skin. An incision site acts as a fulcrum point. During suction-assisted lipoplasty the surgeon frequently and commonly torques or lifts the suction cannula about the incision fulcrum, largely without complication, although skin abrasion and stretching will occur. With an ultrasonically vibrating probe, such a technique will result in the immediate heating of the edges of the incision, especially if the incision is too small and the skin is tightly sphinctered around the vibrating probe. Skin ports have been designed to insulate the vibrating probe from the skin incision edges and they do a very good job. However, even skin ports will heat if the vibrating probe is torqued about the incision site and will thus heat the skin edges through the skin port. The proper technique is to avoid torquing and lifting of the vibrating probe about the incision point. Straight radial strokes without torquing eliminate coupling at the incision fulcrum and heating of the skin edges. Common mistakes include lifting the probe to try to reach around a curved body area or pushing the probe to extend the action of the tip beyond the reach of the probe. Additional incisions easily solve these problems. Torquing at the incision is by far the most common mistake of surgeons early in their experience with ultrasonic instrumentation, especially if they are classically trained in suction-assisted lipoplasty.

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41.5.2 External Burns Away from the Incision Site The vibrating probe can be pressed into the unprotected skin away from the incision site and will cause a friction burn. It usually appears as a “line blister” where the probe was momentarily pressed into the skin and most often happens where rounded areas of skin are contacted when the surgeon tries to keep the probe flat and parallel to the skin. The most frequent areas are the “pouch” between the suprapubic area and the umbilicus when the surgeon is working in the epigastrium through the umbilicus and the buttock when working in the banana rolls or medial thighs. This type of skin burn is 100% preventable with proper placement of a protective towel so that when the probe is moved to a position such that it would be in contact with the skin, it is instead pressing on the towel. One layer of towel is usually not sufficient as it will conduct heat rapidly to the skin below. A folded towel with two to three layers provides sufficient protection in almost all instances. The towel may be wet or dry as long as sufficient layers (folds) are used.

41.5.3 End-Hits End-hits are simply pressing (poking) the vibrating tip of the probe into the underside of the dermis. This most often happens when the anatomy curves away from a flatter area and the probe is advanced so that the tip pokes into the skin, resulting in a concentration of energy at the tip of the probe. End-hits will most often leave small points of hyperpigmentation that heal over time. End-hits are 100% avoidable by maintaining a probe orientation as flat as possible with the skin surface and by avoiding the tendency to “reach around a corner.”

41.5.4 Contribution of Excessive Amplitude As the amplitude of vibration in the probe is increased, the potential to generate heat through friction also increases. Amplitude should be set at the minimum value, which allows for graceful gliding motion of the probe without significant “hanging” or “drag.” Directly related to this issue is the proper choice of the probe

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for the type of tissue. One style of probe is not appropriate for all tissue types. Fibrous tissues require smaller diameter probes and probes with less coupling. Softer tissue allow for larger probe diameters and probes with more coupling. If a larger diameter probe is used in fibrous tissue, excessive vibration amplitude will be required to get the probe to pass through the tissue. This is the source of many of the complications associated with first and second-generation ultrasonic instrumentation.

41.5.5 Complications Associated with Volume of Wetting Solution Ultrasonic instrumentation requires more wetting solution than suction-assisted lipoplasty. The wetting solution provides thermal protection to the tissues, aids in forming a soft emulsion for removal with aspiration cannulas, and ensures wide and uniform distribution of epinephrine for vasoconstriction. Two of these three benefits are not required for suctionassisted lipoplasty. When insufficient wetting solution is used, patients may experience prolonged edema, induration, a tingling/burning sensation, or increased pain. Use of sufficient wetting solution will largely, if not completely, eliminate these problems. Suctionassisted lipoplasty generally and widely uses a 1:1 ratio for wetting fluid infused to estimated aspirate out, most commonly referred to as the “superwet technique.” Other techniques use more wetting solution, with upper ranges as high as 2:1 or 3:1. Ultrasoundassisted lipoplasty requires a range of 1.5:1–2:1. This amount of fluid generally eliminates the potential complications discussed above and is widely and successfully used in ultrasound-assisted lipoplasty surgery. Other than skin burns, the most frequent complaint related to the use of ultrasound-assisted lipoplasty devices is prolonged healing or edema, or pain. This result can almost always be directly correlated with the use of insufficient fluid. Suction-assisted lipoplasty surgeons are often slow to adopt the increased requirements for wetting solution in ultrasoundassisted lipoplasty, believing that the familiar 1:1 should be sufficient. It is important to the final result and to the comfort of the patient postoperatively that sufficient wetting solution be used.

W. W. Cimino

41.5.6 Complications Associated with Aggressive Aspiration Once the adipose tissue has been emulsified, it does not require aggressive avulsive aspiration. Special cannulas have been designed to rapidly remove the emulsified tissues and fluids with minimal avulsive trauma. When the emulsified tissues and fluids have been removed, an amount of traditional suctionassisted lipoplasty with its attendant avulsive trauma may be required to achieve the final contour. If the avulsive suction phase is pursued aggressively, it will destroy the benefit and gains of the ultrasonic phase, namely the emulsification of the adipose tissue with no avulsive trauma. Thus, it is important not to use overly aggressive aspiration subsequent to the ultrasonic emulsification phase.

41.5.7 Complications Associated with Over Application of Ultrasonic Energy Any energy source can be overused or overapplied, and the same holds true for ultrasonic energy. Safe and effective guidelines for ultrasonic energy amplitude and duration have been developed and are supplied as general guidelines with the instrumentation. Generally speaking, 1 min of ultrasonic time per each 100 mL infused into an area results in good emulsification and no postoperative problems. With experience and sufficient wetting solution, 1 min and 30 s of ultrasonic time per 100 mL of infused wetting solution is commonly used. As ultrasonic time approaches 2 min/100 mL of infused wetting solution, the complications described above related to the volume of wetting solution begin to become more pronounced. Fortunately, almost all of the targeted adipose tissue can usually be addressed before the 1 min 30 s/100 mL infused limit is reached. It is important to note that not all ultrasonic instrumentation can be treated similarly in this regard. First and second-generation UAL devices are generally too much powerful to be used with these time/ amplitude guidelines and should be adjusted accordingly.

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41.5.8 Complications Associated with Instrumentation Design The original ultrasonic instrumentation for lipoplasty was the SMEI Sculpture system. This system had large diameter probes with blunt smooth ends. Such a design has no area of ultrasonic activity except the central portion of the hemispherical tip, a very small area. This design was so inefficient that extended application was required to produce emulsification. This design thus resulted in unnecessarily extended application times. Second generation devices added a central lumen to the vibrating probes for aspiration. The central lumen was approximately 2 mm in diameter on a 5-mm probe. Usually a 1.8–2.0-mm aspiration cannula is much shorter than the 27–32 cm lengths of these ultrasonic probes, specifically because aspiration with such a small diameter lumen is extremely slow and applicable to only small volumes. Thus, a very slow aspiration system was combined with a large and powerful 5 mm ultrasonic probe. Surgeons had the mistaken concept that the aspiration that they were seeing was related to the effect of the ultrasound in the tissue as they were visualizing the aspirant. This is not correct. The transit time for the aspirant up the 2 mm lumen was on the order of 2–5 s, while the tip was vibrating at 22,000– 27,000 times/s. Only a single to a few hits of the vibrating probe are required to fragment the adipose tissue in a particular area, requiring only thousandths of a second. Thus, surgeons tended to continue applying excessive ultrasonic energy because they were working with a time constant of 2–5 s or more (visual) and the ultrasound was effective with a time constant of a few thousandths of a second. Further, adipose tissue and saline were essentially “frothed” in the vibrating aspiration channel, changing the color and texture of the aspirant relative to the actual emulsified tissue/fluids in the body, further distorting the perception of the surgeon. Further still, the vacuum at the tip of the vibrating probe pulled the tissue up against the vibrating probe tip and strongly increased coupling, unnecessarily damaging the tissue. Ultrasonically, vibrating probes generate an acoustic pressure that pushes the tissue away from the probe, thus minimizing the excessive application of energy unless the probe is pressed strongly into the tissue. All third-generation ultrasound technology for lipoplasty is solid probe technology for these reasons and the complications associated with a central lumen for aspiration have been eliminated.

Fig. 41.6 A 5-mm hollow golf-tee ultrasonic probe

A golf-tee type tip design was introduced with the second-generation Lysonix 2000 system (Fig. 41.6). This design had a concave tip with a central lumen and a reasonably sharp edge around the edge of the tip. When vibrated at ultrasonic frequencies, the sharp edge becomes very sharp, in fact making this probe design a “powered curette.” This design is thus responsible for many of the reported complications with early generation UAL systems. For the past decade, there has been wide circulation of certain photos showing large areas of necrosed skin related to the use of ultrasonic instrumentation for lipoplasty. While such a result could be produced through improper and excessive use of ultrasonic instrumentation, the same result could be produced through improper and excessive use of suction-assisted lipoplasty. These are pictures of “bad surgery”; not pictures of “results of ultrasonic instrumentation for lipoplasty.” If indeed these pictures are the result of a surgery where ultrasonic instrumentation was used, the disastrous results could have been easily avoided with (1) sufficient use of wetting solutions, (2) appropriate

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application of ultrasonic energy addressing both the duration of application and the amplitude of vibration, and (3) proper and reasonable aspiration of the emulsified tissues, thus limiting the avulsive trauma of the suction cannula.

41.6 Conclusions Ultrasound-assisted lipoplasty is now a stable and growing method of lipoplasty. Applications have been expanded from basic body contouring to the contouring of the face and neck, breast, and other delicate areas such as the knees and ankles. New applications and treatments are under investigation for the permanent treatment of axillary hyperhidrosis. Complications resulting from first to second-generation ultrasonic technology/devices have been largely eliminated; firstly by significantly improved third generation instrumentation design, and secondly, by significantly improved information and understanding of proper techniques and surgical endpoints when using ultrasonic instrumentation for lipoplasty. Published

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studies now show the substantial decrease in blood loss when using third-generation UAL technology compared to SAL. Ultrasonic technology for lipoplasty has progressed from initial high excitement with rudimentary first-generation technology to waning excitement with second-generation technology to stable and growing acceptance and utilization with third-generation technology.

References 1. Cimino WW. Ultrasonic surgery: power quantification and efficiency optimization. Aesthetic Surg J. 2001;21(3):233–40. 2. Cimino WW, Bond LJ. Physics of ultrasonic surgery using tissue fragmentation: part I. Ultrasound Med Biol. 1996; 22(1):89–100. 3. Bond LJ, Cimino WW. Physics of ultrasonic surgery using tissue fragmentation: part II. Ultrasound Med Biol. 1996; 22(1):101–12. 4. Garcia O, Nathan M. Comparative analysis of blood loss in suction-assisted lipoplasty and 3rd-generationinternal ultrasound-assisted lipoplasty. Aesthetic Surg J. 2008; 28:430–5.

History of Ultrasound-Assisted Lipoplasty

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42.1 Introduction The use of high-frequency vibrations in surgical instru ments, commonly referred to as ultrasonic surgical instrumentation, typically involves a frequency of vibration in the range from 20,000 cycles per second (20 kHz) to 60,000 cycles per second (60 kHz). The metal probe or tip of the surgical instrument moves forward and backward at the aforementioned frequencies to create a desired surgical effect. The choice of frequency and the design of the tip of the metal probe determine the application of the instrument and how the device interacts with the targeted tissue.

42.2 History Ultrasonic instrumentation for surgical application was first introduced for the dental descaling of plaque in the late 1950s and early 1960s [1]. This technique and technology for dental scaling are still widely used today. In 1969, Kelman [2, 3] adapted the vibrating metal probe to the phacoemulsifcation procedure. Aspiration and irrigation capability were added to the basic vibrating device to facilitate the safe and effective removal of the cataract. Today, over two million cataracts each year are removed in the U.S. using this technology and associated technique [4]. The clinical effect of the phacoemulsification device on the cataract has been attributed to a micro-chopping effect [5].

W. W. Cimino 578 W. Sagebrush Ct., Louisville, CO 80027, USA e-mail: [email protected]

Safe and effective techniques and technology for this ultrasonic instrumentation have evolved to the degree that the cataract removal portion of the phacoemulsification procedure is often finished in less than 5 min per eye and over 98% of all cataract removals in the U.S. are now done using the phacoemulsification technique. In 1974, the phacoemulsification device was further modified and applied to neurosurgery for tumor removal. The objective of the device was to selectively remove pathologic brain and spine tissues with minimal residual trauma to remaining tissues. The CUSA (cavitron ultrasonic surgical aspirator) device, the first such instrument, is still in wide use today. Several companies produce ultrasonic aspirators for neurosurgery and are used in over 200,000 procedures per year worldwide. The tissue selective nature of the devices, i.e., the ability to spare nerves and vessels, has been attributed to the device’s ability to differentiate between tissues with different water contents and to a process called cavitation. The cavitation theory has never been proven and alternative theories have been presented that base the selective tissue effect on an interaction between the strength of the tissue and a mechanical action of the device [6–8] and view the cavitation process as an unavoidable consequence, but not the primary mechanism of tissue interaction. In the late 1980s and early 1990s, the concept of an ultrasonic instrument was adapted to a cutting and coagulating device with application to laparoscopic surgery in the abdomen. Techniques and technology were developed and are used today for laparoscopic cholesystectomies, laparoscopic appendectomies, laparoscopic Nissen fundoplications, and other laparoscopic procedures. It is estimated that between 400,000 and 600,000 procedures per year are done using this technology (worldwide).

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The application of ultrasonic instrumentation to body contouring surgery began in the late 1980s and early 1990s. Scuderi [9] and Zocchi [10–14] pioneered the application of ultrasonic vibration to fat emulsification and removal. The hope and objective of this effort was to create both technology and associated techniques that consistently produced a safer and more effective means of aesthetic body contouring when compared to known methods of the time, namely suction-assisted lipoplasty (SAL). The benefits of tissue selectivity demonstrated and utilized in the previously mentioned surgical applications, especially neuro surgery, were expected to produce a method of lipoplasty that was more “fat specific” than the existing and well-known suction cannula. This technology (and technique) was named ultrasound-assisted lipoplasty (UAL). The first-generation UAL device was produced by the SMEI Company of Italy and utilized smooth, solid probes at a frequency of 20 kHz. The solid probes had a stepped design with diameters at the tip as small as 3.0 mm (small probe) and diameters at the base as large as 6.0 mm (large probe). The basic technique involved good surgical practice and two fundamental rules: (1) the essential use of a wet environment produced by infiltration of sufficient wetting solution, and (2) constantly moving the probe to prevent thermal injury [13]. Initial surgical times were in the range from 10 to 12 min for a 250–300 ml removal or approximately 4 min of ultrasound time per 100 ml of aspirate [13]. Around 1995, a growing interest in UAL in the United States prompted the plastic surgery community leadership to create a UAL Task Force that included representation from the American Society for Aesthetic Plastic Surgery, Aesthetic Society Education Research Foundation, American Society of Plastic Surgery, Lipoplasty Society of North America, and Plastic Surgery Education Foundation. The mission of the Task Force was to evaluate the new ultrasonic instrumentation for lipoplasty and to assist in its teaching and introduction in the United States. Teaching courses were offered under the oversight of the Task Force with didactic and hands-on training. Subsequent to his Task Force efforts, Fodor [15] published his experience on 100 patients using a contralateral study model. His conclusions comparing SAL to UAL found no significant differences between SAL and UAL and failed to prove the claimed benefits attributed to UAL.

W. W. Cimino

During the UAL Task Force period, second-generation UAL devices became available. These devices included the Lysonix 2000 (Lysonix Inc., Carpinteria, CA) and the Mentor Contour Genesis (Mentor Corporation, Santa Barbara, CA). The Lysonix system operated at a frequency of 22,500 Hz (22.5 kHz) and utilized hollow ultrasonic cannulae that aspirated emulsified fat simultaneously with the emulsion process. Cannula offerings were “golf-tee” and “bullet” designs with diameters of 4.0 and 5.1 mm. The “golf-tee” tip design with a 5.1 mm diameter was, in theory, the most commonly used design because of its “higher” efficiency. The Mentor Contour Genesis was an integrated system with suction, infusion, and an ultrasonic generator all packaged in one moveable system. The ultrasonic frequency was 27,000 Hz (27.0 kHz) and also utilized hollow ultrasonic cannula, with diameters offered from 3.0 to 5.1 mm. The shape of the tip of the Mentor cannulae was flat with side ports for aspiration for all tip diameters. The UAL technique continued to evolve with both the Lysonix and Mentor devices. Originally, application times were long, and significant complications were reported, and safety was questioned [16–21]. As application times were reduced, the complication rate declined. Application times were reduced to 1 min of ultrasound per 100 ml of aspirate [22, 23]. The concept of “loss of resistance” became widely known as a realistic surgical endpoint. Rapid probe movement [23] was introduced as another means to safely control the energy presented by the second-generation machines. Overall, results ranged on one end from safe and effective use of UAL to high complication rates and questionable safety on the other end. In 1998, Topaz [24] published an article concerned with the long-term impact of UAL due to hypothesized sonoluminescence, sonochemistry, and free-radical generation. To study the safety issues raised by this publication, ASERF organized a Safety Panel Meeting, held in St. Louis in November 1998, which included experts in biochemistry, ultrasonic surgery, cavitation physics, and experienced UAL users. A number of research efforts and studies were launched and completed to address issues identified at the meeting, and a summary report was produced by the Safety Panel coordinator [25]. Conclusions reached by the panel of experts record that (1) more needs to be known about the tissue interaction process, (2) hydrogen peroxide is the only reactive oxygen species potentially produced

42 History of Ultrasound-Assisted Lipoplasty

by UAL that is capable of inducing DNA damage, (3) that hydrogen peroxide was not detectable following direct sonication of wetting solution with a UAL machine (100 nmol resolution), and (4) that the authors must conclude that there is no significant risk of malignant transformation from H2O2 (or any other ROM) produced during UAL [25]. In the late 1990s, the Lysonix Company and the Mentor Corporation, the 2nd generation device manufacturers and distributors, became involved in litigation concerning patent infringement. The lawsuit lasted until late 2001 when the Mentor Corporation prevailed and received a judgment against Lysonix. As a direct consequence, the Lysonix Company was subsequently absorbed by the Mentor Corporation. During this litigation period, technologic advancement and continued development of the equipment and accessories were literally frozen, resulting in a complete lack of response to clinical and market needs. As a consequence of the Topaz article, the Lysonix/ Mentor litigation, the generally less-than successful clinical success, and clearly visible feuding between the European progenitors of the UAL technique and the plastic surgery leadership in the United States, ultrasonic instrumentation for body contouring surgery began to fall into disfavor as a technique of choice for body contouring surgery. Analysis of this process showed that cost of the equipment, a long learning curve, manufacturer marketing without sufficient clinical and fundamental science, improper application techniques, larger incisions, longer surgical times, and conflicting results presented at major plastic surgery meetings resulted in confusion and disappointment in the surgical community worldwide. A number of surgeons continued to use the ultrasonic instrumentation safely and effectively [42–45]. Their evolving technique allowed them to get effective results without the complications noted at the introduction of the technology. Further, use of the ultrasonic devices was safely expanded to the face and breast [26, 27]. In early 2001, a third-generation of ultrasonic instrumentation for body contouring surgery became available. This technology was named VASER, for Vibration Amplification of Sound Energy at Resonance. The VASER technology and associated technique (Sound Surgical Technologies, Louisville, CO), referred to as VAL for VASER-Assisted Lipoplasty, was designed to minimize or eliminate known complications from earlier generations of UAL technology

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and to simultaneously realize the benefits of ultrasonic instrumentation as established in other surgical arenas. The guiding concept was to develop instrumentation that would emulsify fatty tissue quickly and safely with the absolute minimum amount of energy, thereby achieving the desired result with little or no residual trauma to the remaining tissues. VASER instru mentation introduced the concepts of pulsed delivery of ultrasonic energy, small-diameter solid probes (2.2–3.7 mm), and grooved probe designs to increase efficiency. Gentle emulsion cannulae for the aspiration phase were introduced to preserve the delicate structure of the tissue matrix after the emulsion process was completed. In 1999 and 2001, Cimino [8, 28] published the first scientific studies that defined the amount of power delivered to the tissues by various ultrasonic surgical devices and clearly defined the variables under the control of the surgeon that determine safety and outcomes. This basic scientific information led to clearly understood relationships between “causes” and “effects” when using ultrasonic surgical instrumentation for body sculpting surgery. As a direct consequence, the suction aspect of the ultrasonic instrumentation was eliminated (hollow ultrasonic cannulae) and replaced by solid probe designs, probe diameters were significantly reduced, efficiency was improved using the grooved probe designs, and pulsed energy delivery was introduced, all of which significantly reduced the energy delivered to the patient. A pilot clinical study on 77 patients completed by Jewell et al. [29] using the VASER and the VAL technique (multicenter) showed zero complications and effective results.

42.3 Conclusions At present, the first-generation SMEI technology (Sculpture) and the second-generation Mentor technology (Contour Genesis) have been removed from the market. The second-generation Lysonix technology remains in the market, largely unchanged, and with declining overall presence. The third-generation VASER technology is stable and growing, and has become the dominant internal UAL instrumentation in the market. The precise energy control and refined instrumentation provided by the VASER system have expanded

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utility, principally due to safe and effective application in the superficial layers. The VASER is currently being used to contour the face and neck [30, 31], for breast contouring and reduction [32–34], and for an advanced “high-definition” contouring procedure [35]. New VASER applications are being developed such as a treatment for permanent elimination of axillary hyperhidrosis [36]. Published scientific studies have shown reduced blood loss when using VASER compared to SAL [37] and the viability of VASER aspirate for autologous fat transfer [38]. VASER has been successfully and safely combined with excisional surgery and is a key component of new methods of lipoabdominoplasty [39–41].

References 1. Forrest JO. Ultrasonic scaling. A five-year assessment. Br Dent J. 1967;122(1):9–14. 2. Kelman C. Phacoemulsification and aspiration. A new technique of cataract removal. A preliminary report. Am J Ophthalmol. 1967;64(1):23–5. 3. Kelman C. Phacoemulsification and aspiration: a report of 500 consecutive cases. Am J Ophthalmol. 1973;75(5): 764–8. 4. http://www.alconlabs.com 5. Seibel BS. Phacodynamics. Thorofare, NJ: Slack; 1993. 6. Cimino WW, Bond LJ. Physics of ultrasonic surgery using tissue fragmentation: Part I. Ultrasound Med Biol. 1996;22(1): 89–100. 7. Bond LJ, Cimino WW. Physics of ultrasonic surgery using tissue fragmentation: Part II. Ultrasound Med Biol. 1996;22(1):101–12. 8. Cimino WW. The physics of soft tissue fragmentation using ultrasonic frequency vibration of metal probes. Clin Plast Surg. 1999;26(3):447–61. 9. Scuderi N, Devita R, D’Andrea F, Vonella M. Nuove prospettive nella liposuzione la lipoemulsificazone. Giorn Chir Plast Ricostr ed Estetica. 1987;2(1):33–9. 10. Zocchi ML. Metodo di trattamento del tessuto adiposo con energia ultrasonica. Congresso dell Societa Italiana di Medicina Estetica. Roma, Italy: Apr 1988. 11. Zocchi ML. New prospectives in liposcultpuring: the ultrasonic energy. 10th ISAPS Congress. Zurich, Switzerland; 1989. 12. Zocchi ML. Clinical aspects of ultrasonic liposculpture. Perspect Plast Surg. 1993;7:153–74. 13. Zocchi ML. Ultrasonic assisted lipoplasty. Clin Plast Surg. 1996;23(4):575–98. 14. Zocchi ML. Basic physics for ultrasound-assisted lipoplasty. Clin Plast Surg. 1999;26(2):209–20. 15. Fodor PB, Watson J. Personal experience with ultrasoundassisted lipoplasty: a pilot study comparing ultrasoundassisted lipoplasty with traditional lipoplasty. Plast Reconstr Surg. 1998;101(4):1103–16.

W. W. Cimino 16. Troilius C. Ultrasound-assisted lipoplasty: is it really safe? Aesthetic Plast Surg. 1999;23(5):307–11. 17. Lack EB. Safety of ultrasonic-assisted liposuction (UAL) using a non-water-cooled ultrasonic cannula. A report of six cases of disproportionate fat deposits treated with UAL. Dermatol Surg. 1998;24(8):871–4. 18. Baxter RA. Histologic effects of ultrasound-assisted lipoplasty. Aesthetic Surg J. 1999;19:109–14. 19. Perez JA. Treatment of dysesthesias secondary to ultrasonic lipoplasty. Plast Reconstr Surg. 1999;103(5):1534. 20. Gerson RM. Avoiding end hits in ultrasound-assisted lipoplasty. Aesthetic Surg J. 1997;17:331–2. 21. Grolleau JL, Rouge D Chavoin JP, Costagliola M. Severe cutaneous necrosis after ultrasound lipolysis. Medicolegal aspects and review. Ann Chir Plast Esthet. 1997;42(1): 31–6. 22. Tebbetts JB. Minimizing complications of ultrasoundassisted lipoplasty: an initial experience with no related complications. Plast Reconstr Surg. 1998;102(5): 1690–7. 23. Tebbetts JB. Rapid probe movement ultrasound-assisted lipoplasty. Aesthetic Surg J. 1999;19(1):17–23. 24. Topaz M. Long-term possible hazardous effect of ultrasonically assisted lipoplasty. Plastic Reconstr Surg. 1998;102(1):280; author reply 280–1. 25. Young VL, Schorr MW. Report from the conference on ultrasound-assisted liposuction safety and effects. Clin Plast Surg. 1999:26(3):481–524. 26. DiGiuseppe A. The harmonic lift: ultrasonically assisted skin remodeling. Int J Cosmet Surg. 2000;2(2):125–31. 27. DiGiuseppe A, Santoli M. Ultrasound assisted breast reduction and mastopexy. Aesthetic Surg J. 2001;21:493–506. 28. Cimino WW. Ultrasonic surgery: power quantification and efficiency optimization. Aesthetic Surg J. 2001;21(3): 233–40. 29. Jewell ML, Fodor PB, de Souza Pinto EB, Al Shammari MA. Clinical application of VASER-assisted lipoplasty: a pilot clinical study. Aesthetic Surg J. 2002;22(2):131–46. 30. Di Giuseppe A. Ultrasound-assisted lipoplasty for face contouring with VASER. In: Shiffman MA, Di Giuseppe A, editors. Liposuction: principles and practice. Berlin: Springer; 2006. p. 245–53. 31. Di Giuseppe A., Commons G. Face and neck remodeling with ultrasound assisted (VASER) lipoplasty. In: Shiffman MA, Mirrafati SJ, Lam SM, editors. Simplified facial rejuvenation. Berlin: Springer; 2008. p. 137–48. 32. Di Giuseppe A. Breast reduction with ultrasound-assisted lipoplasty. Plast Reconstr Surg. 2003;112(1):71–82. 33. Di Giuseppe A. Mastopexy (breast lift) with ultrasoundassisted lipoplasty. In: Shiffman MA, Di Giuseppe A, editors. Liposuction: principles and practice. Berlin: Springer; 2006. p. 254–7. 34. Di Giuseppe A. Ultrasound-assisted lipoplasty for breast reduction. In: Shiffman MA, Di Giuseppe A, editors. Liposuction: principles and practice. Berlin: Springer; 2006. p. 415–24. 35. Hoyos AE, Millard JA. VASER-assisted high-definition liposculpture. Aesthetic Surg J. 2007;27:594–604. 36. Commons GW, Lim AF. Treatment of axillary hyperhidrosis/bromodrosis using VASER ultrasound. Aesthetic Plast Surg. 2009;33(3):312–23.

42 History of Ultrasound-Assisted Lipoplasty 37. Garcia O, Nathan M. Comparative analysis of blood loss in suction-assisted lipoplasty and 3rd-generation internal ultrasound-assisted lipoplasty. Aesthetic Surg J. 2008;28:430–5. 38. Panetta NJ, Gupta DM, Kwan MD, Wan DC, Commons GW, Longaker MT. Tissue harvest by means of suction assisted or 3rd-generation ultrasound assisted lipoaspiration has no effect on osteogenic potential of human adipose-derived stromal cells”. Plast Reconstr Surg. 2009;124(1):65–73. 39. De Souza Pinto EB, Federico R, De Melo SP, Contin L, De Souza RPM. Lipomioplasty with VASER: a new approach to body contouring. In: Eisenmann-Klein M, NeuhannLorenz C, editors. Innovations in plastic and aesthetic surgery. Berlin: Springer; 2008. p. 433–42. 40. Jewell ML. Innovation in plastic and aesthetic surgery. In: Eisenmann-Klein M, Neuhann-Lorenz C, editors. Lipoplasty

403 innovations in plastic and aesthetic surgery. Berlin: Springer; 2008. p. 443–53. 41. Senyuva C. VASER lipoabdominoplasty, Turkey: Elit Ofset; 2007. 42. Maxwell GP. Use of hollow cannula technology in ultrasoundassisted lipoplasty. Clin Plast Surg. 1999;26(2):255–60. 43. Kloehn RA. Liposuction with “sonic sculpture”: six years’ experience with more than 600 patients. Aesthetic Surg J. 1996;16(2):123–8. 44. Rohrich RJ, Beran SJ, Kenkel JM, Adams WP Jr, DiSpaltro F. Extending the role of liposuction in body contouring with ultrasound-assisted liposuction. Plast Reconstr Surg. 1998; 101(4):1090–102; discussion 1117–9. 45. Gilliand MD, Commons GW, Halperin B. Safety issues in ultrasound-assisted large volume lipoplasty. Clin Plast Surg. 1999;26(2):317–35.

Face and Neck Remodelling with Ultrasound-Assisted Lipoplasty (Vaser)

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Alberto Di Giuseppe

43.1 Introduction The author started to apply an internal ultrasound solid probe to face and neck in 1996 to defat the heavy face or to undermine lax skin of the neck to possibly achieve skin retraction, utilizing the sculpture ultrasound device (SMEI, Italy) with a solid probe 2.5 mm in diameter and 17 cm long [1]. While utilizing the solid probe in the face, the power administered was 30% of the total potential of the ultrasound tool to reduce the undesirable side effects of ultrasound energy (essentially heat). The aim of the technique was: 1. To reduce the number and extension of scars of the face for remodeling procedures of face and neck. 2. To perform essentially the majority of facial contouring surgery under local tumescent anesthesia. 3. To induce skin retraction in face and neck even with lax skin, avoiding major open surgery operation such as the standard face-lift. 4. To undermine and induce skin retraction with minimal trauma by utilizing a solid probe and ultrasound energy, instead of an open approach and a scalpel. 5. To debulk the heavy face, neck, and jowls with a smooth device able to emulsify fat in specific target with a minimal trauma, low energy, and safe surgical planes. 6. To contour difficult areas such as the mandibular border, neck line, and chin.

A. Di Giuseppe Department of Plastic and Reconstructive Surgery, School of Medicine, University of Ancona, 1, Piazza Cappelli, 60121 Ancona, Italy e-mail: [email protected] e-mail: [email protected]

7. To make facial surgery accessible even for patients who refuse major open surgical operations that normally lead to a longer recovery time. Under those circumstances, what the author called at that time “The harmonic lift” was not used as a substitute for standard rhytidectomy, but to offer an alternative technique in facial contouring surgery.

43.2 Patient Selection The “harmonic lift” can be used in young patients with fatty necks and cheeks, as well as in older patients with loose skin and wrinkles. Each patient is evaluated as to the aims of surgery such as treatment of crow’s feet, nasolabial and commissural folds, jowls, and waddle neck. The procedure is appropriate in the following type patients: 1. Face and neck lift in Fitzpatrick type 4–6, thereby avoiding keloid formation and postinflammatory hyperpigmentation that may occur with skin rejuvenation using laser or peel. 2. Young patients who require only treatment of chubby cheeks and double chin. 3. To enhance neck definition with chin augmentation. 4. To substitute for endoscopic forehead lift in balding scalps. 5. To achieve dermal stimulation and retraction in the neck beyond areas amenable to laser resurfacing. 6. To release acne scarring of the cheeks. 7. In secondary and tertiary face-lifts when partial removal of the skin is a questionable procedure, but the central face needs further tightening.

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Other indications include rhytids in the malar area, crow’s feet, frontal, nasolabial, glabella (horizontal and vertical), and neck as well as descent of the cheek fat, ptosis of the lateral eye-brows, laxity of the upper lids, jowls, and diffuse acne scarring of the cheeks and neck.

43.3 Technique Lines are drawn on the face to show the full area of undermining, the vectors of muscle tension, relaxation creases and folds, and crisscrossing lines of tunneling and dermal stimulation. Incisions are placed at different sites to allow ease of access depending on the target areas (Fig. 43.1). In the forehead, incisions are vertical to avoid nerve damage and are at the hairline, midline, or frontal recess. Temporal incisions are parallel to the hairline while submental incisions are at the submental crease. Preauricolar incisions are made at the earlobe and upper and lower eyelid incisions are at blepharoplasty sites.

Fig. 43.1 Incision lines: frontal, temporal, retroauricular, submental, laterocervical, and eyelid

A. Di Giuseppe

The use of the tumescent technique reduces bleeding and bruising and decreases surgical time. Klein’s solution [2] used contains 1,000 mL of normal saline with 1.5 mL epinephrine (15 mg), 1,500 lidocaine, and 12.5 mEq sodium bicarbonate. Intravenous sedation is generally utilized but when general anesthesia is used and lidocaine is reduced to 200 mg with elimination of sodium bicarbonate. Between 75 and 1,510 mL of solution is utilized on each side. Total infiltration never exceeds 450 mL in the heavy face plus neck. A blunt-tipped, 14 gauge cannula is used to infiltrate the subcutaneous tissues of the neck, jowls, cheeks, temple, and brow. Digital pressure aids in directing and expanding the fluid evenly.

43.4 Ultrasonic-Assisted Dissection Ultrasonic dissection is performed with a titanium solid probe 2.2 mm diameter, which is the thinnest armamentarium produced by S.S.T. (Sound Surgical Technologies, Denver, Co, USA) Vaser ultrasonic device. The power setting is lowered to 30% of total power [3, 4]. The areas include frontal from the hairline to the brow, glabella, dorsum of the nose, temple, lateral canthal region (crow’s feet), cheeks to nasolabial grooves, chin, jowls, and anterior neck from chin to sternal notch (anterior triangles). The probe is advanced subdermally and the tip of the probe tents the skin while it is withdrawn. Blanching of the skin occurs with treatment and is more noticeable in the patient with ruddy complexion. The skin softens and smoothes following use of the probe. The sequence of dissection starts with the submental area and neck from the submental and earlobe incisions. The probe is then used over the mandible, cheek, and temple reaching the nasolabial fold, side of the nose, and the crow’s feet in a radiating fashion through the earlobe incision. An upper eyelid incision allows access to the glabella and central portion of the forehead releasing the cutaneous insertion of the corrugator and procerus muscles without altering skin sensation. The rest of the forehead is dissected through a separate hairline incision (Fig. 43.2). The fat emulsion and tumescent fluid is evacuated by gentle massage of the areas. When the harmonic face-lift (ultrasonic skin rejuvenation) is used alone, the skin incisions are closed with skin sutures and

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Epifoam is applied to the skin and a chin strap applied. Ice packs are used on the face and orbital regions not covered by the foam. A supporting garment is applied for 1 week, and then for 2 weeks more, at night time (Fig. 43.3).

43.5 Concomitant Procedures The superficial musculoaponeurotic system (SMAS) can be tightened by dissection and resection or imbrication for face- and neck lift. Skin excision is usually minimal, if required at all (Fig. 43.4) [5]. Any other cosmetic procedure can be performed at the same time including upper and lower blepharoplasty, platysmaplasty, face-lift, neck lift, chin or cheek implants, temporal lift, forehead lift, and skin rejuvenation with laser or chemical peel. Vaser can be used for face remodeling with autologous fat transfer. Fig. 43.2 Tension lines of action with Vaser UAL solid probe: 50% of total power, 5–12 min for full face undermining

43.6 Complications Two patients developed postoperative hematoma that required aspiration; however, both were hypertensive and noncompliant with their medications. Contour deformities of the neck were noted in three patients with two of them improving over 2 months. One patient required surgical release of the subdermal scar and asked for a more extensive surgery, a standard open face-lift with SMAS (Fig. 43.5) [6, 7]. There were no instances of nerve injury, alopecia, or a vascular necrosis. The ultrasonic assisted facial rejuvenation was safe, effective, and reproducible. The results were comparable to more extensive, difficult surgeries with higher morbidity, risks, and costs.

43.7 Discussion

Fig. 43.3 Face supporting garment

There has been a lot of interest in the use of ultrasonic liposuction for body contouring. Skin retraction has been reported as a result of the concomitant use of internal ultrasound from the large amount of fat removed, removal of subdermal fat, skeletonization

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c d

Fig. 43.4 (a) Flap harvesting. (b) Vaser undermining. (c) Emulsion cleaning. (d) Verifying tunnels made by probe. Note untouched supporting structures of the skin

of the superficial fascial system, and thermal effects on the subdermal surface and collagenous structures of the superficial facial system (Fig. 43.6) [8–11]. Facial aging is due to fat and skin ptosis and not muscle or facial ptosis. Therefore, the supra-SMAS plane is ideal for the harmonic lift with ultrasonic rejuvenation of the face. The osteofacial dermal ligaments can be released or attenuated in this plane allowing direct contouring of the malar, nasolabial, jowl, and submental fat collections. Fat removed close to the under surface of intact skin results in skin retraction with permanent contour changes. Postoperative care requires careful nursing assistance, punctilious wound protection, and prolonged seclusion of elaborate makeup. Recovery time varies from 4 to 14 days. The postoperative care is limited to the use of Reston foam and elastic compression bandages that are changed by the

patient. Although there are no histological examinations in this study, there have been previous reports on the results of subdermal ultrasound and liposuction [12, 13]. The long-term results have not been evaluated and are probably related to the type of skin, patient age and sex, and the long-term effect of ultrasound energy. Disadvantages are the cost of ultrasonic machine, increased hassle factor in the operating room, and machine dependency, but after achieving proficiency in using the machine, there is no turning back because it is addicting. The conclusion, at that time, was that the harmonic lift is a safe, effective, and reproducible form of skin remodeling. It can be performed under local, regional, or general anesthesia, and can be repeated with no increase in surgical difficulty or cumulative effect. Advantages include negligible blood loss and pain, short and

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a1

a2

a3

b1

b2

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Fig. 43.5 Vaser UAL with poor result, face-lift with SMAS flap: (a) Preoperative. (b) Postoperative

Skin Contraction: 3 Theories Collagen contraction due to injury (thermal?, original proposition) Defatting the superficial layer-retained structures minus fat allow skin to contract Gentle stimulation to cause contraction through controlled damage

Fig. 43.6 Skin contraction theories

uncomplicated recovery, and simple postoperative care. The results are comparable to those obtained with more extensive surgery that frequently involves overnight stay, higher risks, increased morbidity, and higher costs. In United States, from 1995 to 2000, a series of articles published in the medical literature pointed out the increasing number of complications related to body contouring procedures when ultrasound energy was involved [14]. Analysis of all these complications,

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though there is difficulty assembling all clinical data, brought the following results: • • • • • • • •

Seroma (30% of body contouring cases) Delayed wound healing (18% of clinical cases) Prolonged edema (15% of clinical cases) Dysesthesia (12% of clinical cases) Fibrosis (8% of clinical cases) Asymmetries (4% of clinical cases) Skin necrosis (0.3% of clinical cases) Burn (0.2% of clinical cases)

Despite that burn and skin necrosis were largely the less common related complications and represented really a rare issue, the potential risk of these two complications was overemphasized. A major issue was introduced by many authors in the literature, probably because these two related to procedure complications were not seen with the other technique of liposuction (superficial, traditional, power assisted). The task force established by the American Society of Aesthetic Plastic Surgery (ASAPS), by the American Society of Plastic and Reconstructive Surgery (ASPRS), and the Educational Foundation met many times in order to establish safety criteria of utilization of ultrasound energy in body contouring surgery. The first safety indication, to prevent complications such as burn and skin necrosis, was to avoid the utilization of the ultrasound probe close to the underlying skin-dermis, which was really, on the contrary, the most important step of once so called “Harmonic-lift.” However, only working “superficially” with a solid ultrasound probe, the surgeon can undermine the cutaneous and subcutaneous layers, assembling a thin but vascularized flap more prone to retract and adapt to a reduced body volume. The great misunderstanding in those years, which led to and created confusion and mixing of clinical data, was due to the fact that all the complications-related data came through the utilization of the two most diffused ultrasound tools in the U.S. market: The Contour Genesis (Mentor, Santa Barbara, California), and the Lysonics (Inamed Corporation). These two ultrasound tools have similar technical characteristics: • High energy. • Hollow probes with simultaneous ultrasound energy administration, thus emulsification and simultaneous subsequent aspiration. • 5.0 mm large probe. The SMEI sculpture tool is a less powerful tool with solid titanium probes and without aspiration at the time of emulsification (which are two different clinical

Fig. 43.7 Sculpture by SMEI (low) and infiltration peristaltic pump. Not in production since 2001

phases). Adopting a finer probe for the face and neck, the author never had such kind of complications as related in American Literature in those years. However, the number of ultrasound tools sold by SMEI (Fig. 43.7) in the world (probably 700) was far less than those sold by Mentor and Lysonics (probably more than 2,500 units). The American market was far superior to all the remaining worldwide market, thus the published literature included only the experience (and complications) of the American technology in internal ultrasound energy. In 2001, Cimino, a physician who had great experience in ultrasound energy and had been previously involved with the task force on ultrasound energy, published an article on power quantification and efficiency of ultrasound energy [15]. This article was of capital importance to understand all the mistakes made by the two main American manufacturers in assembling the two most common ultrasound tools. • Too much energy that produced unnecessary overheating, which increased the side effects of ultrasound (seroma, mainly) without enhancing the results and the clinical outcomes. • Too large probes with low efficacy in transmitting energy to the tip, and thus, reducing the emulsification rate. • Poor design of the tip of the probe due to lack of technological research, with a reduced efficacy of the system in order to raise the rate of emulsification, the manufacturer increased the power of the tools.

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Fig. 43.9 Different probes: 1, 2, and 3 rings at the top of the shaft

Fig. 43.8 Vaser System Ultrasound with aspiration-ventex and infiltration

The two main ultrasound devices were far from a good technical standard, technologically was low in the development of the machines, and the majority of complications came from these limits. Fortunately, in 2001, a new ultrasound device, called Vaser, (by SST-Denver, Colorado, USA), was introduced in the US market (Fig. 43.8). This new tool has new features such as: • New designed probes of different caliber and shape. • The tip is designed (with one, two, and three rings) to increase the efficiency of the emulsification, which now affects not only the tip, but also the sites of the last part of the shaft (Fig. 43.9).

• The number of rings are related to the efficacy of the emulsion depending on the type of tissue encountered (more or less fibrotic, type of fat, more or less dense). • New generator of ultrasound energy with less power, but optimization of the distribution of energy at the different frequencies and wave length. High efficiency with less energy, which means less related complications due to overheat of the system. So far, in the last 5 years of the “Vaser Ultrasound Generation,” no report of burn or skin necrosis has been published. An insignificant percentage of seroma was reported. • New aspiration system, the so called VENTEX, with a new pathway expressively designed for increasing the rate of aspiration, without damaging the tissue, thereby aspirating “noble” structures such as vessels nerves and elastic tissue and impossible to be blocked by undue aspiration of wrong tissue. • Skin protector, expressly designed to prevent tissue damage from friction injuries related to the consecutive passages of the probe from the same entrance point (Fig. 43.10). • Reduced extension entrance scar of skin to allow introduction of the solid titanium probes, which are smaller in diameter (standard probe varies from 2.2 to 3.7 mm). Facial probe is 2.2 mm in width. • Tissue trauma is minimal, edema is largely reduced, bleeding is virtually absent, and the recovery of tissue is consistently reduced. Even the sites of entrance are now compatible with the typical diameter of the standard liposuction cannulas (between 2 and 4 mm of diameter). The author has started utilizing the Vaser system for body contouring surgery, breast reduction, facial contouring, reduction of breast tissue in male and female, treatment of Buffalo hump lipodystrophies, face and neck contouring, and axillary hyperhidrosis treatment.

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Fig. 43.10 Skin ports

This method is not a substitute of the standard facelift technique, but may shorten and make easier many procedures of facial contouring, with minimal trauma and virtually no complications, if performed by a surgeon trained with Vaser. The role of the dermis in the subcutaneous anatomical structure has been undervaluated in the past. Rudolph (1977) [16] first described the importance of dermis layer for skin retraction. In plastic surgery, it is commonly known that a split skin graft (no dermis left, in this case) is not really indicated to cover joint-areas (as elbow) for the possibility of leading to skin retraction, thus functional problems to the area. If a full thickness graft is utilized (with a layer of dermis but no fat), the same area is less prone to contraction, and to functional problems (Fig. 43.11). This is connected with the role of the dermis [16]. This aspect has never been considered in skin contraction after ultrasoundassisted body contouring [17, 18]. Emulsifying the body fat and thus conserving the connective tissues and supporting structures of the subcutaneous tissue (Fig. 43.12), the skin retracts much more than in standard condition. If the surgeon can harvest a skin dermal flap

Fig. 43.11 The thinner the subcutaneous fat, the greater the retraction achieved. UAL solid titanium probe works close to the dermis to thin the subcutaneous fat and achieves retraction

Fig. 43.12 Layers of emulsification with Vaser UAL: S superficial; I intermediate; P deep

43 Face and Neck Remodelling with Ultrasound-Assisted Lipoplasty (Vaser)

that is well vascularized and with the addition of an instrument that helps preparing such a surgical plane, the potential of skin retraction is minimized and it results in a safe procedure (Fig. 43.13). In this Vaser technique for face and neck contouring, the surgeon can emulsify fat areas (chin, jowls) or just extensively undermine the interested areas, counting on a deep, severe, intense skin retraction and simulating the effect of a subcutaneous rhyti dectomy, but without cutaneous scars (Figs. 43.14–43.18).

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Fig. 43.13 Fat thickness varies in different body areas. Thigh and abdomen are the thickest. Back and face are the thinnest

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Fig. 43.14 (a1, 2) Preoperative 38-year-old patient. (b1, 2) Postoperative after jowl, chin, and neck contouring with Vaser UAL

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Fig. 43.15 (a) Preoperative 37-year-old female. (b) Postoperative following neck–chin–jowl contouring

43 Face and Neck Remodelling with Ultrasound-Assisted Lipoplasty (Vaser)

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Fig. 43.16 (a1, 2) Preoperative 28-year-old male with heavy cheeks and chin retrusion. (b1, 2) Postoperative after neck contouring and intra oral chin implant

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Fig. 43.17 (a1, 2) Preoperative 42-year-old female. (b1, 2) Postoperative following endo brow lift and Vaser to cheek and neck. (c1, 2) One year postoperative

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Fig. 43.18 (a1-3) Preoperative 45-year-old female. (b1-3) Postoperative after Vaser of neck, chin contouring, and fat transfer. (c1-3) One year postoperative

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References 1. Di Giuseppe A. The harmonic lift: ultrasonic assisted skin remodelling. Int J Cosm Surg Aesthet Dermatol. 2000;2(2): 125–31. 2. Klein J. Tumescent technique: tumescent anesthesia & microcannular liposuction. St. Louis: Mosby; 2000. 3. Rohrich RJ, Beran SJ, Kenkel JM. Ultrasound assisted liposuction. St. Louis: Quality Medical Publishing; 1998. 4. Grotting JC, Beckenstein MS. The solid probe technique in ultrasound-assisted lipoplasty. Clin Plast Surg. 1999;26(2): 245–54. 5. Toledo LS. Facial rejuvenation: the role of the skin retraction. In: Annals of the International Symposium: Recent Advances in Plastic Surgery. Brazil: Sao Paulo; March 1992. 6. Gingrass MK. Lipoplasty complications and their prevention. Clin Plast Surg. 1999; 26(3):341–54. 7. Tebbetts JB. Minimizing complications of ultrasoundassisted lipoplasty: an initial experience with no related complications. Plast Reconstr Surg. 1998;102(5):1690–7. 8. Illouz YG. Study of subcutaneous fat. Aesthetic Plast Surg. 1990;14(3):165–77. 9. Gibson T. Physical properties of skin. In: McCarthy JG, May JW, Littler JW, editors. Plastic surgery. Philadelphia: WB Saunders; 1990.

A. Di Giuseppe 10. Gibson T, Kenedi RM. The structural components of the dermis. In: Montagna W, Bentley JP, Dobson L, editors. The dermis. New York: Appleton-Century Crofts; 1970. 11. Southwood WF. The thickness of the skin. Plast Reconstr Surg. 1955;15(5):423–9. 12. Pitman GH. Liposuction and aesthetic surgery. St. Louis: Quality Medical Publishing; 1993. 13. Fodor PB, Watson J. Personal experience with ultrasound assisted lipoplasty: a pilot study comparing ultrasound assisted lipoplasty with traditional lipoplasty. Plast Reconstr Surg. 1998;101(4):1103–16. 14. Scheflan M, Tazi H. Ultrasonically assisted body contouring. Aesthetic Surg J. 1996;16:117–22. 15. Cimino WW. Ultrasonic surgery: power quantification and efficiency optimization. Aesthetic Plast Surg J. 2001;21(3): 233–41. 16. Rudolph R, Guber S, Suzuki M, Woodward M. The life cycle of the myofibroblast. Surg Gynecol Obstet. 1977; 145(3):389–94. 17. Becker H. Subdermal liposuction to enhance skin contraction: a preliminary report. Ann Plast Surg. 1992; 28(5):479–84. 18. Gasparotti M. Superficial liposuction: a new application of the technique for aged and flaccid skin. Aesthetic Plast Surg. 1992;16(2):141–53.

High Definition Liposculpting

44

Alfredo Hoyos

44.1 Introduction Beauty, or the lack of it, plays a crucial role in virtually every human function and endeavor. It determines our popularity, our perception of ourselves, and often our success in business and career. Darwin postulated that beauty, in certain animals and human beings, also plays an important role in sexual selection and reproduction. While noone questions the importance of the role of beauty, the concept of what is beautiful has changed dramatically over the years. From the traditional GrecoRoman beauty standard, changes are seen according to factors as economics and fashion, sometimes in complete opposition to the previous one. For instance, in the eighteenth century, the full-figured, buxom women were considered to be the epitome of beauty; this Ruebenesque notion of beauty lauded the round shaped body as it was considered a sign of wealth and, ironically, good health, just the opposite as today’s mindset. In more recent times, there has been a continuous shift in the concept of beauty. Starting in the 1970s, the concept of beauty moved from the large and round to the slender and angular. In the recent decade, as we see more and more obesity in the general population, the trend has moved even more toward to a fit, athletic body. The muscular, athletic body shape has become the gold standard for the new millennium. Typically, one strives to achieve this athletic look through the efforts of rigorous diet and exercise. Aerobic and weight bearing exercises can all lead to a well-developed muscular appearance. However, diet

A. Hoyos Evolution Medical Center Calle 119, 11D-30 (Nueva), Bogota, Colombia e-mail: [email protected]

and exercise do not always provide the desired results. Many individuals have stubborn areas of fat that block their goals despite strenuous exercise and diet. This may drive many to resort to the use of questionable drugs such as steroids.

44.2 History Over the years a number of surgical techniques have been developed to assist patients in reaching their goals. Gastric bypass surgery has helped patients where diet has failed. Liposuction, first described by Fischer [1] in 1975, has addressed the issue of stubborn areas of fat. In groundbreaking work, Illouz and de Villers [2] described the use of liposuction to sculpture the female body. Recently, new and innovative surgical techniques have been developed which present these patients with the opportunity to reach their goal. The tumescent technique, the super-wet technique, and ultrasound-assisted lipoplasty (UAL) have all proved to help plastic surgeons in their mission to provide patients with more precise results and quicker recovery time. VASER (Vibration Amplification of Sound Energy at Resonance) assisted lipoplasty, the most recent addition to the UAL, provides a significantly improved ability to contour fat [3]. Not only is it selective in what is resected, but also in what it leaves behind. Much of the connective tissue, nerve and vascular tissue, that are important in the patients’ healing process are left untouched. Mentz et al. [4] point out that traditional liposuction techniques often fail to achieve the “washboard” aesthetic goal because “subdermal fat obscures the muscular detail.” Their response to this challenge is a technique used in male contouring called abdominal etching, which refers to differential liposuction hat

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details abdominal musculature, specifically to the rectus abdominis muscle. The anatomical appearance of this muscle is enhanced with localized superficial liposuction to deepen the natural grooves or furrows. While this technique offered options in body sculpting in males, it still results in a common problem where the muscles may appear unnatural. As a result, it is limited in that it focuses on only one muscle group, while not addressing many other muscles that contributed to that area of the anatomy. The term “liposculpture” first appeared in 1991 and was described as a technique that “shapes the body by removing fat cells in areas where there is excess fat and/or by adding fat cells to areas where additional padding is desired” [5]. It is a highly surgeon-dependent procedure in that the results depend entirely on the skill and the aesthetic “eye” of the surgeon. The next big contribution to the area of body contouring was superficial liposuction. De Souza Pinto developed this approach of addressing the superficial layer by removing and relocating fat using small caliber cannula. This technique achieved skin retraction along with resection of fatty excess, but often resulted in contour irregularities and asymmetry. Addressing superficial liposuction with VASER also became much more efficient, consistent, and rapid technique. The traditional goal of the liposuction techniques is to achieve flat surfaces. In opposition to the previous goals, the author has taken the liposculpture technique to the next level by refining it even further into what is referred to as High Definition Liposculpture. The idea is to create the natural muscular anatomy and enhance it. By using deep, superficial, or transitioning techniques over the rectus abdominus, serratus magnus, external obliques, pectoralis major, inguinal ligaments, and in the sacral area, the author has been able to create a more natural muscular appearance [6]. Through the appropriate use of contouring by liposuction, a new alternative is now available for the treatment and improvement of the gluteal, pectoralis, and other regions.

44.3 Anatomy The surface anatomy is an accurate reflection of the disposition and development of the abdominal wall muscles, specifically the rectus abdominis and obliquus abdominis muscles. They act as the blueprint for High Definition Liposculpture.

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The rectus abdominis are strong, paired, longitudinal muscles that extend from the xyphoid process of the sternum and the 5th, 6th, and 7th costal cartilages to the pubis symphysis and the pubic crest. These two muscles are attached to each other in the middle by connective tissue forming the linea alba. The muscle is enclosed within the rectus sheath formed by the aponeuroses of the lateral abdominal muscles. Along the length of this strap muscle, there are three fibrous intersections separating the muscle into four segments. When the space between these muscles deepens, it results in a depression in the wall above the umbilicus. These are the muscles patients relish and refer to as “six-packs” or “washboards.” The transition between the lateral border of the rectus muscle and the oblique creates a well-defined depression and extends to the waist. This transition in the lateral view is the “double S.” This is the pillar of the natural muscular appearance that patients desire. In the lower portion of the back, the sacrum surface anatomy is focused on. Athletic individuals have minimal adipose tissue in this region. The result is the formation of a triangular-shaped depression covering the sacrum and terminating in the intergluteal crease. Examining the surface reveals two depressions located where the sacrum junction is closest to the skin. These depressions also tend to accentuate the gluteal region. There are substantial differences in the surface anatomy of men and women. In men, there is a more clear visualization of the six-pack, while in women it is generally not as desirable to see the musculature as well defined because they may give a more masculine appearance. In women, the waist, lateral to the limit of the rectus abdominis, is a key point of feminine definition, as is the waist contour above the gluteal region. The obliquus muscles form two lateral prominences in their junction with the inguinal ligament due to high muscular development. While this is desirable muscle pattern in men, a mild depression in this region is more desirable in women. In the dorsal view, the sacral region should be well defined in women due to the more accentuated lordosis and less fat present in that region. The increased muscular enhancement of the latissimus dorsi of the male results in an inverted triangular shape in the back area, which can be useful in liposculpture because some fat can be left there. In females, because of the lack of this defined muscular development, this shape is rectangular. As a result, with females, there is less aesthetic tolerance to remaining fat deposits in this area.

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44.4 Surgical Technique

44.4.3 Superficial Liposculpture

High Definition Liposculpture technique follows four general steps as follows:

Starting in the prone position, most cases had only liposuction to the superficial layer. When starting, the VASER is used at 80% power in the pulse mode, initiating the VASER and liposuction on the superficial layer and then advancing to the deep layer. This makes the work on the superficial layer less challenging by providing a stable deep layer. Later, aspiration sculpting is performed on the sacral triangle, the lateral portion of the waist, the midline, and the sacral depressions, as well as the back rolls that are going to be detached from the profound layer. The waist is then worked on in the midline above the umbilicus, the lateral lines of the rectus abdominis muscle, and portions of the rib cage. Special attention was given on the lateral border of the rectus beneath the ribs, where we do more superficial work to define the rectus abdominis. When working on the abdominal area, special attention must be given to the preoperative interview to accurately gauge the expectations of the patient. In patients who want a more muscular shape and desire a more athletic look, the author highlights the lateral border of the rectus abdominis, the depression beneath the ribs, and indicates mild depressions on the serratus area and above the inguinal ligament lateral to the rectus abdominus muscle. The transition areas lateral to the rectus and above the umbilicus are treated very aggressively. In female patients who fear having a “masculine look” or those who have mild-to-moderate obesity, the lateral lines of the rectus abdominis and the transition areas of this zone are only treated. This leaves a very natural look, particularly in obese patients where a very highly defined abdomen would look unnatural. The transition zones or union areas of the superficial and deep layer liposculpture area require special attention. These areas in the female body are defined as the union of the lateral rectus abdominis muscle, the supra and infragluteal areas, and the union of the sacral triangle and the lower back. If these areas are not treated properly or if the patient gains weight, there will be localized accumulation of fat resulting in an out-ofproportion appearance. The treatment of the transition zones must be a melding of deep and superficial liposculpture for it to look very smooth and natural.

44.4.1 Marking With the female patient in a standing position, the fat deposits to be removed to improve the body contour are marked. These deposits will be removed with deep liposculpture. The areas of depression that will need more projection such as the gluteal region, particularly if there is lateral depression in that area, are marked. Those areas will be treated with fat transplant. After the conventional marking, the surface anatomy that is going to be reproduced by superficial liposculpture is traced: in the dorsal view, the sacral triangle, the sacral depressions, the desired position of the infragluteal crease, and the areas of fat deposits in the back, specifically the fat rolls and creases. In the ventral view, the lateral borders of the rectus abdominis muscle, the obliquus muscle, the rib cage, and the alba line above the umbilicus. The author strives to produce a mild supraumbilical depression as it tends to give a more natural look.

44.4.2 Deep Layer Liposculpture With the patient under general or epidural anesthesia and in the prone position, tumescent solution is infiltrated consisting of 1,000 mL of normal saline and two ampules of epinephrine 1:1,000. In the current study, only suction-assisted liposculpture was done in 638 patients, and in 264 patients, VASER and liposuction were used. The VASER was used in the deep layer at 80% of power in continuous mode, approximately 1 min per each 100 mL of infiltration. On the lateral and medial thighs or legs, 50% power at pulsed mode was used. Later, aspiration at low power suction was performed. The ratio of infiltration to volume of fat removed was approximately 1:1. The aspiration of fat was performed on the medial and lateral thighs, the back, the waist, and sometimes on the arms and legs. In the supine position, liposuction was performed on the medial and lateral thighs, the flanks, and abdomen, and was limited to the deep layer.

44.4.4 Fat Grafting With the patient in the prone position, fat is harvested with a 5-mm blunt cannula into a sterile bottle trap

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containing 1 g of cefazoline. Decantation is the only process used to separate the fat cells from the saline and serosanguinous components. In the gluteal area, the volume of the fat injection ranges from 400 to 1,000 mL, with a mean of 472 mL/patient. This “fat reorientation” is done through injection using a 3-mm blunt cannula in the intramuscular plane, and a 2-mm blunt cannula in the subdermal plane.

44.5 Discussion The High Definition Liposculpture technique was developed to address the large demand for a procedure that

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can naturally reproduce an athletic female body shape. This exacting technique, combining superficial and deep liposculpture to reproduce the superficial anatomy, was developed over 3 years. The process of producing a natural athletic appearance required a steep learning curve. This was especially true in women where the anatomy is somewhat well defined but, at the same time, smooth. A three-dimensional contouring of the female body has been achieved. (Fig. 44.1) The author chose not to address just the rectus abdominis, but the entire torso and, in doing so, achieved a healthy natural result with a combination of superficial and deep layer fat extraction and reassignment. The adequate melding of these transitional areas insured a natural and long-lasting

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Fig. 44.1 Three-dimensional contouring of the female and male torso. (a1–5) Preoperative. (b1–5) Postoperative

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result. The overall volume extracted by this technique was less than that in the more traditional techniques. The use of autologous fat to augment the gluteal area, used as part of the procedure, enhanced the final results. The patients not only experienced a change in their body fat distribution, but also in their fat deposit zones. As a result, if the patients gain weight, they maintain the improvement in their appearance even though they are overweight. Less than satisfactory results were directly attributable to the following: • Inadequate presurgical marking, • Insufficient fat extraction from the superficial layer of the lateral abdomen or from the deep layer of the central abdomen,

• The asymmetrical union of the lower back and the waist. The use of the VASER has proved to be a powerful tool to facilitate fat extraction while increasing the volume of aspirated fat permitted per patient. It also ensured excellent results in the superficial layer liposculpture, and keeps to a minimum postoperative pain and bruising. The VASER patients experience a faster decrease in swelling and minimal contour irregularities, postoperatively. Results appeared more quickly and were longer lasting. If the High Definition Liposculpture patient should gain weight over time or experience a change in the body fat pattern of the back, arms, lower limbs, and/or the gluteal region, a second procedure can correct the situation.

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In women, addressing the vertical component of the rectus abdominis muscle was usually enough to provide an athletic look. Working with the entire torso, sculpting the waist, the perigluteal area, and the buttocks provides a very impressive change resulting in a more feminine look. High Definition Liposculpture is a refinement that efficiently reproduces all the anatomical landmarks of an athletic body. It was developed in a systematic way to ensure an adequate technique and to obtain natural, long-lasting results.

References 1. Fischer G. Surgical treatment of cellulitis. IIIrd Congress International Acad Cosm Surg. Rome: 31 May, 1975.

A. Hoyos 2. Illouz, YG, de Villers Y. Body sculpturing by lipoplasty. Edinburgh: Churchill Livingstone; 1989. 3. Jewell ML, Fodor PB, Souza Pinto EB, Al Shammari MA. Clinical application of Vaser assisted lipoplasty: a pilot clinical study. Aesthetic Surg J. 2002;22(2):131–46. 4. Mentz HA III, Gilliland MD, Petronella CK. Abdominal etching: differential liposuction to detail abdominal musculature. Aesthetic Plast Surg. 1993;17(4):287–90. 5. Toledo LS. Syringe liposculpture: a two-year experience. Aesthetic Plast Surg. 1991;15(4):321–6. 6. Hoyos AE. VASER-assisted high-definition liposculpture. Aesthetic Surg J. 2007;27(6):594–604.

Vaser-Assisted Liposculpture for Body Contouring

45

Alberto Di Giuseppe

45.1 History Body contouring is an expression of the surgical capability of the plastic surgeon to modify lines and volumes of the body in all its parts. The artistry of the surgeon consists in his tridimensional vision of the body and in the full understanding of a surgical project of recreating pleasant lines and new proportions among all the body parts. To fulfill this target, the surgeon should utilize the best device and techniques in the market. Since 1992, the author has been using ultrasound-assisted lipoplasty (UAL) with the solid probe of the SMEI Sculpture that was later called first generation ultrasound (US). This device was developed in Italy after the initial study of Scuderi et al. (1987) [1], who applied US energy to emulsify fat instead of mechanically destroying it as in Suction-assisted lipoplasty (SAL). The second generation US was represented by Lysonics and Mentor devices. They had 5 mm cannulas, bullet tip design, 2 mm internal lumen for simultaneous aspiration, golf tee or bullet design, and sheath style cannulas with infuse wetting solutions (Mentor). US energy was administrated only in a continuous fashion. Sound Surgical Vaser represents the third generation of UAL devices, with smaller probes (Fig. 45.1) that are 2.2, 2.9, 3.7, and 4.5 mm, all side grooved, solid probes for tissue fragmentation, pulsed US or continuous, 4 mm access incisions, and upgrade pathway.

A. Di Giuseppe Department of Plastic and Reconstructive Surgery, School of Medicine, University of Ancona, 1, Piazza Cappelli, 60121 Ancona, Italy e-mail: [email protected] e-mail: [email protected]

Fig. 45.1 Probe vs. cannula design. Left: Lysonic 5.1 gauge cannula. Middle: 3.7 mm three grooved Vaser probe. Right: 2.9 mm two grooved Vaser probe

The technical advancements of Vaser in comparison with the previous technologies are as follows: 1. Power of the device that is nearly half of the previous devices. This reduced consistently the rate of complication connected with an excess of unnecessary energy utilized in the past. 2. Efficiency of the device, connected with the new solid probes that are all grooved. One, two, and three grooves are located at the tip of the shaft increasing the surface of emission of the US energy, which means more fat emulsification in unit of time. 3. Optimization of power to prevent excess US. 4. Role of pulsed delivery of US energy that cuts by 50% the energy delivered in the unit of time, thereby decreasing unnecessary power, which rather becomes heat. Vaser shows that it is possible to minimize US energy and achieve emulsification. High power with low

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efficiency becomes heat, high efficiency with low power means emulsification. Technically, grooves significantly increase efficiency, and with high efficiency, small diameter probes can be used, allowing smaller access incisions and minimizing scars. The Vaser system consists of the US device, the aspiration system, and the infiltration system. All together it is assembled in a built-in unit. Vaser means vibration amplification of sound energy at resonance. The system has different alarms for preventing technical problems. It stops the device in case of bad connection, broken handpiece, torquing and levering a probe, or finally using high efficiency probe in fibrous tissue, which leads to change and use of the correct probe. Probe size should be utilized following the tissue encountered. For more fibrotic tissue, the surgeon should prefer a one ring probe, as for standard fat, the two or three rings probe is indicated. The aspiration system is very efficient, with new types of eight holes cannula, Mercedes type. The aspiration of the Ventx cannula is highly efficient and makes the removal of emulsification fat really fast.

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were done and where a good maneuver was achieved. The surgeon must keep in his hands and brain the feeling and the sensation he had in molding a buttock or a trochanter, how to direct his cannula and probe, how to stay superficial with the level of undermining, where there is a need to increase fat removal to shape a flank, where and how to remove fat to thin a gluteus in order to lift it up, and how to treat superficial cellulite or peau d’orange appearance to improve skin tone and look. All plastic surgeons know that talent is a peculiar aspect of their work and that it is a sense of proportion, aesthetic, and taste, and is not on sale. Technique can be learnt with time and constant application, whereas talent is unique and normally shows only in a later stage of our professional life and helps establish if you really are a great artistic surgeon or just a simple handyman. Results have to be repeatable in order to show the ability of the surgeon and correct understanding of the maneuver act to obtain a certain result.

45.2.1 Planning and Marking 45.2 Technique Planning is essential in all aspects of life and work and in aesthetic plastic surgery more than ever. Body is tridimensional, so the approach to the vision of the image has to be full as the understanding of the beauty appearance and the harmony which should be created or restored ideally. These concepts will groove with experience as in all kinds of aesthetic surgeries. The ability to fully restore a low gluteal fold, to correct the wrong line of a trochanter, to lift a flank, or to give lines to thorax and spine lines is part of the talent of the surgeon. Body contouring is not mere reduction of volume, but a sense of proportions and the vision of the body in its full displacement. The surgery restores body lines and shape and gives a natural and nice appearance to the areas being treated. This approach became systematic to the author and gave constant good results. Feeling the tissue is another aspect that is difficult to explain. Only plastic surgeons, aestheticians, and body massage therapists develop a sense of interaction with their hands and the mass of the body they are treating. Constant vision of the body shape and how changes, as a consequence of a surgical procedure, are essential to evaluate the result of the action. Preoperative and postoperative photographs help to visualize good and bad results in order to analyze honestly where mistakes

With the patient standing nude, front, back, lateral, oblique, left, and right photos are taken with a digital camera with the same distance and zoom. It is essential to remove all elastic which can change also minimally the lines at the trochanter and flanks. The need for the lateral view and the oblique view will be clear when examining the tridimensional thigh. In a standard case of body contouring, the author prints a picture where areas are marked for volume reduction, areas to be conserved, areas of undermining that require redraping and contraction, and areas to be left untouched (Fig. 45.2) Correction and planning are marked in all the photos in order to have a systematic view of the body balance and the requirements of shaping. Single areas need a special approach to understand how to address surgical maneuvers. Correction of trochanter deformity, which is the result of the presence of a zone of adherence as a gluteal depression over the great trochanter, requires to draw a line of the new shaped gluteal and trochanter definition by placing a fully extended hand in order to press the tissue excess and define the area to thin and the lines to obtain and shape (Fig. 45.3). Flank deformity is similar in men and women. A new line is obtained by gently pressing over the excess of tissue in order to draw the line according to the proportions of the body (Fig. 45.4). When planning a full remodeling of flanks, abdomen, gluteus, trochanter, and thighs

45 Vaser-Assisted Liposculpture for Body Contouring Fig. 45.2 (a) Marking. (b1-3) Left: Preoperative. Middle: Plan markings. Right: Postoperative

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(internal, external, and anterolateral), the author takes photographs in all these projections (Fig. 45.5). A Pentel pen of a fine marker may be used to shape or draw new lines of contouring to show to the patient and to keep in the record, but mostly to remind the surgeon of the plan in the operating room. All the photos are kept on a printed paper sheet and are shown in the diafanoscope during the surgical procedure in order to check the behavior of tissue during shaping. Some cases may show significant asymmetries with uneven side, volume asymmetry, and different lines of contouring that are rather difficult to correct (Fig. 45.6). Despite being more difficult and challenging, the final result is nice a result of multiple maneuvers for a new and more symmetrical shaped (Fig. 45.7). In abdomen and flank contouring, a concave line needs to be recreated from thorax to iliac crest (Fig. 45.8). Clear defatting of this area is essential to give a natural shape and contour mainly to the female body. With aging, the flank areas tend to enlarge, due also to hormonal changes that deeply influence body appearance. In males this phenomenon is less pronounced (Fig. 45.9). Vaser superficial undermining and sculpturing is mandatory in older skin and in lax skin type, which is rather frequent in most of the author’s patients demanding abdomen molding (Fig. 45.10). The real ability is to thin carefully all the areas, respecting the anatomy of the body, leaving fat in the umbilical area, and vertically defining the external part of the rectus abdominis (Fig. 45.11). The epigastric fat is typically fibrous in older patients, impossible to be eliminated with gymnastics, exercise, or diet. Only superficial and deep Vaser is able to correctly thin the area, leaving no dead space, no depression, no bulges, and no skin irregularities. Correct wide undermining is essential as

careful control of skin adhesion to the deeper planes. This is accomplished with elastic postoperative compression with a garment for nearly 2 months or as much as required and with a cycle of lymphatic drainage, with Endermologie LPG. It is much easier to deal with healthy young skin that is suitable to an excellent skin retraction despite the technique utilized (Fig. 45.12). The real challenge is to nicely shape the body, giving particular emphasis to the shape of the dorsum and flank areas. The final shape should harmonize with the new concavity that should enhance the natural appearance (Fig. 45.13). In older women, this radical approach allows to redefine the full shape of the anatomy despite aging, skin quality, and laxity (Figs. 45.14 and 45.15). Other patients feature the gynoid type of fat with a sort of double plies and double rolls over the abdomen. This type of case requires extensive superficial work and deep volume reduction as well, but the final result gives reason to the use of good technique. In major cases, utilizing the 4.5 mm probe is faster in emulsifying the deeper layers. For postoperative elastic compression, silicone baked foam such as Epifoam is recommended (Fig. 45.16) and is excellent for helping skin adhesion and preventing skin irregularities. When approaching thigh and buttock contouring, first choose the patient position in the operating table because: 1. It is impossible to simulate real gravity affecting the tissue if the patient lies flat in the table. 2. The orthostatic bed invented by Fisher is a great idea, but allows surgery only under local anesthesia and not entire body contouring in one session. 3. The idea in positioning is simple and easily applied in most operating rooms.

45 Vaser-Assisted Liposculpture for Body Contouring

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Zone of adherence (woman)

Gluteal depression over great trocanter

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Fig. 45.3 (a1, 2) Zone of adherence in the female with glutel depression over the greater trochanter. (b) Correction of trochanteric deformity

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b1 Zone of adherence (man)

Iliac crest inferior flank margin

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Fig. 45.4 (a) Zone of adherence in the male causing flank deformity. (b1, 2) Correction of the flank deformity

45 Vaser-Assisted Liposculpture for Body Contouring

a

MARKINGS

Fig. 45.5 (a) Markings and photos in all projections. (b1, 2) Left: preoperative. Middle: plan markings. Right: postoperative

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Fig. 45.5 (continued)

A. Di Giuseppe

45 Vaser-Assisted Liposculpture for Body Contouring

Fig. 45.5 (continued)

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434 Fig. 45.6 (a) Left: preoperative. Right: planning. (b) Left: Postoperative 5 weeks. Right: Postoperative

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45 Vaser-Assisted Liposculpture for Body Contouring

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Fig. 45.7 Left: preoperative. Right: postoperative

An operating bed is used that can be partially flexed. The hip area is suspended with a rigid silastic pillow to elevate the hips and the bed flexed 30° (Fig. 45.17). All surgery is performed under these conditions, having recreated the natural position of the gluteal and legs with no interference of the gravity forces. Finally, the operating table is flexed to 90° allowing full assessment of how tissue has changed after completing sculpturing (Fig. 45.18). Eliminating the gravity forces is essential for a correct analysis of the new body shape. There is no other method of performing surgery in this area that allows direct control of the tissue and body shape. In the young patient with good skin tone, it is easy to obtain these fine harmonizing results (Fig. 45.19). With really lax skin, in secondary surgery or in legs elephantiasis, the technique is important. Vaser is probably the only technique suitable in these cases where circumferential remodeling is performed to reduce volume and help skin redraping all over the area (Fig. 45.20). Even postbariatric cases are really challenging and difficult to perform with standard SAL. With Vaser, on the contrary, you can operate on these cases with a reasonable amount of quality of the result (Fig. 45.21). Many of the patients who have had abdominoplasty may be suitable for Vaser liposculpture, sparing long

scars, a long postoperative recovery period, and sensory frequent loss in the hypogastric skin. The key is to fully undermine superficially at the subdermal layer together with a deep plane defatting (Fig. 45.22). Even the large abdomen is suitable for good early results and rapid skin tightening when 6,000 mL of solution is removed in one stage (Fig. 45.23). In patients with extremely lax skin and poor abdominal tone, the potential for skin retraction is still great even in a case probably indicated for an abdominoplasty elsewhere. To allow this kind of dramatic improvement, the surgeon must thin and undermine the full area to obtain a thin, viable flap, with minimal dermal thickness (Fig. 45.24). The thinner the subcutaneous fat, the greater the skin retraction that is achieved. The dermis plays the most important role in skin contraction, as is clear in plastic reconstructive surgery when flaps are preferred to skin graft to prevent retraction, or full thickness grafts are preferred to skin graft for the same indication and reason. Vaser works in superficial layer initially, and once undermining is completed, can go deep to the real fat deposit (Fig. 45.25). Fat thickness varies in different body areas, with thigh being the thickest and back and face the thinnest (Fig. 45.26).

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Markings pre operative planning

Concave line from thorax to flanks Fig. 45.8 Markings for preoperative planning and concave line from thorax to flank

45 Vaser-Assisted Liposculpture for Body Contouring Fig. 45.9 (a) Left: preoperative. Right: postoperative. (b) Left: preoperative. Right: postoperative. (c) Left: preoperative. Right: postoperative

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438 Fig. 45.9 (continued)

A. Di Giuseppe

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Fig. 45.10 Left: preoperative. Middle: planning. Right: postoperative

45 Vaser-Assisted Liposculpture for Body Contouring Fig. 45.11 (a) Left: preoperative. Right: postoperative. (b) Left: preoperative. Right: postoperative

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Fig. 45.12 Left: preoperative. Middle: planning. Right: postoperative

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Fig. 45.13 (a) 1 Preoperative. 2 Plan with marking. 3 Postoperative. (b) Left: preoperative. Right: postoperative

45 Vaser-Assisted Liposculpture for Body Contouring Fig. 45.14 Left: preoperative. Right: postoperative

Fig. 45.15 Left: preoperative. Right: postoperative

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Fig. 45.16 Compressive garment and foam

Fig. 45.17 Positioning

Fig. 45.18 Positioning at the end of surgery

A. Di Giuseppe

45 Vaser-Assisted Liposculpture for Body Contouring Fig. 45.19 (a) Left: preoperative. Right: planning. (b1-3) Left: preoperative. Right: postoperative

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444 Fig. 45.19 (continued)

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45 Vaser-Assisted Liposculpture for Body Contouring Fig. 45.20 (a) Left: preoperative. Right: 3 months postoperative. (b) Left: preoperative. Right: 3 months postoperative (c) Left: preoperative. Right: 3 months postoperative. (d) Left: preoperative. Right: 3 months postoperative

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446 Fig. 45.20 (continued)

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45 Vaser-Assisted Liposculpture for Body Contouring Fig. 45.21 (a) Left: preoperative. Right: 3 months postoperative. (b) Left: preoperative. Right: 3 months postoperative (c) Left: preoperative. Right: 3 months postoperative

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448 Fig. 45.21 (continued)

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Fig. 45.22 (a) Left: preoperative. Right: 3 months postoperative. (b) Left: preoperative. Right: 3 months postoperative (c) Left: preoperative. Right: 3 months postoperative

45 Vaser-Assisted Liposculpture for Body Contouring Fig. 45.22 (continued)

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450 Fig. 45.23 (a) Left: preoperative. Right: postoperative. (b) Left: preoperative. Right: postoperative. (c) Left: preoperative. Right: postoperative

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45 Vaser-Assisted Liposculpture for Body Contouring Fig. 45.23 (continued)

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Fig. 45.24 Thinning the skin flap with Vaser UAL

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452 Fig. 45.25 (a) Layers of subcutaneous emulsification with Vaser UAL. (b) The thinner the subcutaenous fat, the greater the retraction achieved. UAL solid titanium probe works close to the dermis to thin the subcutaneous fat and achieve retraction

A. Di Giuseppe

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b

In secondary surgeries, the experience of the surgeon plays a key factor. The surgeon must understand the previous surgeon’s mistakes or what was done incorrectly. Then, understand if the case is improvable and how (Figs. 45.27–45.32). For collecting fat, the

Tissue-Trans Mega 1,000 cl (Shippert, USA) is used for large volume fat transfer. The harvested fat is obtained in a sterile bag, unwanted fluid is removed by a luer lock syringe, and the final clear viable fat is obtained ready for injection.

45 Vaser-Assisted Liposculpture for Body Contouring Fig. 45.26 Fat thickness varies in different body areas

Fig. 45.27 Transforming a flat square buttock into a round harmonic buttock and improving gluteal cellulite with Vaser UAL and fat transfer

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Fig. 45.28 Transforming convexity into concave lines to recreate shape and natural contouring

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Fig. 45.29 (a) Left: preoperative banana fold deformity. Right: postoperative following adjustment of minor irregularities of the banana fold and trochanter with a 2.2-mm probe and undermining and superficial sculpturing to thin the gluteus. Note postoperative upward rotation of the buttock. (b) Left: preoperative

banana fold deformity. Right: postoperative following adjustment of minor irregularities of the banana fold and trochanter with a 2.2-mm probe and undermining and superficial sculpturing to thin the gluteus. Note postoperative upward rotation of the buttock

45 Vaser-Assisted Liposculpture for Body Contouring Fig. 45.29 (continued)

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Fig. 45.30 Secondary banana fold deformity: Left: preoperative. Middle: planning. Right: postoperative after Vaser sculpting with 2.2 mm probe and thinning of all areas

456 Fig. 45.31 (a) Left: preoperative with asymmetrym bulges, fat deposits, lax skin, and cellulite. Right: plan with marking. (b) Left: preoperative. Right: postoperative following superficial and deep Vaser shaping and extensive fat grafting (arrows)

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45 Vaser-Assisted Liposculpture for Body Contouring

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Fig. 45.32 (a) Left: preoperative. Note depression (arrow). Right: planning. (b) Left: preoperative. Right: 1 year postoperative

Fig. 45.33 Large volume autologous fat transfer made easy

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Fig. 45.34 Harvested fat

Reference 1. Scuderi N, Devita R, D.Amdrea F, Vonella M. Nuove prospettive nella liposuzione la lipoemulsificazione. Giorn Chir Plast Ricostr Esthetica. 1987;2(1):33–9.

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Fig. 45.35 Drain unwanted fluid: Hang bag for fat and waste to separate. Drain unwanted fluid by opening the white clip. Drain unwanted fluid into a basin or attach a luer syringe and draw it off

Circumferential Para-Axillary Superficial Tumescent (CAST) Liposuction for Upper Arm Contouring

46

Andrew T. Lyos

46.1 Introduction Today, preoccupation with fitness has made muscular definition in the female a sought-after goal [1, 2]. Wellproportioned arms and upper back with muscular development are the goal of today’s physically fit women and prominently featured in today’s fashion [3–5]. The increase in bariatric surgery for the morbidly obese has added to the group interested in aesthetic improvement of their arms. Rejuvenation of the upper arms continues to provide a challenge to both the surgeon and patient. Aging of the upper arm is extremely variable and depends on numerous factors, the most important of which appear to be genetics, the consistency of upper body toning exercises, obesity, and the variations of weight throughout life. The net result is an unaesthetic appearance with skin laxity and lipodystrophy of various degrees with the most severe form frequently designated the “batwing” deformity. Traditional liposuction of the upper arms has failed to meet the expectations of our patients. Commonly reported undesired sequelae of liposuction of the arms include worsening of skin laxity and wrinkling, central overresection on the inferior brachial border, and the lack of regional harmony [6–8]. Brachioplasty procedures improve contour, but are frequently unacceptable to our patients because of the undesired sequelae of widened, misplaced, or hypertrophic scars, contour irregularities, numbness, and skin necrosis [9–15]. Circumferential para-axillary superficial tumescent

A. T. Lyos Division of Plastic Surgery and Bobby R. Alford Department of Otorhinolaryngology and Communicative Sciences, Baylor College of Medicine, Houston, TX, USA e-mail: [email protected]

(CAST) liposuction alone or with minibrachioplasty has offered a reliable technique for arm contouring which maximizes retraction of the skin [3–5].

46.2 Technique Patient Classification. Patients are classified according to the scheme proposed by Teimourian and Malekzadeh (Table 46.1) (Fig. 46.1) [16]. Category 1: Minimal to moderate subcutaneous fat with minimal skin laxity: Patients generally have circumferential increase in fat volume, but adequate skin tone and elasticity. These patients do well with circumferential liposuction of the arm and para-axillary area. Relatively small amounts of fat are removed. Ultrasonic-assisted liposuction (UAL) is not required Category 2: Generalized accumulation of subcutaneous fat with moderate skin laxity: Patients generally have an increased volume of fatty tissue circumferentially as well as noticeable loss of skin elasticity with ptosis. Circumferential liposuction encourages skin tightening. Minibrachioplasty may be required. Ultrasonic energy can encourage enhanced skin retraction, frequently reducing the need for skin excision. Category 3: Generalized obesity and extensive skin laxity: Patients generally have more significant lipodystrophy and skin laxity. Obese patients typically accumulate a large volume of fat in the para-axillary region and upper arm. Ultrasonic-assisted circumferential liposuction maximizes the potential for adequate skin retraction. Minibrachioplasty confided to the axilla is frequently required for Group 3 individuals. The larger the volume of fat removal, the better the prognosis for skin retraction with CAST liposuction and the shorter the brachioplasty scar if required.

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_46, © Springer-Verlag Berlin Heidelberg 2010

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Table 46.1 Upper arm contouring classification Category 1

Minimal arm fat with good skin tone

Category 2

Moderate fat with moderate skin laxity

Category 3

Marked excess skin and fat

Category 4

Minimal to moderate fat and marked excess skin

Category 4: Minimal subcutaneous fat and extensive skin laxity: These individuals demonstrate marked skin laxity and depletion of subcutaneous fat. Full brachioplasty is capable of producing an aesthetically pleasing contour of the arm and straight inferior brachial boarder. The surgical scars can be detouring, particularly in those individuals who have Fitzpatrick III to VI skin type and those who scar poorly. CAST liposuction combined with a minibrachioplasty confined to the axillas can produce improvement of the upper arm with some residual skin laxity, particularly distally. As noted, the larger the volume of fat removed, the greater is the potential for skin retraction, thereby reducing the length of the brachioplasty scar.

46.3 Preoperative Marking Patients requesting arm reduction were marked in the preoperative area in the standing position. The arms were marked in the abducted position with 90° flexion a

c

Fig. 46.1 Upper arm contouring categories: (a) Category 1. (b) Category 2. (c) Category 3. (d) Category 4

at the elbow. Preoperative markings divide the arm and contiguous para-axillary regions into nine zones (Fig. 46.2). Distal forearm, upper back, deltoid, axilla, and lateral pectoral extensions are included for regional harmony. For individuals with excessive skin laxity, in addition to lipodystrophy, a minibrachioplasty is designed. Puncture sites are marked at the anterior and posterior axilla, medial and lateral distal arm 1.5 cm proximal to the olecranon. Infrequently a puncture site is marked in the middle third of the posterolateral arm. Preoperative marks were checked with the arms in the adducted relaxed position to ensure appropriate placement for minimal delectability.

46.4 Anesthesia CAST liposuction of the arms may be performed under local or general anesthesia. It is the author’s preference to treat the arms under general anesthesia while performing liposuction of multiple areas. Superwet or tumescent anesthesia is utilized for hemostasis, compartment magnification, and postoperative analgesia [17, 18]. A greater volume of infiltration is utilized to minimize the thermal effect if UAL is required [19]. For procedures performed under general anesthesia, to each three liters of lactated ringers are added 50 mL of 1% lidocaine (500 mg) and 3 mL of 1:1,000 epinephrine. For procedures performed under local anesthesia, b

d

46 Circumferential Para-Axillary Superficial Tumescent (CAST) Liposuction for Upper Arm Contouring Fig. 46.2 Right arm para-axillary area with eight anatomical zones: (a) Anterior. (b) Posterior

a

the concentration of lidocaine may be increased by the addition of 150 mL of 1% lidocaine (1,500 mg) and 3 mL of 1:1,000 epinephrine. The surgeon must be aware of the dose of lidocaine being administered and keep the total lidocaine dose well below 35 mg/kg [17–22]. The volume of infiltrate is typically 800– 1,500 mL/arm.

46.5 Position Arm contouring in the lateral decubitus position is preferred. Although arm contouring can be performed in the prone and supine position, access to the para-axillary region is limited. The lateral decubitus position allows for circumferential treatment.

46.6 Technique Arm contouring is most frequently performed as part of total body contouring. When done so, the procedure is performed in an AAAA certified surgery center with the assistance of a board certified anesthesiologist. The patient is prepped in the standing positions to the level of the axilla. She is then placed on the operative table on a bean bag in the supine position. After achieving adequate general endotracheal anesthesia, she is draped in a sterile fashion. The patient is turned to the lateral decubitus position and an axillary roll is placed. The arm and upper forearm are prepped with Betadine and wrapped in a sterile towel from the elbow down, covering

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b

intravenous (IV) tubing and anesthesia monitoring devices. The arm is then placed on a mayo stand padded with a pillow and covered with a sterile towel. The arm is freely mobile, offering the advantage of access to all incision sites. The incisions are made with an 11 blade. Tumescent fluid is infiltrated under pressure to achieve a peu de’orange appearance. In the lateral decubitus position, typically the back, hips, thighs, and buttocks are treated before the arms to allow additional time for vasoconstriction. The arm is conceptually divided into three regionsanteromedial, anterolateral, and posterolateral (Fig. 46.3). CAST liposuction of the arms is site specific with pretunneling and/or deep liposuction, superficial, or all-layer liposuction. Circumferential pretunneling is performed with a 3-mm Mercedes cannula through multiple access sites. UAL, when utilized, is performed with a Mentor Contour Genesis (Mentor Corp., Dallas, TX) utilizing a 20-mm solid tip cannula with a generator setting of 75. Treatment is limited to 2–3 min for the posterolateral and paraaxillary region utilizing the posterior axillary incision. Circumferential liposuction is performed most aggressively in the posterolateral one third, less aggressively in the anterolateral one third, and least aggressively in the anteromedial one third.

46.6.1 Anteromedial Pretunneling is performed from the olecranon and axillary sites longitudinally. If the pinch test is 10 mm or less, only pretunneling is done. No liposuction is performed

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Fig. 46.3 Cross-section of the left arm demonstrating three anatomical regions: medial, anterolateral, and posterolateral

Anterolateral

Anteromedial

Posterolateral

under thin, anteromedial skin due to the propensity for wrinkling, especially near the axilla. Cross tunneling and/ or deep suctioning is performed from the middle third of the arm to create a final pinch test of 10–15 mm.

overresection centrally (Zones 2 and 3) by checking the pinch test frequently.

46.6.4 Para-Axillary 46.6.2 Anterolateral Superficial liposuction from the anterior axillary site, dorsoradial arm, and mid arm is performed with a 3 × 20-mm Mercedes cannula. The final pinch test should be 9–14 mm.

46.6.3 Posterolateral Ultrasonic energy is delivered through the posterior axillary incision as described. All-layer liposuction is performed with deep, superficial, and subdermal liposuction frequently required. A 3 × 20-mm Mercedes cannula is used initially. For larger volume extractions, a 4 × 30-mm cannula enables access to the entire length of the posterolateral compartment. Avoid

UAL is particularly useful for the deltoid region and upper back (Zones 7 and 8). No ultrasonic energy is delivered to the axilla proper (Zone 6). The fat is evacuated with 3 and 4 mm Mercedes cannulas. More aggressive liposuction is performed with a 3 mm Gasparotti to encourage the formation of a confluent layer of collagen forming circumferentially around the arm connecting to the trunk. The axilla, deltoid, and lateral pectoral extensions are treated with a 3 mm Mercedes to minimize wrinkling. The suture sites are closed with a single 5-0 nylon suture

46.7 Postoperative Care Care is taken in applying Reston foam. The author prefers Reston foam to the nonadherent Lipofoam

46 Circumferential Para-Axillary Superficial Tumescent (CAST) Liposuction for Upper Arm Contouring

for CAST liposuction of the arms. The adherent side to the Reston is covered with bacitracin ointment or vaseline to allow adherence, yet minimizing the risk of blistering. With the arm extended, the circulating nurse grasps the anterolateral skin to elevate the dependent posterolateral skin, and the sheet of Reston is placed under the posterolateral skin to redrape sagging skin smooth along the posterior arm. Wrinkling is directed anterolaterally. The arm is wrapped with a 4-inch ace wrap from the elbow proximally. Drains are no longer used as reported previously [3–5]. The Reston foam is removed the following day. Nonadherent Reston or Lipofoam is applied and a surgical compression garment that extends below the elbow is placed. The Reston may be kept in place for up to 1 week depending on the degree of skin laxity. The compression garment is worn at all times for 6 weeks. For more severe skin laxity, an additional 4 weeks of compression at least 12 h/day is recommended. The sutures are removed at 6–7 days. Frequent inspection for seromas is required for 6 weeks postoperatively. Persistent postoperative pain most frequently represents a seroma that should be treated with serial aspiration and compression. Painful bands or scar tissue or focal nodules representing fat necrosis are treated with message and microinjection of 0.2 mL triamcinolone (2 mg/mL). Injection is performed deep to avoid thinning of the skin. Limited range of motion of the shoulder due to axillary tightness is treated with message and range of motion exercises.

46.8 Minibrachioplasty Technique The minibrachiolasty incision is marked in the preoperative area with the arm abducted 90° from the trunk. The crease marking the junction of the medial arm with the axilla is located. The skin to be excised is marked with a symmetric ellipse of tissue measuring 4–6 by 12–15 cm in length. All attempts are made to confine the resulting scar to the axilla and avoid delectability, particularly posterior. The procedure can be performed in the lateral decubitus position; however, the author prefers to perform both minibrachioplasties in the supine position following the completion of the

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CAST liposuction. The demolipectomy is performed initially, leaving the superficial fascia intact to avoid injury of the vital structures located in the axilla. Metzenbaum scissors are then used spreading in the direction of the axillary vessels to identify the axillary vein. After locating the axillary vessels, superficial fascial system suspension sutures are placed of 2-0 Vicryl. Four to five sutures are preplaced and tagged prior to securing. Care is taken to incorporate the superficial layer of axillary fascia to prevent migration of the scar [13, 23–25]. Advancement is performed centrally to minimize standing cones. Standing cones are excised anteriorly if required. The subcutaneous tissue is closed with 3-0 Vicryl. A subcuticular suture of 4-0 clear PDS is placed. Interrupted 4-0 nylons sutures are placed to reinforce the inci sion and removed at 5–6 days. Postoperative care is similar to CAST liposuction of the arms with the exception that range of motion of the arms, particularly abduction, is limited for 4–6 weeks following surgery.

46.9 Results Between July 2001 and March 2009, 190 patients have undergone CAST liposuction alone (152) or with minibrachioplasty (38). Average age was 52.3 years (range, 20–71). Follow-up was 5–36 months (average, 16.2 months). There were 189 women and one man included in this series. One hundred and eighty nine patients underwent CAST Liposuction in combination with another cosmetic surgical procedure, most frequently liposuction of other regions. Represen tative before and after images are illustrated in Figs. 46.4–46.10. The following complications have been reported with liposuction of the arm with and without minibrachioplasty, but occurred infrequently in this series: Seroma, hematoma, pseudobursa, chronic pain, hypertrophic scarring, and wrinkling [1, 3–7, 16]. Use of ultrasonic liposuction, particularly time of use, and aggressive fat removal increase the likelihood of seroma. Aesthetic results were reviewed with the patients 6–12 months after the procedure. Secondary surgeries were offered at a reduced cost as outlined in the financial agreement discussed preoperatively.

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Fig. 46.4 Twenty-year-old female who underwent circumferential para-axillary superficial tumescent (CAST) liposuction with removal of 300 mL of fat from the right and 300 mL fat from the left: (a1, 2) Preoperative. (b1, 2) Five months postoperative

Residual skin flaccidity in Zone 4 proximal to the elbow and in Zone 1 anteromedial is relatively common in Category 3 and 4 patients, but is well accepted in lieu of the scars resulting from full brachioplasty. One patient who underwent CAST liposuction and minibrachioplasty requested revision on the posterior aspect of the incision due to visibility at the posterior axillary fold.

46.10 Discussion Requests for rejuvenation of the arms are increasing, particularly by young and middle aged women, who are frequently well-educated and physically fit. They receive a psychological boost from the appearance of

well-proportioned muscular arms. Early efforts to prevent, delay, or even halt skin degeneration and ptosis may include exercise, weight loss, and massage. It is only after these initial conservative efforts fail that individuals seek a consultation for surgical correction. Frequently, women are trying to prevent the development of “bat wing” deformity which they see in their mothers and grandmothers. There is evidence that early liposuction in these category 1 patients prevents the progressive lipodystrophy, which results in ptosis of the superficial fascia resulting in skin ptosis and flaccidity [1, 5]. The goal of CAST liposuction of the arm is to create regional harmony with a straight brachial border and minimal changes of skin quality, with minimal detectable scarring [3]. Correction of the upper arm utilizing traditional liposuction techniques has

46 Circumferential Para-Axillary Superficial Tumescent (CAST) Liposuction for Upper Arm Contouring

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Fig. 46.5 Thirty-two-year-old female who underwent CAST liposuction with removal of 500 mL of fat from the right and 500 mL of fat from the left: (a1, 2) Preoperative. (b1, 2) Twelve months postoperative

presented a challenge with satisfaction rates for the arms significantly lower than other regions [1]. Caution has been advocated in the application of liposuction of the arm in patients over 50 years of age [8]. Traditional brachioplasty is capable of producing the improvement in arm shape that patients request, but most individuals are unwilling to accept the brachioplasty scar. Reported complication rates for traditional brachioplasty are up to 25% and revision rates of 12.5% [15]. CAST liposuction of the arms differs from traditional (standard) tumescent liposuction of the arms as follows. Traditional tumescent liposuction of the arms involves deep liposuction over the posterolateral arm feathering of anteromedially and anterolaterally without circumferential treatment and without ultrasonic energy. Standard tumescent liposuction has the potential to worsen skin laxity and sagging. CAST liposuction combines several

principles to obtain more predictable aesthetic results. Circumferential treatment of the upper arm and paraaxillary region creates a subcutaneous confluence (lattice) of collagen deposition during healing, which promotes regional harmony. Small cannulas (3–4 mm) are utilized to minimize the risk of contour irregularities. Liposuction is performed from multiple directions in a multilayered approach. Circumferential liposuction is performed most aggressively in the posterolateral one third, less aggressively in the anterolateral one third and least aggressively in the anteromedial one third. For this reason, the majority of the delivery of the ultrasonic energy and the extraction of fat are done in the lateral decubitus position through a puncture site in the posterolateral axillary fold [3–5]. Liposuction through the posterior axillary incision minimizes the risk of overresection posterolaterally in zones 2 and 3 and allows for excellent

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Fig. 46.6 Thirty-eight-year-old female who underwent CAST liposuction with removal of 600 mL of fat from the right and 550 mL of fat from the left: (a1, 2) Preoperative. (b1, 2) Seven months postoperative

access the axilla and para-axillary region (zones 6, 7, and 8). For individuals with moderate fat and moderate skin laxity (Category 2), the application of ultrasonic energy with tumescent infiltration allows for compartment magnification and greater fat removal. Extraction of the emulsion with small cannulas results in a smoother appearance and enhanced skin retraction. Extraction with small cannulas is done utilizing a multilevel, multidirectional approach. The majority of the liposuction is done in the posterolateral arm where there is generally the greatest adiposity. The skin of the posterior lateral arm is thickest and has the greatest potential for contraction. Care is taken in avoiding overresection in the thin-skinned areas of the anterolateral and anteromedial arm. This is particularly important in the individuals with photoaged Fitzpatrick

I and II skin types, to minimized worsening of wrinkles and ptosis in these areas. For individuals with marked excess of skin and fat (Category 3), CAST liposuction alone may provide the degree of correction. In general, the greater the amount of fat removal, the less likely skin excision will be required. Skin excision in the form of minibrachioplasty offers the advantage of tightening of the skin in Zones 1 and 2 in the anteromedial and posterolateral skin with an incision hidden in the axilla. Minibrachioplasty produces no improvement in the tightness of the skin in Zones 3 and 4. The scar of the minibrachioplasty is in general well tolerated as it rarely widens or becomes hypertrophic. Although additional skin can be excised, the dimension of the excised skin needs to be confined to the axilla, particularly posteriorly, to avoid visibility from behind. An

46 Circumferential Para-Axillary Superficial Tumescent (CAST) Liposuction for Upper Arm Contouring

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Fig. 46.7 Forty-seven-year-old female who underwent CAST liposuction with removal of 450 mL of fat from the right and 400 mL of fat from the left: (a1, 2) Preoperative. (b1, 2) Four months postoperative

additional advantage is that excised skin reduces the hair baring skin of the axilla and reduces hydrosis. As the distal skin margin of the excision is longer than the proximal margin, early postoperative wrinkling is common, which improves within several months. Reported variations of modified brachioplasties or limited incision techniques leaving scars extending out of the axilla have been reported [1, 16, 23–25]. Extension may be in the form of a T or an L or may extend posteriorly on to the back. These reported techniques relied primarily on skin excision rather than liposuction. Individuals with minimal to moderate fat and marked excess of skin (Category 4) who are seeking arm rejuvenation are increasing due to the prevalence of bariatric surgery. Elderly women will invariably have wrinkling of the skin of their arms,

just as they will have wrinkling elsewhere. They will generally accept an imperfect result which appears natural. CAST liposuction provides improvement which the patients perceive as being more natural than the improvement resulting from a brachioplasty with anteromedial scarring of the arm. It is important to avoid overresection anteromedially in Zone 4, which results in wrinkling above the elbow. Performing CAST liposuction and minibrachioplasty does not obviate traditional brachioplasty in the future. For those with minimal to moderate fat and extreme skin laxity, traditional brachioplasty may provide the best alternative. Individuals wellsuited for traditional brachioplasty are those over the age of 60 years who are Fitzpatrick I or II skin types without personnel or family h istory of a bnormal scarring. Disadvantage of traditional

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Fig. 46.8 Twenty-year-old female who underwent CAST liposuction with removal of 450 mL of fat from the right and 450 mL of fat from the left: (a1, 2) Preoperative. (b1, 2) Four months postoperative

brachioplasty involves scarring, possible delayed healing, and numbness. Great care must be taken in the discussion of the risks involved in a traditional brachioplasty and in the informed consent process [13, 15]. Meticulous postoperative care is vital to obtaingood results. Compression is essential to achieve accurate redraping of the skin. Most frequently, the skin is loose and sagging posteriorly. Pulling the skin anterolaterally to smooth any wrinkles anterior medially and then fixing it with Reston foam facilitates re-draping and stabilization of the skin [3, 4, 7]. Weekly checks for seromas are required for the first 4 weeks. Seroma

formulation is decreased with reduced duration of ultrasonic energy delivery and the use of a greater number of liposuction access sites. Postoperative compression is required for 6 weeks for optimal aesthetic results. The primary attraction of CAST liposuction with or without minibrachioplasty is enhanced skin retraction with minimal scarring compared to a traditional brachioplasty. Extensive preoperative educational is advisable. Realistic expectations should be stressed in terms of the amount of improvement which can be anticipated. Photographs of patients who have undergone liposuction, with and without minibrachioplasty,

46 Circumferential Para-Axillary Superficial Tumescent (CAST) Liposuction for Upper Arm Contouring

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Fig. 46.9 Twenty-six-year-old female who underwent CAST liposuction with removal of 600 mL of fat from the right and 550 mL of fat from the left: (a1, 2) Preoperative. (b1, 2) Nine months postoperative

as well as full brachioplasty, should be available to demonstrate realistic results and sites of surgical scars. A financial policy should be spelled out prior to the procedure regarding financial obligations, should a secondary procedure be required.

46.11 Conclusions Liposuction of the arms in the patient with aged and flaccid skin has traditionally produced disappointing results. CAST liposuction was developed to maximize

skin retraction can regional harmony by compartment magnification followed by circumferential treatment of the arm and adjacent aesthetic units. Rigorous patient selection and education are essential as the goal of CAST liposuction is improvement, not perfection. The postoperative care is demanding in order to achieve accurate skin redraping requiring complete patient compliance. Minor complications including seromas and wrinkling are not uncommon. The patient must be aware that there may be the need for a secondary surgical procedure in the form of a modified brachioplasty to treat redundant skin in the axilla and upper arm.

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Fig. 46.10 Fifty-five-year-old female who underwent CAST liposuction with removal of 800 mL of fat from the right and 800 mL of fat from the left combined with minibrachioplasty. (a1, 2) Preoperative. (b1, 2) Five months postoperative

References 1. Vogt PA, Baroudi R. Brachioplasty and brachial suctionassisted lipectomy. In: Cohen M, editor. Mastery of plastic and reconstructive surgery. 1st ed. Boston: Little Brown; 1994. p. 2219–36. 2. Lillis PJ. Liposuction of the arms. Dermatol Clin. 1999; 17(4):783–97. 3. Gilliland MD, Lyos AT. CAST liposuction of the arm improves aesthetic results. Aesthetic Plast Surg. 1997;21(4): 225–9. 4. Gilliland MD, Lyos AT. CAST liposuction: an alternative to brachioplasty. Aesthetic Plast Surg. 1997;21(6):398–402. 5. Gilliland MD. Ultrasound-assisted circumferential paraaxillary superficial liposuction effect on arm contour. Oper Tech Plast Reconstr Surg. 2002;8(2):60–6. 6. Illouz YG, DeVillers YT. Body sculpting by lipoplasty. Edinburg: Churchilll Livingstone; 1989. p. 279–81. 7. Schlesinger L. Suction assisted lipectomy of the upper arm: a four cannula technique. Aesthetic Plast Surg. 1990; 14(4):271–4. 8. Grazer FM. Atlas of suction assisted lipectomy. New York: Churchill Livingstone; 1992. p. 139–40.

9. Correa-Iturraspe M, Fernandez JC. Dermolipectomia brachuial. Prensa Med Argent. 1954;41(34):2432–6. 10. Baroudi R. Dermolipectomy of the upper arm. Clin Plast Surg. 1975;2(3):485–94. 11. Guerrero-Santos J. Brachioplasty V. Aesthetic Surg J. 2004;24:1616–9. 12. Pitanguy I. Aesthetic plastic surgery of the upper and lower limbs. Aesthetic Plast Surg. 1980;4:363–72. 13. Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96(4):912–20. 14. Pascal JF, Le Louarn C. Brachioplasty. Aesthetic Plast Surg. 2005;29(5):423–9. 15. Knoetgen J, Moran SL. Long-term outcomes and complications associated with brachioplasty: a retrospective review and cadaveric study. Plast Reconstr Surg. 2006;117(7): 2219–23. 16. Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg. 1998;102(2):545–51. 17. Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol. 1990;16(3):248–63. 18. Rohrich RJ, Beran SJ, Fodor PB. The role of subcutaneous infiltration in suction assisted lipoplasty. Plast Reconstr Surg. 1997;99(2):51.4–9.

46 Circumferential Para-Axillary Superficial Tumescent (CAST) Liposuction for Upper Arm Contouring 19. Kenkel JM, Robinson JB, Beran SJ, Tan J, Howard BK, Zocchi ML, Rohrich RJ. The tissue effects of ultrasound assisted lipoplasty. Plast Reconstr Surg. 1998;102(1): 213–20. 20. Pitman GH. Tumescent technique for local anesthesia improves safety in large volume liposuction. Plast Reconstr Surg. 1993;92:1099–100. 21. Matarasso A. Lidocaine in ultrasound assisted lipoplasty. Clin Plast Surg. 1999;26(3):431–9.

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22. Samdahl F, Amland PF, Bugge JF. Plasma lidocaine levels during suction assisted lipectomy using dilute lidocaine. Plast Reconstr Surg. 1994;93(6):1217–23. 23. Richards ME. Minimal incision brachioplasty: a first choice option in arm reduction. Aesthetic Surg J. 2001;21:301–8. 24. Richards ME. Reassessing minimal-incision brachioplasty. Aesthetic Surg J. 2004;25:175–9. 25. Abramson DL. Minibrachioplasty: minimizing scars while maximizing results. Plast Reconstr Surg. 2004;114(6):1631–7.

Body Contouring with Focused Ultrasound

47

Javier Moreno-Moraga and Josefina Royo de la Torre

47.1 Introduction Demand for nonsurgical body weight control treatments has increased in the last few years. Despite offering less corrective results than traditional cosmetic surgery for body contouring (liposuction, crural and brachial lifts and abdominoplasty), nonsurgical treatments have gradually gained ground in the reduction of localized fat and improvement of the skin’s appearance and texture [1–3]. Diet, exercise, and genetics are all important influencing factors in the appearance of indentations in the skin, which are hard to conceal at any age. Demand for nonsurgical, nonablative cellulite treatments have lead many manufacturers to invest in a new generation of sophisticated devices and therapies to repair the skin and improve body shape. A number of these options have a proven softening effect (after multiple treatment sessions).

47.2 General Considerations 47.2.1 Subcutaneous Adipose Tissue Anatomic and physiologic studies on the adipose tissue have been focused on in vivo studies of individual adipocytes or in vivo studies with functional and minimally invasive methods [4–6]. Traditionally, the subcutaneous adipose tissue has been considered as insulation and a source of stored energy. More recently, there has been greater interest in

J. Moreno-Moraga (*) Instituto Medico Laser, General Martinez-Campos 33, 28010 Madrid, Spain e-mail: [email protected]

the distribution and composition of the adipose tissue in relation to health and morbidity. The actual concepts of the adipose tissue’s anatomy are derived from the histological studies of Nurnberger and Muller, who analyzed samples of healthy men and women’s adipose tissue and of women with cellulite [7]. They reported indentations into the deep adipose tissue through the dermis on women, but not in men. They also described modifications on the fibrous septae architecture oriented perpendicular to the cutaneous surface on women and in a criss–cross pattern on men.

47.2.2 Histological Characteristics of Subcutaneous Adipose Tissue The histology of subcutaneous adipose tissue has been thoroughly investigated. There are macroscopic and microscopic differences between skin of men and woman without alterations and on women with celulite [8]. The macroscopic examination of the specimens of full thickness proved the complexity of the 3-dimensional (3-D) net formed by the fibrous bands, which are born from the hypodermis. Pierard felt that there were no continuous layers of connective tissue that may be called septae between the lobules of adipose tissue in women with cellulite, even though the microscopic examination of thigh skin in men shows a dermalhypodermic leveled interface without any clinical signs of cellulite. In contrast, the dermal-hypodermic interface of women’s thigh skin (even without cellulite) demonstrates that the adipose lobules have a granular aspect, which protrudes into the dermis [5]. The lobules rise as valleys and hills under the dermal surface. In some cases, the sweat glands are trapped in these fat lobules. There is no correlation between the extent of this finding and

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_47, © Springer-Verlag Berlin Heidelberg 2010

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the clinical type and severity of cellulite. A more undulated dermis hypodermic interface on women, which corresponds to the fibrous bands observed in the macroscopic studies on corpses, has been confirmed using high-resolution ultrasound (US) images [6]. Recently, the architecture of the fibrous septae net has been visualized through 3-D magnetic resonance imaging (MRI), as well as with a high-resolution ultrasound. Camper’s fascia can clearly be observed as a thin flat structure more or less parallel to the cutaneous surface. Other septae were detected as thin structures oriented like pillars in three directions: perpendicular, parallel, and with a 45° angle. In women with cellulite, there are a higher percentage of perpendicular fibers in comparison with women (and men) who do not have cellulite. As for the fibers in other directions, women with cellulite have a lower percentage of parallel septae to the skin and a higher percentage of angled septae. Furthermore, an MRI study on adipose tissue comparing young and mature women found a higher content of water within the dermis in the older group. A larger amount of free water between the dermis has been related to collagen architecture degradation during the aging process, leaving less interaction sites between water and macromolecules [5, 6]. Skin aging is a process that can be classified into two groups: intrinsic aging and photo aging. These are considered different processes with the first caused by the passage of time and the second due to continuous exposure to the ultraviolet rays from the sun. In both types of aging, the most dramatic histological changes are found in the dermis. Collagen alterations, the main skin component, have been identified as the cause of the changes observed. The dermis contains mainly collagen type I (85–90%) and less collagen type III (10–15%). The dermal fibroblasts synthesize the individual chains of polypeptide procollagen I and II, precursors of collagen type II and type III that are formerly polymerized in the carboxylic rings and amino terminals to form the triple helixes. Skin that is not normally exposed to the sun’s ultraviolet radiation, such as the thighs and buttocks, mainly goes through the intrinsic aging process. In a study about collagen metabolism in the aging process, it was observed that in the areas not exposed to sun, the synthesis of collagen diminishes as the aging process goes on, maintaining a negative balance between synthesis and collagen degradation. Since the buttocks and thighs undergo a lesser degree of photo aging, they are ideal anatomical areas to

J. Moreno-Moraga and J. R. de la Torre

observe the effect of RF energy on the chronologically aged collagen in the adipose tissue [6].

47.2.3 Cellulite Cellulite is a type of lipodystrophy considered by many to be an aesthetic disorder in which the alteration is a morphological constitutional disposition with no significant histological or biological alterations of the adipose tissue [7]. It affects females almost exclusively, and appears around puberty. Approximately 90% of the female population have some degree of cellulite. It is common to confuse cellulite appearance with obesity, even though it is a different condition. Obesity is a generalized condition in which the adipocytes increase in number and size. Cellulite is localized to specific sites with characteristic structural changes (lipodystrophy). Cellulite is mainly located on the lateral aspects of the thighs and buttocks and is highly related to hormonal changes in females. Cellulite differs from the fat on the abdominal wall, which is more dependent on metabolism and diet, and is more easily removed. Skin with cellulite is rough to the touch. When it is pinched, it has the appearance of orange skin, and is often associated with a painful sensation.

47.2.4 Cellulite Pathogenesis In the gynoid zones (thighs, hips, and buttocks), women have adipocytes five times greater than in other body zones. The cutaneous microcirculation has certain special characteristics that deposit more fat and retain more interstitial fluids. The fat is kept in the adipocytes that are found between the skin and muscles and divided by fibrous tissue bands. These fibrous bands give the adipose tissue a wall-like aspect between the skin and muscles which slow down the lymphatic drainage.

47.2.5 Ultrasound (US) in the Study of Cellulite It is complicated to study the RF thermal effect on the subcutaneous tissue in large areas like the thighs and buttocks. A biopsy may cause trauma to the tissue,

47 Body Contouring with Focused Ultrasound

which would modify the next sample by leaving scar tissue that would alter the histological morphology of the study zone. It is technically difficult to take the whole thickness of healthy adipose tissue without causing a deformity during extraction or processing. It was determined that in vivo observation in real time with noninvasive methods, like the ultrasound, would allow us to register changes on large anatomical zones, quantify them, and keep the records of what could happen when heating the tissue with RF. The Real Time Scanning Compound Image (RTSCI) ultrasound has a great variety of medical applications including blood vessels, the musculoskeletal system, gynaecological and abdominal exams, and so forth. However, its use for the study of skin and subcutaneous tissue is not well known [6].

47.3 Ultrasound Ultrasound has been widely applied in varied fields of medicine. A number of companies have put new devices on the market aimed at destroying the subcutaneous adipose tissue, thereby achieving body shape reduction and remodeling. A variety of pressure waves designed for therapeutic effects are available as follows: 1. Generation of mechanical pressure waves [8–10] 2. Electromagnetic radiation: • Lasers, IPL, Radio Frequency devices • Highly absorbed by human tissue • Superficial penetration 3. Focused ultrasound: • 2–10 MHz ultrasound • Very long wavelengths • Minimal relative absorption in tissue • Ability to penetrate deeply into tissue • Ultrasound energy is attenuated as it passes through tissue at approximately 1 dB/cm at 2 MHz.

47.3.1 Methods of Attenuation Absorption • Acoustic energy is converted to heat • Primary factor of attenuation Reflection • Echoes (imaging)

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Scattering • Change of direction The approach of using noninvasive focused ultrasound for tissue disruption differs from other therapeutic ultrasound devices in important ways (Fig. 47.1). The first and most obvious distinction is between invasive therapeutic ultrasound, such as is used in internal ultrasound-assisted liposuction (UAL), and external therapeutic ultrasound of various types. Among external ultrasound treatments, the approach of tissue or substance destruction should be distinguished from tissue warming [11–14]. As a rough generalization of currently marketed systems (which are predominantly for nonaesthetic applications), most noninvasive destructive or disruptive ultrasound devices use focused ultrasound , whereas devices that warm the tissue are nonfocused. For example, shock wave treatments (extracorporeal lithotripsy for renal calculi, orthopaedic treatments for calcifying tendonitis and heel spurs) operate by focusing single, very intense pulses of ultrasound energy onto their target and deliver mechanical (rather than thermal) action [10, 14]. They can be very painful and require sedation and/or anesthesia, but their effect (destruction of a substance) is long lasting. In contrast, thermal treatments, which are very commonly used in physiotherapy, are very well tolerated. Such thermal treatments induce temporary vasodilation and increase blood flow, and this mechanism has been proposed to explain their beneficial effects in temporary relief or muscle and joint pain (Fig. 47.1).

Therapeutic ultrasound

Noninvasive

Invasive Internal UAL Focused

Tissue disruption Durable effect Examples: UltraShapeTM Contour 1 Tumor ablation (prostate, uterine myomas) Cardiac ablation (A Fib) Shock wave therapy (renal calculi, calcifying tendonitis, heel spurs)

Fig. 47.1 Ultrasound used in medicine

Non-focused Tissue warming Nonablative Usually temporary effect Examples: Physiotherapy External UAL

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47.3.2 High Intensity Focused Ultrasound (HIFU) Mechanism Action The HIFU procedure produces its desired effects by presumably rupturing the adipocytes membrane [10]. A nonablative thermal treatment would not be expected to have a significant or durable effect on fat. In fact, external nonfocused therapeutic ultrasound has been applied to body contouring, but was found to be effective only as an adjunct to liposuction, where it is postulated that treatment with external ultrasound after infiltration with tumescent solution improves tissue hydration and distribution of the tumescent solution. Other devices currently marketed for body aesthetics claims (such as temporary cellulite improvement), which act by heating, require numerous treatments (six or more) and generally have short-term effects. In the context of the benefits and drawbacks of previously available therapeutic ultrasound approaches described above, the HIFU body contouring devices were designed to be noninvasive (to improve upon the risks of UAL) and focused (to provide a destructive effect, with an expected longer-lasting effect), but well-tolerated, for office-based use without the need for any sedation or anesthesia, downtime or recovery period. Ultrasound is mechanical pressure waves that spread out through the treated tissue. HIFU is focused ultrasound. Focusing means centering the sum of energies in a single point; thus as it pierces the skin without a build-up effect, it is respected and becomes more effective on the focal point. Focusing depends on the frequency (f) and the ultrasound wavelength (l). Ultrasound is generated in a piezoelectric crystal excited by an electric current. The frequency depends on the crystal’s characteristics and is constant for any ultrasound device. Focusing precision is improved as frequency is increased. Most devices deliver pulsed energy which allows for peaks of maximum intensity in each pulse [6, 9]. HIFU works under the same principles as the ultrasound diagnosis system, although as the very name implies, the levels of therapeutic energy are great in the case of HIFU. HIFU focuses energy in the treated tissue much more than sun rays concentrated through a crystal (magnifying glass) on a specific point. Energy on a focal point is sufficient to cause damage, but outside of this point, solar energy is not concentrated enough to damage tissue. HIFU acts in the same way.

J. Moreno-Moraga and J. R. de la Torre

The therapeutic US emission window is focused on a specific point, known as focal point. This concentration of energy on a specific spot creates thermomechanical damage in the adipose tissue and also affects a small area around the focal point. Actually, the compression/decompression waves exit lineally, but the lineality is inverted on contact with the focal point. This causes bubbles to form due to the abrupt fall in pressure of the inversion. These bubbles rub against each other and the sudden rise in pressure due to lack of lineality generates a large amount of heat energy. The heat is so intense that coagulative necrosis sets in at the focal point [10–13]. Therefore, adipose cells are affected by two mechanisms: mechanical and hyperthermic forces. One cannot occur without the other. Although, according to the type of device used, either the thermal or mechanical effect will be predominant over the other. HIFUs of high and low frequency must be distinguished (Fig. 47.2) as follows: 1. Low frequency (0.1–1 MHz): (a) Lower absorption in tissue (b) Achieves limited thermo effects (c) Slower delivery into tissue (d) Does not tighten collagen (e) Difficult to tightly focus due to longer wavelengths (f) Ultrashape® is an example of this device 2 High frequency (1–10 MHz): (a) More highly absorbed in tissue (b) Achieves thermo-mechanical effects (c) More efficient rapid delivery into tissue. (d) Achieves collagen tightening (e) Can achieve very precise focus due to frequency used (f) It respects the vessels and nerves to a lesser degree, causing haematomas and postprocedural pain in the majority of cases. (g) Lipsonix® is an example of this device

47.3.3 Nonfocused Ultrasound Mechanism Action (Cavitation) Physical phenomenon based on the effect of ultrasounds on liquids that causes the repeated creation of micro vapor bubbles due to the fast oscillation in

47 Body Contouring with Focused Ultrasound Fig. 47.2 Ultrasound absorption vs. frequency at 2 cm

477 Ultrasound absorption versus frequency at 2 cm

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pressure. It can be created by mechanical movements (turbines, propellers, and ultrasounds). This technique is well known but not very useful given its instability and shallow penetration, as well as the drawbacks caused by the high temperatures created by molecular friction generated by the ultrasounds at 1 or 3 MHz. These techniques were used in surgery for hydrolipochalasis, rendering irregular results [10]. With the development of specific last generation devices, a true capacity of permanent treatment of lipodystrophies or localized fat is available. In contradistinction to previous ultrasound devices, greater penetration frequencies are applied using higher compression capacity and a lower thermal effect. This generates stable cavitation fields that create larger micro vapor bubbles continuously and in a controlled manner, allowing for greater capacity and effectiveness. The bubbles created accumulate energy to the point of implosion and collapse. This process liberates energy over 100 kg/cm2. As this phenomenon is recreated in the interstitial fluid contained in the adipose tissue, the adipose cells are exposed to exceedingly high pressure that causes the separation of the fat nodule parcels and the rupturing of cell walls or membranes. This causes the selective and bloodless

destruction of the adipose cell. In turn, as such a large bubble implodes; it launches a high pressure micro jet against the adipocytes, thereby increasing the action even more. This implosion favors the break up of fats liberated from their membranes into shorter chains than fatty acids that stimulate their metabolism and natural elimination. This principle of physics had not been previously used in cosmetic medicine and is the basis of ultracavitation [10–12]. The destruction of adipocytes can be observed without injury to the blood vessels that are resilient, and therefore, can absorb the high pressure without breaking. As the membranes are destroyed, fat is dispersed in the hypodermic interstitial fluid. As the bubbles implode, they generate high temperatures which stimulate fat rupture into shorter fatty acids chains, favoring absorption. The high temperatures created in the tissue favor neocollagenesis, which aid in improving dermis elasticity. It is vital that the emitted frequency spectrum coincides with the absorbed frequency in each tissue for stable cavitation. This will depend on the density, depth, and shape of the cavity it is contained in. So, it is extremely important that the relation between emitted and absorbed frequency be maximum. The

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Fig. 47.3 Ultrasounds for lipolysis

ULTRASOUNDS FOR LIPOSYSIS NONFOCUSED US: . Thermal and vibratory effect . Less lipolysis capacity . Numerous sessions . Infiltration needed for hypoosmolar solutions

FOCUSED US (HIFU): . Few sessions . No infiltration needed . Greater lipolysis

LOW FREQUENCY FOCUSED US (HIFU)

HIGH FREQUENCY FOCUSED US (HIFU)

. . . .

. . . .

Lower absorption Less focalisation Safe, no postoperative Good results in a number of cases

NovaShape® Adjust and Rate functions aid in finding the appropriate frequencies for each area and type of adipose tissue. The device’s ability to focalize emissions allows for selection of wave penetration to more or less depth depending on where the adipose panniculus is located. Once the adipocytes are destroyed with any type of ultrasound , the human body’s healing mechanism sets off. Macrophages act in the damaged area eliminating the cell content, including the fat molecules. Lipids are metabolized by the regular methods. As time goes by, the cell matrix treated is destroyed and remodeling takes place with reduction of the fat layer thickness. The amount of free lipids born out of this procedure is within the body’s metabolism capabilities of adipose tissue. In fact, the indexes obtained by the analysis of fat content in the blood after HIFU treatment are within the normal parameters without observing significant increases in FFA (free fatty acids), HDL, LDL, triglycerides, or total cholesterol [15–18]. A comparative summary of the ultrasounds used for lipolysis is related in Fig. 47.3.

47.3.4 Histopathology The energy deposited in the target (adipose tissue) causes cell death through thermal coagulation of the tissue, ultracavitation, or mechanical vibratory stimulation. Slight bleeding through capillarity is observed. This is translated into ecchymosis in some cases, although the energy protocols worked with render

Higher absorption Better focalisation Postoperative pain and haematoma Application limited to abdomen

ecchymosis unlikely, except in patients with coagulation disorders. After disrupting the adipocyte membranes, inflammation with the emergence of macrophages is apparent along with a fine line of fibrosis after 8 weeks. Calcification, abscesses, or fistulas have not been detected.

47.3.5 Applications Destruction of fat deposits requires a thick enough fat layer to allow to limit the ultrasound action on the adipose tissue without injuring other body structures.

47.3.6 Contraindications 1. Female patients who are or may be pregnant. 2. The patient who has less than 1 cm of adipose tissue thickness beyond the selected focal depth in the area to be treated. 3. The patient who has been diagnosed with a coagulation disorder or is receiving anticoagulant therapy. 4. The patient who has a history of liposuction, any injection lipolysis therapy, abdominoplasty, or surgery (open or laparoscopic) in the area to be treated. 5. Presence of an implantable electrical device, e.g., pacemaker, defibrillator, or neurostimulator.

47 Body Contouring with Focused Ultrasound

6. Presence of neurosurgical cerebrospinal shunt in the area to be treated. 7. Presence of cancer, hernia, sensory loss or dysesthesia, scars or wounds in treatment area. 8. The patient who is under the care of a physician for known or suspected systemic disease of any type, or takes prescription drugs for a chronic condition. 9. Redundant skin folds or poor skin elasticity. Use in such patients may not produce the desired aesthetic effect.

47.4 Clinical Procedure Protocol The procedure should start with a visual study of the area to be treated; an ultrasound will provide a good image of the adipose tissue thickness and safety of the treatment [19] (Fig. 47.4). In order to obtain good results, the area to be treated should not be tense and any protrusion of bone structures avoided, such as in the case of the trochanteric region. This requires the use of gadgets such as foam pillows to place the areas in a comfortable position free from tension. This is important as one of the drawbacks of the procedure is its duration. The fat must be compacted in the treated area using bandages

a

Fig. 47.4 (a) Ultrasound image before the treatment. (b) Ultrasound image after treatment

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or corsets. It is important to always keep the surface covered in a layer of oil to avoid the very rare chance of burning (Figs. 47.5 and 47.6). The stability of the circulating fat profile and the absence of steatorrhoeic hepatosis during treatment assure that this procedure is safe, with no repercussions on the organism due to its ability to handle large amounts of triglycerides (as in the case of the postprandial stage), which are never exceeded in a sole session of ultra liposculpture. Maintaining body weight confirms that the reduction in volume is exclusively due to the loss of adipose tissue in the treated areas.

47.4.1 Results Reduction in the adipose panniculus has been observed, to a greater or lesser degree, in every patient treated using the three systems. Figure 47.7 shows the results obtained with NovaShape®. Figures 47.8 and 47.9 show UltraShape® and Liposonix® results, respectively. At least 20% of the patients had less than 1 cm of reduction in treated fat height, which displays the poor aesthetic result. The flanks and internal part of the thighs and knees are the areas with the greatest aesthetic failure rate.

b

480 Fig. 47.5 Compacted fat in the treated area using bandages and cushion

Fig. 47.6 Ultrasound image with and without bandages and cushions

J. Moreno-Moraga and J. R. de la Torre

47 Body Contouring with Focused Ultrasound Fig. 47.7 (Left) Before treatment. (Right) After treatment with Novashape™

Fig. 47.8 (Left) Before treatment. (Right) After treatment with Ultrashape™

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Fig. 47.9 (Left) Before treatment. (Right) After treatment with Liposonix™

elastocompression apparel) and the good tolerance level of clinical procedures (painless and outpatient) have increased social demand for this type of unwanted fat accumulation treatment.

47.5 Conclusions

Fig. 47.10 Burn after treatment with Ultrashape™

All three devices have caused burns, which in some cases were significant (Fig. 47.10). In most cases, this is due to poor contact of the handpiece with the body area. The discomfort and risks of invasive techniques (hospitalization, anesthesia, postoperative, use of

This is a procedure with minimally undesirable effects, most of which avoidable. It has no repercussion on the organism’s general state and is very well tolerated by patients. It is also believed that the aesthetic results reached, although improvable, are markedly satisfactory.

References 1. Commons GW, Halperin B, Chang CC. Large volumes liposuction: review of 631 consecutive cases over 12 years. Plast Reconstr Surg. 2001;108(6):1753–63.

47 Body Contouring with Focused Ultrasound 2. Ross AB, Vergnanini AL. Cellulite: a review. J Eur Acad Dermatol Venereol. 2000;14(4):251–62. 3. Nürnberger A, Müller G. So-called cellulite an invented disease. J Dermatol Surg Oncol. 1978;4(3):221–9. 4. Matarasso A, Swift RW, Rankin M. Abdominoplasty and abdominal contour surgery: a national plastic surgery survey. Plast Reconstr Surg. 2006;117(6):1797–808. 5. Querleux B, Cornillon C, Jolivet O, Bittoun J. Anatomy and physiology of subcutaneous adipose tissue by in vivo magnetic resonance imaging and spectroscopy: relationship with sex and presence of cellulite. Skin Res Technol. 2002;8(2):118–24. 6. Kennedy J, Ter Haar GR, Cranston D. High intensity focused ultrasound: surgery of the future? Br J Radiol. 2003; 76(909):590–99. 7. Grazer FM, Jong RH. Fatal outcome from liposuction: census survey of cosmetic surgeons. Plast Reconstr Surg. 2000;105(1):436–46. 8. del Pino ME, Rosado RH, Azuela A, Graciela Guzman M, Arguelles D, Rodriguez C, Rosado GM. Effect of controlled volumetric tissue heating with radiofrequency on cellulite and the subcutaneous tissue of buttocks and thighs. J Drugs Dermatol. 2006;5(8):714–22. 9. Haar GT, Coussios C. High intensity focused ultrasound: past, present and future. Int J Hyperthermia. 2007;23(2):85–7. 10. Coussios C, Farny CH, Haar GT, Roy RA. Role of acoustic cavitation in the delivery and monitoring of cancer treatment by high-intensity focused ultrasound (HIFU). Int J Hyper thermia. 2007;23(2):105–20. 11. Leslie TA, Kennedy JE. High intensity focused ultrasound in the treatment of abdominal and gynaecological disease. Int J Hyperthermia. 2007;23(2):173–82. 12. Wu F, Wang ZB, Chen WZ, Zou JZ, Bai J, Zhu H, Li KQ, Xie FL, Jin CB, Su HB, Gao, GW. Extracorporeal focused ultrasound surgery for treatment of human solid carcinomas:

483 early Chinese clinical experience. Ultrasound Med Biol. 2004;30(2):245–60. 13. Haar GT, Coussios C. High intensity focused ultrasound: physical principles and devices. Int J Hyperthermia. 2007;23(2):89–104. 14. Lafon C, Melodelima D, Salomir R, Chapelon JY. Interstitial devices for minimally invasive thermal ablation by highintenstiy ultrasound. Int J Hyperthermia. 2007;23(2): 153–63. 15. Miles JM, Park YS, Walewicz D, Russell-López C, Windsor S, Isley WL, Coppack SW, Harris WS. Systemic and forearm triglyceride metabolism: fate of lipoprotein lipase-generated glycerol and free fatty acids. Diabetes 2004;53(3): 521–7. 16. Garcia-Murray E, Adan Rivas O, Stecco K, Desilets Ch, Kunz L. The use and mechanism of action of high-intensity focused ultrasound for adipose tissue removal and non-invasive body sculpting, Abstract. Am Soc Plast Surg Meeting Chicago, Illinois: September 2006. 17. Smoller BR, Garcia-Murray E, Adan Rivas OE, Stecco KA, Desilets CS, Fodor PB. The histopathological changes from the use of high-intensity focused ultrasound (HIFU) in adipose tissue, Abstract. Am Acad Dermatol Meeting, San Francisco: March 2006. 18. García- Murray E, Fodor PB, Smoller BR, Stecco KA, Desilets CS. Evaluation of the acute and chronic systemic and metabolic effects from the use of high-intensity focused ultrasound for adipose tissue removal and non-invasive body sculpting, Abstract. Am Soc Plast Surg Meeting, Chicago, Illinois: September 2005. 19. Moreno-Moraga J, Valero-Altés T, Riquelme AM, IssariaMarcosy MI, de la Torre JR. Body contouring by non-invasive transdermal focused ultrasound. Laser Surg Med. 2007;39(4):315–23.

Focus Ultrasound on Limited Lipodystrophies

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Michele Cataldo, Luca Grassetti, and David E. Talevi

48.1 Introduction Localized fat deposit in man and woman represents one of the main causes of dissatisfaction of the body image in this millennium, where the consideration for a slim and pleasant proportioned body has taken the place of the fat woman of the middle ages at the beginning of 1900. New models introduced by the media and imaging have pushed the population to follow diet and regime to try to be on shape, and for most of the lifetime, struggling against the temptations of good food and lazy life. Healthy food, gymnastics, exercise, and running are all types of new trends of life scenario that have been introduced in the last 20 years and have revolutionized our lifestyle. Despite all these attempts, fat deposits in women and men have remained unchanged. This is mainly because of hereditary disturbance of constitution and hormonal change mostly in woman, rather than for the difficulty of most races, such as Black and Arab, to change their style of life and nutrition through the ages. The new generation is very focused on the aspects of the body, aiming to be slim and sexy and devote great attention to nutrition, exercise, and body enhancement. For limited areas of fat accumulation, what we generally call lipodystrophies, a new treatment has been introduced recently following the previous experience of internal and external ultrasound energy.

M. Cataldo (*) via Turati 4, 20060 Trezzano Rosa, Milano, Italy e-mail: [email protected]

48.2 History of Medial Applications of Ultrasound Ultrasonic medical devices have been used as a diagnostic and therapeutic tool for a number of years and have proven to be effective, useful, and safe. Ultrasound has been used by plastic and cosmetic surgeons postoperatively to reduce swelling after liposculpture and, since 1991, has been applied preoperatively and intraoperatively as well. After the development of tumescent liposculpture, the application of ultrasound to liposuction surgery became a possibility because ultrasonic energy requires a fluid medium to be transmitted and the tumescent fluid provides such a medium. So ultrasound may be very effective in the attempt to emulsify body fat and may be applied either internally or externally [1]. Internal ultrasound utilizes a special probe that is connected to an ultrasound generator and a handpiece that converts electric energy into ultrasound energy that transmits through a ceramic handpiece. The probe is inserted into the body through the same incisions as liposuction and the sound wave progressively emulsifies the target fat. Thus, internal ultrasound is applied and replaces the actual liposuction procedure. External ultrasound uses a flat round transducer that is held against the skin in the area to be treated. External ultrasound may be used on tumesced areas immediately before liposuction to facilitate the procedure or on follow-up visits during the postoperative period to speed healing [2, 3]. The application of ultrasonic energy to adipose tissue effectively liquefies the fat, releasing a combination of triglycerides, normal interstitial fluid, and the infused tumescent solution. These components form an emulsion that can be removed using vacuum suction. Because of the predilection of the ultrasound waves for low density tissue such as fat, there is felt to

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be a selective targeting of the fat cells without affecting the intervening connective tissue and neurovascular structures. The depth of the penetration is inversely proportional to the frequency used [4]. It is felt that ultrasonic energy affects the adipose tissue via several mechanisms thermally, micromechanically, and through the phenomenon of cavitation. Internal ultrasonic liposuction mainly utilizes the principles of cavitation. The mechanism through which external ultrasound affects fatty tissues is felt to be a micromechanical effect.

48.3 Infiltration Infusion Before being treated with ultrasound, external as well as focus ultrasound, the area of body to be treated should be infiltrated with tumescent solution to provide a medium for the conduction of the ultrasonic waves. The presence of fluid reduces the density of the tissue, thereby facilitating the emulsification process of the tissues. The authors use the solution containing lidocaine (2%) 200 mg in 100 mL of saline solution and 10 mEq disodium bicarbonate. The total solution infiltrated never exceeds 100 ml (Fig. 48.1).

48.4 Focus Ultrasound on Small Fat Deposits The authors investigated the potential of focus ultrasound on small fat deposits of the body in terms of fat emulsification and selective destruction of the target fat deposit. All the patients were submitted to multiple staged treatments. The fat compartments treated were: 1. Abdominal periumbilical area 2. Flanks 3. Trochanter All the patients had pretreatment assessment, cholesterol, triglycerides, liver, and renal function and postoperative check. Other studies have concluded that external and focus ultrasound, when a limited area of the body is treated and a limited quantity of fat is emulsified, does not present any alteration to the renal and liver function. Also the authors’ study arrived at the

Fig. 48.1 Focus ultrasound: The handpiece and the concentrated action of the ultrasound wave on superficial fat 1.5 cm deep from the skin surface

same conclusion. The progressive absorption of the emulsified fat arrives through the renal system, but without failure in the reduction of functionality. The area of the target was 10 by 10 cm2 on the abdomen, the flank, and the trochanter. The depth of the infiltration advised is 1.5 cm at least in the target area. The energy was applied in adipose tissue as thick as 2 cm minimum. The focus ultrasound does concentrate the energy at 1.5 cm of depth. If by mistake the ultrasound energy is directed deeper, the potential for intestine perforation, bowel bleeding, and bone perforation could be reached. The authors assessed the thinning of the fat layers that undergo treatments with the focus ultrasound device. It is necessary to distinguish pure fat reduction from the loss of intracellular fluids, which is clearly temporary and ineffective for a constant volume reduction effect. The number of treatments for each body

48 Focus Ultrasound on Limited Lipodystrophies

Fig. 48.2 (a) Infiltration of the gluteal crease prior to tumescent fluid injection. (b) The infiltration stays no deeper than 2 cm from the surface. (c) Needle in the superficial fat is 2 cm maximum from the surface. Infiltration is concentrated in this layer

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area has never been more than four. Only localized lipodystrophies have been considered. Each treatment was performed with the infiltration of a maximum dose of 100 mL of solution, with lidocaine and sodium bicarbonate, in a 10 by 10-cm2 area. If two areas were to be treated, 50 mL of solution was infiltrated for each side (Fig. 48.2). Tumescent solution has three purposes: 1. Increases the thickness of the adipose tissue, thereby protecting the underlying deep layers. 2. Diminishes the consistency of fat, making the emulsification process easier. 3. Helps ultrasound wave to create the cavitation effect which is the key for adipocyte selective destruction. Prior to infiltration, an 18 gauge needle is utilized to administrate local anesthesia. Then a blunt needle with multiple holes is helpful for infiltration of the tumescent solution. The area to be treated is always marked with a permanent pen and infiltration should be quite

superficial, never deeper than 2 cm from the skin surface. Contrary to classic mesotherapy, where the tissue can be infiltrated as deep as 4 cm in the fat layers, focus ultrasound concentrates its effect on the medium layer fat, 1.5 cm in depth. The focus ultrasound device utilized is named Lipothermae by Genex (Fig. 48.3). The energy applied is 3 MHz, and the handpiece has a 5-cm diameter. Time of treatment is around 30 min for each area. The method is the classic slow massage with a constant action, protecting the skin with a gel. There is a continuous round movement in a circular fashion without pressure on the tissue. The patient hears a fine whistle determined by the cavitation effect in the adipose tissue. This is the first noticeable effect of focus ultrasound compared to the classic external ultrasound. After 15–20 min of action, a spreading erythema appears, the underlying tissue appears progressively less dense and mobile. It softens progressively without pain or discomfort for the patient.

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Fig. 48.4 Erythema following treatment

48.6 Clinical Case

Fig. 48.3 (a) Lipothermae by Genex. (b) Handpiece in action with gel applied to protect the skin

The tool has a power set up that is normally at 75% of the total. If the erythema is soft, it is even possible to increase the power, thereby increasing the cavitation effect of the system (Fig. 48.4). After treatment, the patient wears a compressive garment in order to increase tissue drainage. The patient is also encouraged to increase hydration for dilution of emulsified fat in the blood system and a quicker metabolizing at the liver level and elimination at renal system.

48.5 Complications No complications were encountered in the 25 patients treated.

A 25-year-old patient was treated in multiple areas of the body including the flanks, abdomen, and trochanter. The consistency of the fat reduction was measured with a plicometer, with ultrasound sonography, with digital photos in standard position, and with double blind assessment by two different doctors not involved into the treatment. The medium circumferential reduction of the area treated was of 4.5 cm (Figs. 48.5 and 48.6). The minimum interval between sessions is 15 days. Limits of the technique are represented by the amount of fat reduction for area, the minimum thickness of fat necessary for treatment to allow the action of focus ultrasound (1.5 cm, which is contraindicated in certain areas such as the neck), and the interval time from session to session. No hematoma and no ecchymosis were found in the patients treated. The treatment is well tolerated by the patient and is safe if performed in the correct way by an experienced physician. The degree of satisfaction from the patients was really high.

48.7 Discussion Requests for aesthetic procedures in the last years have really boomed all over the world, but not so much of the surgical procedures, but of less aggressive techniques such as botulinum toxin and fillers. Now, focus ultrasound promises to be really an effective alternative so that surgical treatment of localized fat deposit may not be necessary. This method does not substitute

48 Focus Ultrasound on Limited Lipodystrophies Fig. 48.5 A 23-year-old patient. (a1,2) Preoperative. (b1,2) Following treatment with focus ultrasound on the trochanter and anterior thigh with 4.5 cm reduction at the thigh

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Fig. 48.6 A 30-year-old patient. (a1–3) Preoperative. (b1–3) After four treatments of focus ultrasound

liposculpture, which really can model a body in multiple areas at the same time [5]. However, it can be the first choice in many patients who are afraid of surgery, who cannot take time off

from their work, who do not have money to pay a liposculpture, and who radically refuse the idea of a surgical procedure for their body, considering it too aggressive, too risky, or too invasive.

48 Focus Ultrasound on Limited Lipodystrophies

References 1. Suslick KS. The chemistry of ultrasound. The yearbook of science and the future 1994 encyclopedia. Chicago: Britannica; 1994. p. 138–55. 2. Pignatelli V, Ceccarelli M, Bartoletti CA. Idrolipoclasia ultrasonica nel trattamento della adiposita’ localizzata in

491 eccesso: una modifica del protocollo e ulteriori valutazioni. Medicina Estetic. 1994;18. 3. Ceccarelli M, Bartoletti CA. Adiposita’ localizzata ed idrolipoclasia ultrasonica. Medicina Estetic. 1992;16. 4. Cimino WW. Ultrasonic energy: power quantification, and efficiency optimization. Aesthetic Surg J. 2001;21(3):233–41. 5. Di Giuseppe A. Ultrasonic assisted liposculpture. Presented at World Congress on Liposuction. Dubai: 2007.

Aesthetic Body Contouring of the Posterior Trunk and Buttocks Using Third Generation Pulsed Solid Probe Internal Ultrasound-Assisted Lipoplasty

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Onelio Garcia Jr.

49.1 Introduction The trunk is one of the most common areas for which patients seek lipoplasty [1]. With the exception of minor contouring of a small surface area, it has been my experience that major contouring of the trunk is best performed circumferentially. That personal experience is derived from thousands of lipoplasty cases over a 25-year period. Circumferential contouring of the trunk requires a prone position followed by supine position on the operating table, and since most of these cases require extensive fat removal over a large s urface area, they are performed under general anesthesia. The posterior trunk and flank areas have traditionally been one of the most challenging anatomical areas to properly contour by means of lipoplasty. Although the back dermis is relatively thick, forgiving and capable of camouflaging minor irregularities, the back fat is dense, fibrous, and difficult to extract by means of traditional lipoplasty (SAL). Elimination of the back rolls, in particular, using SAL has been extremely difficult and associated with significant blood loss. Soon after its introduction in this country, “dry lipoplasty” was associated with blood loss of 20–45% of the volume aspirated [2–4] and one can assume that the higher 45% figure was associated with cases involving the posterior trunk. The significant tissue trauma associated with using large

O. Garcia Jr. Division of Plastic Surgery, University of Miami, Miller School of Medicine, 3850 Bird Road, Suite 102, Miami, FL 33146, USA e-mail: [email protected]

diameter suction cannulas for “dry lipoplasty” of these dense areas resulted in extremely bloody aspirate and the inability to properly evacuate fat in volumes that would yield a significant difference in contour. Early attempts to contour the posterior trunk using “dry lipoplasty” were extremely disappointing. The advent of wetting solutions with epinephrine further decreased the blood loss in these procedures [3–6] and made it somewhat easier to extract fat from the back; however, the process was still quite cumbersome and did not yield the ideal back contours due to residual fibrous back fat that could not be extracted. The use of internal ultrasound-assisted lipoplasty (UAL) further decreased lipoplasty blood loss [7–10] and made it significantly easier to extract dense, fibrous fat from the back at the expense of greater potential complications with the early UAL devices [11–14]. The creation of the third generation internal UAL devices has addressed many of the complications associated with the early UAL devices [15, 16]. Recently, Garcia and Nathan [17] performed a series of large volume, posterior trunk lipoplasties using the VASER (Sound Surgical Technologies, Louisville, Co.), a third generation pulsed solid probe internal ultrasound device, and compared them to a similar group treated with traditional superwet suctionassisted lipoplasty (SAL). They reported the average blood loss from the posterior trunk to be approximately seven times greater in the SAL group than in the VASER group. Furthermore, they were able to extract three times more fat from the back in the VASER group when compared to the SAL patients prior to obtaining bloody aspirate. It is as a result of these studies that the author strongly recommends the use of third generation internal ultrasound for all posterior trunk lipoplasties.

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Moderate to large volume lipoplasty procedures impact a significant surgical insult on the patient and are reserved only for those individuals in relatively good state of health. It is important to note during the medical history any of the common medications that may interfere with platelet function such as aspirin and stop their use at least a week in advance of the surgery. Our routine preoperative laboratory work includes a complete blood count, electrolytes, clotting studies, and urine analysis. A pregnancy test is obtained when warranted. The author’s preoperative photography protocol for posterior trunk lipoplasty includes straight view of the back and hips, as well as left and right oblique views against a medium blue background. Preoperative markings are performed in the standing position using a black or dark blue marker and include areas to be contoured as well as the access incision sites. It is the author’s preference, whenever possible, to perform the preoperative markings in the afternoon on the day prior to surgery and digitally photograph the markings. This allows the surgeon to review the markings with the patient on the computer screen. It has been my experience that this preoperative review gives the patient a better understanding of the surgical plan and possibly avoids misunderstandings, such as

the placement of the access incisions or the exact boundaries of the areas to be contoured. This is of particular importance when the surgery involves the posterior trunk since the patient cannot easily visualize the treatment area. On the day of surgery, prophylactic antibiotics are administered while the patient is in the holding area and sequential pneumatic compression stockings are applied. Major lipoplasties that include the posterior trunk and involve placing the patient in the prone position are performed by the author under general endotracheal anesthesia. Frequently a foley catheter is placed at the start of the operation to monitor urine output in the higher volume lipoplasties where the patient is exposed to large volumes of infiltrating solutions and intravenous fluids. When placing the patient in the prone position, it is preferable to place the arms on arm boards away from the operative site. A roll is placed under the pelvis extending between the iliac crests to elevate the hips off the operating table (Fig. 49.1), two longitudinal rolls are placed under the chest for support, and a foam face protector is used to pad the face. Slightly flexing the operating table into a jackknife position provides easier access for the UAL probes and suction cannulas into the posterior trunk. Patients undergoing lipoplasty of the trunk have large body surface areas containing wetting solutions exposed, making them susceptible to hypothermia. As a preventive measure against hypothermia, a Bair Hugger is used over the nonoperative sites and the intravenous fluids are warmed.

Fig. 49.1 The prone position provides good access for lipoplasty contouring of the posterior trunk, particularly the back, and has the advantage of providing simultaneous visual comparison between the two sides. The arms are on padded arm

boards away from the surgery site, the body is supported by two longitudinal rolls, the face lies on a foam face protector, and a horizontal roll between the iliac crests slightly elevates the hips from the operating table

49.2.1 General Considerations

49 Aesthetic Body Contouring of the Posterior Trunk and Buttocks

The small access incisions are easily performed with a #11 scapel blade. Rohrich, Beran, and Kenkel suggest that the access incisions be placed asymmetrically to give a less “surgical” appearance [18]. The areas to be treated are infiltrated with the wetting solution (1 mg epinephrine 1:1,000/L Ringer’s lactate) using a subcutaneous infiltration pump. For tight, fibrous areas such as the back, the author runs the infiltration pump at 400 mL/min. The author has found that solid probe UAL performs more efficiently in a very “wet” environment. The original recommendation of a 1:1 ratio of infiltrate to expected aspirate does not provide enough fluid in the tissues, particularly in the posterior trunk. The author currently uses approximately a 3:1–4:1 ratio of infiltrate to expected aspirate. This large amount of wetting solution in the tissues makes the fat emulsification process more efficient and also provides a greater safeguard against thermal injury by the UAL probe. Allow approximately 12 min following the fluid infiltration for the vasoconstrictive effect of the epinephrine to take place. The UAL treatment employed by the author involves a third generation solid probe internal ultrasound device, (VASER). The energy levels used in the posterior trunk are generally higher than for other anatomical areas. The posterior flanks are usually treated at 80–90% energy levels in the pulsed mode using a 3-ring or 2-ring probe. The back is treated at 90% energy level usually in continuous mode with a 2-ring probe. On occasion, tight back rolls are treated with 100% energy levels in continuous mode for brief periods using a 1-ring probe. Extra wetting solution is infiltrated into these areas prior to this aggressive treatment. While applying the internal ultrasound to the tissues, it is important not to push down on the skin in the area where the probe tip is located. This technique may be helpful during the suction phase to stabilize the suction cannula, but during the ultrasound phase it actually disperses fluid away from the probe tip (Fig. 49.2). Forcefully pushing down on the skin can actually cause a vacuum effect creating a “dry spot” near the tip, which potentially increases the risk for thermal injury. When running high ultrasound energy levels for longer periods such as under very tight, fibrous back areas, it may be helpful to gently work the surrounding tissue fluid toward the probe tip (Fig. 49.3). Most of the suction phase is performed using 3.0-mm and 3.7-mm Ventx cannulas (Sound Surgical Technologies, Louisville, Co.). Other than for the deep fat layer, the author performs the majority of the suction using the 3-mm Ventx cannula. Following proper fat

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Fig. 49.2 During the ultrasound phase, the surgeon should not push down on the tissues over the ultrasound probe. This maneuver pushes fluid away from the tip of the probe creating a “dry spot” near the tip and potentially increasing the risk of thermal injury

Fig. 49.3 Maneuvering adjacent tissue fluids toward the ultrasound probe tip can be helpful when employing higher energy levels for increased periods of time such as when contouring tight, fibrous back rolls

emulsification extraction is very quick and precise with the 3-mm cannula. The small access incisions are closed with one simple absorbable suture of 5–0 plain. Contoured foam is placed over the treated areas under the compressive garment. The initial garment with side zippers is used immediately after surgery since

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Fig. 49.4 Thirty-year-old female with a total volume of 5,400 mL extracted. The posterior trunk (shaded color areas) yielded 2,600 mL of aspirate. Left: areas of liposuction with direction of tunnels. Middle: preoperative. Right: postoperative

Fig. 49.5 Twenty-year-old female with a total volume of 6,200 mL extracted. The posterior trunk (shaded color areas) yielded 2,400 mL of aspirate. Left: areas of liposuction with direction of

tunnels. Middle: preoperative. Right: postoperative. Note high definition contouring of the posterior flanks

it is easier to apply over the foam while the patient is still on the operating table under anesthesia. Several days later, the patient changes to a secondary compression garment without zippers. Massaging the treated areas with a moisturizer is recommended several times a day as soon as the patient can tolerate the discomfort. In high-volume cases the author has found that several sessions of endermologie treatments to the lipoplasty areas are helpful in loosening adhesions and decreasing edema. Our protocol consists of six treatments over a 3-week period beginning as soon as the echymosis disappears. The author performed lipoplasty contouring of the posterior trunk on a large series of female patients [17]. The average age was approximately 37 years and

the average body mass index (BMI) was approximately 25. Since it is preferable to contour the trunk in a circumferential manner, these patients also undergo lipoplasty of the abdomen and anterior hips at a minimum, with other areas such as thighs and arms frequently contoured at the same operation (Figs. 49.4–49.6). The average total aspirate from these patients was approximately 5,700 mL with approximately 2,450 mL extracted from the posterior trunk. The third generation solid probe UAL devices have allowed us to perform high-volume body contouring in selected patients with minimal associated morbidity [19] (Figs. 49.7–49.9). Patients are kept overnight for postoperative recovery as well as monitoring of fluid intake and urine output.

49 Aesthetic Body Contouring of the Posterior Trunk and Buttocks Fig. 49.6 Thirty-seven-year-old female with a total volume of 5,750 mL extracted. The posterior trunk (shaded color areas) yielded 2,200 mL of aspirate. (a) Areas of liposuction with direction of tunnels. (b) Left: preoperative. Right: postoperative. Note high definition contouring of the posterior flanks

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The third generation of UAL devices has made it possible to offer more aggressive body contouring to older patients particularly in the posterior trunk (Fig. 49.10). It is important to create realistic expectations in these patients since their skin elasticity may present limitations on the volumes extracted and the postoperative result may be an improvement over the preoperative appearance, but not necessarily the ideal contour.

49.3 Contouring of the Buttocks Using Third Generation Pulsed Solid Probe UAL The ideal female buttocks have a rounded appearance and merge into the fat of the lateral thigh. Excess fat in the posterior flanks, lateral thighs, and subgluteal area (banana roll) creates a “trapezoid” shape.

Although buttock fat grafting is sometimes necessary to achieve the ideal round shape in extremely flat buttocks, UAL contouring of the posterior flanks, lateral thighs, and subgluteal rolls can often provide aesthetically pleasing buttocks. While contouring these areas, it is important to pay special attention to avoiding the zones of adherence over the tensor fascia lata area of the distal lateral thigh, the posterior thigh (inferior to the subgluteal roll), the lateral gluteal depression (between the flanks and lateral thigh rolls), the gluteal crease, and a small area of the midmedial thigh above the fatty deposit of the medial knee (Fig. 49.11). It is imperative that the gluteal fold is not crossed with either UAL probes or suction cannulas! Third generation solid probe UAL has made it possible to precisely contour these areas with minimal morbidity. Patients have significant improvement in gluteal definition with only fat extraction (Figs. 49.11– 49.13). The author has found that fat grafting is not necessary to improve buttock contour in the majority of patients.

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Fig. 49.7 Twenty-three-year-old female with a total volume of 11,500 mL extracted. The posterior trunk (shaded color areas) yielded 4,200 mL of aspirate. (a) Left: areas of liposuction with direction of tunnels. Middle: preoperative. Right: postoperative.

(b) Buttocks. Left: preoperative. Right: postoperative. Note improved definition of the buttocks obtained following aggressive contouring of the posterior flanks

Fig. 49.8 Forty-year-old female with a total volume of 9,200 mL extracted. The posterior trunk (shaded color areas) yielded 3,700 mL of aspirate. Left: areas of liposuction with direction of tunnels. Middle: preoperative. Right: postoperative

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Fig. 49.9 Twenty-seven-year-old female with a total volume of 8,400 mL extracted. The posterior trunk (shaded color areas) yielded 2,900 mL of aspirate. Left: areas of liposuction with direction of tunnels. Middle: preoperative. Right: postoperative

Fig. 49.10 Sixty-two-year-old female with a total volume of 4,800 mL extracted. The posterior trunk (shaded color areas) yielded 2,200 mL of aspirate. Left: areas of liposuction with direction of tunnels. Middle: preoperative. Right: postoperative

49.4 Fat Grafting for Gluteal Enhancement Patients who exhibit very flat buttocks with poor definition (the trapezoid shape) may be candidates for gluteal contouring with fat extraction from the posterior flanks, lateral thighs, and subgluteal rolls plus fat grafting. Mendieta [20, 21] has described a simple and effective technique for gluteal enhancement that involves aggressive UAL contouring of the perigluteal areas with grafting of the strained harvested

supernatant aspirate into the gluteus. He described 10 aesthetic units to the posterior region and how six of these zones define the buttocks (Fig. 49.14). Following solid probe UAL using the VASER device for the fat emulsification and extraction, Mendieta uses a simple technique for preparation of the harvested fat. The aspirate is placed in a large metal kitchen strainer which allows the tumescent fluid, blood, and oil lipid layer to flow through into an open container, leaving the supernatant fat in the strainer (Fig. 49.15). This harvested fat is then cleansed in antibiotic solution (Clindamycin 600 mg in 20 mL of

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Fig. 49.11 (a) Left: twenty-year-old female with a total volume of 4,200 mL extracted. The posterior flanks, lateral thigh, and subgluteal roll (shaded color areas) yielded 1,800 mL of aspi-

rate. The zones of adherence to be avoided are marked in red. Middle: preoperative. Right: postoperative. (b) Buttocks. Left: preoperative. Right: postoperative

Fig. 49.12 Twenty-two-year-old female with a total volume of 4,800 mL extracted. The shaded color areas yielded 2,000 mL of aspirate. (a) Left: areas of liposuction with direction of tunnels. Middle: preoperative. Right: postoperative (b) Left: preoperative. Right: postoperative

49 Aesthetic Body Contouring of the Posterior Trunk and Buttocks Fig. 49.12 (continued)

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Fig. 49.13 Twenty-seven-year-old female with a total volume of 4,800 mL extracted. The shaded color areas yielded 2,000 of aspirate. (a) Left: areas of liposuction with direction of tunnels.

Middle: preoperative. Right: postoperative. (b) Left: preoperative. Right: postoperative

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Fig. 49.14 The 10 Aesthetic units/zones of the posterior region as described by Mendieta. Left: (1) Sacrum V-zone. (2) Flank. (3) Upper buttock. (4) Lower back. (5) Outer leg. (6) Gluteus. (7) Diamond zone: inner gluteal/leg junction. (8) Mid-lateral buttock point C. (9) Inferior gluteal/posterior leg junction. (10)

Fig. 49.15 The fat is harvested by placing the aspirate in a large kitchen strainer allowing the tumescent fluid, blood, and oil lipid layer to flow through into an open container, leaving the supernatant fat in the strainer. Reproduced with permission of American Society for Aesthetic Plastic Surgery and Aesthetic Surgery Journal

O. Garcia Jr.

Upper back. Middle: six important zones truly define the buttock frame/shape. Right: Zone 8 is the only zone that may require fat transfer to smooth the contour. Reproduced with permission of American Society for Aesthetic Plastic Surgery and Aesthetic Surgery Journal

saline solution and loaded into 60 and 10-mL luerlock syringes). The fat injected intramuscularly with the 60-mL syringes and 3-mm cannulas provide volume and the fat injected subcutaneously with the 10-mL syringes and 2.4-mm cannulas provide contour (Fig. 49.16). Fat grafting of the gluteal area following lipoplasty contouring of the buttocks is a simple, cost effective technique. Mendieta believes that 80–85% of the injected fat is viable at 2 years and that the use of solid probe UAL (VASER) to extract the fat does not affect its survival [20] (Fig. 49.17). The author agrees with Mendieta that contouring the buttocks into an aesthetically pleasing round shape requires aggressive fat extraction from the posterior flank, lateral thigh, inferior gluteal roll, and sacral areas with or without fat grafting.

49 Aesthetic Body Contouring of the Posterior Trunk and Buttocks

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Fig. 49.16 Buttocks. Left: preoperative. Right: postoperative following fat grafting using the Mendieta “gluteal reshaping” technique. Reproduced with permission of American Society for Aesthetic Plastic Surgery and Aesthetic Surgery Journal

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Fig. 49.17 Twenty-sevenyear-old female patient who underwent contouring of the sacrum and flanks plus 750 mL fat injections into each buttock using the Mendieta “gluteal reshaping” technique. Left: preoperative. Right: postoperative. Reproduced with permission of American Society for Aesthetic Plastic Surgery and Aesthetic Surgery Journal

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References 1. The American Society for Aesthetic Plastic Surgery. Cosmetic Surgery National Data Bank, Procedural Statistics; 2007. 2. Illouz YG. Refinements in the lipoplasty technique. Clin Plast Surg. 1989;16(2):217–33. 3. Rohrich RJ, Beran SJ, Fodor PB. The role of subcutaneous infiltration in suction-assisted lipoplasty: a review. Plast Reconstr Surg. 1997;99(2):514–9. 4. Rohrich RJ, Beran SJ, Kenkel JM. Anesthetic considerations. In: Rohrich RJ, Beran SJ, Kenkel JM, editors. Ultrasound-assisted liposuction. 1st ed. St. Louis: Quality Medical Publishing; 1998. p. 69–84. 5. Hetter GP. The effect of low-dose epinephrine on the hematocrit drop following lipolysis. Aesthetic Plast Surg. 1984;8(1):19–21. 6. Fodor PB, Watson JP. Wetting solutions in ultrasoundassisted lipoplasty. Clin Plast Surg. 1999;26(2):289–93. 7. Fodor PB, Watson J. Personal experience with ultrasound-assisted lipoplasty: a pilot study comparing ultrasound-assisted lipoplasty with traditional lipoplasty. Plast Reconstr Surg. 1998;101(4):1103–16. 8. Kloehn R. Liposuction with “sonic sculpture”: six years’ experience with more than 6000 patients. Aesthetic Surg Q. 1996;16:123. 9. Scheflan M, Tazi H. Ultrasonically assisted body contouring. Aesthetic Surg Q. 1996;16:117. 10. Zocchi ML. Ultrasonic-assisted lipoplasty. Clin Plast Surg. 1996;23:575. 11. Rohrich RJ, Beran SJ, Kenkel JM, Adams WP Jr, DiSpaltro F. Extending the role of liposuction in body contouring with ultrasound-assisted liposuction. Plast Reconstr Surg. 1998; 101(4):1090–102.

O. Garcia Jr. 12. Rohrich RJ, Beran SJ, Kenkel JM. Complications. In: Rohrich RJ, Beran SJ, Kenkel JM, editors. Ultrasound-assisted liposuction. 1st ed. St. Louis: Quality Medical Publishing; 1998. p. 347–62. 13. Young VL, Schorr MW. Report from the conference on ultrasound-assisted liposuction safety and effects. Clin Plast Surg. 1999;26(3):481–524. 14. Mladick RA. Personal experience with ultrasound-assisted lipoplasty: a pilot study comparing ultrasound-assisted lipoplasty with traditional lipoplasty (discussion). Plast Reconstr Surg. 1998;101(4):1117–9. 15. de Souza Pinto EB, Abdala PC, Maciel CM, dos Santos fde P, de Souza RP. Liposuction and VASER. Clin Plast Surg. 2006;33(1):107–15. 16. Jewell ML, Fodor PB, de Souza Pinto EB, Al Shammari MA. Clinical application of VASER-assisted lipoplasty: a pilot study. Aesthetic Surg J. 2002;22:131–46. 17. Garcia O, Nathan N. Comparative analysis of blood loss in suction – assisted lipoplasty and third generation internal ultrasound-assisted lipoplasty. Aesthetic Surg J. 2008; 28:430–5. 18. Rohrich RJ, Beran SJ, Kenkel JM. Back and arms. In: Rohrich RJ, Beran SJ, Kenkel JM, editors. Ultrasound-assisted liposuction. 1st ed. St. Louis: Quality Medical Publishing; 1998. p. 231–52. 19. Scuderi N, Paolini G, Grippaudo FR, Tenna S. Comparative evaluation of traditional, ultrasonic and pneumatic-assis ted lipoplasty: analysis of local and systemic effects, efficacy and costs of these methods. Aesthetic Plast Surg. 2000;24(6):395–400. 20. Mendieta CG. Gluteal reshaping. Aesthetic Surg J. 2007; 27(6):641–55. 21. Mendieta CG. Intramuscular gluteal augmentation technique. Clin Plast Surg. 2006;33(3):423–34.

Treatment Options in Benign Symmetric Lipomatosis

50

Madelung’s Disease Anthony P. Sclafani, Kenneth Rosenstein, and Joseph J. Rousso

50.1 Introduction Benign symmetric lipomatosis (BSL) is a rarely encountered disease first described by Brodie in 1846 [1]. Brodie’s description was that of a single patient with symmetric cervical fat deposition. It was not until 1898 that Madelung [2], in a study involving 35 patients, described a classic distribution of fat, including a cervical “horse collar” distribution. Launoise and Bensaude, in 1898 [3], in an extensive review of 65 patients gave a more complete description of the entity as being diffuse and disseminated with characteristic fatty neck deposits. Several forms of the disease have been described; however, Type I is the most common presentation, with a specific fat collar composed of tissue that accumulates in the upper back and neck (Fig. 50.1). This form typically affects middle-aged men of Mediterranean heritage. Cosmetic deformity and limitation of mobility due to swelling of the neck are usually the first presentations of lipomatosis [4]. More advanced deposits of fat can cause extrathoracic airway obstruction and dysphagia. Sixty to ninety percent of patients with Type I BSL have a strong history of alcohol abuse and dependence [5]. Type 2 has characteristic adipose tissue deposition in the upper back, deltoid area, hips, and thighs, and exhibits equivalent male and female prevalence. Type 2 BSL results in a body habitus referred to as “pseudo-

A. P. Sclafani (*) Department of Otolaryngology, Division of Facial Plastic Surgery, The New York Eye and Ear Infirmary, 310 East 14th Street, North Building, New York, NY 10003, USA e-mail: [email protected]

athletic syndrome,” due to the patchy areas of fatty deposition mirroring an overdeveloped physique. Busetto et al. [6] have proposed that type 2 is often unrecognized and has led to underdiagnosis of this phenomenon in females.

50.2 Disease Features Several hypotheses exist regarding the pathogenesis of BSL, but the cause, thus far, remains unknown. The clinical presentation and anatomic distribution of fat unique to BSL remains the defining feature of the disease. In stark contrast to typical lipomas, the adipose tissue of patients with BSL is nonencapsulated allowing it access to anatomical spaces via deep ingrowth of soft tissue [7]. As the disease is primarily a clinical diagnosis, various other lipodystrophies and neck masses must be considered in the evaluation. An exhaustive differential diagnosis of rare neck masses and tumors is possible, although Cushingoid diseases, goiters, and protease inhibitor-associated lipodystrophy are more common considerations [8]. Radiologic assessment and a thoughtful history and physical examination are often adequate to diagnose BSL. Radiographic imaging is essential in diagnosis and treatment planning, as it best illustrates the defining feature of BSL: infiltrative, unencapsulated fatty proliferation (Fig. 50.1). Zhang et al. [5] performed CT and MRI studies on sixteen subjects to further characterize the insidious growth pattern of lipomatosis in BSL. In addition to superficial fat deposits, their analysis revealed strikingly deep extension involving and often displacing the sternocleidomastoid, trapezius, paraspinal muscles,

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_50, © Springer-Verlag Berlin Heidelberg 2010

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506 Fig. 50.1 (a) Patient with Madelung’s disease, showing diffuse fatty accumulation in the cervical area. (b) Two and one half years later with progression of fatty accumulation despite cervical liposuction during that period. The patient ultimately required an open procedure. (c) Lateral view of patient demonstrating posterior neck disease, as well as anterior neck and submental involvement. (d) T1-weighted sagittal MRI image demonstrating infiltrative nature of fat in the submental and posterior neck

A. P. Sclafani et al.

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as well as salivary glands, larynx, and deep vessels (Fig. 50.2). It is this insidious growth pattern that is the most clinically relevant factor in determining the need and extent of intervention. Patients with BSL often present with symptoms directly related to the anatomic structures affected by the deep ingrowth of fat. Paratracheal, mediastinal, and laryngeal involvement can cause compressive upper airway symptoms. Involvement of the submental triangle

and parapharyngeal spaces may cause disruption in salivary function. Compression, and later, secondary atrophy of neck musculature may severely limit neck mobility. Involvement of nerves and parapharyngeal musculature may cause dysphagia. Rarely, encasement or stricturing of venous drainage may cause cephalad venous congestion. Each of these potential functional deficits necessitates surgical intervention beyond cosmesis [7–9].

50 Treatment Options in Benign Symmetric Lipomatosis

a

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Fig. 50.2 Histology demonstrates the invasive nature of fat in Madelung’s disease. Hematoxylin and eosin stains show relatively normal-appearing fat surrounding and invading skeletal muscle. (a) 10×. (b) 20×

Although MRI analysis revealed these pathological fat deposits to have equivalent signal intensity to that of normal fat, the pattern of aggressively deep extension has warranted study into the cellular and biochemical origin of these lesions. Although no definitive etiological factor has been identified, the potential metabolic and neoplastic factors affecting lipomatosis in BSL have begun to be elucidated [5, 10].

50.3 Pathophysiology Many investigations have searched for the inciting factor in the accumulation of fatty deposits in BSL. The disease’s unique histology, genetic correlates, and association with alcoholism and glucose intolerance have aided researchers in defining many of the forces at play. Unfortunately, no clear etiology has yet been elucidated and the condition may prove to be a final common pathway for a composite of pathological changes within these patients [11]. Nisoli et al. [12] proposed that the unusual fat deposits may be a result of a neoplastic proliferation of defective brown adipocytes. Activation of the UCP-1 gene in the pathologically located fat (as opposed to that of normally located fat) has been documented in patients with BSL. This gene confers an increase propensity for lipogenicity [8]. The fat growth pattern is often described as hypertrophic, with an increase in the overall number of small adipocytes [11]. In contrast,

typical visceral fat exhibits a hyperplastic growth pattern where adipocytes increase in size and storage capability. In obesity-associated diabetes mellitus, the storage capacity of these fat cells is overwhelmed, lipids accumulate in the liver and pancreas, and insulin resistance develops. Although an increased incidence of glucose intolerance has been reported in patients with BSL, no clear association between fatty accumulation and metabolic abnormalities has been elucidated independent of comorbid conditions. Interestingly, some studies have shown a relative insulin sensitivity as the fatty proliferation removes elevated lipids and fatty acids from the systemic circulation and stores them away from visceral fat [11]. A pharmacologic correlate has been identified in the treatment of diabetes with thiazolidinediones, where improved glycemics and insulin sensitivity is accompanied by a deposition of subcutaneous fat [13]. Although some evidence exists that patients with BSL have relatively benign obesity-associated metabolic comorbidites, the high prevalence of alcohol-related hepatopathy and its sequalae are often of more significant concern [9]. Despite a known increase in fatty proliferation and storage, a failure in lipolytic pathways has also been implicated in the etiology of BSL. A familial form of the disease characterized by defective mitochondrial function has been identified. The A8344G mutation confers decreased activity of respiratory function enzymes inciting depressed lipolytic function [8].

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Additionally, chronic alcohol ingestion depresses catecholamine-induced lipolysis by direct depression of catecholamine receptors on brown adipocytes and may also affect mitochondrial function [8]. Finally, there is clear epidemiologic evidence that alcohol abuse predisposes patients to the development of BSL. Alcohol induced liver disease limits the ability of the organ to process lipids, and it is postulated that BSL patients respond with an increase in lipogenesis [13].

50.4 Palliation and Treatment Medical intervention with the use of the beta-2 agonist salbutamol and intralesional low molecular weight heparin injections have been studied and found to be inconclusive at best [14]. Decreasing alcohol intake, weight loss, control of endocrine disorders such as diabetes and hypothyroidism are all advocated, but have not been shown to halt or reverse the disease once it is present [15]. The natural course of the disease is characterized by a period of rapid initial growth followed by a prolonged phase of slow growth of lesions. No medical treatment has shown to affect growth suppression or involution. Due to the failure of medical treatments, surgical intervention is crucial to decreasing morbidity and mortality in patients suffering from BSL. In addition to the severe cosmetic deformities that the disease can cause, there has been several case reports of compressive symptoms related to the location of the lesions. Lesions can cause aero-digestive tract obstruction, sleep apnea, dysphagia, neuropathy, and cardiac pathology secondary to mediastinal compression [16]. Furthermore, Chan et al. [17], in a study of eight patients with BSL, believe that there is a correlation between the development of head and neck cancers and the presence of BSL. The correlation may simply be the synergistic effect of both smoking and alcohol abuse for the development of both BSL and head and neck cancers. In the appropriate circumstances, screening aero-digestive tract panendoscopy should be considered. The two most accepted surgical interventions are liposuction and open surgical excision of lesions with the removal of redundant skin. Liposuction is advantageous in smaller lesions and can be performed under local anesthesia. However, larger lesions and those

A. P. Sclafani et al.

with deep infiltration of vital structures are not amenable to liposuction and will require careful excision. Because of the nonencapsulated nature of the lesions and profound vascularity, it can be nearly impossible to remove the entire mass, particularly if it places essential structures at risk. Neurovascular, phonatory, and gustatory postoperative deficits are unacceptable in the resection of benign disease. Simple debulking is acceptable since it is difficult to determine what is part of the pathology and what is normal fat [18]. As the vast majority of patients typically present with only cosmetic concerns, the initial step in surgical planning is evaluation of operative risk. The two major concerns in this patient population are difficulties in airway management due to severely limited neck mobility and increased frequency of postoperative bleeding. The high incidence of alcoholism has led to a higher prevalence of liver disease and associated coagulopathies [9]. Comprehensive medical clearance and evaluation by anesthesiology is essential to ensure the safety of patients undergoing these procedures, the majority of which are elective in nature [19]. The surgical planning phase is also the appropriate time to tailor an approach to the individual patient. Several approaches have been used to address cervicofacial lipomatous tumors of BSL. These include primary liposuction, multiple incisions, and local excisions, as well as apron incisions and flap elevation for improved access and gross debulking [18]. Both patient-specific and site-specific surgical risks need to be addressed at this time and the patients counseled on potential complications and sequelae of treatment. If the submental area requires surgical excision, care must be taken to preserve the muscular floor of mouth and salivary glands and associated ducts. Occasionally, the submandibular glands may be sacrificed as they may be deeply infiltrated by tumor [18]. For optimal contouring of submental, submandibular, and occipital involvement, a staged procedure involving primary lipectomy followed by “wet” or “super-wet” liposuction several months later has been described. This strategy reduces blood loss and improves cervicofacial contouring when compared to the “dry” technique [20]. Other case reports reveal a similar limited use of liposuction for refinement and contouring following a necessary open excision [21]. Despite its limitations, tumescent liposuction is considered a conservative approach, accepted by many

50 Treatment Options in Benign Symmetric Lipomatosis

as the cosmetic treatment of choice in mild to mode rate cases of BSL, or when patients refuse an open approach. Despite minimizing surgical risk, the patients’ medical status leads to one concerning ramification. Many of these patients have impaired liver function secondary to their history of ethanol- induced hepatic cirrhosis; this leads to risks of a decrease in the cytochrome P450 3A4 enzymes and their ability to metabolize lidocaine [22]. Several authors recommend minor sessions of tumescent liposuction with lidocaine amounts of up to half of the recommended dosage of patients with

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Fig. 50.3 Patient with advanced form of Madelung’s disease at presentation. Despite the striking appearance, this patient only recently had developed dysphagia as his only functional complaint. (a1,2) Preoperative patient with large “horse collar”

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normal liver function [9]. Some researchers have also experienced a high incidence of postoperative hematoma in this population [18]. These patients need to be monitored for at least 24 h after the administration of local anesthesia. Furthermore, Grassegger et al. [23] recommend peri-operative use of Azithromycin for antibacterial prophylaxis since it is not metabolized via the cytochrome P450 3A4 pathway. In levels II through V of the deep neck, surgery typically involves incision and dissection analogous to modified neck dissection (Fig. 50.3). Wong et al. [18] propose that one larger apron incision with elevation

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deformity. (b1–3) Postoperative after debulking of the anterolateral neck fat and redundant skin through an apron incision. The patient was offered second stage posterior neck debulking, but failed to follow-up

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of subplatysmal flaps allows for optimal excision. By this method, a larger and more targeted debulking, as well as more symmetric postoperative contour, can be achieved. Additionally, involvement of the great vessels, nerves, thyroid and parathyroids, and musculature of the neck can be safely assessed and addressed. The fatty infiltration of local tissues may distort the normal cervical anatomy, and following standard neck dissection planes may aid in the identification of vital structures. With adherent infiltrative disease, the surgeon must prefer leaving benign disease in the neck to any risk of vital structures. Preservation of parotid structures and branches of the facial nerve becomes paramount if the resection must precede superolaterally onto the face and the need for adequate debulking here precludes liposuction [9]. Rare involvement of the tongue requires debulking to restore speech, swallowing, and improve airway caliber; however, cautious and limited excision is warranted to preserve lingual function. Although BSL recurrence following incomplete excision may occur, the functional and cosmetic deficits that the patient has presented with are often reversed with limited resection. Mediastinal and thoracic disease requires a combined surgical approach with involvement of both an aesthetic surgeon and a thoracic surgeon. Wide excision is warranted if compressive symptoms lead to any compromise of cardiac function. Arrythmia and compressive pathology are life threatening and require prompt surgical attention. Deep infiltration of these areas also precludes liposuction as a surgical approach [9, 18].

50.5 Conclusions BSL is an unusual disease in which fat diffusely infiltrates local structures. Excessive accumulation in specific areas can cause functional as well as aesthetic concerns. If identified early, small deposits can be treated with liposuction. Unfortunately, most patients present with advanced deformities, and the choice to operate must balance the cosmetic goals, the functional deficits present, and the approach required. In these advanced cases, the surgery follows a more reconstructive paradigm, as incisions and scars may be extensive and the final result improved but still suboptimal.

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References 1. Brodie BC. Clinical lectures on surgery. Delivered at St. Georges hospital. Philadelphia: Lea & Blanchard; 1846. p. 275–80. 2. Madelung OW. Uner den Fetthals (diffuses Lipom des Halses). Diffuse lipomatosis of the neck. Arch Klein Chir Berlin. 1888;37:106–30. 3. Launois PE, Bensaude R. De l’adeno-lipomatose symmettrique. (The symmetrical adenolipomatosis). Bull Soc Med Hop Paris. 1898;1:298–318. 4. Fernandez-Vozmediano J, Armario-Hita J. Benign symmetric lipomatosis (Launois-Bensaude syndrome). Int J Dermatol. 2005;44:236–7. 5. Zhang X, Li N, Wen-lin X. Madelung disease: manifestations of CT and MR imaging. Oral Surg Oral Med Oral Pathol Oral Radio Endod. 2008;105:e57–64. 6. Busetto L, Strater D, Enzi G, Coin A, Sergi G, Inelman EM, Pigozzo S. Differential clinical expression of multiple symmetric lipomatosis in men and women. Int J Obes Relat Metab Disord. 2003;27(11):1419–22. 7. Enzi G, Busetto L, Ceschin E, Coin A, Digito M, Pigozzo S. Multiple symmetric lipomatosis: clinical aspects and outcome in a long-term longitudinal study. Int J Obes Relat Metab Disord. 2002;26:253–61. 8. Meningaud JP, Pitak-Arnnop P, Bertrand JC. Multiple symmetric lipomatosis: case report and review of the literature. J Oral Maxillofac Surg. 2007:65:1365–9. 9. Constantinidis J, Steinhart H, Zenk J, Gassner H, Iro H. Combined surgical lipectomy and liposuction in the treatment of benign symmetrical lipomatosis of the head and neck. Scand J Plast Reconstr Surg Hand Surg. 2003;37:90–6. 10. Ahuja AT, King AD, Chan ES, Kew J, Lam WW, Sun PM, et al. Madelung disease: distribution of cervical fat and preoperative findings at sonography, MR, and CT. AJNR Am J Neuroradiol. 1998;19:707–10. 11. Nielsen S, Levine J, Clay R, Jensen MD. Adipose tissue metabolism in benign symmetric lipomatosis. J Clin Endocrinol Metab. 2001;86:2717–20. 12. Nisoli E, Regianini L, Briscini L, Bulbarelli A, Busetto L, Coin A, Enzi G, Carruba MO. Multiple symmetric lipomatosis may be the consequence of defective noradrenergic modulation of proliferation and differentiation of brown fat cells. J pathol. 2002;198(3):378–87. 13. Haap M, Siewicke C, Schick F, et al. Multiple symmetric lipomatosis: a paradigm of metabolically innocent obesity. Diabetes Care. 2004;27:794–5. 14. Leung NW, Gaer J, Beggs D, Kark AE, Holloway B, Peters TJ. Multiple symmetric lipomatosis: effect of salbutamol. Clin Endocrinol (Oxf). 1987;27:601–6. 15. Smith PD, Stadelman WK, Wasserman RJ, Kearney RE. Benign symmetric lipomatosis (Madelung’s disease). Ann Plast Surg. 1998;41:671–3. 16. Josephson GD, Sclafani AP, Stern J. Benign symmetric lipomatosis (Madelung’s disease). Otolaryngol Head Neck Surg. 1996;115(1):170–1. 17. Chan ES, Ahuja AT, King AD, Lau WY. Head and neck cancers associated with Madelung’s disease. Ann Surg Oncol. 1999;6(4):395–7.

50 Treatment Options in Benign Symmetric Lipomatosis 18. Wong DSY, Lam LK, Chung JHP, Ng RWM, et al. Aesthetic considerations in the cervicofacial management of Madelung syndrome. Scand J Plast Reconstr Surg Hand Surg. 2003;37:34–40. 19. Conroy JP. Airway management: a patient with Madelung disease. AANA J. 2006;74(4):281–4. 20. Klein JA. The tumescent technique for liposuction surgery. Am J Cosmet Surg. 1987;4:236–67.

511 21. Guilemany JM, Romero E, Blanch JL. An aesthetic deformity: Madelung’s disease. Acta Otolaryngol. 2005;125(3):328–30. 22. Klein JA. Cytochrome P450 3A4 and lidocaine metabolism. In: Klein JA, editor. Tumescent technique: tumescent anesthesia and microannular liposuction. St Louis: Mosby; 2000. p. 131–40. 23. Grassegger A, Haussler R, Schmalzl F. Tumescent liposuction in a patient with Launois-bensaude syndrome and severe hepatopathy. Dermatol Surg. 2007;33:982–5.

Liposuction for Madelung’s Neck

51

Robert Yoho

51.1 Introduction Madelung’s neck is a variant of multiple symmetric lipomatosis (symmetric adenolipomatosis, Madelung’s syndrome, Buschke’s syndrome, Launois-Bensaude syndrome) [1–3]. The syndrome involves unencapsulated symmetrical lipomas, usually involving the neck, shoulders, and trunk. Microscopic examination shows normal fat tissue [4]. Madelung’s neck consists of multiple symmetrical lipomas of the neck and shoulders.

lipids have been reported [9]. Defects in lipolysis [10] and mitochondrial genetic errors [11] have been demonstrated. Treatment of the disorder has been mainly aggressive surgical resection [12, 13], but liposuction has been attempted as well [14]. Oral salbutamol (12 mg daily in divided doses) has been reported to be beneficial [15].

51.3 Clinical Case 51.2 Clinical Syndrome Clinically, the onset of multiple symmetrical lipomatosis is between the age of 35 and 45 years and is most prevalent in the male [5]. A familial pattern has been suggested [6]. At first, the patient notices difficulty in buttoning the collar of his shirt and symmetrical masses appear in the posterior part of the neck. Then masses occur in the submandibular region, the chest, and the rest of the body except for the extremities. Asthenia and apathy are usually present, compression of peripheral nerves can result in pain but not paresis, and dyspnea and cough may develop from airway compromise and mediastinal compression [7, 8]. Alcohol overuse has been frequently noted. Liver function tests may be slightly abnormal. Hyperuricemia, glucose intolerance, and high blood

R. Yoho 797 South Arroyo Parkway, Pasadena, CA 91105, USA e-mail: [email protected]

The 40-year-old male with a history of untreated hypertension gave a history of increasing size of asymptomatic lipomas of the neck and shoulder girdle over a 10-year-period of time. The patient was not obese, but examination disclosed large lipomatous masses in the neck and shoulders (Fig. 51.1). He was given salbutamol (3 mg 3 times daily) for a year. This appeared to limit the rate of growth of the lipomas. There had been three previous attempts at surgical removal of the masses. Aggressive tumescent liposuction of the neck was performed in May 1997. The tumescent solution consisted of 1,800 mL of saline solution containing 0.1 mg% lidocaine and 1:1,000,000 epinephrine. A total of 3,400 mL of fat and fluid was removed from the shoulder girdle. Following an uneventful recovery, the neck and back lipomas were removed by liposuction using 1,200 mL tumescent solution and removing 1,500 mL of fat and fluid. The patient was continued on salbutamol. The results were excellent at 7 weeks postoperatively (Fig. 51.2). Some of the areas of fatty deposit recurred over the following 2 years.

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_51, © Springer-Verlag Berlin Heidelberg 2010

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514 Fig. 51.1 Preoperative patient with Madelung’s neck

R. Yoho

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Fig. 51.2 Seven weeks postoperative following liposuction and oral salbutamol

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51 Liposuction for Madelung’s Neck

51.4 Discussion Although there is no capsule around the fatty deposits in this syndrome, the liposuctioned areas respond like lipomas with the capsule left in situ in that there is a high likelihood of recurrence. In the areas where aggressive surgery had been performed, the long-term cosmetic results were better, although aggressive liposuction was more difficult because of the fibrosis. Salbutamol had a definite effect because the patient noted a significant worsening of the fat deposits when he was off the drug.

References 1. Agrez M, Hellew A, Barrie P. Benign symmetric lipomatosis. Aust NZ J Surg. 1995;65(8):616–8. 2. Enzi G. Multiple symmetric lipomatosis, an updated clinical report. Medicine (Baltimore). 1984;63(1):65–4. 3. Martin DS, Sharafuddin M, Boozan J, Sundaram M, Archer C. Multiple symmetric lipomatosis (Madelung’s disease). Skeletal Radiol. 1995;24(1):72–3. 4. Ruzicka T, Vieluf D, Landthaler M, Braun-Falco O. Benign symmetric lipomatosis Launois-Bensaude: report of ten cases and review of the literature. J Am Acad Dermatol. 1987;17(4):663–74.

515 5. Stavropoulos P, Zouboulis CC, Trautmann C, Orfanos CE. Symmetric lipomatosis in female patients. Dermatology 1997;194(1):26–31. 6. McKusick VA. Mendelian inheritance in man. Baltimore: Johns Hopkins University; 1978. p. 242. 7. Luscher NJ, Prein J, Spiessi B. Lipomatosis of the neck IMadelung’s neck. Ann Plast Surg. 1986;16(6):502–8. 8. Katou F, Shirai N, Motegi K, Satoh R, Satoh S. Symmetric lipomatosis of the tongue presenting as macroglossia: report of two caases. J Craniomaxillofac Surg. 1993;21(7):298–301. 9. Greene ML, Glueck CJ, Fujimoto WY, Seegmiller JE. Multiple symmetric lipomatosis with gout and hyperlipoproteinemia. Am J Med. 1970;48(2):239–46. 10. Enzi G, Inelman EM, Baritussio A, Dorigo P, Prosdocimi M, Mazzoleni F. Multiple symmetric lipomatosis: a defect in adrenergically stimulated lipolysis. J Clin Invest. 1977; 60(6):1221–9. 11. Klopstock T, Naumann M, Schalke B, Bischof F, Seibel P, Kottlors M, Eckert P, Reiners K, Toyka KV, Reichmann H. Multiple symmetric lipomatosis: abnormalities in complex IV and multiple deletions in mitochondrial DNA. Neurology 1994;44(5):862–6. 12. Selvaag E, Schneider M, Wereide K, Kviem M. Benign symmetric lipomatosis Launois-Bensaude successfully treated with extensive plastic surgery. Dermatol Surg. 1998;24(3):379–80. 13. Springer HA, Whitehouse JS. Launois-Bensaude adenolipomatosis. Plast Reconstr Surg. 1972;50(3):291–4. 14. Carlin MC, Ratz JL. Multiple symmetric lipomatosis: treatment with liposuction. J Am Acad Dermatol. 1988;18(2 Pt 1): 359–62. 15. Leung NW, Gaer J, Beggs D, Kark AE, Holloway B, Peters TJ. Multiple symmetric lipomatosis (Launois-Bensaude syndrome): effect of oral salbutamol. Clin Endocrinol (Oxf). 1987;27(5):601–6.

Body Contouring of the Thigh: The Third Dimension by Leonardo Da Vinci

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Alberto Di Giuseppe

52.1 Introduction In order to achieve competence in aesthetic surgery of the body and face, it is expressively required for a board certified plastic surgeon to acquire ability in the techniques taught and learnt, together with an ability to sculpture the body through an evaluation of the body proportions. The talent to prefigure how to correct body asymmetries and imperfection is an art which needs to be studied, fully understood, and done on sculpture and drawing before performing it directly on a patient. When operating on a flat surface as the abdominal wall in a standard tummy tuck correction, no particular talent is required to figure and sculpture this area because of the safe general vision of the fat thickness of different zones of the abdomen. But when the area to be corrected is the thigh, the surgical plan should take into consideration the body proportions from a frontal and posterior view as a minimum. The analysis of the areas and zones to be corrected has always been taken from these two views, and the surgical techniques have been addressed to correct flanks, trochanter deformities, banana fold, inner side of the thigh, inner side of the knees, etc. (Figs. 52.1 and 52.2). This criterion has been followed by plastic surgeons in the last decades, following the indications that our teachers suggested to us. In the past I have been impressed as other surgeons by the classic drawing by Illouz (Fig. 52.3) [1] published in 1989 indicating the areas of adherence of the low body contouring to avoid threat or to threat with A. Di Giuseppe Department of Plastic and Reconstructive Surgery, School of Medicine, University of Ancona, 1, Piazza Cappelli, 60121 Ancona, Italy e-mail: [email protected] e-mail: [email protected]

care in order to prevent potential complications. As a matter of fact, the analysis of Illouz was also concentrated on the evaluation of the frontal and posterior view of the patient.

52.2 History The author reviewed the studies on the body proportions by Leonardo da Vinci, starting from his paintings of a nude man, (1503, 1509) where he started studying the body figure and proportions from two standards views, frontal and dorsal, or anterior and posterior, as we have been instructed through all these years by our masters. The history of classic authors interested in the analysis of body proportions starts with Policleto who founded the so-called Mount Athos scheme that divided the total length of body figure into nine units. Alberti (1404–1472) introduced in his “The Statua: (1434–1435)” the new concept of depth of the body. Independently from the studies of Alberti and the others, da Vinci started to develop his own theories on body proportions: defining single parts of the body and then putting them in comparison with the total body of other single units. Instead of evaluating single absolute measure of the body parts, he evaluated the measurements in comparison with the body length, defining different criteria of proportions; not in absolute terms, but in relation to other body parts with studies on proportions of the head, trunk, arm, head, leg, and arm (Figs. 52.4 and 52.5). For a few years, da Vinci was influenced by the studies and theories of Durer (1471–1528), but mostly followed the scheme of the Uomo Vitruviano described by Marcus Vitruvius Pollio (first century bc)

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_52, © Springer-Verlag Berlin Heidelberg 2010

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Fig. 52.1 Left: preoperative. Middle: surgical plan with lines showing concavities and convexities. Right: postoperative

in De Architectura, Libri Decem, where he introduced a Greek measurement system. Following this da Vinci introduced his anthropometric studies of body proportions and parts, simplifying the absolute criteria of Vitruvius based on a Greek measurement scheme (Fig. 52.6). Finally, he introduced the third dimension, as indicated in his drawings of the analysis of leg proportions (Fig. 52.7). The leg is measured with Greek letters at different distances, and compared between

upper, middle, and lower third of the leg that are done in absolute and relative terms. The lateral view of the thigh appears finally, after frontal and dorsal views which have been the only consideration in the previous period. In his drawing on study of proportions of the body standing, sitting, and on the knees (1490) (Fig. 52.8), he clearly indicated the correct way to approach and evaluate the body symmetry and evaluate body contouring.

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Fig. 52.2 Left: preoperative. Middle: surgical plan with lines showing concavities and convexities. Right: postoperative

The lost third dimension (Fig. 52.9) told the author of a different criteria to evaluate, and thus, correct body deformity mainly in the thigh area that has been considered for long time as a “forbidden area.” This relative hostility was due to the difficulty of sculpturing and mastering the anterior and anteromedial part of the thigh, and for the fear of damage with secondary irregularities and depressions. Since 2006, the author has used digital photos with bilateral side view, and bilateral 3/4 view, together

with the classical frontal and dorsal (anterior and posterior) views as standard evaluation for body contouring of the buttocks, thighs, and lower leg. This increases the global view of the asymmetries and body disproportions of the patient, and allows a better careful analysis of the areas of surgical intervention. Surgical planning (Fig. 52.10) comes after evaluation of fat body lipodystrophies, skin laxity, and flaccidity body lines. The target is to recreate a natural body line, with convexity and concavity lines, in order to really shape

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Fig. 52.3 Zones of adherence as described by Illouz

Fig. 52.4 Leonardo da Vinci studies on head, trunk, thighs proportions. Circa 1490, Royal Library, Windsor Castle

the body. Particularly in the thigh, the third dimension is reached with the possibility of thinning and modeling the frontal medial part of the thigh with Vaserassisted liposuction [2–5].

This technique is derived from the classic ultrasound-assisted lipoplasty [6], but utilizes fine titanium probes of 2.9–3.7 mm diameter. The 2.2-mm probe can be used to tailor the thin, soft areas of the knees

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Fig. 52.5 Leonardo da Vinci studies on face, arms, legs proportions. Circa 1490, Royal Library, Windsor Castle

with excess fat that need contouring. In the anterior thigh a plan is made and drawn in the area that needs thinning of fat, mostly from the superior patella to the inguinal crease. This is still considered by most authors an extremely difficult area to work on, with potential side effects and depressions, dimples, irregularities, etc. This might happen if a good device is not used. But with the help of a great technology as Vaser, the surgeon can master and approach this area without fear, in the attempt to sculpture the body fat as he likes. Thinning the anterior part of the thigh is the way to treat the area circumferentially and defining this third dimension that really increases the quality of the results (Fig. 52.11). From the photos it is possible to understand how the surgical plan is evaluated in the side view, ¾ view, and rear view in order to draw a new ideal line and shape. Surgically, apart from the classic approach to flanks, buttocks, banana fold, etc., the new approach concerns the anterior part of the thighs, the inner part of the thighs, and the suprapatella area. Incisions to approach these areas are made at the inguinal crease and over the knee. VASER requires superwet infiltration and superficial careful undermining of the soft tissue of the anterior thigh in order to allow secondary tissue retraction. The fat component of the anterior part of the thigh is normally limited to one layer. So surgical thinning

must be careful, but Vaser’s delicate action contributes to find the right surgical plane to work on. After completing the undermining of the superficial layer with the finest probe, the surgeon can approach the deeper layers with a thicker probe (3.7 mm). Normally, the two ring probe is utilized, power tunneled at 70% of power and timing of the ultrasound action with continuous wave varying from 5 to 20 min depending on the size of the body, thickness of the area, and amount to be removed. Even the shape of the buttock area can be refined with this technique, thinning carefully the target areas. In this case, the surgical plan includes thinning of the buttocks, banana fold correction, dorsum reshaping, and anterior thigh thinning. Of capital importance is planning the surgeries correctly (Fig. 52.9). The author normally uses yellow to mark the areas that should be thinned and defatted mainly, with care to imagine how to recreate a natural shape and a proportioned body area. The areas in red are not to be touched because there is no tissue to remove. There is no area forbidden with Vaser contouring, but of course there are areas that do not need to be touched because they are already well-shaped or just not improvable. Areas to be treated should be preplanned and marked. Digital photographs in similar conditions should also be the rule. A plastic surgeon

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Fig. 52.6 Leonardo da Vinci drawing of proportions following Vitruvio. Circa 1490, Venice, Gallerie Dell’Accademia

learns from his mistakes only by watching carefully his own results and is the best judge of his results. The different results in body shape of the thigh are approached with Vaser, even in the anteromedial part of the thigh together with the treatment of the trochanter. Only this fully circumferential approach to the thigh allows the treatment of the third dimension, giving a natural and really proportioned shape to the area, no matter for the size of the case (Fig. 52.12).

In limited case of localized lower body disproportions (Fig. 52.13), it is impressive how circumferential contouring can improve the general proportion of the area. From the various views it is possible to appreciate the natural shape acquired with the good proportions between elements reestablished. What da Vinci defined as the “Third Dimension” was not lost, but just forgotten by us as surgeons because we were worried about surgical approaches to

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Fig. 52.7 Leonardo da Vinci analysis of the proportions of the leg. Circa 1490, Royal Library, Windsor Castle

what was considered difficult or forbidden areas of the thigh. The author’s surgical experience with Vaser shows how this area can be successfully approached and treated and the superior aesthetic results obtained. Of course, Vaser can help a good plastic surgeon to perform body contouring of the thighs, but the talent to sculpture the body by the feeling with fat, noting body imaging and realizing how to reach your final goal is always a personal quality that cannot be taught.

The da Vinci’s drawing 1507 (Fig. 52.14) in his study of the musculature of the abdominal wall, where he already figured the surgical anatomy of the rectus abdominis and oblique muscles and the so-called six packs or eight packs, clearly indicates that what we supposed to have invented or discovered today was in reality invented or discovered 500 years ago. It is just a question of reading and studying da Vinci’s drawings.

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Fig. 52.8 Leonardo da Vinci’s studies on the proportion of a sitting, kneeling, or standing body. Circa 1490, Royal Library, Windsor Castle

Fig. 52.9 Surgical plan in red area untouched, yellow is volume to be reduced, and green area to be filled

52.3 Technique of Circumferential Thigh Vaser Contouring The process of the anteromedial approach to the thigh is to thin the subcutaneous fat of the thigh in areas

considered to be risky for the approach with classic liposuction. At the same time, the undermined tissues raise and represent a substantial benefit for the final contouring of the leg. Of course, the approach to the anterolateral part is the final step of a circumferential sculpturing of the thigh. A tridimensional vision of the

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axis in order to allow careful undermining of the tissue from underlying fat. This maneuver is essential for the final contouring of the area of the thigh, as it will allow the reduced tissues to adhere to the new, reduced body. The undermining ends when all the area has no more resistance with the underlying structures, respecting the vascular connection with the underlying layers that are not disturbed by the action of the ultrasound probe that carefully undermines without injuring the vascular network of the skin. This selectivity distinguishes Vaser ultrasound from other techniques in terms of protection of the subcutaneous vascular plexus (Fig. 52.16) [6].

Fig. 52.10 Anteromedial thigh planning interior thigh. Blue lines show increasing thickness to be reduced

full area is mandatory to model the different sides in harmony in between them. Infiltration of tumescence is vital in ultrasoundassisted lipoplasty. 1. The tumescent infiltration initially distends the tissue allowing vasoconstriction that diminishes bleeding and compacting the tissues that become uniform. The fluids are distributed superficially first and deeper to follow (Fig. 52.15) [7]. 2. Fat tissue is not dense, and tissue infiltration in the deep as well as in the superficial layer allows a firm surgical plane to be obtained. There are no anatomical layers of distinction in fat tissue so the two planes anatomical work with Vaser needs a precise layer of action of the probe (Fig. 52.16). The superficial superwet technique of infiltration really distends the tissue and allows a precise undermining by the 2.9 or 3.7 mm with one or two ring probes. With the power tunneled at 70% of power, the probe is directed parallel to the skin

The undermining, which may require 5–6 min of delicate Vaser action, always respects the skin superficial layers, the probe being directed into the deeper layers of the thigh. The volume of fat in the thigh has a peculiar distribution. The lateral part is normally the thinnest, corresponding to the fascia lata where the fat is normally minimally represented. This is the only forbidden area in body contouring, as the risk of depression is high and there is no need for fat removal. The anteromedial thigh, which is the proper target of this new technique, presents a thicker fat deposit, different from case to case, which can be emulsified with the same 2.9 or 3.7-mm probes. The power is raised to 80, or even 90%, with a total timing that is normally around 20 min of Vaser action. Once this phase is completed, the surgeon starts the most delicate part of the contouring, the removal of emulsified fat from the deeper layer (Fig. 52.17), the superficial spreading of the skin, and the careful aspiration in respect of the shape of the body (Fig. 52.18). Aspiration in the superficial layer has to be very conservative This part of the sculpting of the body allows the plastic surgeon to express his own talent and artistry, and is the unique part of the technique which cannot be taught, but just shown. Sculpturing the body by recreating lines of natural convexity or concavity is the fascinating and creative part of surgery. A 2.8-mm fine cannula is utilized to shape the superficial planes, with virtually no aspiration, and a 3.7-mm cannula to aspirate in the deeper planes (Fig. 52.18). Surgeon must go step by step, checking the new shape of the thigh, as the aspiration is progressing. Mistake may occur from excess aspiration and may

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Fig. 52.11 Left: preoperative. Middle: surgical plan with lines showing concavities and convexities. Right: postoperative

create depressions and irregularities. A tridimensional view of the surgical plan and a constant control of the preoperative photos allow a general evaluation of how surgery is progressing in terms of aesthetic result. The surgical approach to the thigh is through inguinal crease and suprapatellar skin incisions. Thanks to

these skin incisions, all of the anteromedial thigh is approached with the standard 25-cm long probes. Fat thickness in the thigh is different from anterior, medial, and lateral sides. The surgeon must take into account these anatomical limits when molding the area. Respecting proportions is a constant matter for the plastic surgeon in aesthetic surgery. Careful

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Fig. 52.11 (continued)

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52 Body Contouring of the Thigh: The Third Dimension by Leonardo Da Vinci Fig. 52.12 Tridimensional approach. (a) Front, (b) side, (c) back. Preoperative. Right: postoperative

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removal of fat in the anteromedial area of the thigh is essential to avoid unpleasant depressions or an overall not aesthetic result (Fig. 52.19). Gentle massage at the end of surgery helps the clearance of the remaining emulsified fluids from the skin incisions. In the abdomen suction drainage is routinely applied, but in other areas just leave the solution to spread out gently. Garment and elastic stockings area placed at the end of surgery and maintained for 2 months postoperatively. Lym phatic or leg Endermologie starts 10 days postoperatively and is continued for 8 weeks at a rate of 2 times per week.

52.4 Discussion The outcome from 250 cases is impressive (Figs. 52.20 and 52.21) and the improvement of the overall view of the thigh is a major issue, giving reason to the concept introduced by da Vinci in his drawings. The lost or forgotten third dimension of the thigh is that portion of the leg that has been ignored for many years because of the difficulties in treating this zone. But Vaser can give a hand to approach the area, thanks to the possibility of working on the superficial layers allowed by the fine probes and the ultrasonic energy.

52 Body Contouring of the Thigh: The Third Dimension by Leonardo Da Vinci Fig. 52.13 (a) Front, (b) side, (c) 3/4, (d) back. Left: preoperative 23-year-old female. Right: postoperative following three dimensional contouring of the thighs. Balance and proportions, other than volume reduction, are essential to acquire and ideal profile with contouring, convexities, and concavities

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52 Body Contouring of the Thigh: The Third Dimension by Leonardo Da Vinci Fig. 52.14 Leonardo da Vinci’s studies on abdominal wall muscles. Circa 1490, Royal Library, Windsor Castle

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Fig. 52.15 Skin incisions: inguinal and knee

c Fig. 52.17 (a, b) Level of undermining and emulsification. (c) Tissue adhesion after emulsified fat cleaning

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52 Body Contouring of the Thigh: The Third Dimension by Leonardo Da Vinci Fig. 52.18 (a) Side, (b) front. Sin incision superficial with undermining using 2.9 or 3.7 probes with one or two rings

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Fig. 52.19 (a) The position of the probe (b) The visual effect: the skin raised by the probe. Careful aspiration of emulsified fat from superficial layers

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References 1. Illouz YG. Refinements in the lipoplasty technique. Clin Plast Surg. 1989;16(2):217–33. 2. Di Giuseppe A. Ultrasonic assisted liposculpture. Presented at the World Congress on Liposuction. San Francisco: 3–5 May 1996. 3. Scheflan M, Tazi H. Ultrasonically assisted body contouring. Aesthetic Plast Surg. 1996;19:117. 4. Tazi H, Scheflan M. Endoscopic evaluation of ultrasonic assisted liposculpture comparison to traditional liposuction

A. Di Giuseppe (video). Presented at American Congress of Aesthetic Plastic Surgery. San Francisco: 14–8 April 1995. 5. Zocchi M. Ultrasonic assisted lipectomy. Adv Plast Reconstr Surg. 1995;2:27–65. 6. Di Giuseppe A. Ultasound-assisted liposuction: physical and technical principles. In: Shiffman MA, Di Giuseppe A, editors. Liposuction: principles and practice. Berlin: Springer; 2006. p. 229–38. 7. Klein JA. The tumescent technique for liposuction surgery. Am J Cosmet Surg. 1987;4:263–7.

Liposuction of the Calves and Ankles Associated with Calf Implant

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Adrien E. Aiache

53.1 Introduction Removal of fat from fatty ankles was first described by Schrude. This procedure consisted of making an incision in the posterior area of the ankles and using a curette for removal of the fat below the gastrocnemius. Complications were relatively numerous for the procedure to gain wide acceptance. Before Schrude, a French surgeon in the early 1900s had done this type of treatment; however, a ballerina treated by curettage ended up with generalized infection and lost her leg. With the new technique of liposuction, the improvement has been quite significant as it was developed by Fischer and later by Illouz.

53.2 Anatomy In view of the fact that the fascia superficialis is adherent to the muscular fascia, there are no deep fat deposits and the superficial fat layer represents a dense connective tissue associated with a florid lymphatic system. One needs to use an even fat liposuction to prevent irregularities. The anterior leg suction is performed on the prone patient with the legs flexed in order to proceed comfortably. It is often necessary to thin out around the ankles to a maximum and allow more fat in the upper leg at the junction with the gastrocnemius muscle belly. The anatomy consists of, posteriorly, the soleus muscle which comes from the

A. E. Aiache 9884 Little Santa Monica Blvd, Beverly Hills, CA 90212, USA e-mail: [email protected]

femoral condyle and goes down into the Achilles tendon into the calcaneus bone, and this muscle is covered by the gastrocnemius muscle which has usually two bellies, the medial belly being larger and lower than the lateral belly. The sural nerve travels between the two heads of the gastrocnemius and gives sensation to the posterior ankle area. Deeper than the gastrocnemius, the posterior popliteal nerve comes from the bifurcation of the posterior femoral nerve and goes around the fibular tubercle to enervate the muscles of the anterolateral aspect of the foot, and it gives a sensory nerve going to the lateral and posterior area of the leg and the foot. Medially, the posterior tibial nerve bifurcates and enervates the muscles of the leg, and gives, in addition, a sensory branch to the outer aspect of the leg. These nerves are to be avoided carefully during the liposuction and during the calf implantation (Fig. 53.1).

53.3 Indications Indications consist of either thin legs with an association of large knees needing liposuction or sometimes fat legs which have no special shape and are to be suctioned at the knee level and at the ankle level, and sometimes need to be associated with calf implants in order to give them a better shape. The appearance of the leg is deleterious to the aesthetic aspect of the leg in females. The problem consists of fat deposits interspersed with some fibrous tissue. It is found mainly in some ethnic groups. The condition worsens with age and it should be distinguished from dependent edema secondary to venous stasis. Palpation and the pinch test must reveal an excess of fat since some of the ankle bulk may be due to edema.

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and the element to be augmented by the implant. The patient is in the standing position and the exact amount of fat can be assessed. The area is marked up to the belly of the gastrocnemius muscle down to the ankle itself and around the Achilles tendon. This zone is extremely difficult since the circulation is poor in the midline above the Achilles tendon and often is the cause of superficial skin loss and even sometimes full thickness skin losses. The incision is usually made lateral and medial to the Achilles tendon. More anteriorly, some fatty deposits may be encountered and they are liposuctioned through an anterior horizontal foot incision.

53.5.2 Anesthesia Depending on the extent of the suction, anesthesia can be local, but more often general anesthesia is given. In cases of multiple suctioned areas, general anesthesia is preferable and the legs are then infiltrated, in addition, with the usual tumescent infiltration of the diluted solution of Xylocaine with epinephrine 1:1,000,000. In local anesthesia cases, the same anesthetic is used with some sedation instead of general anesthesia.

Fig. 53.1 Anatomical demonstration of the location of the gastrocnemius muscle and the different nerves such as the sural nerve, the lateral peroneal nerve, and the inferior tibial nerve

53.4 Contraindications Older patients with poor circulation, poor vascular supply, and extreme venous stasis are contraindications since the secondary problems can become serious after liposuction. The skin tone should show adequate elasticity since in some patients with poor circulation and brawny edema, there is a very thick layer of fibrous fatty tissue with lymphatic engorgement.

53.5 Technique 53.5.1 Markings Markings are done in the standing patient and the markings are used in marking the element to be suctioned-out

53.5.3 Instruments Four and three millimeter cannulas are useful. Finer cannulas are used in order to prevent the untoward direction of the cannula immediately below the skin creating dents and longitudinal depressions.

53.5.4 Incisions An incision lateral to the Achilles tendon in the ankle is used. This should be avoided if the surgeon is concerned about injuring the lateral peroneal nerve. Incision medial to the Achilles tendon is the most commonly used and allows the proper suction to the whole medial posterior area of the leg. A less common incision in the posterior popliteal fold can be useful if there are extremely heavy deposits of fat and the suction is done going downward. In addition, this incision will allow insertion of the posterior calf implants. Anteriorly, the incision can be situated in the upper portion of the

53 Liposuction of the Calves and Ankles Associated with Calf Implant

foot and below the patella either medially or laterally, allowing proper suction in front of the tibial bone and more medially over the tibia where more accumulation can be seen. In addition, an incision can be made in the lateral or medial port of the popliteal folds and this allows suction of the lateral legs and the ankles.

53.5.5 Procedure The procedure is performed most often on the patient prone and the local anesthesia product is infiltrated. Then the usual sawing wood motion of the cannula is used in parallel tunnels methodically in each tunnel, trying to be even in the suction process. Proper projection of the suction is checked continually by palpation and observation using the pinch test and the flat palm of the hand to assess the remaining thickness of the skin below, on top of the cannula, and below the hand. Although this defatting is adequate in most of the cases, it has been found that vigorous defatting suction is necessary to achieve a remarkable difference in the shape of the ankle. Aside from circulatory problems immediately on top of the Achilles tendon, no other untoward effect has been seen from strenuous suction. In other words, superficial suction is indicated in these cases and is the only possibility in the leg. While 0.5 cm is sufficient around the ankle, 1 cm will be necessary in the upper leg which is supposed to be larger in volume than the lower leg. To improve on the exact shape of the result, a computer suction machine can be used. It helps in comparing the fat removal on both sides (1.5–1,000 Aspirator by MD Engineering, 2536 Barrington Court, Hayward, CA 94545).

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procedure. This technique has been suggested by some, and under proper circumstances, it can be useful.

53.5.7 Calf Implantation After this has been done, the incision is performed in the posterior popliteal fold measuring approximately 1½–2 in. The incision goes down to skin, subcutaneous tissues, down to the deep fascia which consists of a multiple-layer type of fascia, and when all the layers have been entered with a knife, the surface of the gastrocnemius muscle can be seen. At this point, the dissection is carried out using the finger over the gastrocnemius muscle and under the deep fascia. Continuation of the dissection is performed using the ball dissector and the hammer dissector that are useful in severing the remaining septa and vessels that are touching the fascia and the muscle to the deep leg fascia (Fig. 53.2). Once the pocket is judged adequate for the implants medially, a pocket is dissected laterally leaving a large segment of untouched

53.5.6 Refinements Feathering at the junction of the defatted and nondefatted areas is performed with finer cannulas and either minimal suction or no suction at all. In addition, proper defatting in a less aggressive manner is done anteriorly and at the lower edge of the gastrocnemius muscle. The refinements are made using a Robles 2.4 or 3-mm cannula with either one or three openings. A proximal tourniquet can be sometimes used if large amounts of fat have to be removed; however, this has a negative effect of extreme bleeding in each leg when it is released at the end of the

Fig. 53.2 Dissection of the implants using a ball dissector and around the pocket in the superficial level. The fat could be either liposuctioned or reinjected, as well as in the ankles themselves

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layers of tissue under the deep fascia in order to prevent movement of the implants from one side of the pocket to the other. The second pocket is then created laterally over the lateral belly of the gastrocnemius muscle and under the deep fascia of the leg. Again, the finger is used first followed by the round ball dissector and the hammer dissector, which are useful to sever the remaining fascia or vessel present in the area. Once the two pockets have been properly created and checked, the implants are then introduced in the medial and lateral segments of the leg respecting the central segment of tissue containing the posterior sural nerve. Once the implants have been correctly placed, their proper position and location are checked on both sides in order to have correct symmetry with the other leg that is done in the same fashion. Once correct symmetry has been obtained, adjustment of the suction be performed, especially in the medial aspect of the knee and the lateral aspect of the calf laterally using a lateral part of the incision that has been used for the calf implantation. Once satisfaction is obtained, the deep fascia is closed using 3–0 or 4–0 Vicryl sutures followed by a subcuticular suture with 4–0 Vicryl sutures. Unless an inordinate amount of bleeding has been obtained, no drains are left in situ and the wounds are perfectly closed followed by the dressing, and the postoperative care is then given.

53.5.8 Postoperative Care Compression and massaging of the area are useful to reduce the edema postoperatively. Once complete defatting has been obtained, the incisions are closed with absorbable sutures reinforced by Steri-Strips. A garment can be applied, in addition to Ace bandages, to prevent deep vein thrombosis. The patients are asked to ambulate ad lib and are allowed to have moderate activities. The compressive garments are the most useful. Support hose is often reinforced by Reston foam (Allmed, 297 High Street, Dedham, Massachusetts 02026) and kept in place with a 6-in. Ace bandage (Fig. 12).

53.5.9 Circumferential Ankle Liposuction Using the posterior and anterior approaches, circumferential suction is used in fatty legs when a definite increase in the superior fatty layer is palpated.

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It is performed with a 4 or 3-mm cannula. It is safe, depending on the specific vascular condition of the patient. Caution is advised is older patients with poor vascular status for fear of local skin slough and venous stasis and thrombosis. Through four incisions, the suction is then performed and the proper incision can reach the ankle and should crisscross the anterior midline. A combination of a long 4-mm cannula and a 3-mm cannula is sufficient to obtain good suction. Continuous feeling and the pinch test will direct such a process and, combined with repeated inspection and palpation, it will allow proper results and long-term postoperative results.

53.6 Complications The complications that are sometimes seen are mentioned such as infection, irregularities, and nerve injuries. Complications which are more common are swelling, excessive pain for an extended period of time, some areas of irregularities, extreme bleeding, and longterm pigmentation, in addition to complications seen with calf implantation consisting of bleeding, seroma formation, poor location of the implants, and eventual infection of the implanted area (Table 53.1). Table 53.1 Ankle liposuction complications Complication

Remedies

Insufficient removal

Fat grafting

Excess removal and dents

Allows only token improvement. The skin should be 0.5–1 cm thin all around

Hyperpigmentation

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Pain

Hypesthesia

Uneven or unequal

Seroma and/or hematoma

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Infection

Implant removal

Contraindications: Circulatory problems, varicose veins, ankle edema, Raynaud’s syndrome, lymphedema, hypertrophic gastrocnemius muscle Comments: Ankle with pitting edema should be a contraindication. Lymphatic or venous incompetence can be the cause. The skin tone should be showing adequate elasticity, otherwise liposuction is not advised

53 Liposuction of the Calves and Ankles Associated with Calf Implant

53.7 Discussion Liposuction has been found to be extremely useful in cases of lipodystrophy of the lower leg. This technique can bring dramatic improvement to these cases. Contraindications are well known and they include old age with circulatory problems, varicose veins, ankle edema, Raynaud’s syndrome, lymphedema, etc. Association of liposuction with calf implantation has been shown to be beneficial in improving the shape of the leg and improving the shape of the knee and the ankle (Fig. 53.3). Determination of the exact desire of the patient will help in deciding the amount of fat to be removed and aggressive suctioning may lead to irregularities in the ankle, but the overall result will be better than cases that are done too conservatively. The possibilities afforded by implants have shown that some patients can be improved in their contour by a combination of augmentation and reduction by liposuction allowing real sculpture of the body. Such cases are pectoral implants calf implants, buttock implants, as well as malar and chin implants. All of these cases can be associated with liposuction to improve their contour, in addition to augmentation by fat injection.

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In cases of deformities of the leg consisting of an underdevelopment of the muscular elements in the calf associated with excess fatty deposits around the lower thigh, the knees, and the upper leg, a combination of calf implants with liposuction of the knees, the lower thighs, and the upper calves has been shown necessary. Some patients will necessitate an inferior leg liposuction sculpturing the ankles and the areas below the gastrocnemius followed by subfascial implantation of the calf implants. This combination of techniques is used in conjunction during the same operation. The technique of calf liposuction is only secondary to the technique of implantation since the implantation itself is a procedure necessitating more vigorous asepsis, and the author favors the preliminary implantation of the calf implants and a closure of the layers of the fascia and the subcutaneous tissues followed then by liposuction of the knees and the calves. This combination approach has given more security in the attempt at reducing the potential problems of infection. The calves are marked in the usual manner for implantation, and the incision for the calf is used as in regular calf implantation shown in the following chapter. Following this implantation, the incisions for liposuction are performed in the lateral and medial aspect of the posterior popliteal incision for implantation, and in

c

Fig. 53.3 (a) Preoperative patient. (b) Preoperative markings of the liposuction areas. (c) Postoperative

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the medial and lateral aspect of the Achilles tendon if ankle suction is necessary. Once the suction has been performed in these cases, the patient is turned in the supine position, and using a small incision in the medial aspect of the knee above the patella, the completion of the liposuction of the knees is performed.

A. E. Aiache

53.8 Conclusions A combination of liposuction of the ankles, knees, and lower thighs in association with calf implants gives a better result than either one of these procedures alone.

Management of HIV-Associated Lipodystrophy: Medical and Surgical Options for Lipoatrophy and Lipohypertrophy1

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C. Scott Hultman and Anne Keen

54.1 Introduction Over 25 years after the first published cases of the acquired immunodeficiency syndrome in 1981, human immunodeficiency virus (HIV) has infected an estimated 65 million people and resulted in at least 25 million deaths [1]. During the latter part of the 1990s, potent HIV therapies became available and produced a dramatic improvement in the prognosis of this fatal viral illness. Suppression of viral replication by highly active antiretroviral therapies (HAART) and subsequent increases in CD4+ cell count have yielded increases in disease-free survival. The benefits of HAART, however, have been tempered by the development of metabolic complications and morphologic changes in patients receiving these therapies, which may occur in 10–60% of this population [2]. Insulin resistance, dyslipidemia, lactic acidosis, and alterations of fat distribution in varying combinations have been observed during HAART [2]. Given the association of these conditions with heightened risk of cardiovascular disease, there is increasing concern about the long-term consequences of HIV treatment. Further, metabolic complications can threaten the success of HAART. The need for lipid-lowering or hypoglycemic medications can increase pill burden and jeopardize medication adherence. In addition, adverse metabolic effects, particularly those that

Funding: Supported in part by the Ethel and James Valone Plastic Surgery Endowment.

1

C. S. Hultman (*) Division of Plastic and Reconstructive Surgery, University of North Carolina, Suite 7040, Burnett-Womack Building, CB#7195, Chapel Hill, NC 27599-7195, USA e-mail: [email protected]

impact appearance, can reduce patient acceptance of HIV therapy. Disfiguring body shape changes from HAART, in addition to potentially compromising the success of medical control of HIV infection, can threaten confidentiality and lead to increased stigmatization of those living with HIV. Originally described by Carr in 1998, HIV-associated lipodystrophy results in abnormal fat redistribution, with lipoatrophy of the nasolabial folds, malar region, temples, buttocks, and distal extremities, and lipohypertrophy of the neck, trunk, and breasts [3–12]. Furthermore, adverse body shape changes can have psychological consequences and contribute to feelings of unattractiveness, low self-esteem, poor selfimage, and depression [13–17]. Accumulation of fat in the cervicodorsal region and anterior neck can also interfere with function, causing significant pain, altered posture, limited range of motion, and sleep apnea [18].

54.2 Pathophysiology Developing effective treatment for fat distribution abnormalities accompanying HIV therapy has been limited by a continuing lack of understanding of the etiology of fat accumulation in the setting of HIV. While early studies implicated antiretroviral agents of the protease inhibitor (PI) class in fat accumulation, recent data suggest that other antiretroviral classes and host factors are also responsible [2]. Many of the PIs and nucleoside reverse transcriptase inhibitors (NRTIs) bind to homologous regions on endogenous proteins that control normal lipid metabolism, leading to paradoxical, concurrent adipocyte apoptosis and/or hypertrophy. Specific targets of inhibition that have been implicated include cystoplasmic retinoic-acid binding protein type 1, which may

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_54, © Springer-Verlag Berlin Heidelberg 2010

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control adipocyte differentiation and maturation, and low-density lipoprotein-receptor-related protein, which may negatively impact clearance of serum triglycerides and transport of hepatic chylomicrons [19–23].

54.3 Patient Assessment A complete assessment of the patient is critical to help identify and guide patient expectations, optimize procedural outcomes, minimize perioperative morbidity, and decrease risk to the providers. As with all patients, a thorough history and physical examination must be performed. Preoperative history should include determination of disease status and overall health, confirmation that the patient has a medical home and is followed by an infectious disease expert, and review of previous and current antiretroviral regimen. Furthermore, the provider should investigate history of opportunistic infections, sexually transmitted diseases, viral hepatitis, tuberculosis, cardiovascular status, substance abuse, and insulin resistance and hyperlipidemia [24]. Regarding the physical examination, the surgeon should evaluate the status of the airway and focus on morphologic changes in body habitus, differentiating subcutaneous from visceral fat and assessing the severity of lipoatrophy and lipohypertrophy. Suitable candidates for surgery included those individuals who (1) have specific anatomic areas amenable to lipectomy (anterior neck, posterior neck, trunk, extremities), (2) have stable HIV disease with an optimized HAART regimen, (3) display a history of compliance with medical therapy, (4) have attempted to improve their lipodystrophy through exercise and nutrition, and (5) demonstrate realistic expectations regarding the possible benefit of surgery. In addition to checking a full viral panel (CD4+/CD8+ cell counts and viral RNA titers), we also obtain such laboratory data as lipid panels (triglycerides, LDL/HDL, cholesterol), routine serum chemistries, hemoglobin/hematocrit, and platelets. Higher complication and mortality rates have been associated with absolute CD4+ counts less than 200 cells/mL and viral load greater than 10,000 copies/mL [24]. Radiographic imaging may be helpful in selected cases: lateral cervical spine roentgenograms screen for cervical disc disease, while computerized tomography may evaluate the extent of subplatysmal fat and parotid hypertrophy or cystic degeneration.

C. S. Hultman and A. Keen

Perioperative considerations include deep venous thrombosis prophylaxis and patient education regarding postoperative pulmonary toilet and early mobilization. Prophylactic antibiotics are administered within 30 min prior to the incision and are continued postoperatively only if a drain is placed or unexpected contamination occurs. Antibiotics are not used for injection of permanent or semipermanent subdermal fillers, but are utilized for structural fat grafting.

54.4 Medical Therapy The efficacy of medical therapy for HIV-associated lipodystrophy is largely unknown, and treatment options, therefore, remain limited. Diet and exercise have been found to lead to some reduction in abdominal fat, but these changes have been modest and many patients have difficulty adhering to such lifestyle interventions. Recombinant growth hormone has been shown to reduce visceral and cervicodorsal fat in HIVinfected patients; however, this agent, which is prohibitively expensive, is associated with a number of toxicities, including worsening glucose intolerance, myalgias, and carpal tunnel syndrome. Further, reaccumulation of fat is often seen following discontinuation of growth hormone. Small studies of the PPAR-gamma agonist rosiglitazone, as well the insulin sensitizer metformin in HIV-infected patients with insulin resistance, have found beneficial effects on visceral fat accumulation, but larger studies have yielded contrary results [2].

54.5 Surgical Treatment Surgical approaches to HIV-associated lipodystrophy show considerable potential in correcting the stigmata of fat redistribution [25–52]. For lipoatrophy, soft tissue replacement can be achieved by structural fat grafting via autotransplantation, dermal-fat grafts, subperiosteal malar implants, semipermanent soft tissue fillers, off-label silicone injection, and even intramuscular gluteal implants [24–39, 52]. Polylactic-l-acid (Sculptra) was approved by the FDA in 2004 for large volume restoration and/ or correction of facial lipoatrophy in patients with

54 Management of HIV-Associated Lipodystrophy

HIV-associated lipodystophy, with augmentation lasting at least for 2 years [38, 39]. Another semipermanent filling agent, calcium hydroxylapatite (Radiesse), has been used off-label to treat HIV-associated facial lipoatrophy and demonstrates an excellent safety profile with favorable 1-year durability [37]. Recently, polyacrylamide hydrogel (Aquamid) has been used as a semipermanent filler to provide contour correction of the nasolabial folds and midface, with significantly improved quality of life, as measured by objective inventories [52]. Specific anatomic areas of lipoatrophy that benefit from soft tissue augmentation include temples, glabella and brow, zygomatic arch, lower eyelid, nasojugal groove, malar triangle, nasolabial fold, oral commissures, chin, and peri-jowl area. For lipohypertophy, the patient must understand that surgery can function as a primary or adjunctive modality, and that techniques for fat resection are still in evolution [40–51]. Surgery should be offered only to patients with stable HIV infection, who have realistic expectations regarding outcomes, and who have focal areas of fat accumulation that are amenable to UAL, SAL, and/or direct, open lipectomy. Informed consent must include the understanding that suboptimal correction or recurrence of the lipohypertrophy may occur and that staged or late reoperation may be necessary. Surgical planning may benefit from preoperative imaging, which helps to define the extent and distribution of abnormal fat accumulation. Despite the potential for recurrence, a combination of UAL and SAL appears to be very effective and safe in reducing the volume of the cervicodorsal fat pad, improving range of motion and neck posture, and reducing discomfort. Because of the fibrous nature of the fat observed in HIV lipodystrophy, UAL is required for surgical resection, as this modality allows for cavitation of adipocytes and extraction of lipoaspirate, with considerably less tissue trauma than SAL alone. Direct excision of extremely dense fat, such as in the mastoid region, should also be considered and can be accomplished through a pretrichal, posterior scalp incision. The anterior neck, however, represents a significant challenge, in terms of safety, efficacy, and longterm improvement. The two goals of fat removal and improved contour may be difficult to achieve with liposuction alone, due to the extensive amount of subplatysmal fat and potential for parotid hypertrophy or cystic degeneration. Subplatysmal fat is not

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safely accessible by liposuction and may require open, direct excision, through a submental approach or transverse cervical approach. Furthermore, UAL may cause neuropraxia or nerve injury, secondary to collateral ultrasonic damage, thereby placing the facial nerve at risk. This potential for nerve injury, combined with the inaccessibility of subplatysmal fat, redundant neck skin, and anterior platysmal diastasis, argues toward an open approach that incorporates SAL with a face-lift and neck lift. The best results may be obtained by superficial liposuction, direct submental and subplatysmal lipectomy, anterior platysmal plication, SMAS elevation, and skin resection via traditional face-lift and neck lift methods. Recently, the authors have utilized a transverse anterior neck excision to remove both supra- and subplatysmal fat, tighten the platysma, and redrape the excess anterior neck skin. Regarding the torso, body contouring can be performed via a combination of UAL/SAL of the abdominal wall, back, and flanks. Standard principles of patient safety (fluid resuscitation, low-volume liposuction of <5.0 L, anesthetic monitoring, deep venous thrombosis prophylaxis, perioperative antibiotics) and surgical technique (preoperative marking with patient standing, super-wet tumescence, UAL/SAL with multiple port sites, postoperative drainage and/or compression) also apply to patients with HIV-associated lipodystrophy. Given the presence of inaccessible visceral fat and an inability to alter the mechanism of fat redistribution, patients with lipohypertrophy of the trunk must have realistic expectations of surgical goals, may benefit from staged removal of fat, and may require reoperation for recurrence of lipohypertrophy. Management of male gynecomastia follows accepted principles of UAL/SAL for mild to moderate cases and reduction pattern templates for severe cases. Female patients with symptomatic macromastia should have standard breast reduction techniques, which can include conventional SAL with or without open resection via inverted T or vertical patterns. UAL is not utilized as there exists concern for the long-term adverse effects of ultrasonic energy on breast parenchyma, in terms of potential for neoplastic changes and impact on imaging. All women who have breast reduction surgery should have a baseline preoperative mammogram, especially for patients older than 40 or with a family history of breast cancer.

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54.6 Discussion The authors’ surgical experience with HIV-associated lipodystrophy was recently published [51] concerning 12 consecutive patients, who underwent UAL, SAL, and open lipectomy to treat focal lipohypertrophy of the head, neck, trunk, and extremities, from 2001 to 2006, with a mean follow-up of 30 months [51]. Despite the potential for late recurrence (>1 year), which was observed in 25% of our patients, surgical management of HIV-associated lipohypertrophy was efficacious and safe, with minimal morbidity. Nerve injury, infection, hematoma, fat necrosis, or thermal injury were not observed. Reoperation was performed in 2/12 patients to correct contour irregularities or residual areas of lipohypertrophy. Based upon the results of this small case series, the authors believe that UAL/SAL is particularly beneficial in reducing the cervicodorsal fat pad, while face-lift and neck lift may be necessary to adequately address anterior neck lipohypertrophy. Truncal procedures may need to be staged or repeated during follow-up. The authors, in 2007, [51] combined the data from 11 studies on the surgical management of HIVassociated liposdystrophy and identified 88 patients who underwent surgical removal of fat in the anterior neck, posterior neck, torso, and breasts. The overall rate of reported complications was 26.1%, and the recurrence rate in 72 patients available for follow-up was 23.6%. Length of follow-up, however, was only reported in four studies, with a range of 12–30 months. No major systemic complications or deaths were observed. This pooled analysis supports our conclusion that surgical management of the HIV-related lipohypertrophy is efficacious and effective in the majority of patients. Most recently, Davison et al. [24, 49, 50] provided comprehensive perioperative guidelines and a surgical algorithm for the management of HIV-associated lipodystrophy. In their cohort of 27 patients, 3 underwent treatment for isolated buffalo hump, 10 underwent treatment for isolated facial wasting, and 14 were treated for both conditions. Mild facial wasting was treated with synthetic, semipermanent fillers, moderate wasting was treated with structural fat grafting, and severe wasting was treated with fat, parotidectomy, and mastectomy graft material. Cervicodorsal lipohypertrophy was addressed by UAL and SAL. The

C. S. Hultman and A. Keen

authors raise the possibility of superficial parotidectomy to address cystic degeneration and hypertrophy, which is often observed in HIV-associated lipodystrophy and can contribute to abnormal facial morphology. To reduce the incidence of Frye’s syndrome to less than 10%, this group utilizes a layer of acellular dermal matrix between the deep lobe of the parotid and the skin flaps.

54.7 Patient Studies Lipoatrophy: This 31-year-old HIV+ male patient, with body mass index of 24.1, had severe facial lipoatrophy, manifested by wasting of the malar and buccal fat pads, temporal hollowing, and prominence of the nasolabial fold (Fig. 54.1). He had been on a HAART regimen for 9 years, with a CD4 count of 800 and no detectable viral load. The posterior oblique view helps to illustrate this pathognomonic form of HIV lipoatrophy. Treatment involved four sessions of poly-l-lactic acid injections, spaced 3–4 weeks apart, using 6 mL of reconstituted filler per side. The malar and submalar regions were treated with a radial fanning technique, injecting 3–4 mL of material from a medial to lateral direction, as the 25 gauge needle is withdrawn, at the junction between the dermis and subcutaneous fat. The nasolabial folds were augmented using a cross-hatching pattern, placing product in the subcutaneous fat, deep to the dermal surface. The nasojugal folds and lower eyelids, which have thinner skin than the cheek, were injected in a submuscular plane, with less than 0.5 mL per session. Temporal depot shots, with ~1 mL of product, were placed between the temporalis muscle and temporal bone. Finally, the zygomatic arch was augmented with 0.5 mL in a supraperiosteal plane to facilitate lateral tapering of the malar region. The patient experienced no adverse sequellae such as subcutaneous nodules or inflammatory papules and has a stable appearance, 1 year following his reconstruction (Fig. 54.1). Lipohypertrophy: This 52-year-old HIV+ male patient, with a body mass index of 32.1, had been on a HAART regimen for 13 years with stable disease and no opportunistic infections. He complained of neck ache, shoulder strain, and decreased range of motion in his neck, plus self-reported sleep apnea. In addition to

54 Management of HIV-Associated Lipodystrophy

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a1

a2

a3

a4

b1

b2

b3

b4

Fig. 54.1 (a1–4) Preprocedural views of a 31-year-old man, body mass index of 24.1, with lipoatrophy of nasolabial folds and malar region. (b1–4) Postprocedural after four rounds of

subcutaneous and submuscular augmentation with semipermanent filler (poly-l-lactic acid)

having mild lipoatrophy of the malar region and moderate to severe anterior neck lipohypertrophy, he had severe cervicodorsal fat accumulation (Fig. 54.2), affecting cervical posture and causing abnormal neck flexion and head extension. Ultrasonic-assisted liposuction was utilized to emulsify the fat in the posterior neck, through three port sites (Fig. 54.2). After infiltrating the cervicodorsal fat pad with 600 mL of wetting solution (from a solution of 1,000 mL of Ringer’s lactate, 1 amp of epinephrine 1:1,000 and 50 mL of 1% lidocaine), 300 mL of fat was cavitated over 4.5 min with the blunt-tipped ultrasound probe, on a setting of 6 out of 10. Using this technique, the surgeon can emulsify this fat, which is extremely fibrous, at a rate of

50–75 mL/min. The liquefied fat was then removed with conventional suction-assisted lipectomy, utilizing progressing smaller cannulas, to help taper the resection onto the lateral neck and posterior chest. Extreme care should be taken near the posterior triangle of the neck to avoid injury to the spinal accessory nerve, which passes subcutaneously from the sternocleidomastoid to the trapezius muscle, for a short distance. Traditional endpoints for UAL are used – loss of resistance, presence of blood-tinged lipoaspirate, and reaching the preoperatively calculated duration of cavitation – to minimize potential for thermal injury. Drains are now only placed for largevolume UAL, and compression garments are critical to assist with final shaping.

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a1

b

C. S. Hultman and A. Keen

a2

a3

c1

c2

Fig. 54.2 (a1–3) Preoperative 52-year-old man, body mass index of 32.1, with lipohypertrophy of anterior and posterior neck. (b) Intraoperative. (c1,2) Postoperative

54.8 Future Directions While the definitive management of HIV-associated lipodystrophy has yet to be determined, future approaches will most likely include manipulation of the HAART regimen to reduce drug toxicities, addition of pharmacologic agents to improve adipocyte metabolism and lipid processing, dieting and exercise, and surgical intervention. Reconstructive techniques to correct fat redistribution show considerable promise and may be effective as primary or adjunctive therapy in well-selected candidates. The combination of soft tissue augmentation for lipoatrophy, via semipermanent fillers, and fat removal for lipohypertrophy,

through UAL/SAL, offers the potential to correct the stigmata and functional sequellae seen in patients with HIV-associated lipodystrophy.

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551 are related to lipodystrophy and metabolic disorders in HIVinfected men under antiretroviral therapy. AIDS 2003; 17(10):1503–11. 21. Buffet M, Schwarzinger M, Amellal B, Gourlain K, Bui P, Prevot M, Deleuze J, Morini JP, Gorin I, Calvez V, Dupin N. Mitochondrial DNA depletion in adipose tissue of HIVinfected patients with peripheral lipoatrophy. J Clin Virol. 2005;33(1):60–4. 22. Cherry CL, Lal L, Thompson KA, McLean CA, Ross LL, Hernandez J, Wesselingh SL, McComsey G. Increased adipocyte apoptosis in lipoatrophy improves within 48 weeks of switching patient therapy from Stavudine to abacavir or zidovudine. J Acquir Immune Defic Syndr. 2005;38(3): 263–7. 23. Roge BT, Calbet JA, Moller K, Ullum H, Hendel HW, Gerstoft J, Pedersen BK. Skeletal muscle mitochondrial function and exercise capacity in HIV-infected patients with lipodystrophy and elevated p-lactate levels. AIDS 2002;16(7):973–82. 24. Davison SP, Reisman NR, Pelligrino ED, Larson EE, Dermody M, Hutchison PJ. Perioperative guidelines for elective surgery in the human immunodeficiency virus-positive patient. Plast Reconstr Surg. 2008;121(5):1831–40. 25. Moyle GJ. Plastic surgical approaches for HIV-associated lipoatrophy. Curr HIV/AIDS Rep. 2005;2(3):127–31. 26. Abood A, Ong J, Withey S, Johnson M, Butler P. Facial atrophy in HIV-related fat redistribution syndrome: a plastic surgical perspective on treatment options and a look to the future. Int J STD AIDS. 2006;17(4):217–20. 27. Serra-Renom JM, Fontdevila J. Treatment of facial fat atrophy related to treatment with protease inhibitors by autologous fat injection in patients with human immunodeficiency virus infection. Plast Reconstr Surg. 2004;114(2):551–5; discussion 556–7. 28. Burnouf M, Buffet M, Schwarzinger M, Roman P, Bui P, Prevot M, Deleuze J, Morini JP, Franck N, Gorin I, Dupin N. Evaluation of Coleman lipostructure for treatment of facial lipoatrophy in patients with human immunodeficiency virus and parameters associated with the efficiency of this technique. Arch Dermatol. 2005;141(10):1220–4. 29. Guaraldi G, De Fazio D, Orlando G, Murri R, Wu A, Guaraldi P, Esposito R. Facial lipohypertrophy in HIVinfected subjects who underwent autologous fat tissue transplantation. Clin Infect Dis. 2005; 40(2):e13–5. 30. Strauch B, Baum T, Robbins N. Treatment of human immunodeficiency virus-associated lipodystrophy with dermafat graft transfer to the malar area. Plast Reconstr Surg. 2004;113(1):363–70; discussion 371–2. 31. Wechselberger G, Sarcletti M, Meirer R, Bauer T, Schoeller T. Dermis-fat graft for facial lipodystrophy in HIV-positive patients: is it worthwhile? Ann Plast Surg. 2001;47(1):99–100. 32. Benito-Ruiz J, Fontdevila J, Manzano M, Serra-Renom JM. Hip and buttock implants to enhance the feminine contour for patients with HIV. Aesthetic Plast Surg. 2006; 30(1): 98–103. 33. Funk E, Bressler FJ, Brissett AE. Contemporary surgical management of HIV-associated facial lipoatrophy. Otolaryngol Head Neck Surg. 2006;134(6):1015–22. 34. Hodgkinson DJ. Facial atrophy in HIV-related fat redistribution syndrome: anatomic evaluation and surgical reconstruction. Ann Plast Surg. 2003;50(3):328.

552 35. Talmor M, Hoffman LA, LaTrenta GS. Facial atrophy in HIV-related fat redistribution syndrome: anatomic evaluation and surgical reconstruction. Ann Plast Surg. 2002;49(1):11–7; discussion 117–8. 36. Binder WJ, Bloom DC. The use of custom-designed midfacial and submalar implants in the treatment of facial wasting syndrome. Arch Facial Plast Surg. 2004;6(6):394–7. 37. Silvers SL, Eviatar JA, Echavez MI, Pappas AL. Prospective, open-label 18-month trial of calcium hydroxyapatite (Radiesse) for facial soft-tissue augmentation in patients with human immunodeficiency virus-associated lipoatrophy: one-year durability. Plast Reconstr Surg. 2006;118(3 Suppl):34S–45S. 38. Lam SM, Aizzadeh B, Graivier M. Injectable poly-l-lactic acid (Sculptra): technical considerations in soft-tissue contouring. Plast Reconstr Surg. 2006;118(3 Suppl): 55S–63S. 39. Valantin M, Aubron-Olivier C, Ghosn J, Laglenne E, Pauchard M, Schoen H, Bousquet R, Katz P, Costagliola D, Katlama C. Polylactic acid implants (New-Fill) to correct facial lipoatrophy in HIV-infected patients: results of the open-label study VEGA. AIDS 2003;17(17):2471–7. 40. Ponce-de-Leon S, Iglesias M, Ceballos J, Ostrosky-Zeichner L. Liposuction for protease-inhibitor-associated lipodystrophy. Lancet 1999;353(9160):1244. 41. Wolfort FG, Cetrulo CL, Nevarre DR. Suction-assisted lipectomy for lipodystrophy syndromes attributed to HIVprotease inhibitor use. Plast Reconstr Surg. 1999;104(6): 1814–20. 42. Rohrich RJ, Kenkel JM. Invited discussion: suction-assisted lipectomy for lipodystrophy syndromes attributed to HIVprotease inhibitor use. Plast Reconstr Surg. 1999;104: 1821–2. 43. Chastain MA, Chastain JB, Coleman WP. HIV lipodystrophy: review of the syndrome and report of a case treated with liposuction. Dermatol Surg. 2001;27(5):497–500. 44. Gervasoni C, Ridolfo AL, Rovati L, Vaccarezza M, Carsana L, Galli M. Maintenance of breast size reduction after mas-

C. S. Hultman and A. Keen toplasty and switch to a protease inhibitor-sparing regimen in an HIV-positive woman with highly active antiretroviral therapy-associated massive breast enlargement. AIDS Patient Care STDS. 2002;16(7):307–11. 45. DeWeese JE, Delaney AR, Klein D, Horberg M. UAL of HIV lipohypertrophy of the head and neck. Presented at the Poster Session of the Annual Scientific Meeting of the American Society of Plastic Surgeons, San Diego, CA, 25–29 Oct, 2003 and published in Plastic Surgical Forum 2003;XXVI:317–8. 46. Piliero PJ, Hubbard M, King J, Faragon JJ. Use of ultrasonography-assisted liposuction for the treatment of human immunodeficiency virus-associated enlargment of the dorsocervical fat pad. Clin Infect Dis. 2003;37(10):1374–7. 47. Gervasoni C, Ridolfo AL, Vaccarezza M, Fedeli P, Morelli P, Rovati L, Galli M. Long-term efficacy of the surgical treatment of buffalo hump in patients continuing antiretroviral therapy. AIDS 2004;18(3):574–6. 48. Connolly N, Manders E, Riddler S. Suction-assisted lipectomy for lipodystrophy. AIDS Res Hum Retroviruses. 2004;20(8):813–5. 49. Davison SP, Timpone J, Hannan CM. Surgical algorithm for management of HIV lipodystrophy. Plast Reconstr Surg. 2007;120(7):1843–58. 50. Reilly MJ, Burke KM, Davison SP. Wound infection rates in elective plastic surgery for HIV-positive patients. Plast Reconstr Surg. 2009;123(1):106–11. 51. Hultman CS, McPhail LE, Donaldson JH, Wohl DA. Surgical management of HIV-associated lipodystrophy: role of ultrasonic-assisted liposuction and suction-assisted lipectomy in the treatment of liphypertrophy. Ann Plast Surg. 2007;58(3):255–63. 52. De Santis G, Jacob V, Baccarani A, Pedone A, Pinelli M, Spaggiari A, Guaraldi G. Polyacrylamide hydrogel injection in the management of human immunodeficiency virusrelated facial lipoatrophy: a 2-year clinical experience. Plast Reconstr Surg. 2008;121(2):644–53.

Prevention and Treatment of Liposuction Complications

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Melvin A. Shiffman

55.1 Introduction Liposuction may be associated with a variety of complications most of which can be avoided. The more aggressive the liposuction, especially in the superficial subcutaneous tissues and with large amounts of fat removal, the more likely a complication will occur. “It is not what is removed that is so much important, but what is left behind” [1]. The surgeon performing liposuction must be cognizant of the risks and complications of the procedure and the ways to prevent or treat them. Early recognition of a complication is essential and treatment should be started in a timely fashion. The surgeon must inform the patient of the complication, its probable or possible cause or causes, the proposed treatment, and the length of time for complete recovery. Consultation may be obtained and should be done in a timely manner.

55.2 Complications 55.2.1 Asymmetry If the patient has asymmetry of the abdominal wall preoperatively, this should be pointed out to the patient and recorded with adequate photos. More fat may have to be removed from one side or one area because of the asymmetric accumulation.

M. A. Shiffman 17501 Chatham Drive, Tustin, CA 92780-2302, USA e-mail: [email protected]

Asymmetry can be avoided by being aware of the amounts of fat and fluid removed from each side of the abdomen, so that there is no large discrepancy. Observing the results carefully at the end of liposuction may disclose further areas that need correction. Asymmetry can be corrected by removing more fat from the excess area, liposhifting fat into the depressed area, or reinjecting autologous fat. Asymmetry that is present postoperatively may need revision liposuction for the removal of excess fat from those areas affected. If there is a deficit in any area that needs correction, injection of autologous fat may be considered.

55.2.2 Bleeding, Hematoma Tumescent technique in liposuction has reduced the amount of bleeding to a minimal degree. To prevent or limit bruising, the patient must be forewarned to stop all aspirin containing products, nonsteroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen, and herbals at least 2 weeks before and after surgery. Excessive liposuctioning in a single area may cause bloody fluid to appear in the tubing and this should forewarn the surgeon not to continue surgery in that area unless further tumescent solution is used. Compression over the areas of liposuctioning will help to limit bruising. This includes the use of garments, stretch tape, and foam dressings (polyurethane pads). Bleeding following liposuction may appear as bright red blood coming from the incision site or may be hidden and appear as orthostatic hypotension when the patient tries to sit up or stand. Postoperative dizziness and feeling faint should not be considered as a

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_55, © Springer-Verlag Berlin Heidelberg 2010

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drug reaction or dehydration until after the Hgb or HCT is checked. Intravenous fluid resuscitation may be enough if the bleeding is not over 15% of the blood volume, but some patients with more blood loss may require Hespan, Dextran, albumin, or blood to restore the blood volume. A low Hgb or HCT does not necessarily require transfusion. The patient’s clinical status is more important and if vital signs are stable, conservative measures such as volume replacement may be taken. The patient who has had an acute episode of bleeding and stabilizes with low Hgb or HCT may be followed for at least a week at which time the Hgb and HCT should start to rise. It may take a few weeks for the blood count to come back to normal, but usually the patient can resume normal activity after the Hgb reaches 8 g. If the bleeding continues and conservative measures do not work, surgical exploration may be necessary. This is more likely with other concomitant procedures such as abdominoplasty, since compression in the areas of liposuctioning will usually stop any bleeding from small vessels. Hematoma in the tissues can be treated conservatively with aspiration. This should be distinguished from bruising that requires no treatment. A hematoma that becomes a persistent untreated mass will form a seroma and then a chronic pseudocyst. The pseudocyst can be treated with aspiration followed by injection of an equal amount of room air. This will usually cause the walls to adhere to each other and prevent further accumulation of fluid.

M. A. Shiffman

55.2.4 Depressions (Grooves, Waviness) Excessive or superficial liposuction too close to the skin may result in depressions. (Fig. 55.1) Superficial liposuction should not get closer than 1 cm below the skin in most areas except the face and neck, and smaller cannulas (<3.5 mm) should be utilized in comparison to the deep liposuction that can be performed with cannulas over 3.5 mm (3.5–5.0 mm depending on the thickness of the fat layer). Depressions can be corrected by selectively liposuctioning the areas around the depression and filling the indented area with autologous fat [2]. If the indentation is noted while performing the liposuction, autologous fat can be injected at that time. It is possible to fill the defects with the “liposhifting” technique by tumescing the areas around the depression, loosening the fat with multiple criss-crossing tunnels, and molding the fat into the defect by rolling a large cannula (6–10 mm) across the prepared areas toward the depression [3]. The skin scar may become depressed and is usually due to the suction staying on when the cannula is removed and reinserted multiple times. This can be prevented by turning off the suction before removing the cannula or by having a finger vent in the handle of the cannula.

55.2.3 Chronic Edema Although infrequent, persistent edema in the area of liposuction can be distressing to the patient. This may be due to excessive trauma to the tissues, but liposuction is a traumatic procedure causing so-called “internal burn-like injury.” Proper compression is usually the key for prevention. Remember that excessive compression of an extremity can result in venous thrombosis and possible embolic disorder. Repeat liposuction (in an amount to break up the edematous tissues and flatten the region) of the area with tumescent technique is usually helpful after several months, but must be followed by adequate compression dressings.

Fig. 55.1 Indentation after liposuction of thighs

55 Prevention and Treatment of Liposuction Complications

55.2.5 Dissatisfaction with Results The surgeon performing the liposuction should try to gain some insight into the patient’s body image:in other words, what exactly does the patient want and expects from the liposuction. Some expectations are more than what can be delivered by the surgeon. A detailed explanation of the limits to the procedure of liposuction, the risks and complications, and the presence of irregularities or asymmetries is an important beginning for the patient to understand that surgery, on the average, does not get perfect results. Preoperative explanation that further refinements may have to be performed to better approach the patient’s expectations is necessary. Beware of the dysmorphic personality, where the patient does not have a significant problem, but perceives a severe problem. This type of patient dwells on a problem that does not really exist and the surgeon can never satisfy that patient.

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Infection, especially mycobacterial, can leave a mass that will not resolve. Trauma to a surgical area resulting in a mass will usually resolve over time without treatment, unless there is an inflammatory component. Normal scar formation will mature over 6 months and then soften. The complete evolution of a scar can take a year, but the biochemical changes are complete in 6 months.

55.3 Evaluation and Treatment

55.2.7 Fibrosis

A postsurgical mass should be evaluated clinically to rule out hematoma or seroma. Needle aspiration, under sterile conditions, can frequently make the diagnosis. If the mass persists for more than 3 weeks without evidence of some resolution, ultrasound evaluation should be considered even if the fluid cannot be aspirated. If serous fluid is found on ultrasound, the radiologist should aspirate the liquid and inject an equal amount of room air. Reevaluation by ultrasound in 1 week will usually show resolution, but if any fluid persists, repeat aspiration with the injection of room air should be performed. If an infection is present, usually with erythema and tenderness, aspiration of the pus with culture and sensitivity (C & S) should be performed. Usually, the patient is already on antibiotics and the medication may need to be stopped for 24 h before attempting a C & S. The antibiotics may need to be increased in dosage or changed. Residual subcutaneous fibrotic changes will resolve over time if the infection is properly treated. Incision and drainage may be necessary if the abscess is large and/or does not respond rapidly to the antibiotics. Following liposuction, folds in the garment can result in indentations and subcutaneous fibrosis. The garment should be checked on the first postoperative day and the patient informed on how to prevent or limit the folds in the garment (especially an abdominal binder). If subcutaneous fibrosis occurs, early treatment for the problem should be undertaken. Early treatment will resolve the complication more rapidly than when waiting for the fibrosis to mature. The conservative course of treatment for residual fibrosis from any source consists of:

Subcutaneous nodularity following liposuction is often a fibrotic reaction, usually with an inflammatory component, that can be a residual of hematoma or seroma.

1. Start Medrol DosPak (7 day treatment taking a daily dose of one time with food). 2. At day seven, start nonsteroidal anti-inflammatory medication (NSAID) daily for at least 8 weeks.

55.2.6 Fat Embolism Fat embolization results from the release of fat droplets into the systemic circulation [4–8]. Fat embolism syndrome (FES) is an infrequent consequence of fat embolization with pulmonary distress, mental status changes, hypoxemia, pyrexia, tachycardia, thrombocytopenia, and petechial rash [9–11]. Studies than can be used for diagnosing fat embolism include computerized tomography (CT) [12–14] and magnetic resonance imaging (MRI) [15, 16]. Treatment consists of general supportive measures with the maintenance of fluid and electrolyte balance and administration of oxygen, and endotracheal intubation and mechanical ventilatory assistance when necessary [17]. Respiratory symptoms have been reported to improve with high-dose methylprednisolone [18]. Huemer et al. [19] felt that heparin, cortisone, and dextran have not demonstrated a beneficial effect.

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3. Ultrasound may be started at least 3 weeks after surgery to the area at 3 W for 15 min twice weekly for at least 16 treatments. Treatment within 3 weeks of surgery may cause hematoma or seroma. 4. If there is no response after 8 weeks of ultrasound treatment, injections into the fibrous tissue with 5-fluorouracil (5FU) at 50 mg doses may be attempted on a weekly basis until the resolution of the mass. This can be combined with small doses of steroid (10–20 mg triamcinolone). If steroids are used, the injection should be carefully administered into the fibrous mass, being careful that the fluid does not extrude into the surrounding fatty tissues. This may cause fat atrophy, which can be easily treated by tumescing the tissues with normal saline solution, so that the precipitated steroid is reabsorbed. The mixture the author uses is 1 mL 5FU (50 mg), 0.5 mL triamcinolone [40 mg/mL] (total 20 mg), and 1 mL lidocaine (0.5%) with epinephrine diluted in 1 mL of 0.5% lidocaine with epinephrine. Surgical intervention with the resection of the mass can result in a skin scar that may not have been present previously, indentation from the removal of tissue, and possibly a residual fibrous mass again. Surgery is a last resort after conservative measures have been tried for at least 6 months. Indentations that result from surgery may require autologous fat transfer.

55.3.1 Hyperpigmentation

M. A. Shiffman

tendency to consider liposuction as a minor surgery with minimal care about sterility in the surgery suite can be detrimental to the patient. Serious infections have been documented following liposuction [20, 21]. Necrotizing fasciitis [22–24] and toxic shock syndrome [25, 26] have been reported. The combination of both necrotizing fasciitis and toxic shock syndrome can occur in the same patient [27]. When an infection appears in 10 days to 6 weeks after surgery and is in the form of a mass with overlying erythema, mycobacterium should be considered. This may be very difficult to diagnose through cultures of the purulent discharge, but the physician must be persistent. Vigorous prolonged treatment may be necessary. Rifampin, 600 mg two to three times weekly combined with isoniazide, Pyrazinamide, ethambutol, and/or streptomycin should be used for up to 6 months. Side effects include hepatitis, arthralgias, thrombopenia, nephritis, optic neuritis, gastrointestinal distress, and flu syndrome. An infectious disease consultant is usually necessary. Scarring is not uncommon especially if the abscesses are drained surgically through large incisions or persistent fibrous masses are excised (Fig. 55.2). If there is a persistent fibrous mass following proper antibiotic treatment and drainage, if necessary, the mass can be injected with steroids. Postsurgical infection should be diagnosed as early as possible in order to prevent more serious manifestations of the infection such as necrosis, septicemia, or toxic shock. Blisters may presage the appearance of necrosis and should be treated and observed closely. There are

Hyperpigmentation following liposuction can be in the scars or in the area of the liposuction. If there is bruising and the patient gets into the sun, the skin overlying the operated area can develop increased pigmentation. Treatment consists of 4% hydroquinone, cream or gel, rubbed into the affected area twice daily. During the day, an effective sunscreen should be utilized and unnecessary sun exposure must be avoided or protective clothing worn. Sun exposure will cause repigmentation.

55.3.2 Infection The occurrence of infection in a clean surgery case is approximately 1% in outpatient surgery centers and office surgeries and 3% in hospital surgeries. The

Fig. 55.2 Liposuction with postoperative infection from mycobacterium resulting in scars on thighs after drainage procedures and excisions of masses

55 Prevention and Treatment of Liposuction Complications

various dressings that may cause blisters such as tape on the skin and Reston foam. Any significant erythema is an indication of inflammation or infection and should be treated as such with antibiotics and close follow-up.

55.3.3 Lidocaine Anaphylaxis The injection of lidocaine in small amounts as a local anesthetic has been associated with death from allergic reaction to the preservative, methylparaben [28] (Faber, Personal communication 1999). Anaphylaxis has been reported with lidocaine administration [29–32]. Lidocaine is not a completely benign medication and the surgeon should be aware and prepared for acute allergic reactions. Treatment with ephedrine, oxygenation, and intravenous fluids can relieve the symptoms. Steroids may be necessary and if there is bronchospasm, intubation may have to be done.

55.3.4 Lidocaine Toxicity There is very little treatment for lidocaine toxicity except for supportive measures. This problem can be easily avoided by keeping the lidocaine at a safe level through the use of less than 35 mg/kg or, when absolutely necessary, a maximum of 55 mg/kg in the total tumescent fluid. The more rapid the infiltration of the lidocaine, the more likely there will be lidocaine toxicity. The epinephrine effect causing vascular contraction takes 15 min following injection. Therefore, the lidocaine can be rapidly absorbed for the first 15 min. However, “just because a surgeon has infiltrated, without mishap, 50–60 mg/kg lidocaine in hundreds of cases, it does not necessarily imply that either such a large dose of lidocaine can be given with impunity, or this dose recommendation is safe” [33]. If general anesthesia is used, the lidocaine total can be much less or omitted. A careful history must be taken to make sure that the patient has not been taking Cytochrome P450 inhibitors that may result in lidocaine toxicity even with the total lidocaine dosage within the usually accepted maximum [34]. Lidocaine occurs in the body as unbound pharmacologically active lidocaine and protein bound inactive lidocaine. Factors affecting the

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protein binding of lidocaine include age, stress, obesity, hepatic function, renal function, cardiac disease, cigaret smoking, use of oral contraceptives, beta blockers, tricyclic depressants, histamine-2-blockers, inhalation anesthetics, and anorexants [35].

55.3.5 Loose Skin Liposuction of certain areas of the body are prone to develop loose skin because of the amount of fat that needs to be removed and the lack of complete skin retraction. Those areas most likely to have this problem include: 1. Abdomen: especially with large panniculus. 2. Arms: especially elderly or very fat patients 3. Medial Thighs: postoperative loose skin is a major problem in a large percentage of patients Treatment for the loose skin requires a surgical approach with significant scars. Abdominoplasty, usually modified, may have to be performed to resolve the loose hanging skin of the lower abdomen, brachioplasty to resolve loose hanging skin of the arm, and thigh plasty for the loose skin of the medial thigh.

55.3.6 Median Nerve Compression Acute median nerve compression has been reported [36] in three patients by the administration of large amounts of intravenous fluids during liposuction. The edematous compression of the nerve resolved with the elevation of the extremities and the use of diuretics. The range of intravenous fluids was 4,000 –6,000 mL. Obviously, the anesthesiologist in each case did not understand that small amounts of intravenous fluids should be administered in liposuction cases, limiting the amount to 250 mL or less per hour.

55.3.7 Necrosis There may be skin necrosis after liposuction if the cannula comes too close to the skin and disrupts the

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Table 55.1 Fatal outcomes from liposuction [37] Disorder

Fatalities

Thromboembolism

30

Abdomen/viscus perforation

19

Anesthesia/sedation/medication

13

Fat embolism

11

Cardiorespiratory failure

7

Massive infection

7

Hemorrhage

6

Unknown

37

496,245 cases from 1994 to 1998 130 fatalities (1/3817 cases or 26/1,00,000 [0.026%])

subdermal plexus of vessels. Chronic smokers who do not stop smoking before and after surgery have a high incidence of necrosis. Necrosis is more likely to occur with the use of cannulas with sharp edges and turning the openings toward the skin surface. Combining excessive liposuction of the mid upper abdomen and full abdominoplasty increases the risk of necrosis of the abdominoplasty flap. Necrotizing fasciitis has been reported following liposuction (Table 55.1) [22–24]. This disorder is due to fulminant streptococcal group A infection or mixed bacterial infection frequently with anaerobes that involves the subcutaneous tissues and deep fascia producing thrombosis of the subcutaneous vessels and gangrene of the underlying and surrounding tissues. Treatment requires surgical debridement, antibiotics, and when necessary, hyperbaric therapy.

55.3.8 Need for Further Surgery Since the surgeon can ordinarily improve the contour deformities by about 50%, the patient may not be satisfied with the results. There may also be a need to refine or correct the original procedure because of complications such as irregularities (grooves, waviness, and indentations), asymmetries, perforation of vessel or viscus, excessive scarring, bleeding, hematoma or seroma, loose skin, necrosis, necrotizing fasciitis, and infection. The patient should be warned preoperatively of this possibility.

55.3.9 Neurologic Problems Decreased sensation or sensory loss may occur but is almost always temporary. Chronic pain may be due to a small neuroma, but is more often due to injury to the underlying fascia or muscle. Injection of local anesthetic into the area of pain will usually relieve the complaint for a short period of time. Multiple injections may be necessary to relieve the pain permanently. A neuroma can be surgically resected. If a scar in the tissues (subcutaneous fat, fascia, or muscle) is tethered to the skin, there may be chronic unrelieved pain. The pain may have to be treated by the release of the scar.

55.3.10 Perforation of Vessel or Viscus Perforation of the abdominal wall is most likely to occur in the presence of hernia or abdominal wall scar that can divert the direction of the cannula. The nondominant hand should always feel the end of the cannula. When the cannula is not palpable, the surgeon should reassess his technique and consider the possibility of perforation. Under local tumescent anesthesia, perforation can be detected at the time of surgery by the presence of abdominal pain [37–39]. If there is an unusual abdominal or chest pain postoperatively such as increasing pain or severe pain, perforation must be considered. It may be difficult to examine the abdomen directly by pressure because liposuction alone will cause pain in the area. The presence of rebound tenderness usually indicates peritonitis. Flat plate and upright abdominal X-rays may show free air if the bowel is perforated. The patient may have to be observed in the hospital if there is the possibility of viscus perforation. Vascular perforation that causes significant blood loss will result in abdominal pain, orthostatic hypotension, and shock. Insertion of a small catheter (Angiocath) into the abdominal cavity and the instillation of some sterile saline can produce bloody drainage consistent with vascular injury. If the blood is totally retroperitoneal, CT scan may be necessary. Emergency exploratory laparotomy is usually indicated.

55 Prevention and Treatment of Liposuction Complications

Liposuction over the ribs can be aided by the use of pressure on the lower ribs with the flat portion of the nondominant hand that will result in the cannula easily going over the ribs instead of under, with perforation into the chest. Severe chest pain, especially with dyspnea, may indicate perforation into the chest. Chest X-ray will usually show a pneumothorax. Insertion of a chest tube will relieve the pain and dyspnea.

55.3.11 Pulmonary Edema Pulmonary edema that was presumed to be from rapid and high-volume hypodermoclysis has been reported [40]. Pitman [41], commenting on this case, believed that the cause of the pulmonary edema was the excessive parenteral fluids that is being given. Ordinarily, most individuals can tolerate large amounts of intravenous fluids, up to 2,000 mL/h, since the fluids enter the extravascular tissues within 15 min of administration. However, where there is a large amount of subcutaneous fluid from the tumescent technique, the pressure of the fluid in the tissues does not allow a gradient for the intravenous fluid to diffuse out of the vessels.

55.3.12 Scars Significant scars following liposuction are not frequent. It is rare to see hypertrophic scars or keloids. Poor placement of incisions may result in easily visible scars. Some scars may become depressed if the suction on the cannula is maintained each time the cannula is withdrawn from the incision. If using a machine for vacuum, either stop the machine before withdrawal or use cannulas with a vent hole in the thumb portion of the handle for easy release. Incision sites may be irritated by the multiple fast passes of the cannula resulting in a reddening around or in the scar. Steroid cream will resolve the problem. The incision performed should be slightly larger than the cannula. Some surgeons use a plastic plug in the incision while performing liposuction that will prevent the cannula from rubbing on the skin. The use of large incisions is not indicated since most cannulas are 6 mm or less, and more often than not, are 4 mm or less. Some surgeons use microcannulas (under

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2 mm), but this requires many more skin incisions, and it takes a longer time to perform the liposuction. The treatment of hypertrophic or keloid scars includes steroid injection, radiation, reexcision, silicone gel sheeting, pressure therapy, or a combination of these [42]. The combination of steroid and 5FU has been helpful in the treatment. None of the treatments is permanently effective for keloids in a large percentage of patients; however, hypertrophic scars have a tendency to resolve on their own over a period of time. Skin necrosis will usually result in a significant scar. Treatment may require excision and careful closure.

55.3.13 Seroma The collection of serous fluid in the liposuction area may be due to the irritation of the tissues by the traumatic procedure, but is more frequently the result of concomitant oversuctioning of a single area with undermining of a flap allowing a cavity to form. Sometimes, a hematoma may appear first and be replaced over time with serosanguinous fluid and then serous fluid. A persistent collection of fluid following liposuction may be treated with needle aspiration followed by adequate compression dressings. This may need to be repeated every few days. If the collection can be reached through one of the liposuction incisions, a drain can be inserted to reduce the fluid and kept in place with compression dressings that need to be changed every couple of days. Prophylactic antibiotics may be used when the drain is in place. If the collection becomes chronic (over 4 weeks), the fluid should be aspirated and an equal amount of room air injected into the cavity to cause irritation (Fig. 55.3). Compression dressings are necessary after each such treatment. Another method that is available, but requires adequate anesthesia is curetting the lining of the cavity through a small incision or through one of the liposuction scars. If the liposuction is combined with abdominoplasty and a chronic seroma occurs, the pseudocyst may be excised through the abdominal scar, but this may leave a visible deformity.

55.3.14 Thromboembolism Superficial thrombophlebitis (an inflamed vein) appears as a red, tender cord. Deep-vein thrombosis

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a

M. A. Shiffman

b

Fig. 55.3 (a) Preoperative 43-year-old patient with a history of liposuction of thighs 6 years previously. (b) One week after circumferential liposuction of legs with seromas of both legs. (c1–3) Areas of seroma marked after 5 months of repeated needle aspirations and use of drains. (d1,2) 1: Ultrasound of seroma (arrow) in right thigh at 5 months postoperatively. 2: Ultrasound

of right thigh seroma (arrow) 1 week following one injection of room air into the seroma. This shows marked decrease in the size of the cavity. The left thigh was injected one time with room air and had a complete closure of the seroma. A second injection of room air into the right seroma resulted in a complete closure

may be associated with pain at rest or only during exercise with edema distal to the obstructed vein. The first manifestation can be pulmonary embolism. There may be tenderness in the extremity and the temperature of the skin may be increased. Increased resistance or pain on voluntary dorsiflexion of the foot (Homan’s sign) and/or tenderness of the calf on palpation are useful diagnostic criteria [37]. Pulmonary embolism is usually manifested by one of three clinical patterns: (1) onset of sudden dyspnea with tachypnea and no other symptoms; (2) sudden pleuritic chest pain and dyspnea associated with the findings of pleural effusion or lung consolidation; and (3) sudden apprehension, chest discomfort, and dyspnea with the findings of cor pulmonale and systemic hypotension. The symptoms occasionally consist of fever, arrhythmias, or refractory congestive heart failure.

Medium and high-risk patients for thromboembolism (over the age of 40 years, prior history of thromboembolic disorder, surgery over 1 h, obesity, postoperative immobilization, estrogen therapy) should have the necessary precautions taken in the perioperative period [43]. These include compression stockings (TEDS) or intermittent compression garments. Failure to warn female patients to stop estrogens (birth control pills or replacement therapy) at least 3 weeks prior to surgery and 2 weeks after surgery increases the risk of thromboembolism [44]. The combination of liposuction of the abdomen with abdominoplasty is especially risky for the occurrence of pulmonary embolism. Thromboembolism has to be diagnosed early if death is to be prevented. Any postoperative patient who develops shortness of breath or chest pain must be considered to have the possibility of pulmonary

55 Prevention and Treatment of Liposuction Complications

c1

561

c2

d1

c3

d2

Fig. 55.3 (continued)

embolism, and a ventilation-perfusion lung scan be obtained. The use of intravenous heparin can be lifesaving, and at times, may be started even before the diagnosis is confirmed.

55.3.15 Toxic Shock Syndrome There have been reports of toxic shock syndrome, which is a potentially fatal disorder [25–27]. The syndrome is caused by the exotoxins (superantigens) secreted with an infection from Staphylococcus aureus and group A Streptococci [45]. Knowledge of the criteria for diagnosis is important in order to treat this potentially fatal disease. These include [46]:

1. Fever (>102°) 2. Rash (diffuse, macular erythroderma 3. Desquamation (1–2 weeks after onset, especially of palms and sole) 4. Hypotension 5. Involvement of three or more organ systems: (a) Gastrointestinal (vomiting, diarrhea at onset) (b) Muscular (myalgia, elevated CPK) (c) Mucous membrane (conjunctiva, oropharynx) (d) Renal (BUN or creatinine > 2 times normal) (e) Hepatic (bilirubin, SGOT, SGPT > 2 times n ormal) (f) Hematologic (platelets < 1,00,000) 6. Negative results on the following studies (if obtained) (a) Blood, throat or cerebral spinal fluid (CSF) cultures

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(b) Serologic tests for Rocky Mountain Spotted Fever, Leptospirosis, measles Treatment consists of surgical debridement for necrosis, antibiotics, circulatory and respiratory care, anticoagulant therapy for disseminated intravascular coagulation, and immunoglobulin [47]. Experimental approaches have included the use of antitumor necrosis factor, monoclonal antibodies, and plasmapheresis.

55.4 Conclusions Complications of liposuction are best avoided when possible. The surgeon should be aware of the preventive methods and the available treatments for the various complications. Aggressive liposuction by removing very large amounts of fat and doing very superficial liposuction in order to get more skin retraction can be associated with increased complications. It may be preferable to remove less than 5,000 of fluid and fat at each sitting and repeat the procedure at a later date than perform large volume or megaliposuction. The risk of complications may then be reduced.

References 1. Illouz Y-G. Principles of the technique. In: Illouz Y-G, editor. Body sculpturing by lipoplasty. Edinburgh: Churchill Livingstone; 1989. p. 67. 2. Fournier P. Autologous fat for liposuction defects during and after surgery. In: Shiffman MA, editor. Autologous fat transplantation. New York: Marcel Dekker; 2001. p. 233–42. 3. Saylan Z. Liposhifting: treatment of post liposuction irregularities. Int J Cosmet Surg. 1999;7(1):71–3. 4. Ross RM, Johnson GW. Fat embolism after liposuction. Chest 1988;93(6):1294–5. 5. Abbes M, Bourgeon Y. Fat embolism after dermolipectomy and liposuction. Plast Reconstr Surg. 1989;84(3):546–7. 6. Laub DR Jr, Laub DR. Fat embolism syndrome after liposuction: a case report and review of the literature. Ann Plast Surg. 1990;25(1):48–52. 7. Dillerud E. Fat embolism after liposuction. Ann Plast Surg. 1991;26(3):293. 8. Scroggins C, Barson PK. Fat embolism syndrome in a case of abdominal lipectomy with liposuction. Md Med J. 1999; 48:116–8. 9. Bulger EM, Smith DG, Maier RV, Jurkovich GJ. Fat embolism syndrome: a 10-year review. Arch Surg. 1997;132(4): 435–9.

M. A. Shiffman 10. Estebe JP. From fat emboli to fat embolism syndrome. Ann Fr Anesth Reanim. 1997;16(2):138–51. 11. Paris DM, Koval K, Egol K. Fat embolism syndrome. Am J Orthop. 2002;31(9):507–12. 12. Arakawa H, Kurihara Y, Nakajima Y. Pulmonary fat embolism syndrome: CT findings in six patients. J Comput Assist Tomogr. 2000;24(1):24–9. 13. Heyneman LE, Muller NL. Pulmonary nodules in early fat embolism syndrome: a case report. J Thorac Imaging. 2000; 15(1):71–4. 14. Ravenol JG, Heyneman LE, McAdams HP. Computed tomography diagnosis of macroscopic pulmonary fat embolism. J Thorac Imaging. 2002;17(2):154–6. 15. Parizel PM, Demey HE, Veweckmans G, Verstreken F, Cras P, Jorens PG, Schepper AM. Early diagnosis of fat cerebral embolism syndrome by diffusion-weighted MRI (starfield pattern). Stroke 2001;32(12):2942–4. 16. Dominguez-Moran JA, Martinez-San Millan J, Plaza JF, Fernandez-Ruiz LC, Masjuan J. Fat embolism syndrome: new MRI findings. J Neurol. 2001;248(6):529–32. 17. Richards RR. Fat embolism syndrome. Can J Surg. 1997; 40(5):334–9. 18. Kubota T, Ebina T, Tonosaki M, Ishihara H, Matsuki A. Rapid improvement of respiratory symptoms associated with fat embolism by high-dose methylprednisolone: a case report. J Anesth. 2003;17(3):186–9. 19. Huemer G, Hofmann S, Kratochwill C, Koller-Strametz J, Hopf R, Schlag G, Salzeer M. Therapeutic approach to the management of fat embolism syndrome. Orthopade 1995; 24(2):173–8. 20. Medical Board of California v Greenberg. Case No. 04-9776124, OAH No. L-1999020165, 1998. 21. Medical Board of California v O’Neill. No. 09-03-26899, 1998. 22. Alexander J, Takeda D, Sanders G, Goldberg H. Fatal necrotizing fasciitis following suction-assisted lipectomy. Ann Plast Surg. 1988;29(6):562–5. 23. Gibbons MD, Lim RB, Carter PL. Necrotizing fasciitis after tumescent liposuction. Am Surg. 1998;64(5):458–60. 24. Heitmann C, Czermak C, Germann G. Rapidly fatal necrotizing fasciitis after aesthetic liposuction. Aesthetic Plast Surg. 2000;24(5):344–7. 25. Rhee CA, Smith RJ, Jackson IT. Toxic shock syndrome associated with suction-assisted lipectomy. Aesthetic Plast Surg. 1994;18:161–3. 26. Umeda T, Ohara H, Hayashi O, Ueki M, Hata Y. Toxic shock syndrome after suction lipectomy. Plast Reconstr Surg. 2000;106(1):204–7. 27. Cawley MJ, Briggs M, Haith LR Jr, Reilly KJ, Guilday RE, Braxton GR, Patton ML. Intravenous immunoglobulin as adjunctive treatment for streptococcal toxic shock syndrome associated with necrotizing fasciitis: case report and review. Pharmacotherapy 1999;19(9):1094–8. 28. Kim Y, Hirota Y, Shibutani T, Sakiyama K, Okimura M, Matsuura H. A case of anaphylactoid reaction due to methylparaben during induction of general anesthesia. J Jpn Dent Soc Anesthesiol. 1994;22(3):491–500. 29. Bircher AJ, Surber C. Anaphylactic reaction to lidocaine. Aust Dent J. 1999;44(1):64. 30. Kennedy KS, Cave RH. Anaphylactic reaction to lidocaine. Arch Otolaryngol Head Neck Surg. 1986;112(6):671–3.

55 Prevention and Treatment of Liposuction Complications 31. Zimmerman J, Rachmilewitz D. Systemic anaphylactic reaction following lidocaine administration. Gastrointest Endosc. 1985;31(6):404–5. 32. Anibarro B, Seoane FJ. Adverse reaction to lidocaine. Allergy 1998;53(7):717–8. 33. de Jong R. Titanic tumescent anesthesia. Dermatol Surg. 1998;24:689–92. 34. Shiffman MA. Medications potentially causing lidocaine toxicity. Am J Cosmet Surg. 1998;15(3):227–8. 35. Fodor PB. Lidocaine toxicity issues in lipoplasty. Aesthet Surg J. 2000;20(1):56–8. 36. Lombardi AS, Quirke TE, Rauscher G. Acute median nerve compression associated with tumescent fluid administration. Plast Reconstr Surg. 1998;102(1):235–7. 37. Grazer FM, de Jong RH. Fatal outcomes from liposuction: census survey of cosmetic surgeons. Plast Reconstr Surg. 2000;105(1):436–46. 38. Teillary v Pottle, New Hanover County (NC), Superior Court. In: Medical malpractice verdict, settlements & experts 1996;12(8):47 and 1996;12(11):46. 39. Talmor M, Fahey TJ, Wise J, Hoffman LA, Barie PS. Largevolume liposuction complicated by retroperitoneal hemorrhage: management principles and implications for the

563 quality improvement process. Plast Reconstr Surg. 2000; 105(6):2244–8. 40. Gilliland MD, Coates N. Tumescent liposuction complicated by pulmonary edema. Plast Reconstr Surg. 1997;99(1): 215–9. 41. Pitman GH. Tumescent liposuction complicated by pulmonary edema. Plast Reconstr Surg. 1997;100(5):1363–4. 42. Shiffman MA. Causes of and treatment of hypertrophic and keloid scars with a new method of treating steroid fat atrophy. Int J Cosm Surg Aesthet Derm. 2002;4(1):9–14. 43. European Consensus Statement of the prevention of venous thromboembolism. Int Angiol. 1992;11:151. 44. Estate of Marinelli v Geffner, Ocean County (NJ), Superior Court. In: Medical Malpractice Verdicts, Settlements Experts. 1999;16(10):54–5. 45. Rhee CA, Smith RJ, Jackson IT. Toxic shock syndrome associated with suction-assisted liposuction. Aesthetic Plast Surg. 1994;18(2):161–3. 46. McCormick JK, Yarwood JM, Schlievert PM. Toxic shock syndrome and bacterial superantigens: an update. Annu Rev Microbiol. 2001;55:77–104. 47. Baracco GJ, Bisno AL. Therapeutic approaches to streptococcal toxic shock syndrome. Curr Infect Dis Rep. 1990; 1(3):230–7.

Comparison of Blood Loss in SuctionAssisted Lipoplasty and Third-Generation Ultrasound-Assisted Lipoplasty

56

Onelio Garcia Jr.

56.1 Historical Perspective One of the most important recent advances in body contouring has been the significant decrease in the blood loss associated with the current lipoplasty procedures [1]. The relatively small amount of blood currently present in ultrasound-assisted lipoplasty (UAL) aspirate has significantly increased the safety and efficacy of lipoplasty procedures. This is particularly important in the high volume aspirations or those involving the posterior trunk. When first introduced in the early eighties, “dry suction lipoplasty” was associated with 20–45% blood losses of the volume aspirated [2, 3]. The use of epinephrine-containing wetting solutions decreased the blood loss to 8–30% of the aspirated volume [3, 4]. The introduction of the superwet technique using a 1:1 ratio of the infiltrating solution to the expected volume of aspirate and the tumescent technique, which required up to a 3:1 ratio of the infiltrate to the expected aspirate, significantly lowered the blood loss associated with these procedures to a single digit percentage of the aspirate volume [1, 5, 6]. The use of UAL further decreased the blood in the aspirate [1, 7–10], and it has been documented that the third-generation internal solid probe UAL yields even a cleaner aspirate, with a higher percentage of supernatant fat [1, 11, 12]. Recently, Garcia and Nathan [1] documented minimal blood loss in the aspirate using the third-generation solid probe UAL in a series of thirty consecutive

O. Garcia Jr. Division of Plastic Surgery, University of Miami, Miller School of Medicine, 3850 Bird Road, Suite 102, Miami, FL 33146, USA e-mail: [email protected]

female patients undergoing VASER-assisted lipoplasty of the posterior trunk. Suction-assisted lipoplasty (SAL) remains the most common cosmetic surgical procedure performed in the United States with over 4,00,000 cases performed last year [13]. In spite of its well documented clinical advantages [7, 11, 14–18], UAL is currently performed in only 17.4% of the lipoplasty cases [13]. Several factors such as increased costs [19], increased surgical time [14, 15, 20], technical difficulty with a steep learning curve [21], greater potential for complication [14, 22–24], complex machinery, and instrumentation certainly play a role in the infrequent use of UAL in body contouring. The introduction of the third-generation internal ultrasound devices has addressed many of the drawbacks associated with the early UAL devices; however, in spite of the well-documented clinical efficiency and safety of the new devices [1, 11, 12, 16–24], the use of UAL has decreased almost 4% in the past 3 years [25].

56.2 Blood Loss in Lipoplasty Current lipoplasty aspirate contains fat, saline, blood, epinephrine, and local anesthetics when utilized. How much blood is there in the aspirate? What is the source of the blood loss? What is the cause of postoperative ecchymosis? These are all valid questions regarding blood loss in lipoplasty. Figure 56.1a shows two rectangular markings of the same dimensions that correspond to the mirror image areas overlying the mid abdominal perforators. SAL was performed on one of these areas and VAL on the other. The same volume and composition of the wetting solution was infiltrated into both areas. The same

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_56, © Springer-Verlag Berlin Heidelberg 2010

565

566

O. Garcia Jr.

a

b

c

d

e

f

Fig. 56.1 (a) Two rectangular markings of the same dimensions that correspond to the mirror image areas overlying the mid abdominal perforators. (b) The exposed superficial epigastric vessels. (c) Injection of the ISOVUE-300 (Iopamidol 61%)

contrast into the vessels. (d) The abdominal specimen subjected to mammography. (e) Vascular perforators intact following SAL. (f) Vascular perforators also intact following VAL

56 Comparison of Blood Loss in Suction-Assisted Lipoplasty and Third-Generation Ultrasound-Assisted Lipoplasty

567

Fig. 56.2 Reverse contrast studies in areas of extensive lipoplasty reveal that most of the extravasation occurs in the microvasculature between the perforators and the subdermal plexus

number of passes were applied to each area with a 3 mm suction cannula over a timed 3 min interval. Figure 56.1b shows the exposed superficial epigastric vessels and Fig. 56.1c depicts the injection of the ISOVUE-300 (Iopamidol 61%) contrast into the vessels. The abdominal specimen was subjected to mammography as depicted in Fig. 56.1d. The radiological contrast study of the intact abdominal perforators in an area subjected to extensive SAL is depicted in Fig. 56.1e, while similarly intact abdominal perforators are seen in Fig. 56.1f that corresponds to the VAL area. Garcia [26], found that major perforators were not injured during extensive SAL or VAL. Reverse contrast studies in areas of extensive lipoplasty reveal that most of the extravasation occurs in the microvasculature between the perforators and the subdermal plexus (Fig. 56.2). Dermal biopsies of the skin overlying the areas subjected to extensive superficial SAL and VAL did not reveal significant injury to the subdermal plexus. This was true as long as there was adequate infiltrating solution present in the superficial tissues and the deep dermis had not been subjected to “end hits” [26]. Superficial SAL when performed with proper technique, does not appear to cause significant damage to the subdermal plexus. However, there appeared to be a greater amount of free blood in the dermal biopsies of skin overlying the SAL area, as opposed to the dermal biopsies of skin overlying the VAL area (Fig. 56.3). An adjacent area

Fig. 56.3 (a) A greater amount of free blood in the dermal biopsies of the skin overlying the SAL area. (b) Control dermal biopsy that is almost bloodless. (c) Dermal biopsies of the skin overlying the VAL area with no bleeding

568

Fig. 56.4 High power magnification of the deep dermis purposely subjected to an “end hit” in the area is highlighted by the arrow

was used for control and had the same wetting solution infiltrated into the tissues but was not subjected to lipoplasty. The control dermal biopsy is almost bloodless and closely resembles the VAL area dermal biopsy. Subdermal plexus injuries are frequently caused by “end hits” as a result of improper lipoplasty technique. These “end hits” are a direct result of thrusting the suction cannula or ultrasound probe perpendicularly into the deep dermis. High power magnification of the deep dermis purposely subjected to an “end hit” in the area is highlighted by the arrow in Fig. 56.4. Note the significant amount of free blood within the dermis in the area of the trauma. “End hits” result in significant postoperative ecchymosis in the area of the dermal injury. They can be avoided by keeping the axis of the suction cannula parallel to the deep dermis when performing superficial lipoplasty. Appropriate use of pulsed solid probe UAL in superficial lipoplasty also avoids injury to the subdermal vessels (Fig. 56.5) which depicts a high power magnification of an intact subdermal vessel in an area subjected to extensive superficial VAL. The microvascular extravasation (Fig. 56.2) depicts the source of free blood in the tissues following lipoplasty and the most likely cause of the postoperative ecchymosis seen in these patients. These vessels are highly responsive to epinephrine when given adequate time for the vasoconstrictive effects of the drug to take place. The author has found that 14 min following the infiltration of the tissues with the epinephrine solution is an adequate time interval for the vasoconstrictive effects to take place. It is surgical time well invested since proper vasoconstriction can significantly reduce the blood loss associated with lipoplasty procedures.

O. Garcia Jr.

Fig. 56.5 High power magnification of an intact subdermal vessel in an area subjected to extensive superficial VASER-assisted lipoplasty

Increased blood loss with sometimes severe postoperative ecchymosis can also occur in lipoplasty patients who take aspirin or certain anti-inflammatory drugs that interfere with platelet function. An adequate medication history is vital in prospective lipoplasty patients so that all the drugs that could interfere with the coagulation process can be stopped preoperatively.

56.3 Comparison of Blood Loss in Third-Generation UAL and SAL 56.3.1 Methods Twenty-seven consecutive female patients ranging in age from 18.75 to 54.5 years, with an average age of 33.3 years, underwent SAL that included contouring of their back and posterior flanks. The patients in this group had a body-mass index (BMI) range of 18.8 to 30.1, with an average BMI of 24.3. The volume of the wetting solution used was approximately a 1:1 ratio of the infiltrate to aspirate and consisted of 1 mg. of epinephrine 1:1,000/L of normal saline. There was approximately a 15-min interval between the infiltration of the wetting solution and the suction phase, to allow for the vasoconstriction effects of the epinephrine to take place. Mercedes-type lipoplasty cannulas (3.5 and 3 mm) were employed and general anesthesia was used in all the cases. The aspirate corresponding to the back and posterior flank lipoplasty was kept separate and sent for analysis. The total volume of the aspirate ranged from

56 Comparison of Blood Loss in Suction-Assisted Lipoplasty and Third-Generation Ultrasound-Assisted Lipoplasty

a

569

b

Fig. 56.6 (a) Typical bloody aspirate from the back and posterior flanks during lipoplasty. (b) Less bloody aspirate with VASER-assisted lipoplasty aspirate from the back and posterior

flanks. Copyright by The American Society for Aesthetic Plastic Surgery Inc. [1]. It is the author’s own work and is reproduced by permission of Elsevier Publishing

1,250 to 5,250 mL, with an average of 3,366 mL. The back and posterior flank portion of the aspirate volume ranged from 450 to 1,400 mL with an average of 768 mL. Thirty consecutive female patients ranging in age from 18.5 to 70.3 years, with an average age of 41.9 years, underwent third-generation internal UAL using the VASER device, (Sound Surgical Technologies, Louisville, CO). The BMI range in this group was 19.6–33.7, with an average BMI of 25.6. All of these cases included lipoplasty of the back and posterior flanks and the aspirate corresponding to those anatomical areas was kept separate and sent for analysis. The total volume of aspirate ranged from 1,600 to 9,200 mL with an average of 5,755 mL. The portion of the aspirate volume corresponding to the back and posterior flanks ranged from 800 to 4,200 mL with an average of 2,450 mL. For the purposes of this study, the wetting solution used also consisted of 1 mg. of epinephrine1:1,000/L of normal saline at a 1:1 ratio of the infiltrate to aspirate. (The author usually uses a ratio of 3:1 infiltrating solution to aspirate). There was also an approximately 15-min interval following the infiltration of the wetting solution to allow for the vasoconstriction effects to take place. For the purposes of this study, the amplitude setting on the device was 90% continuous VASER mode applied for approximately 1 min per 100 mL of the infiltrating solution used. (The author’s usual VASER times are approximately 50–60% longer). The VASER probes used were mainly 3.7-mm 2-ring and 2.9-mm 3-ring. VentX cannulas (Sound Surgical Technologies); 3.7 and 3.0-mm cannulas were used in all of the VAL cases. All of these cases were performed under general anesthesia. Informed consent was obtained from all the patients in both the SAL and VAL groups. The aspirate from the

back and posterior flanks was chosen for analysis because these are tight, fibrous, anatomic areas that are associated with greater blood loss during lipoplasty procedures. The aspirate from the back and posterior flanks was bloody during lipoplasty, whereas with VAL, it was less bloody. (Fig. 56.6). (whereas it was less bloody with VAL)Note that both the SAL and VAL aspirates are approximately of the same volume; however, the VAL aspirate is typically cleaner and contains a higher percentage of supernatant fat. The aspirate analysis consisted of complete blood counts after separation of the fat. This was performed by an independent laboratory on a Beckman Coulter LH 750 blood analyzer (Fullerton, CA). Normal values on this analyzer are 12–16 g/dL for hemoglobin and 37–47% for hematocrit. Since the main purpose of the study was to document and compare the blood loss in the lipoplasty aspirates, only the hemoglobin and hematocrit values of the complete blood counts were evaluated.

56.3.2 Results The hematocrit values for the SAL aspirate ranged from 2 to 7.2%, with a mean of 3.98%, compared to the VAL aspirate, which had a hematocrit range of 0.3–1.1%, with a mean value of 0.61%. The hemoglobin content of the SAL aspirate ranged from 1.2 to 3.4 g/dL, with a mean of 2.23 g/dL. By comparison, the hemoglobin content of the VAL aspirate ranged from 0.01 to 0.9 g/dL, with a mean of 0.3 g/dL. The complete raw data is depicted in Table 56.1. The mean hemoglobin content of the SAL aspirate was 7.5 times greater than that in

570

O. Garcia Jr.

Table 56.1 The complete raw data Patient Age (year) Total aspirate (mL) SAL VAL SAL VAL

Back/flank aspirate (mL) SAL VAL

Hematocrit (%) SAL VAL

Hemoglobin (g/dL) SAL VAL

1

39.75

42.3

3,650

5,600

1,000

2,200

2

0.7

1.8

0.2

2

37.5

48.5

3,000

5,450

800

2,000

2.4

0.6

2

0.6

3

31

34.75

2,850

6,800

700

2,850

2.4

0.4

1.4

0.1

4

42.3

18.5

2,600

3,600

650

1,200

3.2

0.7

1.2

0.2

5

20.5

21

3,250

4,250

700

1,950

2

0.5

1.3

0.1

6

28.75

29.8

4,100

6,600

950

2,800

2

0.5

2

0.2

7

24.3

42.5

4,450

7,450

700

3,450

3.5

0.7

3.4

0.2

8

19.5

47.6

1,800

4,900

500

2,300

7.2

0.5

2.7

0.1

9

49.1

24.3

3,100

6,200

650

2,500

4

0.5

1.4

0.7

10

30.9

56.75

4,750

5,150

900

2,200

2.3

0.7

2.4

0.1

11

36.5

19.5

4,250

3,450

800

1,250

4.5

0.8

3

0.1

12

41.3

46

3,900

6,000

650

2,300

5.5

0.4

1.8

0.2

13

34.75

70.3

1,600

3,850

450

1,450

3

0.5

2.1

0.7

14

54.5

36.9

3,950

9,200

700

4,000

4.5

0.9

2.2

0.1

15

38.3

48.5

4,400

4,800

1,100

2,050

4.2

0.9

2.3

0.2

16

22.2

62.1

1,250

3,000

450

900

4.8

1.1

1.8

0.2

17

32.2

57

4,700

4,600

1,400

2,150

3

0.8

2.8

0.4

18

39

41.3

5,250

8,400

1,250

3,650

5.5

0.5

2.9

0.1

19

43.5

49.75

3,400

5,000

650

2,200

4.9

0.5

2.7

0.1

20

23.75

20.25

2,200

5,750

600

2,250

4.1

0.5

1.9

0.2

21

28

63.9

3,950

1,600

800

800

5.2

0.7

2.8

0.8

22

18.75

47.25

2,450

6,050

700

2,800

6.7

0.3

3.2

0.2

23

40.25

31.1

4,000

8,750

850

4,200

4.7

0.8

2.7

0.2

24

27.8

60.5

4,900

4,800

1,200

1,800

3

0.3

1.8

0.9

25

21.2

30.9

2,150

8,400

500

3,950

4

0.6

2.2

0.1

26

48.5

29.8

1,800

7,750

450

3,700

4.9

0.5

2.4

0.3

27

25.3

50.5

3,200

6,100

650

2,350

4.1

0.6

2

0.2

28

–

47.5

–

5,500

–

2,250

–

0.3

–

0.1

29

–

22.3

–

8,250

–

3,800

–

0.8

–

0.6

30

–

58

–

5,400

–

2,200

–

0.6

–

0.8

Total

–

–

90,900

1,72,650

20,750

73,500

107.6

18.2

60.2

9

Mean

33.3

41.97

5,755

768.5

2,450

3.98

0.61

2.23

0.3

Variance

1,949

0.0372

0.3483

0.0648

SD

1,3961

0.1929

0.5902

0.2546

Copyright by The American Society for Aesthetic Plastic Surgery Inc. [1]. It is the author’s own work and is reproduced by permission of Elsevier Publishing

56 Comparison of Blood Loss in Suction-Assisted Lipoplasty and Third-Generation Ultrasound-Assisted Lipoplasty

the VAL aspirate. The mean hematocrit value for SAL aspirate was 6.5 times higher than that in the aspirate from the VAL group. VAL yielded a more consistent aspirate with significantly less dispersion of both hemoglobin and hematocrit values (Fig. 56.7). The data were subjected to an independent t-test for statistical significance. The t-score for the hematocrit values was +13.13 and for hemoglobin +16.31 ,with p values <0.0001 for both hematocrit and hemoglobin, confirming that the data were highly statistically significant. The back and posterior flanks have traditionally been associated with a high degree of

a

SAL

8

Vaser

571

ecchymosis in the early postoperative period following traditional lipoplasty. Digital photography of the patients who underwent VAL of their back and posterior flanks revealed relatively minimal ecchymosis in the early postoperative period as compared to the SAL patients (Figs. 56.8 and 56.9). There is a significantly greater postoperative ecchymosis in the SAL group as compared to the VAL group. This substantiates previous similar clinical findings by Jewell et al. [11] and de Souza Pinto et al. [12]. None of the patients in this study sustained any VASERrelated complications.

b

Traditional

4

Vaser

6

HEMOGLOBIN g/dI

HEMATOCRIT %

7 5 4 3 2 1 0 1

3 5

7

9 11 13 15 17 19 21 23 25 27 29 PATIENTS

3

2

1

0 1

3

5

7

9 11 13 15 17 19 21 23 25 27 29

Fig. 56.7 VAL yielded a more consistent aspirate with significantly less dispersion of both (a) hematocrit and (b) hemoglobin values. Copyright by The American Society for Aesthetic Plastic

Surgery Inc. [1]. It is the author’s own work and is reproduced by permission of Elsevier Publishing

Fig. 56.8 (a) Preoperative 21-year-old woman. (b) Forty eight hours postoperative after 4,250 mL total aspirate was removed by VAL. (c) Sixty days postoperative after VAL. Copyright by

The American Society for Aesthetic Plastic Surgery Inc. [1]. It is the author’s own work and is reproduced by permission of Elsevier Publishing

572

O. Garcia Jr.

Fig. 56.9 (a) Preoperative 29-year-old woman. (b) Forty eight hours postoperative after 6,600 mL total aspirate was removed by VAL. (c) Thirty days postoperative after VAL. Copyright by

The American Society for Aesthetic Plastic Surgery Inc. [1]. It is the author’s own work and is reproduced by permission of Elsevier Publishing

56.4 Discussion

appropriate quantities serves an important function in diminishing the blood loss as long as the surgeon allows adequate time for the vasoconstrictive effects of the epinephrine to take place. Finally, appropriate preoperative screening for common medications that interfere with platelet function is imperative if one is to achieve a relatively bloodless lipoplasty aspirate.

When all the parameters are kept equal, the amount of blood in the lipoplasty aspirate is location-dependent in a given patient. Tight, fibrous anatomic areas, such as the back and posterior flanks, are associated with a greater amount of blood loss during lipoplasty procedures than “soft areas,” such as the lower abdomen or medial thighs. VAL was always associated with a cleaner aspirate; however, in the “soft areas,” the blood content of the aspirate was only slightly lower when compared to SAL. It is in the posterior flanks and back areas where the significant differences between VAL and SAL become apparent. Our data, based on aspirate from these anatomical areas quantitatively confirms previous clinical observations that VAL is associated with significantly less blood loss than SAL. When using bloody aspirate as the “end point” prior to the removal of the desired amount of aspirate in posterior trunk lipoplasty, the author was able to remove an average of 3.1 times more aspirate from the back and posterior flanks by using VAL as compared with SAL before the “end point” was reached. Blood loss associated with lipoplasty procedures has significantly decreased over the years. Initially, the advent of UAL and lately the third-generation UAL devices have played an important role in diminishing the blood loss associated with these procedures. Epinephrine containing infiltrating solutions in

56.5 Conclusions The author concludes that VAL should be considered for patients undergoing large volume lipoplasty procedures or lipoplasty of tight, fibrous areas such as the back and posterior flanks where increased blood loss is expected.

References 1. Garcia O, Nathan N. Comparative analysis of blood loss in suction assisted lipoplasty and third generation internal ultrasound assisted lipoplasty. Aesthetic Surg J. 2008; 28:430–5. 2. Illouz YG. Refinements in the lipoplasty technique. Clin Plast Surg. 1989;16(2):217–33. 3. Rohrich RJ, Beran SJ, Fodor PB. The role of subcutaneous infiltration in suction assisted lipoplasty: a review. Plast Reconstr Surg. 1997;99(2):514–9.

56 Comparison of Blood Loss in Suction-Assisted Lipoplasty and Third-Generation Ultrasound-Assisted Lipoplasty 4. Hetter GP. The effect of low-dose epinephrine on the hematocrit drop following lipolysis. Aesthetic Plast Surg. 1984; 8(1):19–22. 5. Fodor PB, Watson JP. Wetting solutions in ultrasoundassisted lipoplasty. Clin Plast Surg. 1999;26(2):289–93. 6. Rohrich RJ, Beran SJ, Kenkel JM. Anesthetic considerations. In: Rohrich RJ, Beran SJ, Kenkel JM, editors. Ultrasound-assisted liposuction. 1st ed. St. Louis, MO: Quality Medical Publishing; 1998. p. 69–84. 7. Fodor PB, Watson J. Personal experience with ultrasoundassisted lipoplasty: a pilot study comparing ultrasoundassisted lipoplasty with traditional lipoplasty. Plast Reconstr Surg. 1998;101(4):1103–16. 8. Kloehn R. Liposuction with “sonic sculpture”: six years’ experience with more than 6000 patients. Aesthetic Surg J. 1996;16:123. 9. Zocchi ML. Ultrasonic-assisted lipoplasty. Clin Plast Surg. 1996;23(4):575–98. 10. Scheflan M, Tazi H. Ultrasonically assisted body contouring. Aesthetic Surg J. 1996;16:117. 11. Jewell ML, Fodor PB, de Souza Pinto EB, Al Shammari MA. Clinical application of VASER-assisted lipoplasty: a pilot clinical study. Aesthetic Surg J. 2002;22:131–46. 12. de Souza Pinto EB, Abdala PC, Maciel CM, dos Dantos Fde P, de Souza RP. Liposuction and vaser. Clin Plast Surg. 2006;33(1):107–15. 13. The American Society for Aesthetic Plastic Surgery. Cosmetic Surgery National Data Bank, Procedural Statistics; 2006. 14. Rohrich RJ, Beran SJ, Kenkel JM, Adams WP Jr, DiSpaltro F. Extending the role of liposuction in bodycontouring with ultrasound-assisted liposuction. Plast Reconstr Surg. 1998; 101(4):1090–102.

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15. Baker JL Jr. A practical guide to ultrasound assisted lipoplasty. Clin Plast Surg. 1999:26(3):363–8. 16. Zocchi M. Ultrasonic liposculpturing. Aesthetic Plast Surg. 1992;16(4):287–98. 17. Maxwell GP, Gingrass MK. Ultrasound-assisted lipoplasty: a clinical study of 250 consecutive patients. Plast Reconstr Surg. 1998;101(1):189–202. 18. Matarasso A. Ultrasound-assisted lipoplasty: is this new technology for you? Clin Plast Surg. 1999;26(3):369–75. 19. Scuderi N, Paolini G, Grippaudo FR, Tenna S. Comparative evaluation of traditional, ultrasonic and pneumatic-assisted lipoplasty: analysis of local and systemic effects, efficacy and costs of these methods. Aesthetic Plast Surg. 2000;24(6):395–400. 20. Grotting JC, Beckenstein MS. The solid probe technique in ultrasound-assisted lipoplasty. Clin Plast Surg. 1999;26(2): 245–54. 21. Zukowski M, Ash K. Ultrasound-assisted lipoplasty learning curve. Aesthetic Surg J. 1998;18:104–10. 22. Rohrich RJ, Beran SJ, Kenkel JM. Complications. In: Rohrich RJ, Beran SJ, Kenkel JM editors. Ultrasoundassisted liposuction. 1st ed. St. Louis: MO: Quality Medical Publishing; 1998. p. 347–62. 23. Young VL, Schorr MW. Report from the conference on ultrasound-assisted liposuction safety and effects. Clin Plast Surg. 1999;26(3):481–524. 24. Mladick RA. Discussion; extending the role of liposuction in body contouring with ultrasound-assisted liposuction. Plast Reconstr Surg. 1998;101(4):1117. 25. The American Society for Aesthetic Plastic Surgery. Cosmetic Surgery National Data Bank, Procedural Statistics; 2005.

Part Fat Transfer

VI

57

Fat Transfer Principles Melvin A. Shiffman

57.1 Introduction The introduction of liposuction for fat reduction and body contouring has developed into transplantation of the extracted fat for augmentation of defects or for cosmetic purposes. There has been controversy concerning the manner of collecting, injecting, and cleansing the fat, and the effectiveness of the fat transfer. Some physicians have been disappointed with the long-term results of fat transplantation. The process of fat transplantation has not been standardized and there is a need to analyze some of the methods and results.

57.2 Fat Transplant Survival Vitamin E is a necessary factor in fat tissue maintenance [1] while insulin increases the metabolic activity of fat cells [2] and retards lipolysis [3–7]. Hiragun [8] theorized that insulin may induce fibroblasts to pick up lipid lost from lipolysis and become adipocytes. Skouge [3] felt that fat cells from an area of relatively poor vascularity will be more hardy, have decreased metabolic needs, and increase survival. Asken [9], however, stated that more fibrous areas, such as the upper abdomen are not ideal donor sites. Fat characteristics may be helpful in determining which area of fat is more likely to be retained. Those adipocytes with alpha 2 receptors are antilipolytic with poor

M. A. Shiffman 17501 Chatham Drive, Tustin, CA 92780-2302, USA e-mail: [email protected]

response to diet and appear more likely to survive with little change from weight loss or weight gain in comparison to adipocytes with beta 1 receptors (Table 57.1). Survival of adipocytes depends on the instrumentation used for harvesting and injecting the fat. Damage is inversely related to the diameter of the instrument used to extract and inject [10]. The pressure generated in injecting fat increases as a function of decreasing needle diameter (from 16 to 22 gauge) [11]. There is some decrease in the metabolic activity of fragments passed through 20 gauge needles or smaller (Table 57.1). The presence of blood in the fat injected stimulates macrophage activity to remove the cells. Washing the cells in a physiologic solution prior to injection will solve the problem [12–14]. Skouge [3] raised the question of whether washing decreases the viability of fragile adipocytes. Campbell [11] concluded that adipocyte integrity and metabolism of fat fragments subjected to mechanical manipulation by liposuction using wall suction remain intact. Illouz [12] biopsied the areas of fat injection and found normal fat cells. McCurdy [15] analyzed fat cell survival and concluded that the technical factors to accomplish the goal of 40–50% transplanted adipocyte survival include: 1. Low vascularity of donor site 2. High vascularity of recipient site 3. Low pressure technique of aspiration of fat 4. Filtering and washing the harvested adipocytes 5. Use of ³2 mm cannula for injection to minimize adipocyte injury 6. Multilayered deposition of fat 7. Overcorrection of recipient site Because of the problem of resorption of fat with fat transplantation, 30–50% overinjection is ordinarily used [16–21]. Asadi [16] determined that subdermal injection is important for long-term results.

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_57, © Springer-Verlag Berlin Heidelberg 2010

577

578

M. A. Shiffman

Table 57.1 Fat characteristics [8] Alpha 2 Receptors

Beta 1 Receptors

Lipolysis

Antilypolytic

Lipolytic

Response to diet

Poor

Good

Region of fat

Abdominal, trochanteric (genetic fat)

Facial, arms, upper torso

57.3 Indications for Fat Transplantation There have been two papers that relate the indications for autologous fat transplantation.

Facial Aging changes Melolabial grooves Central cheek depressions Subcommissural depressions Flattened upper lip Glabella Diffuse age-related lipoatrophy Cosmetic Lip augmentation Chin augmentation Malar augmentation Scars Traumatic Lipoatrophy, acne Idiopathic lipodystrophy Facial hemiatrophy Nonfacial Rejuvenation of the hands Body contour defects Depressions, liposuction induced Breast enlargement Traumatic scars Clinical

Indications

In analyzing these lists, a simpler and more useful classification can be devised: Indications (Shiffman) 1. Fill defects (a) Congenital (b) Traumatic (c) Disease (acne) (d) Iatrogenic 2. Cosmetic (a) Furrows (wrinkles) (b) Refill Lost Supportive Tissue (aging) (c) Enhancement

Skouge [22]: Indications for Fat Transplantation

erdeguer [23]: B Transplantation

3. Melolabial folds 4. Hollow cheeks 5. Dorsal hands (c) Esthetic enhancement 1. Cheek augmentation 2. Chin augmentation 3. Breast augmentation 4. Leg contour surgery (d) Congenital defects 1. Hemifacial atrophy 2. Soft-tissue defects of the body

57.4 Complications of Fat Transplantation

for

(a) Depressed scars – face and body • Postsurgical • Posttraumatic (b) Aging skin with loss of supportive tissue 1. Glabellar furrows 2. Upper lip

Fat

Injection of small globules will prevent cyst formation. Johnson [24] showed that one, three, and five cc injections resulted in small cysts, but 10 mL injection had macroscopic cyst formation. Oil cysts develop through confluence of necrotic fat cells, have a lining of macrophages, and resorption may take years thus giving a false impression of a successful transplantation [25]. Sterility of fat retrieval and injection must be maintained. Infection has not been reported [22]. Bruising, temporary swelling, and tenderness may result from fat transplantation [22]. Teimourian [26] reported a case of injection of fat into the glabellar frown lines with the onset of pain and loss of vision in one eye while receiving the injection. There was central retinal artery thrombosis, probably secondary to fat particle embolism. Calcifications have been reported only in fat transplantation to the breast for augmentation. This does

57 Fat Transfer Principles

not appear to be a significant risk since the timing of the appearance, the position, and the characteristics of the calcifications will indicate the etiology. The most important problem encountered is fat resorption. Trauma to the cells, desiccation during transfer, and the presence of blood are contributing factors. At least an 18 gauge needle should be used to reinject fat. Ersek [27] reported that very little autologous fat survives, but his use of a whisk in the cleansing process probably destroyed most of the fat cells.

57.5 Technique of Autologous Fat Transplantation The lack of standardization of fat collection and transplantation technique allows for a wide range of methods with varied results. Following are the methods utilized by certain cosmetic surgeons, which the author obtained by personal communication: (Billie, Autologous fat transplantation, 1996). I do have patients who go back over 10 years, at this point. Overall, I have had good fortune with nonsmokers and actually moderate amount of success with smokers. I have found that the younger the patients, the better they seem to do. We placed it in multiple sites, including defects in legs from traumatic events such as automobile accidents or recluse spider bites, and the nasal labial furrows in aging patients. Over the years, I have washed or not washed the fat, added or not added insulin, tried everything, and currently utilizing a 4-mm cannula to remove the fat, catching it in the sterile in-line trap, not washing it, and reapplying it, utilizing a 16-gauge fat grafting needle with a 10-cc syringe apparatus. (Fragen, Personal communication, 1996). I have found that autologous fat transplantation is a very effective part of my facial rejuvenation surgery, provided I give the patients a detailed explanation of the limited nature of the procedure and the fact that it is always somewhat temporary. Depending on the patient and the location to which the fat is transferred, the fat survives for a variable period. I have found that transferring fat under skin grafts, scars, and on top of

579

semirigid or rigid surfaces improves the viability of the fat transfer. For example, if one transfers fat under the skin post mastectomy, it seems to stay there and offer some padding. Putting it under burn scars will help increase the padding of the burn scar and make the skin grafts over it more pliable and flexible. If fat is transferred to a lip, it seems to survive there least well, which I think is because of the active nature of the lip. My method of transfer is very simple. I like to call it a closed system. Essentially, the area for fat harvesting is prepped and draped and infiltrated with a Klein solution. The fat is then harvested with a 14-gauge blunt cannula on a 10-cc syringe. If there appears to be excess saline, the excess saline is decanted. If there is excess bloody tissue, then the specimen is washed in saline and again decanted. If, as is usual, essentially pure fat is removed from the donor site, then it is maintained within the syringe with the blunt 14 gauge cannula. A small stab incision is made near the site of fat transfer, and the blunt cannula is then placed into the donor area. Several tunnels are made with the blunt cannula so that the fat is not squeezed into the area, but rather easily injected into the donor sire. Then the fat is transferred to the donor site. Both the sites are prepared sterilely. If the patient is under general anesthesia, then usually no anesthesia is used for the recipient site. If this is done under local anesthesia, a small amount of 1% Xylocaine with adrenaline is infiltrated into either the lips or the glabella or whatever site we are transferring the fat to. I usually overfill the graft site by approximately 50%, and I tell the patients that the swelling will last for 3–5 days. I routinely do fat transferring on face lift patients. In the neighborhood, I do 10 or more face lifts per month, and I would guess that 80% of those have a fat transfer associated with it. Untoward effects include bruising, short-term swelling, occasional lumpiness, and stimulation of fever blisters. The lumping has never been a problem, in that the fat can easily be compressed, even months later. Once, a patient had a small fat cyst which was easily evacuated. It is my feeling that fat injected into the lower portion of the nasolabial fold, the lips, and the droll lines has a relatively short life span, with the ideal results being reached in approximately 2 weeks and slow disappearance over 2–4 months. In the glabella, I believe that the fat will last for six to more months, and in many cases, over a year. I think that the area nearer the nose in the nasolabial fold will retain fat a little better. In that area

580

also, the fat will last for six to eight months. According to me, fat injected under graft sites, scars, and over other hard prominences lasts for many months, and I have several cases where the fat has lasted for several years. The primary advantage of fat transfer is that it can very effectively camouflage cosmetic defects (such as thin upper lips with wrinkling, glabellar frown lines, drool line, etc.) which are difficult to correct without other extensive procedures. In Palm Springs, we find many people who do not want to restrict their outdoor activities, such as tennis and golf. These patients accept the safe, though temporary, correction by fat transfer. Their biggest complaint is that the wonderful result they get is short-lived, but, until we find a safe, nonresorbable filler which the FDA will approve, we do not have a better alternative. (Tobin, Personal communication, 1996). About ten years ago, when liposuction surgery was first introduced, we began hearing recommendations for reinjection of fat. My initial experience with this procedure was to attempt to refine breast reconstruction cases by injecting small amounts of fat adjacent to implants or in patients on whom other surgeons had carried out flap reconstructions. We initially harvested the fat with a syringe and reinjected it using an old, mechanical injector that was initially designed to inject Teflon into the vocal cords. In essence, we were injecting it through an 18 gauge needle with a very precise ratchet mechanism. Our results were discouraging with rapid reabsorption. We felt that perhaps this was related to the fact that we were injecting into a scarred area. At about the same time, we began injecting fat into the face. My first experience with this procedure was to attempt to correct grooving in the cheeks that was caused by facial liposuction. We did not understand the risks that were involved when liposuction was carried out in this area. Many of us ended up with patients who had irregularities or waviness. Again, we used the same technique – namely aspiration with a syringe and reinjection through the Teflon gun. Again, our results were discouraging. Because of these failures, we essentially abandoned the technique. Sometime later, we heard about the successes with the injection of fat into the back of the hand and attempted a few cases. By this time, we had stopped using the Teflon gun and were simply aspirating the fat with the syringe and transferring it to smaller syringes through a small transfer tube after which the fat was injected into the back of the hand. Our technique included aspiration of fat with a syringe, rinsing and

M. A. Shiffman

straining with saline, and then reinjection. Again, both we and our patients were disappointed with the results. About 3 years ago, after hearing of the successes with the injection of separated fat, we were tempted to try again. Several surgeons had various techniques of morselizing the fat and injecting the fibrous portion. Often, this material was called autologous collagen, although I am not aware of any confirmation that the material was in any way similar to the bovine collagen that had become so popular under the trade name Zyderm. We utilized the technique recommended by Hilton Becker of Palm Beach. Kits were available which included syringes for transferring the material through a progressively smaller orifice. This resulted in the morselization of the material. Following this, the material was centrifuged and the collagenous component was obtained to be used for reinjection. The material was supposedly capable of being preserved by freezing and we attempted this as well. We probably treated about twenty-five patients with this process, carrying out multiple injections over a period of several months. As far as I can determine, we did not have even one patient who was really pleased with the results and we have since abandoned it. At the present time, our use of injectable fat is uncommon. When patients request it, we explain the fact that out experience has not been very positive, but we do offer it as an option. Occasionally, patients request it but once again, I have not seen any convincing evidence that there is any permanent augmentation. Obviously, I am perplexed by the reports and the literature by reputable surgeons who claim that they see permanent results. Until I see a series of consecutive cases presented over a relatively long period of time, I will remain unconvinced, but will attempt to be open minded. The results of literature review and personal communications are in Tables 57.2 and 57.3. Analysis of the data of 21 surgeons shows that the following techniques were utilized: 1. Harvesting fat Syringe vs. machine

No. of surgeons

Syringe

8

Machine

7

Unstated

8

57 Fat Transfer Principles

581

Table 57.2 Needle size and cell survival [11] 16

Needle gauge 18 20

Pad integrity

+

o

–

Cell morphology

+

+

o

–

Nuclear morphology

+

+

o

–

Fat globule

+

+

+

+

22

+ = 75% or more without cell damage o = 25–75% cell damage – = >75% cell damage

There was a tendency to use the syringe to collect smaller amount of fat and the suction machine to retrieve larger amounts of fat with some surgeons using both methods. Needle

No. of surgeons (7)

13 gauge

2

14 gauge

5

Cannula size

No. of surgeons (12 surgeons)

2 mm

3

3 mm

7

4 mm

4

>4 mm

2

57.6 Insulin Some physicians have added insulin to the fat in preparation for transplantation [12, 40, 41]. The theory is that insulin inhibits lipolysis. Sidman [42] found that insulin decreases lipolysis. Hiragun et al. [43] stated that theoretically, insulin may induce fibroblasts to pick up the lipid lost and become adipocytes. Chajchir et al. [44] found that the use of insulin did not show any positive effect on adipocyte survival during transplantation, compared to fat not prepared with insulin.

57.7 Centrifugation

When a needle was utilized to obtain fat, the 14 gauge was most often the choice. When cannula was utilized to obtain fat, the 3 mm was most often the choice. Some surgeons used multiple sizes. 2. Treatment of the Harvested Fat Ten surgeons washed the fat, five strained it, while six decanted the excess blood and fluid. Some surgeons used more than one method. 3. Reinjection of Fat No surgeon used a cannula to reinject the fat. When using a needle to reinject, six surgeons used more than one gauge.

Needle (gauge)

The 16 and 18 gauge needles were most often used for the reinjection of fat. At the present time, small cannulas have been devised with relatively blunt tips which can be used for reinjection without the problem of bleeding in the recipient area.

Reinjection of fat No. of surgeons

14

5

15

2

16

7

18

7

Some physicians centrifuge the adipose tissue to remove blood products and free lipids to improve the quality of the fat to be injected [40, 45, 46]. Asken [9] stated that his “method of reducing the material to be injected to practically pure fat is to place the fat-filled syringe with a rubber cap (the plunger having been previously removed and kept in a sterile environment) into a centrifuge. The syringe is then spun for a few seconds at the desired rpm and the serum, blood, and liquefied fat collects in the dependent part of the syringe…” Toledo [39] reported that, “for facial injection, we spin the full syringes for 1 min….. in a manual centrifuge (about 2,000 rpm), eject the unwanted solution, and transfer the fat…” Uebel [47] centrifuged autologous fat at 10,000 rpm for 10 min in order to obtain a “fat-collagen graft.” The centrifuged material on histologic examination showed cell residues, collagen fibers, and 5% intact fat cells. The material is absorbed at a slow rate and maintains contour and volume for 18–24 months. A new graft procedure is always performed to achieve a more permanent result. Chajchir et al. [44] centrifuged 1 cc of bladder fat pad from mince (both at 1,000 rpm for 5 min and 5,000 rpm

15

13

14

Ersek [27]

Fournier [32]

Fragen (Personal communication, 1996)

50

520

12

96

43

Johnson [24]

Krulig [35]

Lewis [36]

Newman [37]

Pinski [38]

3

14

13

3

4

3

4

2–3

3

4

4

2–4

3–6

Shiffman

+

+

+

+

+

14

13

14

14

Wash with saline

Spin and decant or wash with Lactated ringers

Decant, wash with lactated ringers if necessary

Sterile trap decanted

Luken’s strap irrigated with lactated ringers

Cleansed with saline

Caught in Trap, Strained and washed with physiologic solution

Sifted and Washed

Remove blood

Wash with saline

Agitated with wire wisk, cleansed Eagles medium suspended in physiologic solution (Tsol)

Decanted

Liquid absorbed with a cottonoid

Strained in coarse gauze pad

No washing

Strained

Excess fluid drained

Irrigated with lactated ringers micro deposition

Drain through Cheesecloth for micro deposition

Treatment

Harvesting fat reinjection Cannula (mm)

3–6 +

+

20 mL

+ (low)

>50 mL

Machine

Needle (gauge)

Toledo [39]

Skouge [22]

37

Illouz [34]

Hin [33]

24

+

Carraway [30]

Chang [31]

+

Bircoll [29]

Billie [28]

+

70

Asadi [1]

<50

Berleguer [23]

1

Agrus [28]

Syringe (mL)

<20

157

Reference

Asken [9]

No. of patients

Table 57.3 Methods of autologous fat transplantation

+

+

Insulin

14 or 18

18

16−18

15−18

18 or 20

13

14 or 16

14

16 or 18

14 or 16

18

16

16

15

d 14

Needle (guage)

582 M. A. Shiffman

57 Fat Transfer Principles

for 5 min) and injected into malar area subdermis. Microscopically, after 1–2 months there were macrophages filled with lipid droplets, giant cells, focal necrosis of adipocytes, and cyst-like cavities of irregular size and shapes. After 112 months following injection, no recognized adipocytes could be found. Total cellular damage was present in both the groups. Brandow and Newman [48] found that centrifugation of harvested fat did not alter the microscopic structured integrity of the cells. Spun and unspun samples were examined and were similar. Fulton et al. [49] found that the centrifuged fat, 3 min at 3,400 rpm, works well for small volume transfers, but not for large volume transfers into breasts, biceps, or buttocks.

57.8 Ratchet Gun for Injection Neuman and Levin [37] designed a lipo-injector with a gear driven plunger to inject fat tissue evenly into the desired sites. Fat injected with excessive pressure in the barrel of a syringe can cause sudden injections of undesired quantities of fat which will pour into recipient sites. Agris [28] stated that a rachet-type gun allows controlled accurate deposition of autologous fat. Each time the trigger is pulled, 0.1 cc is deposited. Neichajev [50] used a ratchet gun for free transplantation of fat harvested at −0.5 atm. pressure. EH noted only partial resorption of the fat but with significant improvement of contour. Asaadi and Haramis [51] described the use of a gun with disposable 10 cc syringe for fat injection. Niechajev and Sevcuk [52] utilized a special pistol and a blunt type cannula, with 2.3 mm internal diameter, to inject the fat. Berdeguer [23] used a lipotransplant gun to inject fat into areas to be enhanced. Fulton et al. [49] stated that it is beneficial for a beginning surgeon to use a ratcheted pistol for injection as this gives a more uniform injection volume.

57.9 Severing Tethering Bands Several authors have suggested severing of tethering bands, usually with a needle paddle shaped, or V shaped (“pickle-fork”) type instrument, to allow the

583

skin to lift more easily with the injection of fat [39, 53–55]. Recurrence of depressions was thought to be less likely.

57.10 Machine Liposuction “Liposuction harvesting of fat is traumatic and results in a graft composed of intact cells combined with cellular debris and free lipid” [56]. Liposuction removal of autologous fat by −1 atm suction was reported by Nguyen et al. [57] as showing microscopically 90% elongated, irregularly shaped, and ruptured adipocytes, and only 10% unchanged, normal-appearing adipocytes. With the use of a 10-cc syringe for the aspiration of fat, they found 95% unchanged adipocytes. May [58], in commenting of Nguyen’s study stated that “….one would have thought that aspiration could produce nearly the same degree of suction (1 atm) as formal suctioning. If the degrees of negative pressure produced by these two techniques, and the cannulas, are similar, then the degree of cell damage should have been similar.” Niechajev [59] obtained fat for grafting using a vacuum pump with −0.5 atm pressure. Using a ratchet gun for injection into the cheek, he noted only partial resorption of the fat over 1½–4 years (mean 3 years). Niechajev and Sevchuk [60] reported 50% fat survival over 3.5 years after single fat transplantation with 50% overcorrection. They found that fat obtained under maximum negative pressure (−0.95 atm) results in partial breakage and vaporization of the fatty tissue. About two-thirds of the fat withstood the trauma of aspiration. Low pressure (−0.5 atm) results in smaller cell size (29% smaller than with aspiration at −0.95% atm pressure), and they assumed that high pressure causes mechanical distention of the adiopocytes which increases the risk of and sometimes causes cell breakage. Elam et al. [61] noted a more effective fat removal by lowering the negative suction pressure during liposuction. Negative pressures varied from 15 in. of mercury (−375 mm mercury) to 30 in. (−750 mm) (−760 mm = 1 atm). Above 25 in. of mercury (−625 mm), an obvious amount of blood appears in the aspiration along with air bubbles. At maximum vacuum (−750 mm), the aspirate is a blood-tinged mixture of fatty globules with significant amounts of dark venous blood. The ideal liposuction vacuum pressure at sea level was felt to be a negative 20 in. of mercury (−500 mm).

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References 1. Meschik Z. Vitamin E and adipose tissue. Edinburgh Med J. 1944;51:486. 2. Katoes AS Jr, et al. Perfused fat cells: effects of lipolytic agents. J Biol Chem. 1933;248:5089. 3. Skouge JW. Autologous fat transplantation in facial surgery. Presented at American Academy of Cosmetic Surgery: Controversies in Breast and Facial Augmentation. Philadelphia; 7–9 Aug 1992. 4. Sidman RL. The direct effect of insulin on organ cultures of brown fat. Anat Rec. 1956;124(4):723–39. 5. Smith U. Human adipose tissue in culture studies on the metabolic effect of insulin. Diabetologia 1976;12(2):137–43. 6. Solomon SS. Comparative studies of the antilipolytic effect of insulin and adenosine in the perfused fat cell. Horm Metab Res. 1980;12(11):601–4. 7. Solomon SS, Duckworth WC. Effect of antecedent hormone administration on lipolysis in the perfused isolated fat cell. J Lab Clin Med. 1976;88(6):984–94. 8. Hiragun A, Sato M, Mitsui H. Establishment of a clonal cell line that differentiates into adipose cells in vitro. In Vitro 1980;16(8):685–93. 9. Asken S. Autologous fat transplantation: Micro and macro techniques. Am J Cosmet Surg. 1987;4(2):111–21. 10. Dolsky RL. Adipocyte survival. Presented at the Third Annual Scientific Meeting of the American Academy of Cosmetic Surgery and The American Society of LipoSuction Surgery. Los Angeles; Feb 1987. 11. Campbell GL, Laudenslager N, Newman J. The effect of mechanical stress on adipocyte morphology and metabolism. Am J Cosmet Surg. 1987;4(2):89–94. 12. Illouz YG. The fat cell “graft”: a new technique to fill depressions. Plast Reconstr Surg. 1986;78(1):122–3. 13. Krulig E. Lipo-injection. Am J Cosmet Surg. 1987;4(2): 123–9. 14. Lewis CM. Correction of deep gluteal depression by autologous fat grafting. Aesthetic Plast Surg. 1992;16(3):247–50. 15. McCurdy JA Jr. Five years of experience using fat for leg contouring (Commentary). Am J Cosmet Surg. 1995;12(3):228. 16. Asadi M, Haramis HT. Successful autologous fat injection at 5-year follow-up. Plast Reconstr Surg. 1993;91(4):755–6. 17. Chajchir A, Benzaquen I. Liposuction fat grafts in face wrinkles and hemifacial atrophy. Aesthetic Plast Surg. 1986; 10(2):115–7. 18. Chajchir A, Benzaquen I. Fat-grafting injection for soft tissue augmentation. Plast Reconstr Surg. 1989;84(6):921–34. 19. Chiu DT, Edgerton BW. Repair and grafting of dermis, fat, and fascia. In: McCarthy, J, editor. Plastic Surgery. Philadelphia: WB Saunders; 1990. p. 515. 20. Illouz YG. De l’utilization de la graisse aspiree pour combler les defects cutanes. Rev Chir Esth Langue Franc. 1985;10(40):13. 21. Matsudo PK, Toledo LS. Experience of injected fat grafting. Aesthetic Plast Surg. 1988;12(1):35–8. 22. Skouge J. The effectiveness and long term survival of transplanted fat. Presented at Amer Acad Cosmet Surg, Philadelphia; 7–9 Aug 1992. 23. Berdeguer P. Five years of experience using fat for leg contouring. Am J Cosmet Surg. 1995;12(3):221–9.

M. A. Shiffman 24. Johnson GW. Body contouring by macroinjection of autogenous fat. Am J Cosmet Surg. 1987;4(2):103–9. 25. Smahel J. Fat cylinder transplantation: an experimental study of three different kinds of fat transplants. Plast Reconstr Surg. 1996;98(1):97–8. 26. Teimourian B. Blindness following fat injections. Plast Reconstr Surg. 1988;82(2):361. 27. Ersek RA. Transplantation of purified autologous fat: a 3-year follow-up is disappointing. Plast Reconstr Surg. 1991;87(2):219–27. 28. Agrus J. Autologous fat transplantation: a 3-year study. Am J Cosmet Surg. 1987;4(2):95–102. 29. Bircoll M. Autologous fat tissue augmentation. Am J Cosmet Surg. 1987;4(2):141–9. 30. Carraway JH, Mellow CG. Syringe aspiration and fat concentration. A simple technique for autologous fat injection. Ann Plast Surg. 1990;24(3):293–6. 31. Chang KN. Surgical correction of postliposuction contour irregularities. Plast Reconstr Surg. 1994;94(1):126–34. 32. Fournier P. Microlipoextraction and injection. Presented at annual meeting of American Society of Dermatology, California: Palm Springs; 1986. 33. Hin LC. Syringe liposuction with immediate lipotransplantation. Am J Cosmet Surg. 1988;5(4):243–8. 34. Illouz YG. The fat cell “graft”: a new technique to fill depressions. Plast Reconstr Surg. 1986;78(1):122–3. 35. Krulig E. Lipo-injection. Am J Cosmet Surg. 1987;4(2):123–9. 36. Lewis CM. Correction of deep gluteal depression by autologous fat grafting. Aesthetic Plast Surg. 1992;16(3):247–50. 37. Newman J, Levin J. Facial lipo-transplant surgery. Am J Cosmet Surg. 1987;4(2):131–40. 38. Pinski KS, Roenigk HH Jr. Autologous fat transplantation. J Dermatol Surg Oncol. 1992;18(3):179–84. 39. Toledo L. Syringe liposculpture: a two-year experience. Aesthetic Plast Surg. 1991;15(4):321–6. 40. Ellenbogen R. Free autogenous pearl fat grafts in the face – a preliminary report of a rediscovered technique. Ann Plast Surg. 1986;16(3):179–94. 41. Newman J. Preliminary report on “fat recycling” – liposuction fat transfer for facial defects. Am J Cosmet Surg. 1986;3:67–9. 42. Sidman RL. The direct effect of insulin on organ cultures of brown fat. Anat Rec. 1956;124(4):723–39. 43. Hiragun A, Sato M, Mitsui H. Establishment of a clonal line that differentiated into adipose cells in vitro. In Vitro 1980;16(8):685–93. 44. Chajchir A, Benzaquen I, Moretti E. Comparative experimental study of autologous adipose tissue processed by different techniques. Aesthetic Plast Surg. 1993;17(2):113–5. 45. Toledo LS. Syringe liposculpture: a two-year experience. Aesthetic Plast Surg. 1991;15(4):321–6. 46. Zocchi M. Produccion y utilizacion de Colegeno Autologo para el remodelaje facial. II Congreso Chileno de Cirugia Plastica, 1991. 47. Uebel CO. Facial sculpture with centrifuged fat-collagen. In: Hinderer VT, editor. Plastic surgery. vol II, Amsterdam: Excerpta Medica; 1992. p. 749–52. 48. Brandow K, Newman J. Facial multilayered micro lipoaugmentation. Int J Aesthet Restor Surg. 1996;4(2):95–110. 49. Fulton JE, Suarez M, Silverton K, Barnes T. Small volume fat transfer. Dermatol Surg. 1998;24(8):857–65.

57 Fat Transfer Principles 50. Niechajev I. Autologous transplantation of fat (lipo-filling) for the improvement of the cheek contour, long-term results. In: Hinderer VT, editor. Plastic surgery. vol II, Amsterdam: Excerpta Medica; 1992. p. 747–8. 51. Asaadi M, Haramis HT. Successful autologous fat injection at 5-year follow-up. Plast Reconstr Surg. 1993;91(4):755–6. 52. Niechajev I, Sevcuk O. Long term results of fat transplantation: clinical and histologic studies. Plast Reconstr Surg. 1994;94(3):496–506. 53. Fournier PF. Liposculpture: the syringe technique. Paris: Arnette; 1991. 54. Gasparotti M. Superficial liposuction: a new application of the technique for aged and flaccid skin. Aesthetic Plast Surg. 1992;16(2):141–53. 55. Grazer FM. Cellulite lysing. Aesth Surg. 1991;11:11. 56. Eppley BL, Sidner RA, Platis JM, Sadove AM. Bioactivation of free-fat transfers: a potential new approach to improving graft survival. Plast Reconstr Surg. 1992;90(6):1022–30.

585 57. Nguyen A, Pasyk KA, Bouvier TN, Hassett CA, Argenta LC. Comparative study of survival of autologous adipose tissue taken and transplanted by different techniques. Plast Reconstr Surg. 1990;85(3):378–86. 58. May JW Jr. Comparative study of survival of autologous adipose tissue taken and transplanted by different techniques (Discussion). Plast Reconstr Surg. 1990;85(3): 387–9. 59. Niechajev I. Autologous transplantation of fat (lipo-filling) for the improvement of the check contour, long-term results. In: Hinderer VT, edtior. Plastic surgery. vol II, Amsterdam: Excerpta Medica; 1992. p. 747–8. 60. Niechajev I, Sevchuk O. Long-term results of fat transplantation: clinical and histologic studies. Plast Reconstr Surg. 1994;94(3):496–506. 61. Elam MV, Packer D, Schwab J. Reduced negative pressure liposuction (RNPL): could less be more? Int J Aesthet Restor Surg. 1997;5:101–4.

Enhancing Muscle Appearance with Extensive Liposuction and Fat Transfer

58

Alfredo Hoyos

58.1 Introduction Muscular appearance plays a major role in body aesthetic standards. Having a highly toned, shaped contour is the major goal of fitness and exercise. High Definition lipoplasty can reproduce the muscular anatomyaccurately, while enhancing muscular volume through selective reduction of vicinity areas, like the waist and hip reduction to relatively increase the aspect of the gluteal area. However, certain areas need a real volumetric augmentation for enhancing the muscular appearance, like the gluteal area, the pectoralis in the male, and deltoid muscles. For the female, the use of implants in the breast area is the gold standard: the results are aesthetically pleasant, reproducible, and reliable in most patients. In contrast, the options for male enhancement have been divided in mostly implants for augmentation [1–8], or the use of flaps [5, 8]. Implants have been the gold standard method for the treatment of the deficiency in the male chest, a frequent claim is the unnatural appearance of these [1–7]. In other regions, multiple types and shapes of implants have been used: buttocks [2], calf [7], and special shaped and customized ones [5, 7]. Implants add costs to surgery and are not exempt from complications as displacement, seromas, hematomas, capsular contracture, discomfort, infections, unnatural results [2, 6, 7]. Fat grafting has been described for several areas, almost since the mere upcoming of liposuction [9–26]. A. Hoyos Evolution Medical Center Calle 119 #11D-30, Bogota, Colombia e-mail: [email protected]

The safety and efficacy of the procedure have been described by several authors [19–23], To date, fat grafting in the body has been confined to gluteal enhancement, secondary deformities, and hand rejuvenation [12, 23, 27–32], but these applications have been expanded to areas like deltoids and female breast [9, 33–35]. The combination of fat extraction and grafting to female gluteal and female breast has been used for aesthetic purposes [9, 27, 28, 33–35], and as an adjunctive procedure for reconstruction after lumpectomy or mastectomy with breast reconstruction [9, 33, 36]. It has been documented to be a safe and effective technique [34, 37, 38]. Superficial liposuction has been reported to induce skin retraction and has better results than traditional methods [39, 40]. This principle was used as an adjunct for Vaser-Assisted High Definition Liposculpture (VHD) in the gluteal area for female and for the pectoral area in male [41, 42]. A method for gluteal, pectoral, and deltoid reshaping and/or enhancement using deep, intermediate, and superficial liposuction following Avelar concept [39] in specific anatomical areas to promote skin retraction [43–49] and reshaping combined with selective fat grafting [27, 28, 50] to enhance the areas is described.

58.2 Anatomy The aesthetic surface anatomy is the reflection of the disposition and development of the muscles. Although it is a reflection of the muscle mass, the surrounding areas of fat obscure this anatomy, so these areas must be treated in order to allow a better definition [62].

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_58, © Springer-Verlag Berlin Heidelberg 2010

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The gluteal area can be divided in three areas: upper, intermediate, and lower poles. This division can provide information about the specific anatomical volume deficiency and correction by fat grafting. Upper pole deficiency can be addressed by intramuscular fat grafting (as the majority of the gluteus maximus m. is in this area), while lower pole and the trochanteric areas would require subdermal fat graft. Also, addressing the neighboring areas, like the sacral triangle (formed by the intergluteal crease and the sacral dimples), the waist line, the perigluteal, and subgluteal areas, is of major importance. Gender differences can be observed in fat distribution: the tendency in female to store fat in the hips, waist, and the banana fold, as well as the lack of it in the trochanters is not seen in male. While in men this trochanteric depression can be the sig nature of muscular development, to produce a smoother contour. The pectoralis area in male can be addressed in a similar way: in contrast to the female superficial anatomy, the external appearance of this area in male is the shape and volume of the pectoralis m. muscle. It can be divided in superior and inferior poles. Some of the anatomical features surrounding the pectoralis muscle must be identified: the triangular area between the subclavicular line in junction with the deltoid muscle, this area in certain individuals retains fat that obscures the muscle anatomy. Another triangular area can be seen between the lateral border of the muscle and the anterior axillary line that needs special consideration on the surgical approach: this area has to be aggressively treated in order to create a defined contour. Last, the horizontal line along the inferior border of the pectoralis m. (usually 1 cm below the nipple level in male), is of key importance to create a muscular appearance. The third area of interest is the deltoid area. Fat grafting over this area was previously described by… Although is not a widespread technique, the actual success of the technique is to be joined by selective lipoplasty to show the muscular anatomy. In female, the posterior deltoid line should be addressed, accompanied by a careful extraction of the posterior arm fat. Special attention to the distal and proximal region is of key importance in order to avoid deformities. In selected males, the deltoid can be addressed in the anterior and posterior deltoid, following the border of the muscle. Afterward, a triangular shaped area over

A. Hoyos

the area of major projection of the muscle bundle is selected for fat grafting.

58.3 Surgical Technique 1. Marking: In standing position, outline of the fat deposits that are necessary to improve the contour. This is going to be removed with deep liposculpture. The author also marks the depressions or the areas that need more projection (specially the superior pole of the pectoralis m. in male, gluteal upper-intermediate poles, trochanters in female, the central deltoid area in the arms) to be treated with fat transplantation. After the conventional marking, we trace the surface anatomy that is going to be reproduced by superficial liposculpture: in the gluteal area, the superior border of the gluteus maximus muscle, the sacral triangle, the limit of the waistline, and the slightly overcorrected inferior gluteal fold; in the pectoralis area, the lateral and inferior borders of the pectoralis major m. The inferior horizontal line should be overcorrected in the intermediate and subdermal liposuction. Also, a triangular area lateral within the external border of the pectoralis muscle to the anterior axillary line is marked for superficial and deep fat extraction. If present, the axillary fat pad over the superior lateral border of the pectoral area beneath the deltoid m. is marked. In patients with gynecomastia, the entire gland bud is marked and its area beyond the pectoralis m. limits is marked for selective extraction. In the deltoid area, the anterior and posterior borders of the muscle are marked, as well as a triangular shaped area over the central muscular mass. 2. Deep layer lipoplasty: Under general anesthesia, proceed to infiltrate tumescent solution with 1,000 ml of normal saline, 50 ml of lidocaine 1%, and 1 ampoule of epinephrine 1:1,000. The ratio of infiltration and volume of fat removed is approximately 2:1. Vaser was used in an 80% continuous mode for the deep fragmentation, 2.9-mm probe (Sound Surgical Technologies, Denver, Co). In gynecomastia patients, a Vaser sharp-tip probe was used (Sound Surgical Technologies, Denver, Co) 90% continuous mode setting. The aspiration of fat includes all the major contour deformities.

58 Enhancing Muscle Appearance with Extensive Liposuction and Fat Transfer

3. Superficial lipoplasty: In the superficial layer, aspiration sculpting the anatomical muscular lines is performed. In VASER patients, it was used in 80% pulsed mode using a 2.9-mm probe (Sound Surgical Technologies, Denver, Co). Subdermal liposuction [63, 64] is performed following the muscular limits using ventX cannulas (Sound Surgical Technologies, Denver, Co). 4. Intermediate lipoplasty: The junction of the superficial and the deep zones are blended to produce a defined border of the surrounding areas: gluteal superior and lateral, an area above and below the lateral gluteal fold in order to make it “vanish.” In pectoralis area, the lateral and inferior borders. 5. Fat grafting. Fat was harvested with a 4-mm blunt cannula from other sites to an empty sterile bottle trap. 1 g of cefazoline was added to the trap. Decantation was the only process used to separate the fat cells from the saline and serosanguinous components. Two incisions were placed to do the fat grafting in the majority of areas to perform a criss-cross fat grafting: in the gluteal area, one in the subgluteal and one in the intergluteal crease. In the pectoral area, within the areola, that allows us to perform contralateral fat grafting in the supramuscular layer, the other within the anterior axillary fold. The later one if of key importance to detect and pinch the pectoralis major m. to insert a 2-mm blunt cannula in the intramuscular layer. The rest is performed through this incision in the submuscular layer. The deltoid area is approached by a single incision at the distal portion of the muscle.

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58.5 Discussion This procedure is performed as part of High definition Lipoplasty. The technique combining superficial, intermediate, and deep lipoplasty adjunct to fat grafting to reproduce the superficial anatomy was done over 5 years. It required a long learning curve to make an athletic look in a natural way. The gluteal area has been identified as an area of high success. The contour improvement with combined methods allows enhancing and changing the body shape. The average rate of resorption is unknown, but an overcorrection in average of 15% was enough to produce long-lasting results. The author clearly identified that the early poor results in the pectoralis correspond to poor presurgical marking as marking the patients with the arms abducted, and to low fat extraction in the lateral triangle or in the inferior border of the pectoralis muscle. Underdiagnosis of gynecomastia leads also to mistreatment of the area. In the deltoid area, a “shy” approach to the area led to poorly defined results. Due to the low level of familiarity of the surgeon with the superficial lipoplasty in this area, the surgeon is afraid of causing a deformity when performing the procedure. The recommendation is to gain experience by using the VASER technology to ease the mechanical limits of the traditional methods. The higher the level of familiarity, the more reliable the results, as well as more accurate the fat grafting.

58.6 Conclusions 58.4 Results The combined multilamellar lipoplasty brought about much athletic results in most patients. Through the multilayer approach of fat grafting, the areas had a significant improvement: in the gluteal area, an average of 300 mL was used on each side (150–450 mL); in the pectoralis area, the muscular layer allowed no more than 40 mL of fat. The average of total fat injection was 130 mL on each side (70–250 mL). In the deltoid area, it was between 15 and 35 mL.

Combined fat grafting and extraction is a safe, low cost, time saving, and effective alternative to implants or liposuction alone. Also, as an adjuvant procedure for High Definition Lipoplasty is a liposculpture refinement that efficiently reproduces all the anatomical landmarks of an athletic body (Fig. 58.1). The use of Vaser facilitated the fat extraction, increased the volume of aspirated fat permitted per patient, ensured adequate results in the superficial layer liposculpture, and diminished to a minimum the postoperative pain and bruising tending to earlier results [51–61].

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a1

a2

a4

a5

a3

Fig. 58.1 (a1–5) Preoperative. (b1–5) Postoperative following liposuction and fat transfer reproducing the anatomical landmarks of an athletic body

58 Enhancing Muscle Appearance with Extensive Liposuction and Fat Transfer

b1

b2

b4

b5

Fig. 58.1 (continued)

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b3

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References 1. Horn G. A new concept in male reshaping: anatomical pectoral implants and liposculpture. Aesthetic Plast Surg. 2002; 26(1):23–5. 2. Benito-Ruiz J. Buttock implants for male chest enhancement. Plast Reconstr Surg. 2003;112(7):1951. 3. Novack BH. Alloplastic implants for men. Clin Plast Surg. 1991;18(4):829–55. 4. Pereira LH, Sabatovich O, Santana KP, Pincanco R. Pectoral muscle implant: approach and procedure. Aesthetic Plast Surg. 2006;30(4):412–6. 5. Marks MW, Argenta LC, Izenberg PH, Mes LG. Management of chest wall deformity in male patients with Polands syndrome. Plast Reconstr Surg. 1991;87(4):674–8; discussion 679–81. 6. Marks MW, Argenta LC, Lee DC. Silicone implant correction of pectus excavatum: indications and refinement in technique. Plast Reconstr Surg. 1984;74(1):52–8. 7. Nordquist J, Svensson S, Johnsson M. Silastic implant for reconstruction of pectus excavatum: an update. Scand J Plast Reconstr Surg Hand Surg. 2001;35(1):65–9. 8. Silfen M, Ritz M, Southwick G. Use of pedicled local flaps for male chest augmentation and reshaping. Plast Reconstr Surg. 2006;117(5):1447–51. 9. Bircoll M. Cosmetic breast augmentation utilizing autologous fat and liposuction techniques. Plast Reconstr Surg. 1987;79(2):267–71. 10. Chajchir A. Fat injection: long-term follow-up. Aesthetic Plast Surg. 1996;20(4):291–6. 11. Pereira LH, Radwansky H. Fat grafting of the buttock and lower limbs. Aesthetic Plast Surg. 1996;20(5):409–16. 12. Lewis CM. Correction of deep gluteal depression by autologous fat grafting. Aesthetic Plast Surg. 1992;16(3):247–50. 13. GuerreroSantos J, Gonzalez-Mendoza A, Masmela Y, Gonzalez MA, Dios M, Diaz P. Long term survival of free fat grafts in muscle: an experimental study in rats. Aesthetic Plast Surg. 1996;20(5):403–8. 14. Toledo L. Fifteen years of fat injections. Presented At The XXVIII Colombian Society of Plastic Surgery Annual Meeting, Cali, Colombia: 8–12 Nov 2001. 15. Hudson DA, Lambert EV, Bloch CE. Site selection for fat autotransplantation: some observations. Aesthetic Plast Surg. 1990;14(3):195–7. 16. Moore JH, Kolaczynski JW, Morales LM, Considine RV, Pietrzkowski Z, Noto PF, Caro JF. Viability of fat obtained by syringe suction lipectomy: effects of local anesthesia with lidocaine. Aesthetic Plast Surg. 1995;19(4):335–9. 17. Sommer B, Sattler G. Current concepts of graft survival: histology of aspirated adipose tissue and review of the literature. Dermatol Surg. 2000;26:1159. 18. Chajchir A. Comparative experimental study of autologous tissue processed by different techniques. Aesthetic Plast Surg. 1993;17(2):113–5. 19. Carpaneda CA, Ribeiro MT. Percentage graft viability versus volume in adipose auto transplants. Aesthetic Plast Surg. 1994;18(1):17–9. 20. Baran CN, Celebioglu S, Sensoz O, Ulusoy G, Civelek B, Ortak T. The behavior of fat graft in recipient areas with

A. Hoyos enhanced vascularity. Plast Reconstr Surg. 2002;109(5): 1646–51. 21. Ersek RA. Transplantation of purified autologous fat: a 3-year follow-up is disappointing. Plast Reconstr Surg. 1991; 87(2): 219–27. 22. Lewis CM. The current status of autologous fat grafting. Aesthetic Plast Surg. 1993;17(2):109–12. 23. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg. 1997;24(2):347–67. 24. Fournier P. Fat grafting: my technique. Dermatol Surg. 2000; 26(12):1117–28. 25. Guerrerosantos J, Chicas M, Rivera H. Palatopharyngeal lipoinjection: an advantageous method in velopharyngeal incompetence. Plast Reconstr Surg. 2004;113(2):776–7. 26. Yanai A. Lipoinjection. Plast Reconstr Surg. 2003;111(1): 528. 27. Mladick RA. Combined gluteoplasty: liposuction and lipoinjection. Plast Reconstr Surg. 1999;104(5):1532–3. 28. Cardenas-Camarena L, Lacouture AM, Tobar-Losada A. Combined gluteoplasty: liposuction and lipoinjection. Plast Reconstr Surg. 1999;104(5):1524–31. 29. Guerrerosantos J. Simultaneous rhytidoplasty and lipoinjection: a comprehensive aesthetic surgical strategy. Plast Reconstr Surg. 1998;102(1):191–9. 30. Coleman SR. Structural fat grafting. Plast Reconstr Surg. 2005;115(6):1777–8. 31. Coleman SR. Hand rejuvenation with structural fat grafting. Plast Reconstr Surg. 2002;110(7):1731–44. 32. Carraway JH. Hand rejuvenation with structural fat grafting by Sydney R Coleman. Plast Reconstr Surg. 2002;110(7): 1745–7. 33. Zocchi ML, Zuliani F. Bicompartmental breast lipostructuring. Aesthetic Plast Surg. 2008;32(2):313–28. 34. Coleman SR, Saboeiro AP. Fat grafting to the breast revised: safety and efficacy. Plast Reconstr Surg. 2007;119(3): 775–85. 35. Yoshimura K, Sato K, Aoi N, Kurita M, Hirohi T, Harii K. Cell-assisted lipotransfer for cosmetic breast augmentation: supportive use of adipose-derived stem/stromal cells. Aesthetic Plast Surg. 2008;32(1):48–55. 36. Carjaval J, Patino Jairo H. Mammographic findings after breast augmentation with autologous fat injection. Aesthet Surg J. 2008;28(2):153–63. 37. Spear SL, Wilson HB, Lockwood MD. Fat injection to correct deformities in the reconstructed breast. Plast Reconstr Surg. 2005;116(5):1300–5. 38. Palugam SR, Poulton T, Mamounas EP. Long-term clinical and radiologic results with autologous fat transplantation for breast augmentation: case reports and review of the literature. Breast J. 2006;12(1):63–5. 39. Avelar J. Regional distribution and behavior of the subcutaneous tissue concerning selection and indication for liposuction. Aesthet Surg J. 1989;13:155–65. 40. Gasparotti M, Lewis CM. Superficial liposculpture: manual of technique. New York, NY: Springer; 1990. 41. Hoyos AE. High definition liposculpture. Presented in the XIII International Course of Plastic Surgery, Bucaramanga, Colombia: 2003. 42. Hoyos AE, Millard JA. Vaser-assisted high definition lipoplasty. Aesthet Surg J. 2007;27:594–604.

58 Enhancing Muscle Appearance with Extensive Liposuction and Fat Transfer 43. Gasparotti M. Superficial liposuction: a new application of the technique for aged and flaccid skin. Aesthetic Plast Surg. 1992;16(2):141–53. 44. Gasperoni C. Suction-assisted lipectomy of the subdermal liposuction fat layer: subdermal liposuction. Ann Int Symp Recent Adv Plast Surg. 1990;90:477. 45. Gasperoni C. Subdermal liposuction. Aesthetic Plast Surg. 1990;14(2):137–42. 46. Gasperoni C, Salgarello M. Rationale of subdermal superficial liposuction related to the anatomy of subcutaneous fat and the superficial fascial system. Aesthetic Plast Surg. 1995;19(1):13–20. 47. Gasperoni C, Salgarello M. MALL liposuction: the natural evolution of subdermal superficial liposuction. Aesthetic Plast Surg. 1994;18(3):253–7. 48. de Souza Pinto EB, Indaburo PE, Da Costa Muniz A, Martinez YP, Gerent KMM, Iwamoto H, Marão Miziara AC. Superficial liposuction: body contouring. Clin Plast Surg. 1996;23(4):529–48. 49. Gasparotti M. Superficial liposuction for flaccid skin patients. Ann Int Symp Recent Adv Plast Surg. 1990;90: 441. 50. Chamosa M, Murillo J, Vazquez T. Lipectomy of arms and lipograft of shoulders balance the upper body contour. Aesthetic Plast Surg. 2005;29(6):567–70. 51. Zocchi ML. Ultrasound-assisted lipoplasty. Adv Plast Reconstr Surg. 1995;11:197–221. 52. Zocchi ML. Ultrasound-assisted lipoplasty. Technical refinements and clinical evaluations Clin Plast Surg. 1996;23(4): 575–98.

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Remodelling Breast and Torso with Liposuction and Fat Grafts

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Alfredo Hoyos and David Broadway

59.1 Introduction The feminine body shape is defined by the equilibrium between the different anatomical fea tures, describing an appealing female contour. The relation between the breast size and shape and the contour of the hip–waist line is the main factor. The enhancement of these features can be accomplished in various ways. The use of implants in the breast area is the gold standard: the results are aesthetically pleasant, reproducible and reliable in most patients. There were approximately 3,48,500 cosmetic breast augmentations performed in the United States in 2007, indicating the increasing demand for aesthetic enhancement in the breast area. However, multiple factors can lead to think of alternatives of implants. The use of fat grafts in the breast area has spread in recent times. Fat has many attributes of the ideal filler, but the results, like those of any procedure, are technique-dependent [1]. Also, the concern of possible misguidance in cancer detection should be taken into account [2, 3]. In the hip region the only option is the use of fillers, specifically fat grafts, and reshaping through liposuction of the waist. After using free fat autologous grafts as a filling material as was first proposed in 1893 by Neuber, the idea rapidly gained enthusiasm and endorsements. Since then, further clinical works by Guerrerosantos [4, 5], Bircoll [6], Coleman [7–10] and others [11–24] have shown that it is possible by

A. Hoyos (*) Evalution Medical Center Calle 119 #11D-30 (nueva), Bogota, Colombia e-mail: [email protected]

careful handling of transplanted fat to improve the survival of this tissue.

59.2 Anatomy The pectoral area in female is defined by the breast gland contour. Some of the anatomical features surrounding the breast gland are important to enhance the shape and the relative volume of the gland and include the triangular area between the subclavicular line in junction with the deltoid muscle, the axillary portion of the gland or tail of Spence and the area surrounding the lateral pole of the gland, defined as a “lazy S.” In the hip area, the indication for fat grafting is defined by the relationship between the thorax and the hip. In a posterior view, the ideal feminine shape is when the thorax is smaller than the hip. So there are three basic contours: when thorax–hip ratio is <1, squared when the ratio is 1:1 and v shaped: >1. A square and V shape are indications for fat grafting. Additionally, a V shape should be treated with extensive liposuction and waist liposuction.

59.3 Surgical Technique 59.3.1 Marking In the standing position, outline the gland. This is going to be removed with deep liposculpture. Dep ressions or the areas that need more projection (specially the superior pole of the breast) are marked to be treated with fat transplantation. In the hip area, the point of maximum projection in the posterior view and the trochanteric depressions are marked.

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59.3.2 Deep Layer Lipoplasty Under general anaesthesia, proceed to infiltrate tumescent solution with 1,000 mL of normal saline, 50 mL of lidocaine 1% and 1 ampoule of epinephrine 1:1,000. The ratio of infiltration and volume of fat removed is approximately 2:1. Vaser was used in an 80% continuous mode for the deep fragmentation with a 2.9-mm probe (Sound Surgical Technologies, Denver, Co). Aspiration of fat includes all the major contour deformities. Special attention is paid to the waistline and lateral axillary region.

59.3.3 Superficial Lipoplasty In the superficial layer, aspiration sculpting the anatomical muscular lines is performed. In Vaser patients, it was used in 80% pulsed mode using a 2.9-mm probe (Sound Surgical Technologies, Denver, Co). Subdermal liposuction is performed following the muscular limits using ventX cannulas (Sound Surgical Technologies, Denver, Co). This can produce a better result through a better skin retraction [25, 26].

59.3.4 Fat Grafting Fat is harvested with a 4-mm blunt cannula from other sites to an empty sterile bottle trap. One gram of cefazoline is added to the trap. Decantation is the only process used to separate the fat cells from the saline and serosanguinous components. In the breast area, the axillary approach allows fat grafting in the supramuscular and submuscular layers (Fig. 59.1). The average of injection is 100–250 mL per side. In the hip region, access is made by combining lateral and gluteal fold incisions, with an average of 50–150 mL per side (Fig. 59.2).

59.4 Conclusions The combined multilamellar lipoplasty plus fat grafting results in safe and effective results. Combined fat

Fig. 59.1 Axillary approach for fat grafting with pinching of the pectoralis muscle in order to differentiate the supramuscular and submuscular layers

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Fig. 59.2 (a) Preoperative. (b) Postoperative following the combination of fat removal in the lateral portion surrounding the breast and the immediate result after fat grafting

grafting and extraction is a safe, low cost, and effective alternative to implants or liposuction alone. In the hip area, the combination of liposuction and fat grafting in an anatomical approach leads to a more feminine shape in most patients (Figs. 59.3–59.5).

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Fig. 59.3 (a) Preoperative. (b) 3 months after periareolar breast lift and fat grafting in the supramuscular and submuscular layers.

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Fig. 59.4 (a) Preoperative patient with a squared shape in hip–thorax ratio. (b) Postoperative following the combination of fat extraction in the waist line and fat grafting in the hip areas

598 Fig. 59.5 (a) Preoperative patient with a V shape in hip–thorax ratio. (b) Postoperative after the combination of fat extraction in the waist line and fat grafting in the hip areas. Additional fat extraction was performed in the thoracic area to create an hour-glass shape

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References 1. Boschert MT, Beckert BW, Puckett CL, Concannon MJ. Analysis of lipocyte viability after liposuction. Plast Reconstr Surg. 2002;109(2):761–5. 2. Palugam SR, Poulton T, Mamounas EP. Long-term clinical and radiologic results with autologous fat transplantation for breast augmentation: case reports and review of the literature. Breast J. 2006;12(1):63–5. 3. Carjaval J, Patino Jairo H. Mammographic findings after breast augmentation with autologous fat injection. Aesthet Surg J. 2008;28(2):153–63. 4. Guerrerosantos J. Simultaneous rhytidoplasty and lipoinjection: a comprehensive aesthetic surgical strategy. Plast Reconstr Surg. 1998;102(1):191–9. 5. Guerrerosantos J, Chicas M, Rivera H. Palatopharyngeal lipoinjection: an advantageous method in velopharyngeal incompetence. Plast Reconstr Surg. 2004;113(2):776–7. 6. Bircoll M. Cosmetic breast augmentation utilizing autologous fat and liposuction techniques. Plast Reconstr Surg. 1987;79(2):267–71. 7. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg. 1997;24(2):347–67. 8. Coleman SR. Hand rejuvenation with structural fat grafting. Plast Reconstr Surg. 2002;110(7):1731–44. 9. Coleman SR. Structural fat grafting. Plast Reconstr Surg. 2005;115(6):1777–8. 10. Coleman SR, Saboeiro AP. Fat grafting to the breast revised: safety and efficacy. Plast Reconstr Surg. 2007;119(3): 775–85. 11. Fournier PF. Fat grafting: my technique. Dermatol Surg. 2000;26(12):1117–28. 12. Yanai A. Lipoinjection. Plast Reconstr Surg. 2003;111(1):528. 13. Mladick RA. Combined gluteoplasty: liposuction and lipoinjection. Plast Reconstr Surg. 1999;104(5):1532–3. 14. Cardenas-Camarena L, Lacouture AM, Tobar-Losada A. Combined gluteoplasty: liposuction and lipoinjection. Plast Reconstr Surg. 1999;104(5):1524–31.

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15. Carraway JH. Hand rejuvenation with structural fat grafting by Sydney R. Coleman. Plast Reconstr Surg. 2002;110(7): 1745–7. 16. Pap GS. Autologous fat grafting for body contouring. Plast Reconstr Surg. 1998;101(4):1167–8. 17. Nordstrom RE, Wang J, Fan J. “Spaghetti” fat grafting: a new technique. Plast Reconstr Surg. 1997;99(3):917–8. 18. Badran HA. Histopathologic changes of autogenous fat grafting in albino rats. Plast Reconstr Surg. 1997;99(2): 607. 19. Spear SL, Wilson HB, Lockwood MD. Fat injection to correct deformities in the reconstructed breast. Plast Reconstr Surg. 2005;116(5):1300–5. 20. Haik J, Talisman R, Tamir J, Frand J, Gazit E, Schibi J, Glicksman A, Orenstein A. Breast augmentation with freshfrozen homologous fat grafts. Aesthetic Plast Surg. 2001; 25(4):292–4. 21. Yoshimura K, Sato K, Aoi N, Kurita M, Hirohi T, Harii K. Cell-assisted lipotransfer for cosmetic breast augmentation: supportive use of adipose-derived stem/stromal cells. Aesthetic Plast Surg. 2008;32(1):48–55. 22. Kijima Y, Yoshinaka H, Owaki T, Aikou T. Early experience of immediate reconstruction using autologous free dermal fat graft after breast conservational surgery. J Plast Reconstr Aesthet Surg. 2006;60(5):495–502. 23. Kwak JY, Lee SH, Park H, Kim J, Kim SE, Kim E. Sonographic findings in complications of cosmetic breast augmentation with autologous fat obtained by liposuction. case report. J Clin Ultrasound. 2004;32(6):299–300. 24. Zocchi ML, Zuliani F. Bicompartmental breast lipostructuring. Aesthetic Plast Surg. 2008;32(2):313–28. 25. Gasperoni C, Salgarello M. Rationale of subdermal superficial liposuction related to the anatomy of subcutaneous fat and the superficial fascial system. Aesthetic Plast Surg. 1995;19(1):13–20. 26. Gasperoni C, Salgarello M. MALL liposuction: the natural evolution of subdermal superficial liposuction. Aesthetic Plast Surg. 1994;18(3):253–7.

Buttocks Remodeling with Fat Transfer

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William L. Murillo

60.1 Introduction More than ever, individuals are conscious about the significance played by the buttocks in the context of corporal contouring. The buttocks represent a sexual appealing spot and are also considered as an element of beauty in some ethnic groups. While men seek a small projection, women want a more prominent and round buttocks, which go with their curved body. One important goal is getting a beautiful figure while naked; nevertheless, people also look for a more pleasing fit and harmony in clothing. For these kinds of reasons, demand for buttocks enhancement surgery has increased, attracting the closer attention and analysis of plastic surgeons. Remodeling the buttocks is not a negligible task. It involves aspects such as a good knowledge of the anatomy plus an understanding of its relationship with all neighboring areas being part of the posterior outline. Harmony and body proportions have to be preserved. Relating the buttocks’ measure with that of the waist is critical in determining an important parameter as is the waist-to-hip ratio (WHR). This rapport can be used as an indicator of attractiveness, endocrinological status, and some health risks as stated by Singh [1]. The normal range of the WHR is 0.67–0.80 in healthy premenopausal women and 0.85–0.95 in healthy men [2]. An accurate diagnosis of the actual needs is of paramount importance to achieve the desired refashioning. After having analyzed some hundreds of buttocks cases, the author noticed that some patterns of the

W. L. Murillo Division of Plastic and Reconstructive Surgery, Louisiana State University Medical Center, 1542 Tulane Avenue, New Orleans, LA 70112, USA e-mail: [email protected]

gluteal shape are repetitive. Consequently, a buttock classification becomes essential when discussing this anatomical region.

60.2 Anatomical Classification For didactic purposes and classification, the buttock has been divided here into four direct areas composing its architecture; two indirect topographical areas which, despite not being part of the buttock, can affect its appearance; and a “borderline” area in between.

60.2.1 Direct Areas 60.2.1.1 Gluteus Maximus This quadrilateral spot spans from the posterior gluteal line of the ilium, posterior part of the sacrum and coccyx, going obliquely downward and laterally to the iliotibial band of the fascia lata and the gluteal tuberosity between the vastus lateralis and adductor Magnus. The gluteus maximus’ thickness gives maximal posterior projection to the buttock (Fig. 60.1).

60.2.1.2 Iliac This area is framed by the iliac crest, the posterior gluteal rough line of the iliac bone, and the superior border of the gluteus maximus muscle. It represents the projection of the gluteus medius muscle. This area, especially in the female, is frequently overlaid by excessive accumulated fat (Fig. 60.2).

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Fig. 60.2 Accumulated fat defining the iliac area

Fig. 60.1 Anterior–posterior projection of the buttocks given by the gluteus maximus muscle

60.2.1.3 Trochanteric It is a tendinous area whose natural concavity diminishes the roundness of the buttock. This is composed of the greater trochanter and the insertion of several muscles from the thigh and buttocks. Although this is a natural depression, especially in athletics individuals, women dislike having it and frequently ask for being fat-filled [3] (Fig. 60.3).

60.2.1.4 Ischio-Rectal It is a triangular area with inferior base and superior apex that is medially bounded by the external sphincter of the anus and the inferior fascia of the pelvic diaphragm. The ischial tuberosity and the obturator fascia give its lateral outline. The inferior border of the gluteus maximus and the sacro-tuberal ligament constitutes its

Fig. 60.3 Trochanteric area seen as a lateral buttock dimple

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posterior limit. Anteriorly, it is partially limited by the posterior portion of the inferior fascia of the urogenital diaphragm. This area is filled with adipose tissue and contains nerves and vessels to the rectal and perineal regions (Fig. 60.4).

60.2.2 Indirect Areas Indirect areas by their own may influence positively or negatively the balance and proportion of the buttock.

60.2.2.1 Sacral Normally the sacral area is very thin. Its beauty is well recognized as a diamond-shaped spot. The 5th lumbar vertebra frames it superiorly. Bilaterally, it is limited by the cutaneous projection of the posterior superior iliac spine, ending inferiorly in a soft dive into the inter-gluteal fold. Accumulated fat makes this area thicker, bridges the buttocks, and gives them a bigger and disgraceful appearance (Fig. 60.5).

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Fig. 60.5 (a) Diamondshaped sacral area. (b) Prominent sacral area

Fig. 60.4 Patient with very noticeable ischio-rectal area

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60.2.2.2 Femoral The femoral area corresponds to the projection of the vastus lateralis muscle. In women it harbors an important fat deposit and might face two different situations. When augmented, this area may increase the apparent size of the buttock. By another token, the load of a very large buttock can affect the femoral area giving it a false saddlebag aspect (Fig. 60.6). This last situation can be ruled out by asking the patient to contract the buttocks; in that case, the release of the overlying weight makes the false saddlebag disappear [4].

60.2.3 “Borderline” Area 60.2.3.1 Gluteo-Femoral It is a transitional zone determined by the femoral insertion of the gluteus maximus muscle. Thus, it is in between the gluteus maximus and the femoral area. Normally this part is camouflaged by its surroundings, but when defatted, it is easily recognizable (Fig. 60.7).

Fig. 60.7 The gluteo-femoral area

Fig. 60.6 Femoral area featuring as a protrusion on the lateral upper thigh

According to the diverse presentation of the previously described areas, different kinds of buttocks shape can be encountered. Hence, four basic geometrical buttock silhouettes such as triangular, trapezoidal, round, and square are reported herein (Fig. 60.8) The author’s classification has some similarities with the one already published by Mendieta [5], as we let his editors know by personal communication (Young and Roberts). Mendieta describes points A, C, and B correspondingly to our iliac, trochanteric, and femoral regions. Another classification can be given according to the anterior-posterior projection of the gluteal region, as stated by Cuenca-Guerra. He categorizes the buttocks into four primary types plus a senile or type five [6]. The external gluteal outlook is, of course, tightly related to the pelvis bony frame. It can be envisioned

60 Buttocks Remodeling with Fat Transfer Fig. 60.8 (a) Triangular shape. (b) Trapezoidal. (c) Round. (d) Square

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Fig. 60.9 Caldwell-Moloy pelvis classification

Platypelloid Gynecoid

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when compared to the Caldwell-Moloy pelvis classification, counted in traditional obstetrics [7]. This characterizes four varieties of pelvises based on the type of posterior and anterior segments of the inlet, such as gynecoid, platypelloid, anthropoid, and android (Fig. 60.9). Placing buttocks’ and pelvises’ shapes all together, they could be arranged as follows: 1. Round buttocks shape normally has a good anterior–posterior projection. It coincides with the Cuenca-Guerra’s Type I and with the gynecoid pelvis, which has a round to slightly oval inlet 2. In triangular buttocks or in type II, it is seen a sideto-side expansion, lacking a good anterior–posterior bulge. It could be related to Platypelloid pelvises in which there is flat inlet with a transverse kidneyshaped brim 3. Anthropoid pelvises are especially present in Black women. The Pelvic brim is an anterior–posterior ellipse with a narrow ischial spine. Matching anthropoid pelvises with type III or square buttocks, one can find relative good anterior–posterior buttocks projection along with a poor side-to-side expansion 4. An android pelvis is the male’s type. It is more common in white females, it has a triangular inlet, prominent ischial spines, and more angulated pubic arch. An android pelvis goes with trapezoidal or

type IV buttocks in which there is a lack of volume and projection of the gluteal area Finally, we encounter a mixed variety of buttocks shapes and pelvises that are difficult to be classified. Having all these aspects in mind, one can face any kind of buttocks. Of course, we cannot modify the bony frame but the soft tissues, altering their characteristics and giving them the aimed beautiful appearance.

60.3 Technique Once the diagnosis is carried out, the corresponding actions are taken in order to achieve the desired buttocks recontouring. It includes a combined procedure: liposuction of the fatty areas, as well as fat transfer to those areas lacking protrusion (Fig. 60.10). Skin markings and surgical preparation are performed with the patient standing. To better determine its superior border, the buttock is hand-lifted while marked (Fig. 60.11). A smooth transition with the lower back is considered; for this reason, another line is drawn about 3 cm above the previously marked superior limit of the buttock. It bounds the area to be softly suctioned.

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Platypelloid

Gynecoid

Round

Suction

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Injection

• Iliac • Gluteal (*) • Femoral • Moderate throcanteric

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Trapezoidal

Injection

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Injection

Suction

• Iliac • Gluteal • Iliac • Femoral • Throcanteric (*) • Femoral • Throcanteric (*) • Sacral • Sacral

• Gluteal • Throcanteric • Gluteofemoral (*)

• Iliac • Sacral

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Injection

• Gluteal • Throcanteric • Gluteofemoral

* - Depends on case presentation

Fig. 60.10 Algorithm to determine treatment

Fig. 60.11 Hand-lifting the buttocks defines its superior border better

The operating table is completely sterile draped waiting for the aseptic patient. After marked, patients are scrubbed with a sterile towels soaked with povidone-iodine (Betadine-soap), from the neck to the

ankles, including the genital and anal areas (Fig. 60.12). Afterward they are washed with saline and finally sprayed with Betadine solution. The patient sits on the sterile coated table and the distal lower limbs are sheltered with sterile drapes and bandages. Once the patient is laid down, anesthesia follows. Most of our patients (almost 90% of cases) are done under epidural anesthesia. Vesical catheter is placed and the whole perineal area, although already prepped, is covered with a sterile towel secured with 3–0 silk. Saline solution with epinephrine 1:10,00,000 is infiltrated at the donor regions (1 mg for each 500 mL of saline). Conventional liposuction is our source of autologous material. Frictional damage of the incisions is avoided with the use of sterile plastic ports sutured to the skin with 3–0 silk (Fig. 60.13). The total amount of adipose cells to be transferred to the buttocks must be in accordance to the surrounding areas. Obtaining a pleasant WHR is of paramount importance. In the author’s previous communication [8] a maximum total fat injection of 1,260 mL per side was reported. At that time it was the largest amount of fat transfer ever published in the medical literature. The current average of injection is still 700 mL per side. Harvesting is performed with a 5-mm blunt cannula attached to a liposuction machine at medium vacuum.

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Fig. 60.12 Patient being prepped for surgery

Fig. 60.13 Plastic ports prevent frictional damage and maintain the initial incision size

Low or medium suction pressure prevents the adipocytes from being damaged [3]. At each positional change the patient is resprayed with povidone–iodine. The fat is collected into sterile bags or into canisters adapted to the liposuction hose (Fig. 60.14). Containers are kept closed

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Fig. 60.14 Fat is directly stored into containers in which decantation takes place

to prevent contact with the ambient air, minimizing oxidation and promoting viability of the fat cell [9]. The medical literature describes different methods of dealing with fat, such as washing, filtration, centrifugation, decantation, and so on. Chajchir [10], after conducting a comparative study of the diverse processes, concluded that decantation appeared to be the least harmful method of handling the fat cell. Thus, decantation is the only process we use. After settling for 5–10 min, the watery layer is drawn off and the fat cells are ready to be transferred. The fat is infiltrated making tunnels in a fan-like pattern, into the upper two-thirds of the gluteus muscle layer, avoiding the course of the sciatic nerve (Fig. 60.15). Surgeons can easily fill the muscle’s shake upon entering the cannula into it. Superficial irregularities in the whole gluteal region may entail direct subcutaneous infiltration [11, 12]. Normally fat is injected into the whole buttocks through a single incision at the lower sacrum’s midline, except for the gluteo-femoral area which is better addressed through a subgluteal incision. The same 5-mm blunt cannula used for harvesting is attached to a 60-mL syringe for lipo-injection. The author thinks that using thick blunt cannulas lowers the risk of intravascular inoculation.

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Fig. 60.16 Massage on the buttocks is critical to avoid loculation and abscess formation after fat injection

Fig. 60.15 Fat injection should be done intramuscularly in the upper two-thirds of the buttocks and subcutaneously in the inferior third

A Guerrero-Santos’ report [13] supports the premise that fat injected into muscle will benefit from better vascularization and subsequent host integration. In the development of the procedure, after each 250 or 300 mL fat injection, the assistant is asked to block the incision and the sacral area, while the surgeon vigorously kneads the whole gluteal region to further distribute and contour the fat. Placing a humid towel on the buttock facilitates the massage (Fig. 60.16). When you think distribution is done, the incision is freed, the surgeon keeps kneading the area, and no fat leakage should be present, otherwise all steps ought to be repeated [8]. The massage aims to minimize loculation, abscess formation, and promote integration through more surface contact. According to Carpaneda and Ribeiro [14], the percentage of graft viability depends on the fat thickness and its geometric shape and it is inversely proportional to the graft diameter when greater than 3 mm.

During the massage, some fat can diffuse out to the previously liposuctioned regions, especially the sacral and the femoral regions increasing the possibilities of sacral seroma caused by lipolysis and saddlebag formation due to local fat integration. It is, therefore, recommended that these areas be cleared out with a repeat gentle liposuction. Usually, when the vicinity of the buttocks is not needed as a donor area, it is preferable to perform fat transfer first and then liposuction on the buttock’s surroundings. Formerly, vacuum drainage was left in place at the end of the procedure. The author now thinks it reduces the patient’s comfort, so only Penrose’s drains are left routinely in the sacral and inguinal areas (Fig. 60.17). Since this kind of drainage does

Fig. 60.17 Penrose drain being placed at the sacral area

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not allow for precise volume quantification, they are left in place for 4–6 days postoperatively. Also diapers for adults are used, avoiding fluid leakage to the girdle and clothes. Patients are encouraged to walk with an accompanying person and showering since the day after surgery and are instructed to use an elastic garment, only for the first postoperative month. There is no restriction on sitting or sleep postures. Lymphatic drainage massage is recommended at the donor areas from the 6th to the 15th postoperative day. Stretching exercises are also recommended to diminish subcutaneous scar retractions and fibrosis formation. Domiciliary assistance is appointed twice a week or according to each individual’s necessity. Visits to the office are allotted after the first week.

60.4 Results Patients have showed their great satisfaction with fat transfer. Given that liposuction is necessary to obtain the fat, individuals are very pleased when they see an improved buttocks area associated with a slender figure (Figs. 60.18–60.21). Normally, results are approved by analysis of pre and postoperative photographic documentation. Using magnetic resonance imaging we can confirm patients’ clinical and photographic status. The magnetic resonance imaging allows comparison of the tissue composition of the buttock before and after fat injection (Fig. 60.22) in order to demonstrate that the fat was actually injected intramuscularly, to determine whether the improved volume persists, and to measure, with a standardized scale, the increase of buttock bulk after the procedure [8].

60.5 Complications The author has been doing fat transfer for buttock enhancement for the last 11 years. During this time, hundreds of the author’s own cases plus countless of cases assisting other surgeons have been performed. The encountered difficulties were more related to factors such as volemic management or others than to fat

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transfer. Complications in the author’s series can be divided into three different categories such as systemic, at the donor area, and at the recipient area.

60.5.1 Systemic Complications A good standard of communication is necessary between the surgeon and anesthesiologist to avoid any kind of complication. Urine output and IV fluids status are mandatory to be checked at least once each half an hour. A possible inappropriate fluids management led us to have systemic compromise in two patients operated under general anesthesia. One patient suffered pulmonary edema, which was fortunately diagnosed and successfully treated immediately after finishing the procedure. The second patient manifested with acute renal failure on the third postoperative day. She required 1-week hospitalization and three dialysis sessions for recovery. No further consequences pursued. The medical literature also reports sporadic cases of pulmonary embolism and disseminated intravascular coagulopathy [15].

60.5.2 Complications at the Donor Areas Normally, contour liposuction is performed in large volumes [16] in which factors such as lipolysis, lymphatic trauma, and retention of tumescent fluid are predisposing to seroma formation. Variable seroma volumes have been reported in 40–60% of patients with some resolving spontaneously, and others needing aspiration or drainage [8, 15]. After implementing drainage routinely, seroma formation decreased to almost 3%, being easily managed with lymphatic draining massage or single-needle aspiration. Abscess at the sacral area was observed in one patient. She required drainage, irrigation, and treatment with antibiotics. Another abscess at the thoraciclumbar area appeared in a patient who had returned to her country of residence sooner than expected. She was treated by a local surgeon using drainage, wound packing, and antibiotics. There was no compromise of the cosmetic result.

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Fig. 60.18 (a1–3) Preoperative patient with square, type III buttocks requesting roundness and more projection in this anatomical area. (b1–3). Postoperative following liposuction at the sacral and iliac areas and lipo-injection at gluteal and trochanteric areas

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Fig. 60.19 (a1–3) Pre-op. 20 year old patient featuring mixed characteristics such as square buttocks, lack anterior–posterior projection and excessive iliac outcrop. (b1–3) Postoperative

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after circumferential trunk liposuction, abdominoplasty, and fat injection in the gluteus maximus area. The gluteo-femoral area happened to be noticeable with the gluteal enhancement

60 Buttocks Remodeling with Fat Transfer Fig. 60.20 (a1,2) Preoperative patient with trapezoidal and kidneyshaped buttocks. (b1,2) Postoperative after iliac liposuction and fat injection into the trochanteric, gluteus maximus, and gluteo-femoral areas

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Fig. 60.21 (a1–3) Slightly square buttocks. (b1–3) Postoperative following liposuction of the iliac and femoral areas and fat injection into the gluteus maximus and trochanteric areas

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Fig. 60.22 (a1–3) Preoperative. (b1–3) After fat injection

Sacral numbness is still observed in about 10% of our cases. This is a transient complaint, which normally resolves earlier than the 3rd month. Although not related to buttock augmentation, the author had a case of lumbar skin necrosis after liposuction in a patient who some years previously got biopolimers injected into her buttocks. The lesion was managed with hyperbaric therapy, debridement, and local dressings until complete healing. Even if the contour was not altered, it left behind a noticeable scar.

60.5.3 Complications at the Recipient Area So far only one major complication has been experienced at the recipient area. It was in one of the first operated cases. A unilateral aseptic abscess was observed on the fifth postoperative day. This resolved with single-needle aspiration. The resulting asymmetry was corrected 1 year later with a second fat injection. The author believes it was due to the insufficient spreading massage on the buttocks, leading to probable fat necrosis.

60.6 Discussion Getting beautiful round well-projected buttocks is what patients ask for, and with the advent of liposuction, it has been possible by means of fat transfer. Nevertheless, fat injection remains a controversial issue in the medical practice. Some authors state that fat transfer is worthless and report eventually noticeable reabsorption at the site of implantation [17, 18]. Others, in contrast, defend the benefits of the procedure, encouraged by the positive results obtained in their practice [19, 20]. Both groups sustain their opinions based either on visual observation or on experimental studies, providing strong explanations for their beliefs. Besides, some authors [9, 11, 21] believe that fat grafting longevity is determined by the size and lipogenic activity of the fat cells, the vascularity and mobility of the recipient site, the degree of local fibrosis, and the number of viable cells grafted. Also, the presence of heparin-releasable adipose tissue lipoprotein lipase (ATLPL) and insulin, which increased differentiation of the preadipocytes, are considered other factor. Trying to clarify the controversies while improving our understanding of fat grafting, a study with magnetic resonance imaging (MRI) was conducted in the

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years 2001 and 2002. This study aimed to document the efficacy of fat transfer. In consequence, sagittal, coronal, and axial cut scans were obtained preoperatively and/or at the 1st, 4th, 8th, and 12-month operative intervals, on six patients. High cost of MRI limited the size of the sample [8]. Findings supported the clinical impression that fat cells injected into muscle had been consistently integrated into the host tissue, enhancing the external buttock contour in each patient. The loss of growth effect between the first and the fourth-month interval was estimated in about 20%, according to clinical and scale measurements. From the fourth through the 12th month, topographic characteristics of the buttocks remained unchanged in each of the studied patients. A similar study with MRI was more recently carried out by Wolf et al. [22], having comparable findings in terms of percentage of fat absorption. The difference was in the final result. They found no significant improvement in the buttocks contour after the third month postoperative, attributing the enhanced gluteal effect to liposuction of the surrounded areas. This statement is understandable since they only report 250 mL fat transfer each side. Other authors agree [15] that it is necessary to inject more than 500 mL of fat to obtain an enhanced buttock outlook.

60.7 Conclusions Buttock enhancement can be achieved by means of prosthesis implants, dermo-adipose flaps, or through fat grafting. The chosen method could be dependent on each particular case or on surgeon’s preferences. Fat transfer to the buttocks, despite the remaining controversies, has proven to be a safe and very rewarding procedure, gaining more adepts in the scientific community. To perform lipo-injection, the author recommends decantation of the adipose tissue in closed containers, and the use of thick (5 mm) blunt cannulas in order to avoid vessels or nerves puncturing. Gluteal massage is a very important component of the technique since it minimizes loculation and abscess formation. Also, it promotes integration through more contact with the recipient area.

W. L. Murillo

Buttocks’ improvement using autologous tissue avoids the acknowledged complications [23, 24] related to the employ of implants, such as rupture, extrusion, capsular contracture, and restrictions to the use of pharmaceutical gluteal injections. Acknowledgment I thank my wife and my kids for their help in preparing the figures and the manuscript.

References 1. Singh D. Universal allure of the hourglass figure: an evolutionary theory of female physical attractiveness. Clin Plastic Surg. 2006;33(3):359–70. 2. Roberts TL, Weinfeld AB, Bruner TW, Nguyen K. “Universal” and ethnic ideals of beautiful buttocks are best obtained by autologous micro fat grafting and liposuction. Clin Plastic Surg. 2006;33(3):371–94. 3. Lewis CM. Correction of deep gluteal depression by autologous fat grafting. Aesthetic Plast Surg. 1992;16(3):247–50. 4. Fournier P, Otteni FM, Avelar J. Introdução ao estudo da semiologia estetica do corpo. In: Avelar J, Illouz YG editors. Lipoaspiracao. Rio de Janeiro: Hipocrates; 1986. p. 73–9. 5. Mendieta CG. Classification system for gluteal evaluation. Clin Plastic Surg. 2006;33(3):333–46. 6. Cuenca-Guerra R, Lugo-Beltran I. Beautiful buttocks: characteristics and surgical techniques. Clin Plastic Surg. 2006;33(3):321–32. 7. Caldwell W, Moloy H. Anatomical variations in the female pelvis and their effect in labor with a suggested classification. Am J Obstet Gynecol. 1933;26:479–505. 8. Murillo WL. Buttock augmentation: case studies of fat injection monitored by magnetic resonance imaging. Plast Reconstr Surg. 2004;114(6):1606–14. 9. Sommer B, Sattler G. Current concepts of graft survival: histology of aspirated adipose tissue and review of the literature. Dermatol Surg. 2000;26(12):1159–66. 10. Chajchir A. Comparative experimental study of autologous tissue processed by different techniques. Aesthetic Plast Surg. 1993;17(2):113–5. 11. Pereira LH, Radwansky H. Fat grafting of the buttock and lower limbs. Aesthetic Plast Surg. 1996;20(5):409–16. 12. Toledo L. Fifteen years of fat injections. Presented at the XXVIII Colombian Society of Plastic Surgery Annual Meeting, Cali, Colombia: 8–12 Nov, 2001. 13. Guerrerosantos J, Gonzalez-Medoza A, Masmela Y, Gonzalez MA, Deos M, Diaz P. Long term survival of free fat grafts in muscle: an experimental study in rats. Aesthetic Plast Surg. 1996;20(50):403–8. 14. Carpaneda CA, Ribeiro MT. Percentage graft viability versus volume in adipose auto transplants. Aesthetic Plast Surg. 1994;18(1):17–9.

60 Buttocks Remodeling with Fat Transfer 15. Bruner TW, Roberts TLIII, Nguyen K. Complications of buttocks augmentation. Clin Plast Surg. 2006;33(3): 449–66. 16. Commons GW, Halperin BD. Considerations in large volume liposuction. Semin Plast Surg. 2002;16(2):143–52. 17. Baran CN, Celebioglu S, Sensoz O, Ulusoy G, Civelek B, Ortak T. The behavior of fat graft in recipient areas with enhanced vascularity. Plast Reconstr Surg. 2002;109(5): 1646–51. 18. Ersek RA. Transplantation of purified autologous fat: a 3-year follow-up is disappointing. Plast Reconstr Surg. 1991;87(2):219–27. 19. Chajchir A. Fat injection: long-term follow-up. Aesthetic Plast Surg. 1996;20(4):291–6.

615 20. Lewis CM. The current status of autologous fat grafting. Aesthetic Plast Surg. 1993;17(2):109–12. 21. Hudson DA, Lambert EV, Bloch CE. Site selection for fat autotransplantation: some observations. Aesthetic Plast Surg. 1990;14(3):195–7. 22. Wolf GA, Gallego S, Patron AS, Ramirez F, de Delgado JA, Echeverre A, Garcia MM. Magnetic resonance imaging assessment of gluteal fat grafts. Aesthetic Plast Surg. 2006; 30(4):460–8. 23. Ford RD, Simpson WD. Massive extravasation of traumatically ruptured buttock silicone prosthesis. Ann Plast Surg. 1992;29(1):86–8. 24. Buchuk L. Complications with gluteal prosthesis. Plast Reconstr Surg. 1986;77(6):1012.

Complications of Fat Transfer

61

Hassan Abbas Khawaja, Melvin A. Shiffman, Enrique Hernandez-Perez, José Enrique Hernández-Pérez, and Mauricio Hernandez-Perez

61.1 Introduction

There are many possible complications of fat transfer (Table 61.1).

fat very gently, placing it in small segments, in different layers, and in the subcutaneous tissue to prolong adipocyte survival. It should be injected beneath the gland and under and into the pectoralis major muscle in female breasts, and in the direction of gluteus maximus muscle in the buttocks. If tunnels are made into the donor area before injecting fat, with a blunt cannula, fat will not be squeezed into the area, and this prolongs survival. Fat should be injected while the operator is retrieving, not advancing the cannula, to avoid retrograde trauma. Heavy physical exercise should be avoided by patients who have undergone large volume fat transfer and facial expressions should be minimized for 1 week postoperatively in those undergoing facial fat transfer. Table 61.2 shows the degree of persistence of fat, according to facial and body locations.

61.2.1 Absorption

61.2.2 Infection

Absorption of fat takes place as a result of using damaged fat, bloody fat, infection, not following the correct technique, using machine with pressure above 25 in. of Hg for fat aspiration, and using fat from fibrous areas for transfer like the upper abdomen, upper back, and subscapular fat. The percentage of absorption varies from 0 to 70% [1, 2]. Generally, the authors recommend 30–50% overcorrection because of this. To achieve optimal results, it is necessary to manipulate

Primary infection can be avoided by following strict sterile aseptic operating room technique, peri-operative broad spectrum injectable antibiotics, and starting oral broad spectrum antibiotics 1 day before surgery and continuing for 7–10 days postoperatively. Preoperative tests should be done, especially complete blood count, fasting blood sugar, hepatitis B and C screening, and test for HIV. Blood borne secondary infection (bacteremia/septicemia) can settle in fat causing abscess formation. Any focus of infection in the body (e.g., tonsil or boil) should be treated accordingly. Recently, surgeons have been concerned about the occurrence of mycobacterial infections related to fat transfer. These problems took place as a result of poor

Fat transfer is a procedure that is more than a century old and has been extensively used in cosmetic and reconstructive surgery in the last three decades as a result of the introduction of liposuction. Physicians performing fat transfer must understand clearly the relevant anatomy, pathophysiology, and complications resulting from fat transfer use, their prevention, and treatment.

61.2 Complications

H. A. Khawaja (*) Cosmetic Surgery and Skin Center, 53 A, Block B II, Gulberg III, Lahore 54660, Pakistan e-mail: [email protected]

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_61, © Springer-Verlag Berlin Heidelberg 2010

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Table 61.1 Complications of fat transfer

61.2.2.1 Viral Infection/Warty Overgrowth

Complications of fat transfer Absorption

Pressure and avascular necrosis

Infection

Skin necrosis, sinus formation

Embolism

Hematoma, seroma, bloody fat

Cysts, pseudocysts, liponecrotic cysts

Skin pigmentation

Blindness

Pseudo-tumor

Lipomatous formation and lipomatosis

Calcification

Ossification

Masses

Traumatic fat necrosis (breast)

Asymmetry

Vascular and nerve injuries

Penile and urethral distortion

Cavernous sinus thrombosis

Volumetric hypertrophy

Remote lipomas

Calculi in the urinary tract

Table 61.2 Fat persistence according to site Fat persistence according to site Site

Longer

Nasolabial folds Malar areas

Shorter

Variable

* *

Cheeks

*

Marionette lines

*

Glabellar frown lines

*

Transverse forehead lines

*

Lips

*

Breasts

*

Dorsum of hands

*

Buttocks

*

Calves

*

Tissue defects

*

Male external genitals

*

Female external genitals

*

*Degree of persistence of fat according to location.

asepsis of the surgical instruments. Sterilization with liquids must be condemned. Metallic instruments have to be autoclaved and rubber tubes need gas sterilization. The best treatment is combination of antibiotics.

The authors have noticed warty overgrowths at the cannula entry points in some cases. Cautery of the wart is the only treatment that is required.

61.2.3 Embolism Excessive augmentation of the calves by fat can compress the greater or lesser saphenous vein or the vein linking the two systems resulting in the formation of a thrombus. A propagated clot of phlebothrombosis can likewise produce pulmonary thromboembolism [3]. Septic pulmonary emboli can be produced if infection takes place. Pulmonary infarction, progressive pulmonary hypertension (after recurrent episodes), and extensive mechanical obstruction (after a massive embolus) can occur. Platelets in the thrombus or embolus liberate 5-hydroxytryptamine or thromboxane, which cause spasm of pulmonary vessels [4]. The precise cause of death in many cases of this condition is not understood. Fat transferred to the calves should probably not exceed 60–100 mL on each side. Extremely careful antiseptic technique should be followed in these areas. Compression should not be applied to the calves postoperatively. In order to avoid embolism, fat should not be injected in a centripetal direction (toward the eye) in the peri-orbital area. In the dorsum of hands, injection should be opposite to the direction of venous blood flow and should be slow to avoid large spurts of fat. The fat transfer cannula should always be blunt, and approximately the size of a 14 gauge needle. The accidental opening of a large vein, such as the jugular, may allow air to be pulled in. If air is not taken out of the syringes, it can be injected subcutaneously giving a bubbly appearance to the subcutaneous tissue. In humans, the lethal amount of air injected into the vascular system is less than 9 mL/kg. The effects are very similar to massive pulmonary embolism. The characteristic churning noise that may be heard without the aid of a stethoscope serves to differentiate the two conditions clinically [4]. Careful preoperative marking of important blood vessels is very important. As a preventive measure, all patients should be referred to the cardiologist (regardless of the age) for a complete cardiac and vascular check up. Epinephrine

61 Complications of Fat Transfer

should be used for the procedure and sharp instruments should never be used for transfer.

61.2.4 Blindness Blindness can take place as a result of centripetal (needle pointing toward the eyeball) injection of fat around the orbit. If blunt instruments are not used for fat transfer around the orbit, penetrating injury to the eyeball can occur. Capsular penetration and deposition of hematoma, seroma, or fat deposits around the central retinal artery can lead to central retinal arterial thrombosis. Injection of fat into the glabellar frown lines has resulted in onset of pain and loss of vision in one eye while receiving the injection [5–7]. There was central retinal arterial thrombosis probably secondary to fat particle embolism. The authors recommend placement of centrifugal injections around the eyeball, use of a small blunt cannula, and preinjection marking of important blood vessels and nerves in this area to avoid this complication. Coleman [8] has suggested to limit bolus size, not use a sharp needle, limit syringe size, and not use a ratchet gun in order to avoid arterial emboli. However, venous fat emboli can occur from the glabellar area, rather than injection into the arterial system, and would result in the same blindness. Syringe pressure alone can cause the entry of fat into the vascular system. There have been reports not only of blindness, but also cerebral ischemia and brain damage following injection of fat into the glabellar area [9–13]. The author (MAS) has encountered a case of a female patient born in 1982 with severe cleft palate and cleft lip. Multiple procedures for repair were performed from age 3½ months to age 9. At age 15, she had advancement of the lower lateral cartilages for a deformed nasal tip, and at age 22, she had open nasal tip rhinoplasty. At age 24, she had injection under pressure of 0.5 mL of fat to her right nasal tip using an 18 gauge needle. Three to four minutes after the injection the patient lost vision in her right eye and her right pupil was dilated and there was numbness and weakness of the left arm and hand. She was noted to have left homonymous hemianopsia and developed ptosis and superior rectus muscle palsy indicating a left third nerve palsy. Fat venous emboli were seen in the central retinal veins. The origin of the emboli was most likely from pressure injection of the fat that entered torn veins in the field of needle insertion

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and not direct injection into a vein since aspiration prior to the injection of fat did not produce blood and the injection was in a retrograde manner while withdrawing the needle. There is an intimate connection of the venous supply of the nose to the retina via the ophthalmic veins and to the sagital sinus system that resulted in the visual and neurologic damage.

61.2.5 Cysts, Pseudocysts, and Lipo Necrotic Cysts Cysts are usually small and self-limited, especially on the face and dorsum of hands and male and female genitals. Moderate sized cysts can occur on the face, breasts, and calves in cases of moderate amount of fat transfer. Moderate to large-sized cysts can occur in cases of large fat transfer, especially in the breasts. For smaller cysts, intralesional triamcinolone injections can be used if they persist. Moderate and largesized cysts can be aspirated using a 2-mm cannula Bambi cannula. Posttreatment compression is used in cases of superficial cysts to obliterate the cyst wall. Johnson [14] showed that 1, 3, and 5 mL fat injections resulted in small cysts, but 10 mL injections resulted in macro cysts. Oil cysts occur through confluence of necrotic fat cells and have a lining of macrophages. Resorption may take years, thereby giving a false impression of a successful transplantation. Avoid too much injection of fat in one area to prevent oil cyst formation. For small volume fat transfer, Fischer’s [15] technique of rice grain-size facial fat transfer can be used, even for extra-facial areas. Castello et al. [16] reported a case of a large painful mass that was a large cyst with calcified capsule on mammogram that appeared 10 months after injection. This was excised. Mandrekas et al. [17] had a patient in which 40 mL of fat was injected into a defect in the left groin. Three months postoperatively, there was a mass in the groin at the site of the fat transfer. The mass was excised, and on histology, had mature fat cells and occasional fatty globules. Millard [18] reported liponecrotic cysts after augmentation mammaplasty with fat injections in a 26-year-old female that were later excised. Montanana Vizcaino et al. [19] reported a liponecrotic cyst after autologous fat transplantation. HarShai et al. [20] described a large lipo-necrotic pseudocyst formation after cheek augmentation by fat injection.

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61.2.6 Calcifications Calcifications can take place in localized areas of fat deposits or in cysts. In the female breasts, calcifications could be misdiagnosed as possible breast cancer. The timing of their appearance, their position, and character will indicate the cause. The size and form of these are quite different in the two entities, and they should not be confused by an experienced mammographer. Mic rocalcifications from fat necrosis are periparenchymal and do not exhibit multidensity, rod-like, punctate, or branching spicules [21]. Microcalcifications occur following breast augmentation with implants, open and closed capsulotomy, and breast reduction. Calcifications that remain stable can be observed. Delayed calcifications occurring months after the injection can be sampled by stereotactic core needle biopsy. Open biopsy is unnecessary, if the core shows benign tissue. Pulgam et al. [22] reported one case with bilateral palpable masses in the breasts after fat transfer. On mammography, there were calcified and noncalcified masses, and on ultrasound, hypo-echoic masses were noted that had mild to moderate acoustic enhancement and dense acoustic shadowing was seen. They also described one patient with fat injection for a defect in the breast after lumpectomy and irradiation. There developed a 2.5-cm palpable mass with eggshell peripheral calcification and calcifications within the oil cyst consistent with fat necrosis.

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blow or even indirect trauma (e.g., contraction of the pectoralis major muscle), an often painless lump appears [23]. The swelling is usually attached to the skin and nipple retraction can also take place, which may be misdiagnosed as carcinoma. However, history of fat transfer and injury should alert the clinician. On incising the lump, a chalky white area of necrotic fat is found. Fat injections should be placed beneath the gland and into and below the muscle in female breasts.

61.2.9 Skin Necrosis/Sinus Formation Overaugmentation can lead to this complication. Ten to twenty milliliter of fat is recommended for injection into the malar areas, lips, cheeks, and chin; 150– 350 mL for each side in female breasts; 100–150 mL per side in the buttocks in the direction of gluteus maximus muscle; 60–80 mL in male external genitals; 120 mL for female external genitals at three points: pubic area and two labia majora; 20–30 mL for each side in the dorsum of hands; and 60–100 mL each side for calves [24]. Excessive compression can lead to fat and skin necrosis with sinus formation (Fig. 61.1). Intraarterial injection of fat can result in tissue necrosis [7].

61.2.7 Ossification Calcification in fat deposits and cysts can proceed to ossification, especially if a hormonal abnormality exists. Trauma to fat cells is also a predisposing factor. In cases of cancellous type ossification, liposuction of the deposits usually results in a cure; however, in cases of cortical type ossification, surgical removal is the procedure of choice. In some of these cases, the benign ossific deposits should only be observed if they are symptomless.

61.2.8 Traumatic Fat Necrosis (Breast) Traumatic fat necrosis usually occurs in the breast, but can occur in any other area of fat transfer. Following a

Fig. 61.1 Sinus tract at cannula site

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Hematomas or seromas can take place if sharp 61.2.10 Compression Atrophy (Pressure instruments are used for fat transfer; postoperative coolNecrosis), and Avascular Necrosis Compression atrophy can take place in cases where mega fat transfer has been performed and excessive compression is applied to the area. It can also take place in areas where liposuction has been carried out and excessive compression is applied to the area. The lower abdomen is more vulnerable to pressure necrosis after liposuction, and excessive compression to this area should be avoided postoperatively. Pressure necrosis as a result of overaugmentation of fat or excessive compressive garments can lead to avascular necrosis (arterial/venous thrombosis) with its subsequent sequelae of infarction of important anatomical structures and motor nerve paresis or paralysis. It is best to limit overcorrection of fat up to 30–50%.

61.2.11 Asymmetry Asymmetry can take place in the nasolabial folds, malar areas, cheeks and chin, female breasts, buttocks, calves, and male and female external genitals. Asymmetry can be from incorrect technique, fat absorption, fat hypertrophy or atrophy, or incorrect application of external pressure garments. Lipo-aspiration is required for hypertrophy and atrophy and additional fat transfer is required for absorption. Correct fat transfer technique and application of external garments are also important factors in preventing asymmetry.

61.2.12 Bloody Fat, Hematomas, and Seromas Patients are asked to refrain from aspirin, beta-blockers, vitamin E preparations, nonsteroidal antiinflammatory drugs, and from smoking for at least 10 days before surgery. Coagulation tests are performed preoperatively. In the donor area, supertumescence should be used with chilled Klein’s solution. In the receptor area, 1% lidocaine plus 1:4,00,000 epinephrine should be used only in the incision sites with intravenous sedation (Midazolam plus Fentanil), if necessary.

ing is not done; in cases of arterial or venous damage; in patients taking a variety of allopathic, homeopathic or herbal drugs; and in patients with liver disorder, blood dyscrasia, or vascular disorder. Aspiration and compression of hematomas and seromas can be carried out. Aspiration and injection of room air can resolve chronic seromas [25].

61.2.13 Iatrogenic Iinjuries Facial nerve branches (temporal, zygomatic, buccal, marginal mandibular, and cervical), dorsal nerves in the penis, and nerves in other areas can get damaged during fat transfer. The area at greatest risk of damage is the temporal branch that can be easily avoided by drawing a mark from the ear lobe to the lateral edge of eyebrow and from the tragus to a point just above and behind the highest forehead crease. The approximate path of the ramus to the frontalis muscle can be made by drawing a line from 0.5 cm below the tragus to a point 1.5 cm above the lateral eyebrow. It is most vulnerable as it crosses the midzygomatic arch [26]. To avoid the temporal nerve, procedures should be superficial to the superficial temporal fascia. Over the buccal fat pad, the zygomatic and buccal branches are covered only by their fascia and the variable risorius muscle. Dissection in this area may damage the nerve branches, producing variable weakness of the affected muscles. The marginal mandibular nerve at the jawline near the facial artery and vein is covered only by the skin and platysma muscle, which in some patients may be thinned or atrophic. Temporal and marginal mandibular nerves are at highest risk because they have the least number of arborizations and cross-connections with themselves or adjoining nerves, and have long solitary thinned rami to their muscular destinations. Three types of nerve injuries can be sustained: neuropraxia, axontmesis, and neurotmesis. Fat transfer can compress the nerve producing neuropraxia. A wait and watch policy should be adopted. Because there is temporary physiological disruption in the nerve impulses, complete recovery takes place with the passage of time. If calcification takes place along the nerve, exploration should be done. Sharp instruments should not be used for transfer, and preoperative nerve mapping should be

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carried out to avoid these injuries. In cases of axontmesis and neurotmesis, electromyographic and nerve conduction studies should be carried out. In cases of complete transaction, nerve ends should be sought and end-to-end anastomosis carried out using epineural fine, nonabsorbable sutures. Preoperative percutaneous marking of the facial nerve and its branches is important in preventing damage [27]. The facial artery enters the face by winding round the base of the mandible and piercing the deep cervical fascia at the anteroinferior angle of the masseter muscle. It can be palpated here. First it runs upward and forward to a point half an inch lateral to the angle of mouth. Then it ascends by the side of the nose (angular artery) up to the medial angle of the eye where it terminates by supplying the lacrimal sac and anastomosis with the dorsal nasal branch of the ophthalmic artery. The extreme tortuosity of the artery prevents its walls from being unduly stretched during movements of the mandible, lips, and cheeks. It lies between the superficial and deep muscles of the face. The large anterior branches (superior and inferior labial, lateral nasal) anastomose with similar branches of the opposite side, and with the mental artery. In the lips, anastomoses are large, so that cut arteries spurt from both ends. The transverse facial artery (branch of the superficial temporal), after emerging from the parotid gland, runs forward over the masseter between the parotid duct and zygomatic arch, accompanied by the upper buccal branch of the facial nerve. It supplies the parotid gland and its duct, the masseter, and the overlying skin, and ends by anastomosing with neighboring arteries [28]. The veins of the face accompany the arteries, and drain into the common facial and retromandibular veins. They communicate with the cavernous sinus. The veins on each side form a W-shaped arrangement. Each corner of the W is prolonged upward into the scalp, and downward into the neck. The facial vein is the largest vein of the face. It begins at the angular vein at the medial angle of the eye and is formed by the union of supratrochlear and supraorbital veins. The angular vein continues as the facial vein, running downward and backward behind the facial artery with a straighter course. It crosses the anteroinferior angle of masseter, pierces the deep fascia, crosses the submandibular gland, and joins the anterior division of the retromandibular vein (below the angle of the mandible) to form the common facial vein. The latter drains into the internal jugular vein.

H. A. Khawaja et al.

Careful arterial and venous marking preoperatively in their entire course is very important to prevent vascular damage. Small blunt-tipped cannulas should be used for transfer. Needles should not be used for transfer. The facial vein communicates with the cavernous sinus through deep connections. The first is between the supraorbital and superior ophthalmic veins. The second is with the pterygoid plexus through the deep facial vein, which passes backward over the buccinator. Infections from the face can spread in a retrograde direction, and cause thrombosis of the cavernous sinus. This is especially likely to occur in the presence of infection in the upper lip, lower part of the nose, and adjoining nasolabial triangle. This area is, therefore, called the “Danger Area of Face” [28]. A characteristic picture results with blockage of the venous drainage of the orbit causing edema of the conjunctiva and eyelids, and marked exophthalmos, and transmitted pulsations from the internal carotid artery. Pressure on the contained cranial nerves results in ophthalmoplegia. Examination of the fundus shows papilledema, venous engorgement, and retinal hemorrhages resulting from the acutely obstructed venous drainage [28]. Very careful antiseptic technique should be followed in this area.

61.2.14 Lipomatous (Hypertrophy) Formation, Symmetrical/ Asymmetrical Lipomatosis Lipomatous formation can take place after fat transfer. Cases can occur in the glabella, lower lip, face, dorsum of hands, and penis (Fig. 61.2) [29–31]. This occurs usually after several months to years after initial fat transfer. Symmetrical and asymmetrical lipomatosis can take place in the breasts, gluteal region, and penis (Fig. 61.3). Fat hypertrophy/hyperplasia has been postulated as a cause of this lipomatous formation and lipomatosis, though the exact mechanism remains unknown. Postulated and predisposing causes include trauma to the fat cells, presence of adipocyte precursor cells in the donor area, abnormal blood supply or an aberrant development of blood vessels, neurogenic factors, rachet effect, dominant gene factor, hereditary, race, gender, corticosteroids, insulin, leptin and ob gene, neuropeptide, and a central lipostat (control

61 Complications of Fat Transfer

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Fig. 61.4 Breast masses bilaterally close to cannula entry points as a result of subcutaneous insertion of fat Fig. 61.2 Lipomatous (hypertrophy) formation after fat transfer above the left nasolabial fold and viral wart at the cannula entry point on the right cheek

Fig. 61.3 Lipomatosis (hypertrophy) in the penis after fat transfer

Fig. 61.5 Peri-orbital fatty mass as a result of fat injection that was more than the recommended amount

mechanism) regulating fat deposition and homeostasis. Lipoaspiration using syringe or suction machine usually results in a cure. In smaller cases, triamcinolone acetonide can be injected.

not deep between the gland and the muscle. These can also result when fat injection is more than the recommended amounts (Fig. 61.4). Peri-orbital masses can form also as a result of fat injections exceeding the recommended amounts (Fig. 61.5).The authors have seen metacarpal masses (lipomas) in some patients in whom more than 5 mL of fat is injected per metacarpal. These are more prominent at the metacarpophalengeal joint junctions. Masses are usually self-limiting. If a mass does not disappear after a while, triamcinolone acetonide can be injected that will result in its dissolution.

A Symmetrical Volumetric Hypertrophy The authors have had symmetrical volumetric hypertrophy of fat in the face of a patient who received fat injections twice in the malar areas and cheeks. Fat hypertrophied symmetrically in the form of layers above the SMAS. Fulton [32] reported the problem of breast enlargement following fat transfer to the breast. He attributed this enlargement to the liposuction as reported by Bissacia and Scarborough [33]. B Masses Breast masses appear as a result of incorrect fat injection technique when fat is injected subcutaneously, and

C Remote Lipomas Liquid fat can be displaced and form lipomas elsewhere, especially if fat transfer has been combined with another procedure in which undermining has been used. However, other remote lipomas after fat transfer are hard to explain.

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61.2.15 Penile/Urethral Distortion/ Calculi in the Urinary Tract Penile and urethral distortion can take place if proper technique is not followed while injecting fat, and if more than 100 mL of fat is injected in the penis (Fig. 61.6). In some areas, fat can accentuate giving the appearance of a lipomatous formation. Excess fat deposition along the urethral side and ventral base can lead to compression of urethra. The urethral distortion can lead to urinary symptoms like frequency of micturation, hesitancy, dribbling, distortion of the urinary stream, and poor urinary flow, and can predispose to primary urethral or urinary tract stone formation and stasis that can lead to primary urethral or retrograde infection in the urinary tract.

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61.2.16 Pseudotumor Pseudotumor as a result of edema, bruising, and irregularity of the transfer area can take place. Adequate surgical technique and postoperative cooling of the transplanted area prevent this.

61.2.17 Skin Pigmentation Hyperpigmentation of skin takes place if fat leaks out of the entry points as a result of suture(s) opening postoperatively. This pigmentation is more marked in darker complexioned people. This hyperpigmentation is treated with hydroquinone and sunscreens. It is usually self-limiting.

61.2.18 Fat Migration Excessive injection of fat in a single area, muscle action massaging the fat, external pressure from dressings or sleeping on the area of fat injection, and/or fat transfer to an area with loose skin and minimal fibrous tissue can result in fat migration. The forehead is particularly prone to fat migration, especially if fat is injected under the forehead lines and is pressed to smooth out the result. Some physicians use botulinum toxin injection to paralyze muscle action in the area of fat injection.

61.3 Conclusions

Fig. 61.6 Penile deviation as a result of uneven injection of fat

Fat transplantation is an important component of facial and body rejuvenation. In some cases it has to be repeated one or two times to achieve better results. It is safe in experienced hands. However, a number of complications can take place as a result of fat transfer. Some of these complications are lethal. Therefore, physicians performing fat transfer must understand in detail the relevant fat transfer anatomy, pathophysiology, and complications resulting from the techniques used and

61 Complications of Fat Transfer

their prevention and treatment. They must receive specific training programs from experienced physicians before performing fat transfer independently. Physicians performing fat transfer should be competent in preventing and treating fat transfer complications.

References 1. Bircoll M. A nine years experience with autologous fat transplantation. Am J Cosmet Surg. 1992;9:55–9. 2. Shiffman MA. Principles of autologous fat transplantation. In: Shiffman MA, editor. Autologous fat transplantation. New York: Marcel Dekker; 2001. p. 5–22. 3. Alexander RW. Guidelines for autologous fat transfer. In: Shiffman MA, editor. Autologous fat transplantation. New York: Marcel Dekker; 2001. p. 23–30. 4. Walter JB, Israel MS. General pathology. 6th ed. Edinburgh: Churchill Livingstone; 1987. p. 538–42. 5. Coiffman F. Lipoinjection complications. In: Hinderer U (ed), Plastic Surgery 1992, Vol II. Amsterdam: Excerpta Medica; 1992. p. 759–60. 6. Teimourian B. Blindness following fat injection. Plast Reconstr Surg. 1988;82(2):361. 7. Dreizen NG, Framm L. Sudden unilateral visual loss after autologous fat injection into the glabellar area. Am J Ophthalmol. 1989;107(1):85–7. 8. Coleman SR. Problems, complications, and postprocedure care. In: Coleman SR, editor. Structural fat grafting. St. Louis: Quality Medical Publishing; 2004. p. 75–102. 9. Egido JA, Arroyo R, Marcos A, Jimenez-Alfaro I. Middle cerebral artery embolism and unilateral visual loss after autologous fat injection into the glabellar area. Stroke 1993;24(4):615–6. 10. Feinendegen DL, Baumgartner RW, Schroth G, Mattle HP, Tschopp H. Middle cerebral artery occlusion and ocular fat embolism after autologous fat injection in the face. J Neurol. 1998;245(1):53–4. 11. Danesh-Meyer HV, Savino PJ, Sergott RC. Case reports and small case series: ocular and cerebral ischemia following facial injection of autologous fat. Arch Ophthalmol. 2001;119(5):777–8. 12. Thaunat O, Thaler F, Loirat P, Decrois JP, Boulin A. Cerebral fat embolism induced by facial fat injection. Plast Reconstr Surg. 2004;113(7):2235–6. 13. Yoon SS, Chang DI, Chung KC. Acute fatal stroke immediately following autologous fat injection into the face. Neurology 2003;61(8):1151–2. 14. Johnson G. Autologous fat graft by injection: ten years experience. Am J Cosmet Surg. 1992;9:61–5.

625 15. Fischer G. Fat transfer with rice grain-size parcels. In: Shiffman MA, editors. Autologous fat transplantation. New York: Marcel Dekker; 2001. p. 55–63. 16. Castello JR, Barros J, Vazquez R. Giant liponecrotic pseudocyst after breast augmentation by fat injection. Plast Reconstr Surg. 1999;103(1):291–3. 17. Mandrekas AD, Zambacos GJ, Kittas C. Cyst formation after fat injection. Plast Reconstr Surg. 1998;102(5):1708–9. 18. Millard GF. Liponecrotic cyst after augmentation mammaplasty with fat injections. Aesthetic Plast Surg. 1994; 18(4):405–6. 19. Montanana Vizcaino J, Baena Montilla P, Benito Ruiz J. Complications of autografting fat obtained by liposuction. Plast Reconstr Surg. 1990;85(4):638–89. 20. Har-Shai Y, Lindenbaum E, Ben-Itzhak O, Hirschowitz B. Large liponecrotic pseudocyst formation following cheek augmentation by fat injection. Aesthetic Plast Surg. 1996;20(5):417–9. 21. Bircoll M. Autologous fat transplantation: an evaluation of microcalcification and fat cell survivability following (AFT) cosmetic breast augmentation. Am J Cosmet Surg. 1988; 5:283–8. 22. Pulgam SR, Poulton T, Mamounas EP. Long term clinical and radiologic results with autologous fat transplantation for breast augmentation: case reports and review of literature. Breast J. 2006;12(1):63–5. 23. Mann CV, Russell RCG. Bailey and love’s short practice of surgery, 21st ed. London: Chapman and Hall; 1992. p. 793–4. 24. Hernandez-Perez E. Practice perspectives: fat injection in different parts of the body. Dermatol Nurs. 1998;10:135–8. 25. Shiffman MA. Seromas in cosmetic surgery. Int J Cosmet Surg Aesthet Derm. 2002;4(4):293. 26. Salasche SJ, Bernstein G. Surgical anatomy of the skin. 1st ed. Connecticut: Appleton and Lange, 1988. p. 89–139. 27. Park JI. Preoperative percutaneous facial nerve mapping. Plast Reconstr Surg. 1998;101(2):269–77. 28. Chaurasia BD. Human anatomy regional and applied. 2nd ed. Delhi: Jain Bhawan; 1992. p. 39–49. 29. Khawaja HA, Hernandez-Perez E. Lipomatose formation after fat transfer-a report of 2 cases. Int J Cosmet Surg. 1998–1999;6(2):144–5. 30. Miller JJ, Popp JC. Fat hypertrophy after autologous fat transfer. Ophthal Plast Reconstr Surg. 2008;18(3):228–31. 31. Guaraldi G, Fazio ODE, Orlando MD, Murri R, Wu A, Guaraldi P, Esposito R. Facial hypertrophy in HIV-infected subjects who undergo autologous fat tissue transplantation. Clin Infect Dis. 2005;40(2):e13–15. 32. Fulton JE. Breast contouring with “gelled” autologous fat: a 10-year update. Int J Cosmet Surg Aesthet Dermatol. 2003;5(2):155–63. 33. Bissacia E, Scarborough DA. Breast enlargement after liposuction. Am J Cosmet Surg. 1990;7(2):97–8.

Part Body Contouring After Severe Weight Loss

VII

History of Bariatric Surgery

62

Melvin A. Shiffman

62.1 Introduction In order to understand bariatric surgery one has to be knowledgeable about the history of how bariatric surgery developed and the problems that were encountered in that development. Bariatric surgery has many risks and complications. Some of these complications persist after bariatric surgery and, therefore, may impinge on any future surgery, especially body contouring procedures that are elective surgeries.

62.2 History Linner [1] described his experience with Kremen in evaluating the absorption of nutrients of the small intestine of dogs. Ultimately, an article was published by Kremen et al. [2] on the nutritional importance of the proximal and distal small intestine and the first jejunoileal bypass for weight loss was reported (Fig. 62.1) [2]. The ultimate small bowel length was 12–14 cm jejunum attached to 4 cm of terminal ileum. The jejunocolic bypass was reported by Payne et al. [3]. There were some problems following jejunoileal and jejunocolic bypasses that included diarrhea, steatorrhea, nephrolithiasis, sometimes deficiencies of potassium and calcium, and occasional cases of hepatic failure [4, 5]. The gastric bypass was developed by Mason [6], which consisted of stapling the stomach and using the small intestine for bypass. There were fewer complications than with jejunoileal bypass.

M. A. Shiffman 17501 Chatham Drive, Tustin, CA 92780-2302, USA e-mail: [email protected]

Fig. 62.1 First jejunoileal bypass for weight loss by Kremen et al. [2]

The horizontal gastroplasty of Printon and Mason [7] with staples was achieved because of the development of a variety of staple devices.

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Fig. 62.3 Vertical banded gastroplasty reported by Mason [12]

Fig. 62.2 Biliopancreatic diversion by Scopinaro et al. [8]

Biliopancreatic diversion (Fig. 62.2) by Scopinaro et al. [8] produced malabsorption of nutrients, but reduced the development of liver cirrhosis from intestinal stasis and bacterial overgrowth. Gastric partitioning by Pace et al. [9] created a small gastric pouch that reduced feelings of hunger. The silastic ring gastroplasty was developed by Laws and Piantadosi [10] and the 5-year experience was reported by Eckhout et al. in 1986 [11]. The vertical banded gastroplasty was reported by Mason (Fig. 62.3) [12], which was the most often used procedure when reinforced with polypropylene mesh to prevent stoma stretching. Gastric bypass with Roux-en-Y gastrojejunostomy was devised by Torres et al. [13]. The procedure was best for patients with a body mass index (BMI) exceeding 50 kg/m2 [14]. Granstrom and Bachman [15] successively decreased the gastric band tension to reduce vomiting, but there was less weight loss.

Fig. 62.4 Gastroplasty with gastric banding with an inflatable band was developed by Kuzmak et al. [16, 17]

Gastroplasty with gastric banding with an inflatable band was developed by Kuzmak et al. [16, 17] (Fig. 62.4). This needed a high degree of patient compliance. Biliopancreatic diversion with duodenal switch was first reported by Hess and Hess [18]. This eliminated

62 History of Bariatric Surgery

Fig. 62.5 Laparoscopic Roux-en-Y gastric bypass was reported by Wittgrove et al. [20]

gastric ulcers and the dumping syndrome. The procedure is reserved for the superobese patient [19]. Laparoscopic Roux-en-Y gastric bypass (Fig. 62.5) was reported by Wittgrove et al. [20]. The laparoscopic approach reduced complications [21]. In 2005, 73.5% of bariatric surgery was with laparoscopic technique compared to 56.1% in 2003 [22] There was, however, a higher risk of anastomotic stricture and internal hernia leading to bowel obstruction than with the open procedure [23]. Rutledge [24] first reported on the mini-gastric bypass in 2001. This consisted of a laparoscopic approach to create a small gastric pouch lower than previous techniques and anastamosing a loop of small bowel to provide a malabsorption effect (similar to Roux-en-Y) (Fig. 62.6). The two-stage procedure for high-risk patients with BMI exceeding 60 kg/m2 starts with a sleeve gastrectomy, and after a 200 lb weight loss conversion, leads to a duodenal switch or Roux-en-Y gastric bypass [25].

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Fig. 62.6 Rutledge [24] first reported on the mini-gastric bypass which consisted of a laparoscopic approach to create a small gastric pouch lower than previous techniques and anastamosing a loop of small bowel to provide a malabsorption effect (similar to Roux-en-Y)

62.3 Discussion Possible complications of the bypass procedures include anastomotic leak, bowel obstruction, electrolyte disturbance, anemia, vitamin deficiency, pulmonary embolus, cirrhosis, liver failure, pneumonia, nausea and vomiting, bile reflux, obstruction, and death. The development of the different procedures was an attempt to reduce complications and obtain adequate weight loss. There is a variety of weight loss depending on the type of procedure. Laparoscopic techniques reduced the postoperative pain and avoided a large scar. Sometimes, reversal of or change of the type of the procedure has to be performed because of the severity of the prolonged complications. Although most postbariatric patients consider plastic surgery, 15% will have body contouring surgery [26].

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References 1. Linner JH. Early history of bariatric surgery. Surg Obes Relat Dis. 2007;3(5):569–70. 2. Kremen AJ, Linner JH, Nelson CH. An experimental evaluation of the nutritional importance of proximal and distal small intestine. Ann Surg. 1954;140(3):439–48. 3. Payne JH, Dewind LT, Commons RR. Metabolic observations in patients with jejunocolic shunts. Am J Surg. 1963;106:273–89. 4. Buchwald H, Rucker RD. The rise and fall of jejunoileal bypass. In: Nelson R, Nyhus LM, editors. Surgery of the small intestine. Norwalk: Appleton & Crofts; 1987. p. 529–41. 5. Deitel M. Jejunocolic and jejunoileal bypass: an historical perspective. In: Dietel M, editor. Surgery for the morbidly obese patient. Philadelphia: Lea & Febiger; 1998. p. 81–9. 6. Mason EE, Ito C. Gastric bypass in obesity. Surg Clin North Am. 1967;47(6):1345–51. 7. Printon JJ, Mason EF. Gastric surgery for relief of morbid obesity. Arch Surg. 1973;106(4):428–31. 8. Scopinaro N, Gianetta E, Pandolfo N, Anfossi A, Berretti B, Bachi V. Bilio-pancreatic bypass. Proposal and preliminary experimental study of a new type of operation for the functional surgical treatment of obesity. Minerva Chir. 1976;31(10):560–6. 9. Pace WG, Martin EW Jr, Tetirick T, Fabri PJ, Carey LC. Gastric partitioning for morbid obesity. Arch Surg. 1979; 190(3):392–400. 10. Laws HL, Piantadosi S. Superior gastric reduction procedure for morbid obesity: a prospective, randomized trial. Ann Surg. 1981;193(3):334–40. 11. Eckhout GV, Willbanks OL, Moore JT. Vertical ring gastroplasty for morbid obesity. Five year experience with 1,463 patients. Am J Surg. 1986;152(6):713–6. 12. Mason EE. Vertical banded gastroplasty for obesity. Arch Surg. 1982;117(5):701–6.

M. A. Shiffman 13. Torres JC, Oca CF, Garrison RN. Gastric bypass Rouz-en-Y gastrojejunostomy from the lesser curvature. South Med J. 1983;76(10):1217–21. 14. MacLean LD, Rhode BM, Nohr CW. Late outcome of isolated gastric bypass. Ann Surg. 2000;231(4):524–8. 15. Granstrom L, Bachman L. Weight loss and some metabolic consequences of gastric banding with different band tensions. Acta Chir Scand. 1987;153(2):113–7. 16. Kuzmak LI, Yap IS, McGuire L, Dixon JS, Young MP. Surgery for morbid obesity. Using an inflatable gastric band. AORN J. 1990;51(5):1307–24. 17. Kuzmak LI. A review of seven years’ experience with silicone gastric banding. Obes Surg. 1991;1(4):403–8. 18. Hess DS, Hess DW. Biliopancreatic diversion with a duodenal switch. Obes Surg. 1998;8(3):267–82. 19. Scopinaro N, Gianetta E, Civalleri D, Bonalumi U, Bachi V. Two years of clinical experience with biliopancreatic bypass for obesity. Am J Clin Nutr. 1980;33(2 Suppl):506–14. 20. Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases. Obes Surg. 1994;4(4):353–7. 21. Schauer PR, Ikramuddin S, Gourash W, Ramanathan R, Luketich J. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg. 2000;232(4):515–29. 22. American Society for Bariatric Surgery, Gainsville FL. 23. Rogula T, Brethauer SA, Thodiyil PA et al,. Current status of laparoscopic gastric bypass. In: Buchwald H, Cowan GS Jr, Pories W, editors. Philadelphia: Elsevier; 2007. p. 191–203. 24. Rutledge R. The mini-gastric bypass: experience with the first 1,274 cases. Obes Surg. 2001;11(3):276–80. 25. Regan JP, Inabnet WB, Gagner M, Pomp A. Early experience with the two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg. 2003;13(6):861–4. 26. Matarasso A, Roslin MS, Kurian M: Plastic Surgery Educational Foundation Technology Assessment Committee. Bariatric surgery: an overview of obesity surgery. Plast Reconstr Surg. 2007;119(4):1357–62.

Psychosocial Aspects of Body Contouring Surgery After Bariatric Surgery

63

Troy W. Ertelt, Joanna M. Marino, and James E. Mitchell

63.1 Introduction Obesity is widely recognized as a serious public health problem both in the United States and, increasingly, throughout the world. In the United States, nearly onethird of the adult population is obese, having a body mass index (BMI) of 30 kg/m2 or greater [1]. As the rate of obesity among adults continues to rise, so does the rate of overweight and obesity among children and adolescents [1], suggesting that the problems associated with obesity will continue to be causes for concern for some time to come. A large number of dietary, pharmacological, and counseling techniques have been used as interventions for overweight and obese individuals; however, the weight loss experienced from these interventions is often modest, and in many cases, postintervention weight gain is experienced. The use of bariatric surgery in the treatment of obesity has become increasingly common. Bariatric surgery is indicated for patients with a BMI that exceeds 40 kg/m2 or for patients with a BMI greater than 35 kg/m2 who also have serious associated health problems. Depending on the specific procedure, patients undergoing bariatric surgery can expect to lose between 40 and 60% of their excess body weight within the first 2 years after surgery [2]. From 1998 to 2002, the rate of bariatric surgery increased from 7.0 per 1,00,000 adult patients to 38.6 per 1,00,000 adult patients [3]. An estimated, 1,40,000 bariatric surgeries were performed in the United States in 2004 [2]. Given the current evidence, bariatric surgery appears to be the most effective

T. W. Ertelt (*) Neuropsychiatric Research Institute, 120, 8th Street South, Fargo, ND 58102, USA e-mail: [email protected]

treatment available to combat severe obesity and its related health consequences [2]. Although bariatric surgery is generally successful in leading to substantial weight loss and resolution of various medical comorbidities, a notable proportion of patients desire and, in some cases, require further surgical intervention in the form of body contouring surgery. The massive weight loss associated with bariatric surgery can lead to hanging redundant skin in one or more body areas, and this hanging redundant skin can be both aesthetically displeasing as well as medically problematic [4]. The American Society of Plastic Surgeons reported that 68,134 patients underwent body contouring surgery following bariatric surgery and its associated weight loss during 2005 [5]. Additional investigations have observed that as many as 83% of bariatric surgery patients desire body contouring surgery after massive weight loss [6]. Thus, it should be clear that for many obese patients who seek surgical intervention, bariatric surgery might be the first step in a series of surgical procedures that restore both the patient’s health and physical appearance.

63.2 Clinical Case Example Sandy is a 44-year-old Caucasian woman. She has been married for 14 years and has two children in elementary school. Sandy is employed as a receptionist at a local law firm. Throughout her life, Sandy has struggled with her weight. Beginning in high school and throughout her 20s, Sandy tried a number of fad diets to lose weight, but she experienced only limited success and would always regain any weight she lost within a short time. Sandy’s weight increased markedly after the birth of her second child when she was 34-years-old. During her pregnancy, Sandy found herself snacking throughout

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the day. Sometimes, she would have cravings for specific foods such as her favorite ice cream or potato chips, and upon returning home from work, she would eat an entire bag of potato chips or nearly a full container of ice cream. Although this was more food than most people would consume in a given period of time, Sandy never felt as though she was out of control when eating her favorite foods following a craving. As Sandy approached 40-years-, she began to experience a number of problems due to her increasing weight. She was unable to play with her children the way she wanted and found herself becoming frequently fatigued from limited exertion. Additionally, Sandy was diagnosed with both hypertension and obstructive sleep apnea. These limitations in Sandy’s daily living and her health problems led to increasingly frequent periods of depressed mood and hypersomnia. Knowing that Sandy had been unsuccessful with previous weight loss attempts, Sandy’s primary care physician informed her of surgical weight management options. After receiving a referral from her primary care physician, Sandy met with a bariatric surgeon who suggested the laproscopic adjustable gastric band procedure for her. After considering her options, Sandy agreed to the surgery. Sandy’s BMI was 37 kg/m2 before undergoing surgery. Today, just over 3 years after surgery, Sandy is generally happy with the outcome of bariatric surgery. She has lost nearly half of her excess body weight and no longer suffers from hypertension or obstructive sleep apnea. However, Sandy is unhappy with hanging skin that has formed on both her upper arms and on her abdomen area. She feels self-conscious about this extra skin and wears loose fitting clothing so that the skin would not be noticeable. During a routine follow-up appointment with her bariatric surgeon, Sandy expresses her dissatisfaction about this hanging skin. Sandy is referred to a plastic surgeon to discuss the possibility of undergoing body contouring surgery.

63.3 Psychosocial Factors in Bariatric Surgery Patients Relevant to Body Contouring Surgery Psychopathology among bariatric surgery candidates has received considerable attention in the literature. One recent study stated that 64% of candidates for

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bariatric surgery met diagnostic criteria for a current or lifetime psychiatric diagnosis [7]. Although plastic and reconstructive surgeons might not specifically address psychopathology in these patients, some specific areas of psychosocial functioning are important to understand when working with patients in this population. Binge eating disorder (BED) is the most commonly diagnosed eating disorder in bariatric surgery patients [8]. The core of BED is characterized by eating large amounts of food in a 2-h period during which time the individual experiences feelings of loss of control [9]. Estimates of the prevalence of BED among bariatric surgery patients have varied greatly. Some investigations have indicated that one-third of bariatric surgery candidates met criteria for BED [10, 11]. However, more recent investigation using more stringent diagnostic criteria has indicated a more conservative rate of 4.2% [12]. While meeting full diagnostic criteria for BED among bariatric surgery candidates might be less common than initially suggested, binge eating behavior might still be present in these individuals. Some studies have observed that one-half of bariatric surgery candidates engaged in binge eating behavior, but did not meet diagnostic criteria for BED [13, 14]. Additional investigations have also reported a high percentage of grazing (i.e., continuous eating over extended periods of time) among candidates for bariatric surgery [14]. Although some of these disordered eating behaviors may not meet criteria for a specific psychiatric diagnosis, their presence in postoperative bariatric surgery patients can lead to weight regain [15]. Weight regain, in turn, affects decisions about body contouring surgery because of the importance of weight stability prior to undergoing body contouring surgery. One area of psychosocial functioning in bariatric surgery patients that has received limited research attention is the area of body image. Some suggest that body image dissatisfaction is an important factor for patients in seeking bariatric surgery [16]. Some investigations have reported that ratings of body image improve substantially after bariatric surgery [17, 18]. However, these gains in body image satisfaction might be reduced due to hanging redundant skin that forms after massive weight loss. The relationship between hanging redundant skin and body image in postoperative bariatric surgery patients has not been examined empirically. However, since body image concerns are central in decisions about undergoing bariatric surgery,

63 Psychosocial Aspects of Body Contouring Surgery After Bariatric Surgery

it stands to reason that body image dissatisfaction due to hanging redundant skin is a primary impetus behind seeking contouring surgery. When Sandy met with her plastic surgeon, she had a number of questions about the procedures that could improve the appearance of her upper arms and abdomen area. Sandy’s plastic surgeon also had a number of questions for Sandy regarding her history with regard to her weight and eating behavior. Sandy’s plastic surgeon learned that Sandy’s weight had been generally stable for the past 6 months and that Sandy had not regained any weight since having her bariatric surgery. Sandy explained that she has been successful in avoiding weight regain because she has followed a dietician’s suggestions to improve her eating habits and has continued to work closely with a dietician since her surgery. Sandy’s surgeon asked her about her reasons for seeking bariatric surgery, and Sandy indicated that she wanted to improve her health and quality of life. However, Sandy also stated that she wanted to feel better about the way she looked and feels much better about her appearance since undergoing bariatric surgery. The hanging redundant skin that has developed due to the massive weight loss has, however, made Sandy self-conscious about her appearance, and the skin has affected the exercise plan Sandy implemented after bariatric surgery due to excessive rubbing and subsequent painful rashes. She stated that she would like to do whatever is possible to make her upper arms and abdomen area look better and keep hanging redundant skin from interfering in her daily activities.

63.4 Presurgical Considerations in Body Contouring Surgery with Bariatric Surgery Patients A number of other issues are important for plastic and reconstructive surgeons to address when working with postoperative bariatric surgery patients seeking body contouring surgery. Careful attention to these factors can improve the experience for the patient as well as streamline the process for the surgeon. One of the first and most important issues to address in the initial consultation is the length of time and number of surgeries that might be required to reach desired

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results. In some cases, it appears that the best results are obtained by conducting body contouring procedures in stages [19]. Some have suggested that this process can take between 2 and 3 years to be complete [20]. Patients should be aware of these issues early on the process. In today’s healthcare climate, this is particularly true because third party payors are generally unlikely to cover most body contouring surgeries conducted after bariatric surgery [6]. In fact, discussion about the possible need for body contouring before weight loss surgery may be indicated. A related issue that should be addressed early on is that of patient expectations. It is important that patients are aware of the limitations of body contouring procedures. In some cases, it is necessary to explain to patients that their body will likely never look as though it has not undergone rapid, massive weight loss [19]. Paying close attention to patient expectations early on can help to alleviate later complaints of dissatisfaction with the procedure. A final issue of importance early on in treatment is obtaining informed consent for the procedures [21]. Informed consent ultimately includes the aforementioned information about staging, length of time, expectations, and limitations, but should also discuss other pertinent issues such as the likelihood and number of scars and the potential for complications [21]. One useful suggestion in obtaining informed consent is not only showing photographs of previous work, but also making sure that the photographs represent a range of results, from problematic to desirable [19]. This might temper unrealistic expectations and prepare patients for the realities of body shape and scarring after body contouring. Finally, plastic and reconstructive surgeons should stress the importance of weight maintenance and explain how weight regain can negatively affect body contouring. Table 63.1 provides a checklist of specific items that should be addressed in initial consultations with postoperative bariatric surgery patients. During her initial consultation, Sandy’s plastic surgeon explains to her some of the benefits and risks associated with body contouring procedures to improve the appearance of her upper arms and abdominal area. Sandy was unaware that body contouring procedures might take a substantial investment of time and take place in stages. Also, Sandy was a bit disappointed by some of the results that the surgeon showed her, but ultimately felt that these results were preferable to her

636 Table 63.1 Checklist of items to assess and discuss during initial consultation with postoperative bariatric surgery patients Weight stability Patient should maintain a stable weight for 3 to 6 months before undergoing surgery. Weight reaches a plateau and starts to rise between 18 and 24 months postoperation. Presence of eating pathology Postoperative eating pathology likely leads to weight regain and less than optimal outcome for body contouring surgery. Reasons for seeking body contouring surgery Expectations of body contouring surgery Current body image concerns related to hanging redundant skin Discuss staging of procedures Discuss length of time involved in procedures Discuss scarring Discuss other potential complications Discuss payment and insurance

current appearance. She was willing to accept some of these drawbacks, but she had some concerns over the costs, as her insurer does not cover body contouring procedures. Even though she has a strong desire to undergo body contouring, she does not currently have a medically necessary reason to do so and has to discuss the potential costs with her spouse.

63.5 Desire for Body Contouring Surgery Among Bariatric Surgery Patients Literature on body contouring surgery in postoperative bariatric surgery patients is in the very early stages, especially literature detailing the psychosocial aspects involved in the surgery. However, one recent investigation of postoperative bariatric surgery patients provided useful information about several issues relating to body contouring surgery including patient’s desire for body contouring surgery [6]. This study is useful in explaining additional, previously unexamined, aspects of the relationship between bariatric surgery and body contouring surgery. In the study by Mitchell and colleagues [6], 70 participants were surveyed 6–10 years after undergoing bariatric

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surgery. The participants completed an assessment instrument developed specifically for the study called the Postbariatric Surgery Appearance Questionnaire, which has subsequently been revised, and is appended to this chapter. This questionnaire contained items relating to cosmetic and body contouring issues that arose after bariatric surgery. Participants were asked to rate their overall appearance from extremely unattractive to extremely attractive, and those participants who underwent body contouring surgery were asked to rate the attractiveness of the contoured area on the same scale. When rating their overall attractiveness, participants’ responses fell in the range between neutral to somewhat attractive. However, when rating contoured areas, responses tended to be in the direction of unattractive. Participants were also asked to rate their satisfaction with the skin in specific body areas including the face, chest/breast, upper arms, wait/abdomen, thighs, and rear/buttocks. In making these ratings, participants generally indicated that they were satisfied with the hanging skin in their facial areas. However, marked dissatisfaction was observed with other body areas, most notably the waist/ abdomen (nearly 70% dissatisfied) followed by the upper arms (between 60 and 70% dissatisfied), thighs (60% dissatisfied), rear/buttocks (60% dissatisfied), and chest/breast (nearly 50% dissatisfied). All of these body areas had more ratings of dissatisfaction than satisfaction. Overall, this information suggests dissatisfaction with several body areas, in some cases, even after body contouring. Less than half the sample, approximately 47%, reported having body contouring surgery. The most commonly reported procedure was abdominoplasty, but other procedures, including breast lifts and thigh lifts, were also reported. On the other hand, 83% of the sample reported a desire to undergo body contouring surgery. The waist/abdomen area was identified as the area where participants had the greatest desire for body contouring, and the face was identified as the area where participants expressed the least interest in body contouring. These ratings of desire are consistent with the aforementioned ratings of body area satisfaction, and the high ratings of desire for body contouring in the waist/abdomen area are consistent with the finding that abdominoplasty was the most commonly performed procedure. One of the most striking findings of the study was the number of participants who indicated that they

63 Psychosocial Aspects of Body Contouring Surgery After Bariatric Surgery

desired body contouring surgery, but did not get it. This was likely due to limited financial means and the unwillingness of third party payors to reimburse for the procedures. Although some body contouring procedures were paid for by third party payors, these accounted for around one-half of abdominoplasties and one-third of breast lifts. All other procedures were paid for out-of-pocket by patients.

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Ethnicity: _____ Caucasian _____ African–American _____ Native American _____ Asian American _____ Hispanic American _____ Other: _________________________

Marital Status (please check one):

63.6 Conclusions As the use of bariatric surgery as a means of weight management continues to grow, a parallel increase in body contouring surgery following massive weight loss can be expected. The preceding chapter summarized current knowledge of bariatric surgery patients as it pertains to plastic and reconstructive surgeons. Although specific procedural information has been outlined in the literature, considerably less information is available about the psychosocial aspects involved in body contouring surgery in postoperative bariatric surgery patients. Further research into these aspects of the surgery is needed in order to ensure the best patient care and most beneficial outcomes possible.

63.7 Appendix A. Postbariatric Surgery Appearance Questionnaire

_____ Single _____ Married _____ Divorced _____ Separated _____ Widowed _____ Living with Significant Other

How many years of education have you completed? (circle one) 8

9

10

11

12

13

14

15

16

17

18

19

20

21

22 +

Average Annual Household Income (check one):

The questions that you are being asked about deal with your satisfaction with your appearance since undergoing bariatric surgery. Some of the items ask for general ratings of overall appearance satisfaction, while others ask you about specific body parts. Other items focus specifically on problems encountered by people after weight loss surgery which result from the weight loss. Date:_____________________

Age: __________

Sex:

_____ Female _____ Male

_____ less than $25,000

_____ $150,000 – 175,000

_____ $25,000 – 50,000

_____ $175,000 – 200,000

_____ $50,000 – 75,000

_____ $200,000 – 225,000

_____ $75,000 – 100,000

_____ $225,000 – 250,000

_____ $100,000 – 125,000

_____ $250,000 or more

_____ $125,000 – 150,000

Appearance Evaluation: On a scale from 1 to 9, with 1 being extremely unattractive and 9 being extremely attractive, how would you rate your overall appearance? (circle one) 1

2

3

4

5

6

7

8

9

Extremely

Extremely

Unattractive

Attractive

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1. What is your current height _____________ft. ____________inches? 2. What was your weight just prior to undergoing bariatric surgery? ______________ lbs. 3. What was the lowest weight you achieved after bariatric surgery? ___________ lbs. 4. What is your current weight? _____________ lbs. 5. When did you have bariatric surgery performed? _______ month ________ year 6. What is your current age? _____________ years 7. What was your weight at age 18?_____________lbs. 8. Were you overweight as a child? Yes/No 9. Were you overweight as an adolescent? Yes/No If you have had cosmetic surgery on this body area what was your level of satisfaction with the excess skin in this area prior to cosmetic surgery? (1) very dissatisfied; (2)

If you have not had cosmetic surgery in this body area, how much do you desire to have cosmetic surgery done in this body area? (1)

If you have not had contouring surgery in this body area have you had problems with developing rashes or open sores in this

Yes No

N/A 1 2 3 4 5 6 7

1234

Yes No

If you had cosmetic surgery in this body area did a third party payor (3rd) pay for the surgery or did you pay 3rd OOP

___/___

Yes No

N/A 1 2 3 4 5 6 7

1234

Yes No

3rd OOP

___/___

Yes No

N/A 1 2 3 4 5 6 7

1234

Yes No

3rd OOP

___/___

Yes No

N/A 1 2 3 4 5 6 7

1234

Yes No

3rd OOP

___/___

Yes No

N/A 1 2 3 4 5 6 7

1234

Yes No

3rd OOP

___/___

Yes No

N/A 1 2 3 4 5 6 7

1234

Yes No

3rd OOP

___/___

Yes No

N/A 1 2 3 4 5 6 7

1234

Yes No

3rd OOP

___/___

Rear/ 1234567 buttocks

Yes No

N/A 1 2 3 4 5 6 7

1234

Yes No

3rd OOP

___/___

Thighs

Yes No

N/A 1 2 3 4 5 6 7

1234

Yes No

3rd OOP

___/___

Yes No

N/A 1 2 3 4 5 6 7

1234

Yes No

3rd OOP

Face

What is your current level of satisfaction with the excess skin in this body area? (1) very dissatisfied; (2) dissatisfied; (3) somewhat dissatisfied; (4)

Have you had cosmetic surgery in this body area since you received bariatric surgery? (Yes or No)

1234567

Upper Arms

1234567

Upper Back

1234567

Chin/ neck

1234567

Chest/ breasts

1234567

Waist/ abdomen

1234567

Lower back

1234567

1234567

Lower 1234567 body lift

(If yes, month/ year of surgery)

___/___

63 Psychosocial Aspects of Body Contouring Surgery After Bariatric Surgery

References 1. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999–2004. JAMA 2006;295(13):1549–55. 2. Maggard MA, Shugarman LR, Suttorp M, Maglione M, Sugerman HJ, Livingston EH, Nguyen NT, Li Z, Mojica WA, Hilton L, Rhodes S, Morton SC, Shekelle PG. Meta-analysis: surgical treatment of obesity. Ann Intern Med. 2005; 142(7):547–59. 3. Smoot TM, Xu P, Hilsenrath P, Kuppersmith NC, Singh KP. Gastric bypass in the United States, 1998–2002. Am J Public Health. 2006;96(7):1187–9 4. Borud LJ, Warren AG. Body contouring in the postbariatric surgery patient. J Am Coll Surg. 2006;203(1):82–93. 5. American Society of Plastic Surgeons. 2005 National plastic surgery statistics. Arlington Heights, IL: ASPS; 2006. 6. Mitchell JE, Crosby RD, Ertelt TW, Marino JM, Sarwer DB, Thampson JK, Lancaster KL, Simonich H, Howell LM. The desire for body contouring surgery after bariatric surgery. Obes Surg. 2008;18(10):1308–12. 7. Sarwer DB, Cohn NI, Gibbons LM, Magee L, Crerand CE, Raper SE, Rosato EF, Williams NN, Wadden TA. Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates. Obes Surg. 2004;14(9):1148–56. 8. Mitchell JE, Swan-Kremeier L, Myers T. Psychiatric aspects of bariatric surgery. In: Yager J, Powers PS, editors. Clinical manual of eating disorders. Washington, DC: American Psychiatric Press; 2007. p. 225–53. 9. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed., text revision. Washington, DC: APA Press; 2000. 10. Hsu LK, Betancourt S, Sullivan SP. Eating disturbances before and after banded gastroplasty: a pilot study. Int J Eat Disord. 1996;19(1):23–34. 11. Hsu LK, Sullivan SP, Benotti PN. Eating disturbances and outcome of gastric bypass surgery: a pilot study. Int J Eat Disorder. 1997;21(4):385–90.

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12. Allison KC, Wadden TA, Sarwer DB, Fabricatore AN, Crerand CE, Gibbons LM, Stack RM, Stunkard AJ, Williams NN. Night eating syndrome and binge eating disorder among persons seeking bariatric surgery: prevalence and related features. Obesity 2006;14(Suppl 2):77S–82. 13. Powers PS, Perez A, Boyd F, Rosemurgy A. Eating pathology before and after bariatric surgery: a prospective study. Int J Eat Disord. 1999;25(3):293–300. 14. Saunders R, Johnson L, Teschner J. Prevalence of eating disorders among bariatric surgery patients. Eat Disord. 1998; 6:309–17. 15. Kalarchian MA, Marcus MD, Wilson GT, Labouvie EW, Brolin RE, LaMarca LB. Binge eating among gastric bypass patients at long-term follow-up. Obes Surg. 2002;12(2): 270–5. 16. Wadden TA, Sarwer DB, Arnold ME, Gruen D, O’Neil PM, et al. Psychosocial status of severely obese patients before and after bariatric surgery. Problems General Surg. 2000;17: 13–22. 17. Camps MA, Zervos E, Goode S, Rosemurgy AS. Impact of bariatric surgery on body image perception and sexuality in morbidly obese patients and their partners. Obes Surg. 1996;6(4):356–60. 18. Neven K, Dymek M, LeGrange D, Maasdam H, Boogerd AC, Alverdy J. The effects of Roux-en-Y gastric bypass surgery on body image. Obes Surg. 2002;12(2):265–9. 19. Sarwer DB, Thompson KJ, Mitchell JE, Rubin JP. Psychological considerations of the bariatric surgery patient undergoing body contouring surgery. Plast Reconstr Surg. 2008;121(6):423e–34. 20. Chandawarkar RY. Body contouring following massive weight loss resulting from bariatric surgery. Adv Psychosom Med. 2006;27:61–72. 21. Informed consent for body contouring procedures in the massive weight loss patient. Plast Reconstr Surg. 2006;117 (1 Suppl):31s–44.

Psychosocial Issues in Body Contouring1

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64.1 Introduction The psychosocial aspects of the massive weight loss patient who presents for body contouring is an important aspect of patient care. A thorough understanding of these aspects warrants an appreciation of the obesity treatment as well as the behavioral characteristics of bariatric surgery candidates and how these characteristics affect, and are affected by, postoperative weight loss. As changes in physical appearance are an obvious outcome of bariatric surgery, research on the relationship between weight and body image is reviewed. Many patients seek plastic surgical procedures following massive weight loss. There are potential psychological issues related to body contouring surgery following massive weight loss and the psychological assessment and management of these patients are discussed.

64.2 The Obesity Problem Obesity, defined by a body mass index (BMI) of at least 30 kg/m2, is one of the most significant health issues in the United States. Over the past 30 years, the Work on this chapter was supported, in part, by grants from the National Institute of Diabetes and Digestive and Kidney Diseases and the American Society of Plastic Surgeons/Plastic Surgery Education Foundation. Dr. Sarwer is a consultant to Ethicon and Ethicon Endo-Surgery.

1

D. B. Sarwer University of Pennsylvania School of Medicine, Penn Behavioral Health, 3535 Market Street, Philadelphia, PA 19104, USA e-mail: [email protected]

prevalence of obesity more than doubled from 15% of adults in 1976–1980 to 32% in 2003–2004 [1, 2]. The prevalence of extreme obesity, characterized by a BMI of at least 40 kg/m2, has increased even more rapidly, with a fourfold rise from 1986 to 2000 [3]. Lifestyle modification—characterized by reducing caloric intake and increasing activity levels—is the cornerstone of weight loss treatment. As found in a number of clinical trials, lifestyle modification typically produces a 5–10% decrease in initial weight, which is associated with significant health benefits for overweight (BMI 25–29.9 kg/m2) and obese individuals [4]. Similar weight losses and improvements in comorbidities are seen with pharmacologic treatments. For persons with extreme obesity, however, more drastic weight losses may be necessary to significantly reduce morbidity and mortality risks. Furthermore, many extremely obese persons suffer from impairments in the quality of life and other psychosocial distress [5–8]. These physical and psychosocial factors likely motivate many patients to seek bariatric surgery [4, 9]. Bariatric surgery has surged in popularity over the past decade. In 1998, 13,365 bariatric procedures were performed [10]. The American Society of Metabolic and Bariatric Surgery estimates that approximately 200,000 procedures were performed in 2009. The most common bariatric procedure in the United States is the Roux-en-Y gastric bypass surgery [11]. However, laparoscopic adjustable gastric banding is growing in popularity [12]. A meta-analysis found mean reductions of 41.5 kg with the gastric bypass procedures (approximately 30% of the initial body weight) and 34.8 kg (approximately 25% of the initial body weight) with adjustable gastric banding [13]. Despite these impressive outcomes, there appears to be a good deal of patient-to-patient variability. For

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_64, © Springer-Verlag Berlin Heidelberg 2010

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example, in the Swedish Obese Subjects Trial, the largest and longest study of bariatric surgery to date, 9% of gastric bypass patients and 25% of adjustable gastric banding patients failed to maintain at least a 5% reduction in the initial weight 10 years postoperatively [14]. The mechanism for these less-than-optimal results is not well understood, but it likely involves physiological, psychosocial, and dietary factors.

64.3 Psychosocial Functioning of Bariatric Surgery Candidates In the past several years, several comprehensive reviews of the literature on the psychosocial and behavioral aspects of bariatric surgery have been published [5–8, 15–18]. In general, there is a high rate of psychopathology among persons with extreme obesity. Between 20 and 60% of patients who present for bariatric surgery have been characterized as suffering from an Axis I psychiatric disorder, the most common of which are mood and anxiety disorders [19, 20]. Smaller percentages have been diagnosed with substance abuse problems and personality disorders, both of which may impact surgical management and postoperative outcomes [5–8, 15–18]. Not surprisingly, extreme obesity is also associated with reduced health-related quality of life [21–29]. Extremely obese individuals frequently report significant pain in weight-bearing joints, as well as impaired flexibility and stamina [30–33]. These physical problems lead to difficulties in performing basic activities of daily living, such as walking, climbing stairs, bathing, and dressing [34]. Impairments in the quality of life are believed to contribute to the increased risk of depression found in extremely obese persons [22]. One important aspect of the quality of life is body image. Dissatisfaction with one’s body image is believed to motivate many appearance-enhancing behaviors, including weight loss, exercise, cosmetic and fashion purchases as well as cosmetic surgery [35–41]. Overweight and obese individuals – especially women – tend to be more dissatisfied with their bodies than their normal weight counterparts [38–40, 42]. Body image dissatisfaction is related to lower self-esteem and increased symptoms of depression in obese individuals, and is believed to be a marker for other psychological or psychiatric problems [43–47].

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Weight-related stigma may also contribute to psychosocial distress in those with extreme obesity. Bias against obese individuals has been found in social, educational, occupational, and medical settings and may be associated with discriminatory treatment [48, 49]. While the rate of this bias in extremely obese individuals has not been well quantified, it has been associated with significant psychosocial distress [50]. Disordered eating is common among persons who present for bariatric surgery. A significant number of bariatric surgery patients suffer from binge eating disorder (BED), which is characterized by eating a large amount of food within a 2-h period of time while feeling a subjective loss of control [51]. (Purging or other compensatory behaviors seen in bulimia nervosa are not found in BED.) While early studies suggested that up to half of bariatric surgery candidates displayed features of BED [52, 53], a recent study suggested that the rate of the disorder may be as low as 5% [54]. Regardless of the actual rate of the diagnosis, unhealthy, if not abnormal, eating behaviors is a prime catalyst to the development of extreme obesity. Likely as a function of the psychosocial distress associated with extreme obesity (as well as because of the requirements of third-party payers), the vast majority of bariatric surgery programs in the United States require a mental health evaluation as part of the patient selection process for bariatric surgery [55]. While there is little consensus on the structure of these evaluations, most mental health professionals agree that significant psychiatric issues, such as active substance abuse, active psychosis, bulimia nervosa, severe uncontrolled depression contraindicate bariatric surgery [55–58]. These features are thought to limit the capacity for informed consent or increase the likelihood of postoperative medical complications. Whether these and other psychological factors are related to postoperative weight loss is an issue that has not been adequately resolved. There is no clear relationship between preoperative depression and postoperative weight loss [45, 59–62]. The relationship between preoperative binge eating and postoperative weight loss is similarly unclear [63–65]. Regardless, given the potential association with premature weight regain, most programs evaluate for the presence of disordered eating prior to bariatric surgery [55, 57]. When a formal psychiatric disorder or a significant psychological distress is observed in a bariatric surgery candidate, psychiatric or psychological treatment is

64 Psychosocial Issues in Body Contouring

typically recommended [66]. This recommendation is typically made to between 10 and 30% of bariatric surgery candidates [19, 57, 67]. It is of primary concern to ensure that the distress – whether “garden variety” depression or psychosis – is optimally controlled prior to exposing the patients to the physical discomfort and stress of drastic lifestyle change associated with surgery. In contrast, between 70 and 90% of bariatric surgery candidates are unconditionally recommended for surgery following the psychosocial evaluation. In summary, studies have found high rates of psychopathology, impairments in quality of life, and disordered eating among bariatric surgery candidates. Unfortunately, many of these studies have suffered from a variety of methodological issues. These limitations have made it difficult to make conclusive statements about the impact of preoperative psychiatric status and eating behavior on postoperative outcome, which is the most important question yet to be addressed by this literature.

64.4 Postoperative Psychological Functioning of Bariatric Surgery Patients As noted above, bariatric surgery patients typically experience a 30% reduction in their initial body weight following the gastric bypass procedures and a 25% reduction in their initial body weight following gastric banding procedures [68, 69]. These losses are typically reached within the first 18–24 months of surgery. Over the next decade, patients who undergo both procedures typically experience some weight regain, often of the magnitude of about 10% of the weight that they initially lost. Weight loss following both procedures is associated with significant improvements in many obesity-related comorbidities [13–15, 69–70]. Psychosocial characteristics – including self-esteem, depressive symptoms, health related quality of life, and body image—also improve dramatically in the first year after surgery [5–8,15–17,71,72]. These psychosocial benefits, however, appear to be limited to the first few postoperative years, although there have been relatively few studies of the long-term psychosocial changes associated with bariatric surgery. While bariatric surgery leads to a dramatic decrease in caloric consumption, studies have suggested poor adherence to the postoperative diet as

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well as the occurrence of postoperative binge eating associated with smaller weight losses and/or weight regain within the first 2 years after surgery [ 52, 64,73]. This finding may be particularly important when the timing of the body contouring procedures is considered, as discussed below. The psychosocial construct of the body image is one of the most relevant psychosocial issue to body contouring following massive weight loss. Like other psychosocial issues and as noted above, bariatric surgery patients typically report improvements in the body image in the first few years after surgery [74–77]. Nevertheless, some bariatric surgery patients report residual body image dissatisfaction associated with loose, sagging skin of the breasts, abdomen, thighs, and arms following massive weight loss [40]. More than two-thirds of postbariatric surgery patients considered the development of excess skin to be a negative consequence of surgery [78]. This dissatisfaction likely motivates some individuals to seek body contouring procedures [52].

64.5 Psychosocial Aspects of Plastic Surgery While bariatric surgery has grown impressively over the past decade, it pales in comparison to the growth of plastic surgery. According to the American Society of Plastic Surgery, approximately 17 million plastic surgical procedures were performed in 2008. While minimally invasive procedures contribute greatly to this growth, 58,669 body contouring procedures were performed following massive weight loss. A now sizable literature has investigated the psychological characteristics of prospective cosmetic surgery patients and the psychosocial changes that occur postoperatively [79, 80–85]. While studies in this area have occurred over the past 50 years, much of the research of the past decade has focused on issues related to the body image. Dissatisfaction with one’s appearance or body image has long been thought to play a role in an individual’s decision to undergo appearance-enhancing behaviors [84–86]. Body image dissatisfaction predicts more positive attitudes toward cosmetic surgery [87–89]. Cosmetic surgery patients report heightened body image dissatisfaction prior to surgery [88, 90–94]. Within the first two postoperative

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years, patients report significant improvements in their body image, particularly with the feature altered by surgery [18, 95–98]. Unfortunately, little is known about the longer term psychological effects of cosmetic surgery. For some individuals who present for cosmetic procedures, excessive body image concern may be suggestive of significant psychopathology. Extreme body image dissatisfaction is a symptom of many formal psychiatric conditions, including eating disorders, and perhaps most importantly to plastic surgeons, body dysmorphic disorder (BDD). BDD is characterized by extreme concern or preoccupation with a slight or imagined defect in appearance and which leads to a disruption in the daily functioning [92, 99–102]. Individuals with BDD frequently seek plastic surgery and other appearance-enhancing treatments. Studies conducted around the world have found that between 7 and 16% of plastic surgery patients meet diagnostic criteria for BDD [80]. These patients often believe that their preoccupation with their appearance will improve by improving the appearance. Unfortunately, the vast majority of persons with BDD experience little change or a worsening in their BDD symptoms following cosmetic procedures [103, 104]. As a result, some authorities consider it a contraindication to appearance-enhancing procedures [84, 105, 106]. As the physical deformities found in most massive weight loss patients who seek body contouring are neither slight or imagined, the diagnosis of BDD, technically, cannot be applied to these patients. Studies of patients undergoing other reconstructive surgical procedures suggest that they often report a level of preoccupation with their appearance consistent with BDD [100, 102]. This observation suggests that when BDD is considered, the degree of distress and impairment, rather than the extent of the “defect” may be the more important aspect of the diagnostic criteria [80, 81]. It stands to reason that some body contouring patients likely present for surgery with some form of the disorder, although this is yet to be documented.

64.6 Psychological Aspects of Body Contouring Following Massive Weight Loss As evidenced by this text, as well as other recent books and review papers on body contouring following

D. B. Sarwer

massive weight loss, there has been great development in the surgical treatment of this patient population in a relatively brief period of time. While less is known about the psychological aspects of body contouring surgery at present [18], our understanding of the psychological characteristics of these patients likely play an important role in the preoperative assessment as well as postoperative management [79]. The larger literature on the psychological aspects of cosmetic surgery, as well as the more specific literature on the psychological aspects of breast reduction surgery, can be used as a framework to understand the relevant psychological issues for massive weight loss patients who seek body contouring surgery [9, 18, 107]. The initial consultation with the massive weight loss patient interested in body contouring, like the initial consultation with any plastic surgery patient, should include some assessment of the patient’s psychological functioning. The assessment should focus on several areas: motivations and expectations, appearance and body image concerns, and psychiatric status and history [9, 18, 108–110]. In addition, the plastic surgeon should assess the patient’s stability with their weight as well as their nutritional status. Many massive weight loss patients may hold unrealistic expectations about the potential outcomes of body contouring surgery. Some may inaccurately believe that body contouring surgery will result in changes that will make their bodies comparable to persons who never experienced excessive body weight. Others may not fully appreciate that many body contouring procedures produce large and visible scars, skin irregularities, as well as residual deformities in body shape. Patients should be instructed that while surgery may improve body contour, it will not result in a “perfect” body shape. Counseling the patients that body contouring often requires multiple procedures – each of which encompasses further risk, recovery time, and often expense – may help foster more realistic expectations. Patients should be asked about their expectations on the impact that body contouring surgery will have on romantic and sexual relationships. In the bariatric surgery literature, at least one study has found an elevated divorce rate following bariatric surgery [111]. In the cosmetic surgery literature, there are countless anecdotal reports of married patients who have undergone procedures only to have those marriages dissolve during the first few postoperative years. Body contouring surgery

64 Psychosocial Issues in Body Contouring

may be associated with similar changes to the dynamics of social and romantic relationships. Patients who believe that a troubled marriage may be saved by body contouring, or those who hold other unrealistic expectations about the impact of surgery on their social relationships, may be more likely to express disappointment and dissatisfaction with their postoperative result. The assessment of the patients’ body image is a critical part of the assessment of the patients’ psychological characteristics. One way to assess this is to ask the patients to describe what they specifically dislike about the features that they would like to alter surgically. The degree of dissatisfaction should also be assessed. Some body image dissatisfaction is typical among both plastic surgery and bariatric surgery patients, as detailed above. Body contouring patients who report that they think about their appearance for more than 1-h each day or those who report that their concern leads to significant emotional upset or disruption in daily functioning may be experiencing extreme body image dissatisfaction suggestive of BDD. These patients should likely undergo a psychiatric consultation with a mental health professional prior to body contouring surgery. Individuals who present for bariatric surgery experience elevated rates of psychopathology. While many of the psychological symptoms associated with extreme obesity may improve with the massive weight loss seen in bariatric surgery, many patients continue to struggle with a range of psychological issues [71]. Thus, the plastic surgeon should assess the more general psychiatric status and history of patients presenting for body contouring. Approximately 40% of bariatric surgery patients are engaged in some form of psychiatric treatment at the time of bariatric surgery [19]. Many likely remain in treatment postoperatively. In contrast, approximately 20% of cosmetic surgery patients and 5% of reconstructive surgery patients report ongoing psychiatric treatment [112]. The most common form of treatment for all three groups of patients is the use of psychiatric medications-most typically antidepressants prescribed by a primary care physician [19]. Because of the rates of psychopathology seen in persons with extreme obesity, as well as the high usage of mental health treatment, the body contouring surgeon is recommended to contact the treating mental health professional to ensure that body contouring is appropriate at the present time. Patients who are dissatisfied with their postoperative result following plastic surgery

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(including body contouring) have used their preoperative psychiatric history as part of their legal action against plastic surgeons, arguing that their psychiatric condition prevented them from fully understanding the procedure and its potential outcomes. Written confirmation from the treating mental health professional that the patient is psychiatrically stable may offer some protection to the surgeon in such cases. In addition to asking the patients about their psychiatric history and the use of current mental health treatment, the body contouring surgeon should conduct a brief assessment of the mental status and, specifically, depressive symptoms. Observation of the patients’ mood, affect, and overall presentation during the consultation often will provide important clues to the presence of a mood disorder. If one is suspected, neurovegetative symptoms, including sleep, appetite, and concentration, should be assessed. If patients endorse difficulties in any of these areas, they should be asked about the frequency of crying or irritability, social isolation, feelings of hopelessness, and the presence of suicidal thoughts. Affirmative answers to several of these questions necessitate a mental health consultation. Patients often regain 5–10% of their initial body weight within the first 12–36 months following bariatric surgery and 10–15% over the course of the next decade [14]. Massive weight loss patients often present for body contouring within the first few years of the bariatric procedure. Weight gain following body contouring surgery may affect postoperative satisfaction and potentially compromise the aesthetic result. The plastic surgeon should likely request that body contouring candidates remain weight stable for approximately 3–6 months prior to surgery. Weight stability should be confirmed by in person weigh-ins at the plastic surgeon’s office. Furthermore, patients may be struggling with a number of nutritional deficiencies following bariatric surgery [113]. Dietary adherence and nutritional status should be assessed prior to body contouring surgery.

64.7 Conclusions The scope of the obesity problem has directly led to the growth of bariatric surgery, and, in turn, the development and refinement of body contouring procedures for the massive weight loss patient. The literature on

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the psychosocial aspects of extreme obesity, coupled with the literature on the psychological characteristics of cosmetic surgery patients can be used to inform our thinking about the psychological considerations of the body contouring patients. Individuals with extreme obesity often suffer from significant psychosocial distress. While some aspects of this distress remit following weight loss, particularly the massive weight loss associated with bariatric surgery, some psychological symptoms may remain and impact the patient interested in body contouring. The plastic surgeon should assess these symptoms prior to body contouring surgery for the sake of patient safety and in the spirit of responsible surgical practice.

References 1. Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among US adults. JAMA 2002;288(14): 1723–7. 2. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999–2004. JAMA 2006;295(13):1549–55. 3. Sturm R. Increases in clinically severe obesity in the United States, 1986–2000. Arch Intern Med. 2003;163(18): 2146–8. 4. National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults – the evidence report. Obes Res. 1998;6 (Suppl 2):51–209. 5. Bocchieri LE, Meana M, Fisher BL. A review of psychosocial outcomes of surgery for morbid obesity. J Psychosom Res. 2002;52(3):155–65. 6. Herpertz S, Kielmann R, Wolf AM, Langkafel M, Senf W, Hebebrand J. Does obesity surgery improve psychosocial functioning? A systematic review. Int J Obes Relat Metab Disord. 2003;27(11):1300–14. 7. van Hout GC, van Oudheusden I, van Heck GL. Psychological profile of the morbidly obese. Obes Surg. 2004;14(5): 479–88. 8. Sarwer DB, Wadden TA, Fabricatore AN. Psychosocial and behavioral aspects of bariatric surgery. Obes Res. 2005; 13(4):639–48. 9. Sarwer DB, Fabricatore AN. Psychiatric considerations of the massive weight loss patient. Clin Plast Surg. 2008;35(1): 1–10. 10. Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA 2005;294(15):1909–17. 11. Nguyen NT, Root J, Zainabadi K, Sabio A, Chalifoux S, Stevens CM, Mavandadi S, Longoria M, Wilson SE. Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Arch Surg. 2005;140(12): 1198–202. 12. Buchwald H, Williams SE. Bariatric surgery worldwide 2003. Obes Surg. 2004;14(9):1157–64.

D. B. Sarwer 13. Maggard MA, Shugarman LR, Suttorp M, Maglione M, Sugerman HJ, Livingston EH, Nguyen NT, Li Z, Mojica WA, Hilton L, Rhodes S, Morton SC, Shekelle PG. Metaanalysis: surgical treatment of obesity. Ann Intern Med. 2005;142(7): 547–9. 14. Sjostrom L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlsson B, Dahlgren S, Larssen B Narbro K, Sjostrom CD, Sullivan M, Wedel H. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004;351(26):2683–93. 15. Herpertz S, Kielmann R, Wolf AM, Hebebrand J, Senf W. Do psychosocial variables predict weight loss or mental health after obesity surgery? A systematic review. Obes Res. 2004;12(10):1554–69. 16. Mitchell JE, de Zwaan M. Bariatric surgery: a guide for mental health professionals. New York and Hove: Routledge; 2005. 17. van Hout GC, Boekestein P, Fortuin FA, Pelle AJ, van Heck GL. Psychosocial functioning following bariatric surgery. Obes Surg. 2006;16(6):787–94. 18. Sarwer DB, Thompson JK, Mitchell JE, Rubin JP. Psycho logical considerations of the bariatric surgery patient undergoing body contouring surgery. Plast Reconstr Surg. 2008; 121(6):423e–434e. 19. Sarwer DB, Cohn NI, Gibbons LM, Magee L, Crerand CE, Raper SE, Rosato EF, Williams NN, Wadden TA. Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates. Obes Surg. 2004;14(9):1148–56. 20. Rosenberger PR, Henderson KE, Grilo CM. Psychiatric disorder comorbidity and association with eating disorders in bariatric surgery patients: a cross-sectional study using structured interview-based diagnosis. J Clin Psychiatry. 2006;67(7):1080–5. 21. Choban PS, Onyejekwe J, Burge JC, Flancbaum L. A health status assessment of the impact of weight loss following Roux-en-Y gastric bypass for clinically severe obesity. J Am Coll Surg. 1999;188(5):491–7. 22. Fabricatore AN, Wadden TA, Sarwer DB, Faith MS. Healthrelated quality of life and symptoms of depression in extremely obese persons seeking bariatric surgery. Obes Surg. 2005; 15(3):304–9. 23. Fontaine KR, Cheskin LJ, Barofsky I. Health-related quality of life in obese persons seeking treatment. J Fam Pract. 1996; 43(3):265–720. 24. Kolotkin RL, Crosby RD, Pendleton R, Strong M, Gress RE, Adams T. Health-related quality of life in patients seeking gastric bypass surgery vs non-treatment-seeking controls. Obes Surg. 2003;13(3):371–7. 25. Kolotkin RL, Crosby RD, Williams GR. Health-related quality of life varies among obese subgroups. Obes Res. 2002;10(8):748–56. 26. Kolotkin RL, Crosby RD, Williams GR, Hartley GG, Nicol S. The relationship between health-related quality of life and weight loss. Obes Res. 2001;9(9):564–71. 27. Schok M, Greenen R, van Antwerpen T, de Wit P, Brand N, van Ramshorst B. Quality of life after laparoscopic adjustable gastric banding for severe obesity: Postoperative and retrospective preoperative evaluations. Obes Surg. 2000;10(6): 502–8. 28. Larsson U, Karlsson J, Sullivan M. Impact of overweight and obesity on health-related quality of life- a Swedish

64 Psychosocial Issues in Body Contouring p opulation study. Int J Obes Relat Metab Disord. 2002;26(3): 417–24. 29. Mathus-Vliegen EM, deWeerd S, de Wit LT. Health related quality-of-life in patients with morbid obesity after gastric banding for surgically induced weight loss. Surgery 2004; 135(5):489–97. 30. Larsson UE, Mattsson E. Functional limitations linked to high body mass index, age and current pain in obese women. Int J Obes. 2001;25(6):893–9. 31. Larsson UE, Mattsson E. Perceived disability and observed functional limitations in obese women. Int J Obes Relat Metab Disord. 2001;25(11):1705–12. 32. Peltonen M, Lindroos AK, Torgerson JS. Musculoskeletal pain in the obese: a comparison with a general population and long-term changes after conventional and surgical obesity treatment. Pain 2003;104(3):549–57. 33. Karason K, Peltonen M, Lindroos AK, Sjostrom L, Lonn L, Torgerson JS. Effort-related calf pain in the obese and longterm changes after surgical obesity treatment. Obes Res. 2005;13(1):137–45. 34. Duval K, Marceau P, Lescelleur O, Hould FS, Marceau S, Biron S, Lebel S, Perusse L, Lacasse Y. Health-related quality of life in morbid obesity. Obes Surg. 2006;16(5): 574–9. 35. Cash TF. A “negative body image”: evaluating epidemiological evidence. In: Cash TF, Pruzinsky T, editors. Body image: a handbook of theory, research & clinical practice. New York: Guilford Press; 2004. p. 269–76. 36. Sarwer DB, Didie ER. Body image in cosmetic surgical and dermatological practice. In: Castle D, Phillips KA, editors. Disorders of body image, stroud. England: Wrighton Biomedical Publishing; 2002. p. 37–53. 37. Sarwer DB, Allison KC, Berkowitz RI. Assessment and treatment of obesity in the primary care setting. In: Hass LJ, editor. Handbook of primary-care psychology. New York: Oxford University Press; 2004. p. 435–54. 38. Sarwer DB, Foster GD, Wadden TA. Treatment of obesity I: adult obesity. In: Handbook of eating disorders and obesity. Hoboken, NJ: Wiley; 2004. p. 421–42. 39. Sarwer DB, Thompson JK. Obesity and body image disturbance. In: Wadden TA, Stunkard AJ, editos. Handbook of obesity treatment. New York: Guilford Press; 2002. p. 447–64. 40. Sarwer DB, Thompson JK, Cash TF. Body image and obesity in adulthood. Psychiatr Clin North Am. 2005;28(1): 69–87. 41. Sarwer DB, Magee L. Physical appearance and society. In: Sarwer DB, Pruzinsky T, Cash TF, Goldwyn RM, Persing JA, Whitaker LA, editos. Psychological aspects of reconstructive and cosmetic plastic surgery: clinical, empirical, and ethical perspectives. Philadelphia: Lippincott, Williams & Wilkins; 2006. p. 23–36. 42. Schwartz MB, Brownell KD. Obesity and body image. Body Image. 2004;1(1):43–56. 43. Foster GD, Wadden TA, Vogt RA. Body image in obese women before, during, and after weight loss treatment. Health Psychol. 1997;16(3):226–9. 44. Sarwer DB, Wadden TA, Foster GD. Assessment of body image dissatisfaction in obese women: specificity, severity, and clinical significance. J Consult Clin Psychol. 1998;66(4): 651–4.

647 45. Dixon JB, Dixon ME, O’Brien PE. Pre-operative predictors of weight loss at 1-year after the Lap-Band surgery. Obes Surg. 2001;11(2):200–7. 46. Grilo CM, Wilfley DE, Brownell KD, Rodin J. Teasing, body image, and self-esteem in a clinical sample of obese women. Addict Behav. 1994;19(4):443–50. 47. Neumark-Sztainer D, Haines J. Psychosocial and behavioral consequences of obesity. In: Handbook of eating disorders and obesity. Hoboken, NJ: Wiley; 2004. p. 349–71. 48. Puhl RM, Brownell KD. Bias, discrimination, and obesity. Obes Res. 2001;9(12):788–805. 49. Brownell KD, Puhl RM, Schwartz MB, Rudd L. Weight bias: nature, consequences, and remedies. New York: Guilford Press; 2005. 50. Sarwer DB, Fabricatore AN, Eisenberg MH, Sywulak LA, Wadden TA. Self-reported stigmatization among candidates for bariatric surgery. Obesity 2008;16(suppl 2):S75–9. 51. American Psychiatric Association: Diagnostic and statistical manual of mental disorders. 4th ed., text revision. Washington: APA Press; 2000. p. 594–5. 52. Mitchell JE, Lancaster KL, Burgard MA, Howell LM, Krahn DD, Crosby RD, Wonderlich SA, Gosnell BA. Long-term follow-up of patients’ status after gastric bypass. Obes Surg. 2001;11(4):464–78. 53. Wadden TA, Sarwer DB, Arnold ME, Gruen D, O’Neil PM. Psychosocial status of severely obese patients before and after bariatric surgery. Problems General Surg. 2000;17: 13–22. 54. Allison KC, Thomas WA, Sarwer DB, Fabricatore AN, Crerand CE, Gibbons LM, Stack RM, Stunkard AJ, Williams NN. Night eating syndrome and binge eating disorder among persons seeking bariatric surgery: prevalence and related features. Surg Obes Relat Dis. 2006;2(2):153–8. 55. Bauchowitz AU, Gonder-Frederick LA, Olbrisch ME, Azarbad L, Ryee MY, Woodson M, Miller A, Schirmer B. Psychosocial evaluation of bariatric surgery candidates: a survey of present practices. Psychosom Med. 2005;67(5): 825–32. 56. Buchwald H. Bariatric surgery for morbid obesity: health implications for patients, health professionals, and thirdparty payers. J Am Coll Surg. 2005;200(4):593–604. 57. Fabricatore AN, Crerand CE, Wadden TA, Sarwer DB, Krasucki JL. How do mental health professionals evaluate candidates for bariatric surgery? Survey results. Obes Surg. 2006;16(5):567–73. 58. Wadden TA, Sarwer DB, Womble LG, Foster GD, McGuckin BG, Schimmel A. Psychosocial aspects of obesity and obesity surgery. Surg Clin North Am. 2001;81(5):1001–24. 59. Kinzl JF, Schrattenecker M, Traweger C, Mattesich M, Fiala M, Biebl W. Psychosocial predictors of weight loss after bariatric surgery. Obes Surg. 2006;16(12):1609–14. 60. Powers PS, Rosemurgy A, Boyd F, Perez A. Outcome of gastric restriction procedures: weight, psychiatric diagnoses, and satisfaction. Obes Surg. 1997;7(6):471–7. 61. Hsu LK, Benotti PN, Dwyer J, Roberts SB, Saltzman E, Shikora S, Rolls BJ, Rand W. Nonsurgical factors that influence the outcome of bariatric surgery: a review. Psychosom Med. 1998;60(3):338–46. 62. Averbukh Y, Heshka S, El-Shoreya H, Flancbaum L, Geliebter A, Kamel S, Pi-Sunyer FX, Laferrere B. Depression score predicts weight loss following Roux-en-Y gastric bypass. Obes Surg. 2003;13(6):833–6.

648 63. Dymek MP, le Grange D, Neven K, Alverdy J. Quality of life and psychosocial adjustment in patients after Roux-en-Y gastric bypass: a brief report. Obes Surg. 2001;11(1):32–9. 64. Kalarchian MA, Marcus MD, Wilson GT, Labouvie EW, Brolin RE, LaMarca LB. Binge eating among gastric bypass patients at long-term follow-up. Obes Surg. 2002;12(2): 270–5. 65. White MA, Masheb RM, Rothschild BS, Burke-Martindale CH, Grilo CM. The prognostic significance of regular binge eating in extremely obese gastric bypass patients: 12-month postoperative outcomes. J Clin Psychiatry. 2006;67(12): 1928–35. 66. Wadden TA, Sarwer DB, Fabricatore AN, Jones L, Stack RM, Williams NS. Psychosocial and behavioral status of bariatric surgery patients: what to expect before and after surgery. Med Clin North Am. 2007;92(3):451–69. 67. Pawlow LA, O’Neil PM, White MA, Byrne TK. Findings and outcomes of psychological evaluations of gastric bypass applicants. Surg Obes Relat Dis. 2005;1(6):523–7. 68. Sjostrom L, Narbro K, Sjostrom CD, Karason K, Larsson B, Wedel H, Lystig T, Sullivan M, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357:741–52. 69. Cunneen SA. Review of meta-analytic comparisons of bariatric surgery with a focus on laparoscopic adjustable gastric banding. Surg Obes Relat Dis. 2008;4(3 Suppl):S47-S55. 70. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, Schoelles K. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292(14):1724–37. 71. Sarwer DB, Fabricatore AN, Jones-Corneille LR, Allison KC, Faulconbridge LN, Wadden AN. Psychological issues following bariatric surgery. Primary Psychiatry. 2008;15: 50–5. 72. Sarwer DB, Fabricatore AN. Psychological issues before and after bariatric surgery. In: Dietl et al, editors. Bariatric surgery handbook, in press. 73. Kalarchian MA, Wilson GT, Brolin RE, Bradley L. Effects of bariatric surgery on binge eating and related psychopathology. Eat Weight Disord. 1999;4(1):1–5. 74. Dixon JB, Dixon ME, O’Brien PE. Body image: appearance orientation and evaluation in the severely obese. Changes with weight loss. Obes Surg. 2002;12(1):65–71. 75. Adami GF, Gandolfo P, Campostano A, Meneghelli A, Ravera G, Scopinaro N. Body image and body weight in obese patients. Int J Eat Disord. 1998;24(3):299–306. 76. Camps MA, Zervos E, Goode, Rosemurgy AS. Impact of bariatric surgery on body image perception and sexuality in morbidly obese patients and their partners. Obes Res. 1996; 6(4):356–60. 77. Neven K, Dymek M, le Grange D, Maasdam H, Boogerd AC, Alverdy J. The effects of Roux-en-Y gastric bypass surgery on body image. Obes Surg. 2002;12(2):265–9. 78. Kinzl JF, Traweger C, Trefalt E, Biebl W. Psychosocial consequences of weight loss following gastric banding for morbid obesity. Obes Surg. 2003;13(1):105–10. 79. Sarwer DB, Pruzinsky T, Cash TF, Goldwyn RM, Persing JA, Whitaker LA. Psychological aspects of reconstructive and cosmetic plastic surgery: clinical, empirical, and ethical perspectives. Philadelphia: Lippincott, Williams & Wilkins; 2006. 80. Crerand CE, Franklin ME, Sarwer DB. Patient safety and body dysmorphic disorder in cosmetic surgery patients, Plastic and Reconstructive Surgery, 2008;122(4S):1–15.

D. B. Sarwer 81. Sarwer DB, Crerand CE. Body dysmorphic disorder and appearance enhancing medical treatments. Body Image. 2008;5:50–8. 82. Sarwer DB. The psychological aspects of cosmetic breast augmentation. Plast Reconstr Surg. 2007;120(7 Suppl 1): 110S–117S. 83. Sarwer DB, Brown GK, Evans DL. Cosmetic breast augmentation and suicide: a review of the literature. Am J Psychiatry. 2007;164(7):1006–13. 84. Sarwer DB, Crerand CE. Body image and cosmetic medical treatments. Body Image. 2004;1(1):99–111. 85. Sarwer DB, Wadden TA, Pertschuk MJ, Whitaker LA. The psychology of cosmetic surgery: a review and reconceptualization. Clin Psychol Rev. 1998;18(1):1–22. 86. Cash TF. Body image and cosmetic surgery. In: Sarwer DB, Pruzinsky T, Cash TF, Goldwyn RM, Persing JA, Whitaker LA, editors. Psychological aspects of reconstructive and cosmetic plastic surgery: clinical, empirical, and ethical perspectives. Philadelphia: Lippincott, Williams & Wilkins; 2006. p. 37–59. 87. Henderson-King D, Henderson-King E. Acceptance of cosmetic surgery: scale development and validation. Body Image. 2005;2(2):137–49. 88. Sarwer DB, Whitaker LA, Wadden TA, Pertschuk MJ. Body image dissatisfaction in women seeking rhytidectomy or blepharoplasty. Aesthetic Surg J. 1997;17(4):230–4. 89. Sperry S, Thompson JK, Sarwer DB, Cash TF. Cosmetic surgery reality TV viewership: relations with cosmetic surgery attitudes, body image and disordered eating. Ann Plast Surg. 2009;62(1):7–11. 90. Pertschuk MJ, Sarwer DB, Wadden TA, Whitaker LA. Body image dissatisfaction in male cosmetic surgery patients. Aesthetic Plast Surg. 1998;22(1):20–4. 91. Sarwer DB, Bartlett SP, Bucky LP, LaRossa D, Low DW, Pertshcuk MJ, Wadden TA, Whitaker LA. Bigger is not always better: body image dissatisfaction in breast reduction and breast augmentation patients. Plast Reconstr Surg. 1998;101(7):1956–61. 92. Sarwer DB, Wadden TA, Pertschuk MJ, Whitaker LA. Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery patients. Plast Reconstr Surg. 1998;101(6): 1644–9. 93. Didie ER, Sarwer DB. Factors that influence the decision to undergo cosmetic breast augmentation surgery. J Women’s Health. 2003;12(3):241–53. 94. Sarwer DB, LaRossa D, Bartlett SP, Low DW, Bucky LP, Whitaker LA. Body image concerns of breast augmentation patients. Plast Reconstr Surg. 2003;112(1):83–90. 95. Bolton MA, Pruzinsky T, Cash TF, Persing JA. Measuring outcomes in plastic surgery: body image and quality of life in abdominoplasty patients. Plast Reconstr Surg. 2003;112(2): 619–25. 96. Cash TF, Duel LA, Perkins LL. Women’s psychosocial outcomes of breast augmentation with silicone gel-filled implants: a 2-year prospective study. Plast Reconstr Surg. 2002;109(6):2112–21. 97. Sarwer DB, Gibbons LM, Magee L, Baker JL, Casas LA, Glat PM, et al. A prospective, mutlti-site investigation of patient satisfaction and psychosocial status following cosmetic surgery. Aesthetic Surg J. 2005;25(3):263–9.

64 Psychosocial Issues in Body Contouring 98. Sarwer DB, Wadden TA, Whitaker LA. An investigation of changes in body image following cosmetic surgery. Plast Reconstr Surg. 2002;109(1):363–9. 99. Aouizerate B, Pujol H, Grabot D, Faytout M, Suire K, Braud C, et al. Body dysmorphic disorder in a sample of cosmetic surgery applicants. Eur Psychiatry. 2003;18(7): 365–8. 100. Crerand CE, Sarwer DB, Magee L, Gibbons LM, Lowe MR, Bartlett SP, et al. Rate of body dysmorphic disorder among patients seeking facial plastic surgery. Psychiatr Ann. 2004;34:58–65. 101. Ishigooka J, Iwao M, Suzuki M, Fukuyama Y, Murasaki M, Miura S. Demographic features of patients seeking cosmetic surgery. Psychiatry Clin Neurosci. 1998;52(3): 283–7. 102. Sarwer DB, Whitaker LA, Pertschuk MJ, Wadden TA. Body image concerns of reconstructive surgery patients: an underrecognized problem. Ann Plast Surg. 1998;40(4): 403–7. 103. Crerand CE, Phillips KA, Menard W, Fay C. Nonpsychiatric medical treatment of body dysmorphic disorder. Psycho somatics 2005;46(6):549–55. 104. Phillips KA, Grant J, Siniscalchi J, Albertini RS. Surgical and nonpsychiatric medical treatment of patients with body dysmorphic disorder. Psychosomatics 2001;42(6):504–10. 105. Crerand CE, Cash TF, Whitaker LA. Cosmetic surgery of the face. In: Sarwer DB, Pruzinsky T, Cash TF, Goldwyn RM, Persing JA, Whitaker LA, editors. Psychological aspects of reconstructive and cosmetic plastic surgery: clinical, empirical, and ethical perspectives. Philadelphia: Lippincott, Williams & Wilkins; 2006. p. 233–49. 106. Crerand CE, Franklin ME, Sarwer DB. Body dysmorphic disorder and cosmetic surgery. Plast Reconstr Surg. 2006; 118(7):167e–189e. 107. Young VL, Watson ME. Breast reduction. In: Sarwer DB, Pruzinsky T, Cash TF, Goldwyn RM, Persing JA, Whitaker

649 LA, editors. Psychological aspects of reconstructive and cosmetic plastic surgery: clinical, empirical, and ethical perspectives. Philadelphia: Lippincott, Williams & Wilkins; 2006. p. 189–206. 108. Sarwer DB, Grossbart TA, Baker A. Psychosocial evaluation of the cosmetic surgery patient. In: Kaminer MS, Dover JS, Arndt KA editors. Atlas of cutaneous aesthetic surgery. 2nd ed., 2009, 3–9. 109. Sarwer DB. Psychological considerations in cosmetic surgery. In: Goldwyn RM, Cohen MN, editors. The unfavorable result in plastic surgery: avoidance and treatment. 3rd ed. Philadelphia: Lippincott-Raven; 2001. p. 14–23. 110. Sarwer DB. Psychological assessment of cosmetic surgery patients. In: Sarwer DB, Pruzinsky T, Cash TF, Goldwyn RM, Persing JA, Whitaker LA, editors. Psychological aspects of reconstructive and cosmetic plastic surgery: clinical, empirical, and ethical perspectives. Philadelphia: Lippincott, Williams & Wilkins; 2006. p. 267–83. 111. Rand CS Kuldau JM, Robbins L. Surgery for obesity and marriage quality. J Am Med Assoc. 1982;247(10): 1419–22. 112. Sarwer DB, Zanville HA, LaRossa D, Bartlett SP, Chang B, Low DW, Whitaker LA. Mental health histories and psychiatric medication usage among persons who sought cosmetic surgery. Plast Reconstr Surg. 2004;114(7):1927–33. 113. Mechanick JI, Kushner RF, Sugerman HJ, Gonzalez-Campoy JM, Collazo-Clavell ML, Guven S, Spitz AF, Apovian CM, Livingston EH, Brolin R, Sarwer DB, Anderson WA, Dixon J. Executive summary of the recommendations of the american association of clinical endocrinologists, the obesity society, and american society for metabolic and bariatric surgery for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Endocr Pract. 2008;14:318–36. (Co-publication in Surg Obes Relat Disord. 2008;5S:S109–84).

65

Nutrition Issues After Bariatric Surgery for Weight Loss George John Bitar and Sally Myers

65.1 Introduction Recently, we have started seeing adult diseases such as Type II Diabetes mellitus and gall bladder disease in adolescents, and even children [1]. Obesity is the main culprit. It is no secret that obesity has become a major problem in the United States affecting health care, lifestyle, and the economy. With the rise of obesity, we have witnessed a rise in bariatric surgery as the most effective way to manage morbid obesity. On average, it takes a person a year to 18 months to lose 60–80% of their excess weight after a bariatric procedure. The pattern of weight loss varies in individuals and rebound weight gain may occur in about 20% of them [2]. During the weight loss phase, there is an improvement in the medical profile of the patient ranging from a decrease in hypertension to increased mobility, along with resolution or improvement in other comorbidities [3]. It is very important for the bariatric surgeon, as well as the plastic surgeon, to understand the nutritional issues that can arise after the different types of bariatric surgery in order to better manage the patient’s care. After bariatric surgery, the myriad of nutritional deficiencies that can develop may present serious, and sometimes, life threatening problems to a patient who had just begun to enjoy life after being morbidly obese. The nutritional issues are especially important for patients seeking plastic surgery after weight loss because optimal results can only be obtained when the nutritional status of the weight loss patient has been optimized. The following will be an overview of the types of bariatric surgery for weight

G. J. Bitar (*) Bitar Cosmetic Surgery Institute, Northern Virginia, 8501 Arlington Blvd. Suite 500, Fairfax, VA 22031, USA e-mail: [email protected]

loss and possible nutrition issues that can occur with each one. Suggestions for improvement of the postbariatric patient diet, as well as recommendations for both patients and surgeons, will be discussed.

65.2 Types of Bariatric Procedures There are essentially three types of bariatric surgery for weight loss: Restrictive • Laparoscopic adjustable gastric banding (LAGB) • Vertical banded gastroplasty (VBG) • Sleeve gastrectomy (SG) Restrictive/mildly malabsorptive – combination • Roux-en-Y gastric bypass, proximal (RYGBP) Restrictive/predominately malabsorptive • Roux-en-Y gastric bypass, extended (RYGBP-E) • Biliopancreatic diversion (BPD) • Biliopancreatic diversion/duodenal switch (BPD/ DS)

65.3 Description of Procedures Restrictive 1. LAGB A band is placed around the upper part of the stomach to create a pouch that can only hold ½–1 cup of food in a single eating period. The band is adjusted by injecting fluid into a small port implanted beneath the skin in the abdominal region.

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_65, © Springer-Verlag Berlin Heidelberg 2010

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2. VBG The upper stomach near the esophagus is stapled vertically approximately 2.5” to create a small pouch. The outlet from the pouch is restricted by a band or ring to slow the emptying of the food resulting in early satiety. Pouch capacity: 4–8 oz.

two channels. One channel is attached to the pouch and carries the food (alimentary limb). The other channel carries the digestive juices from the liver and the pancreas (biliopancreatic limb). The two limbs are connected as a common channel to the ileum. Pouch capacity: 1–1.5 cups.

3. SG The outer margin of the stomach is removed (vertical incision) leaving a sleeve of stomach with the pylorus. Pouch capacity: 1–1.5 cups.

3. BPD\/DS A SG is the first part of the procedure. The duodenum is then divided so that pancreatic and bile drainage is bypassed. The proximal end of the alimentary limb is then attached to the beginning of the duodenum just past the pylorus. The bile and pancreatic juices move through the biliopancreatic limb. A common limb is created by connecting the alimentary and biliopancreatic limbs to the ileum. Food mixes with the digestive juices in this portion of the intestine and is absorbed. Limb lengths vary by surgeon. Pouch capacity: 1–1.5 cups.

65.4 Restrictive/Mildly Malabsorptive (Combination) 1. RYGBP The upper part of the stomach is stapled or transected leaving a one to two ounce pouch. The small intestine is divided around the proximal/medial jejunum (typically 100 cm). The lower section of the small intestine (alimentary limb) is attached to the pouch by a small outlet or anastamosis. The upper section of the small intestine is connected to the jejunum (Roux limb), creating the Y connection. This allows the digestive liquids from the stomach, bile from the liver, and pancreatic enzymes to mix with the food coming down the alimentary limb and liquefy/process the food. Pouch capacity: 4–8 oz.

65.5 Restrictive/Predominantly Malabsorptive 1. RYGBP-E Same as the RYGBP, except that a larger amount of the small intestine is bypassed. Often the stomach pouch is made larger also because of increased malabsorption and greater nutritional needs. Length of bypass and pouch size vary by surgeon. Pouch capacity: 1–1.5 cups. 2. BPD The stomach is transected horizontally and 70% is removed along with the pylorus. This helps decrease stomach acid production. The stomach left is much larger than the RYGBP pouch. The small intestine is divided approximately in half and reconfigured into

65.6 Effects of Nutrient Uptake 65.6.1 Absorption The small intestine is the primary organ for absorption. It is divided into three sections: the duodenum, jejunum, and ileum. The nutrients absorbed in the duodenum [4] include calcium; phosphorus; magnesium; iron; copper; selenium; thiamin; riboflavin; niacin; biotin; folate; and vitamins A, D, E, and K. The nutrients absorbed in the jejunum are: 1. Proximal – Lipids, monosaccharides, amino acids, small peptides 2. Medial – Thiamin; riboflavin; niacin; pantothenate; biotin; folate; B6; vitamin C; vitamins A, D, E, and K; calcium; phosphorus; magnesium; iron; zinc; chromium; manganese; molybdenum 3. Distal – Lipids, monosaccharides, amino acids, small peptides The nutrients absorbed in the ileum include Medial/ Distal – Vitamin C, folate, vitamin B12, vitamin D, vitamin K, magnesium, lipids, bile salts, and acids. Other nutrients may be absorbed depending on transit time. There are multiple sites and methods of absorption for many nutrients. Limb length plays a critical role in

65 Nutrition Issues After Bariatric Surgery for Weight Loss

absorption after bariatric surgery. It should be noted that the small intestine ranges in length from 15 to 30 feet, which will also have an effect on absorption. Over time, the intestine will adapt to its new configuration and will try to accommodate by improved absorption.

65.6.2 Malabsorption Malabsorption is the incomplete uptake of calories and nutrients which may occur in one of two ways: 1. Diversion of bile, pancreatic enzymes, and/or stomach acid away from ingested food. This reduces the capability for complete breakdown and absorption of macro and micro nutrients. 2. Decreasing the amount of small intestine through which the ingested food passes. Less contact with intestinal surface area results in lower absorption. Fat calorie malabsorption occurs in the RYGBPE, BPD, and BPD/DS, although it has been seen in the RYBGP. Undigested fat, carbohydrate, and/ or protein can cause excessive gas and abdominal bloating. Fat malabsorption can cause loose, foulsmelling bowel movements.

65.7 Nutrient Deficiencies 65.7.1 Labs In general, weight loss surgery (WLS) patients should have preoperative labs done before their surgery, so there is an established baseline to compare to after surgery. Typical pre and postoperative labs are a CBC, a complete metabolic profile (CMP), cholesterol panel, thyroid panel, folate, ferritin, B12, thiamin, and vitamin D. Labs are typically drawn every 3 months the first year postop, semi-annually the second year postop, then annually for life. Other labs to consider are TIBC, serum iron, CRP, methylmalonic acid, vitamin A, zinc, and copper as some studies have shown deficiencies of these nutrients, especially in malabsorptive surgeries. Several studies [5, 6] have shown patients are often deficient in several nutrients before bariatric surgeries.

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Currently, the ones that have been identified are as follows: • • • • • • • •

Ferritin (9%) Thiamin (29%) Vitamin D (40–68%) Vitamin A (11%) Vitamin B12 (13%) Zinc (30%) Selenium (58%) Folate (6%)

Studies [7, 8] have reported the following percentages of deficiency 1 year after gastric bypass surgery: • • • • • • • • •

Ferritin (30–50%) Thiamin (11.2%) Vitamin D (7–21%) Vitamin A (8–17%) Vitamin B12 (3%) Zinc (36%) Selenium (3%) Folate (11%) Vitamin C (35.4%)

There are many reasons for these deficiencies such as poor nutrition and/or malabsorption due to medication intake or other medical conditions such as irritable bowel syndrome. Pre and postoperatively, patients should have a consultation with a dietitian to work on improving their nutrition status. All bariatric surgery patients will need to take vitamin/mineral supplements secondary to decreased consumption of foods and/or malabsorption. Many patients may end up with subclinical deficiencies vs. overt clinical signs of deficiencies that will still need to be addressed.

65.8 Specific Nutrient Issues 65.8.1 Protein Protein malnutrition can occur in malabsorptive procedures secondary to the bypass of the duodenum and all or most of the jejunum. Reasons for protein malnutrition in restrictive/combination procedures are as follows:

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• • • • • • •

Prolonged vomiting Food intolerance Substance abuse Depression Fear of weight regain Anorexia Socioeconomic status

If patients are unable to consume adequate protein, they can supplement with modular protein supplements. Caution should be used with products containing collagen as these products may not contain all the essential amino acids that are necessary to build protein. Overall, about 25% of WLS patients are at risk of developing protein–calorie malnutrition for many months after surgery because of the low protein intake [9]. In postbariatric body contouring patients, protein deficiency impairs wound healing because protein is needed for fibroblast proliferation, angiogenesis, and collagen production [10]. A higher protein intake is indicated postbariatric surgery due to stress of surgery, extensive wound healing, and consumption of 600–800 calories initially. A minimum of 70 g/day of protein is needed to avert malnutrition for RYGBP [11]; 90 g for BPD and BPD/DS [12]. A common formula used is 1.5 g/protein per kilogram of ideal body weight or adjusted body weight.

G. J. Bitar and S. Myers

malabsorptive procedures may have deficiencies secondary to delayed mixing of gastric and pancreatic enzymes, as well as bile. Fat malabsorption also alters the transport of fat soluble tissues reliant on lipid components. BPD surgery has been reported to decrease fat absorption by 72%. A few studies have found suboptimal levels of zinc in BPD/DS patients and RYGBP after 1 year, which may manifest as hair thinning and loss [13]. Supplementation of zinc is dependent on lab findings and should be monitored as it affects copper absorption.

65.8.4 Vitamin E Most studies evaluated postoperative values and did not assess preoperative values. Currently, most patients appear to be maintaining adequate levels of vitamin E providing 100% of the daily recommended intake. It is important to stress to patients that taking excess supplementation of vitamin E can be harmful because it can inhibit collagen synthesis and decrease wound healing ability; vitamin E has anti-inflammatory properties similar to steroids [14].

65.8.5 Vitamin C 65.8.2 Copper Copper is absorbed by the stomach and the duodenum. Most reported cases of copper deficiency were associated with taking supplemental zinc of greater than 50 mg daily. There are no specific guidelines for the use of copper in postbariatric patients; however, copper is important for optimal immune system function. If a patient presents with signs and/or symptoms of neuropathy, copper should be tested. Other reasons for copper malabsorption are anemia, infection, or low B12 and iron levels.

65.8.3 Zinc Zinc is required for multiple aspects of cellular growth and replication. It is a mineral that depends on fat absorption as well as vitamins A, D, E, and K. Patients with fat

Approximately 35% of patients have vitamin C deficiency a year to 2 years after a Roux-en-Y gastric bypass surgery [7]. Vitamin C plays an important role in wound healing, specifically in collagen synthesis and angiogenesis, so a vitamin C deficiency is associated with capillary leakage due to decreased collagen production, and thus, susceptibility to wound infections [10]. It is recommended to have vitamin C supplements of 1–2 g daily for the perioperative period until convalescence is complete [10]; afterward, the dietary reference intake (DRI) is 60 mg daily.

65.8.6 Vitamin K In a study by Slater et al. [12], 68% of BPD patients had less than the measurable range of serum vitamin K levels after 4 years. One study found RYGBP patients had a lower prothrombin time percentage [8].

65 Nutrition Issues After Bariatric Surgery for Weight Loss

65.8.7 Vitamin A Studies [8, 12] have shown a 52–68% deficiency in BPD patients postoperatively. One study [8] reported a 52% deficiency in RYGBP and 25% in AGB. Typically, the number of patients who follow-up after 1 year declines, so while reviewing data this must be kept in mind. Clinical consequences of vitamin A deficiency appear to be rare; however, vitamin A is an essential factor in the healing process, as it functions as an immunostimulant enhancing wound healing. The DRI for vitamin A is 3,000 IU; however, it may be increased in postsurgical patients.

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absorption for iron. Lack of acid in the gastric pouch can affect the reduction of iron from the ferric to ferrous. Vitamin C can enhance absorption of iron, so it is often recommended to take an iron supplement containing vitamin C. Although not well studied, the breakdown of fatty tissues releases hormones and causes chemical changes. One of the authors remembers RYGBP patients who have had menstrual periods lasting 6 weeks or longer after surgery possibly secondary to hormone shifts. The excessive blood loss significantly reduces iron stores. Patients are told not to donate blood after surgery for precisely this reason unless they have unusually large stores. Serum iron and total iron binding capacity are the preferred tests for determining iron status as ferritin can fluctuate with age, inflammation, and infection.

65.8.8 Vitamin D/Calcium The percentage of patients having a vitamin D deficiency before surgery can be as high as 68%. Possible mechanisms of vitamin D deficiency include inadequate sun exposure, inadequate dietary intake, and/or decreased availability secondary to fat mass. It is important to ensure that patients are taking adequate amounts of vitamin D and calcium pre and postop. Serum calcium will not be expected to decrease until bone disease has severely depleted skeletal calcium stores. Low levels of vitamin D and calcium may increase risk of cancer (colon, breast, and prostrate), chronic inflammation and autoimmune disorders (diabetes mellitus type, inflammatory bowel disease, arthritis), metabolic disorders (hypertension and metabolic syndrome), as well as peripheral vascular disease. Patients with a history of using the following prescribed medications should also be monitored for metabolic bone disease: methotrexate, heparin, cholestyramine, thyroid hormone, glucocorticoid, and/or antiseizure medications.

65.8.9 Iron Reasons for iron deficiency are multifactorial and not fully explained in published studies. For malabsorptive surgeries including RYGBP, it is thought that there are fewer receptors for absorption due to bypass of the duodenum and proximal jejunum, the major sites of

65.8.10 Vitamin B12 and Folate Vitamin B12 deficiency is most prevalent in RYGBP patients secondary to inadequate production of intrinsic factor and insufficient stomach acid to convert pepsinogen to pepsin and release B12 from protein foods. Proton pump inhibitors also reduce absorption of B12, on which many RYGBP patients are put prophylactically after surgery. Folic acid stores can be depleted within a few months postoperatively if intake is insufficient from supplements and/or diet. Preoperatively, deficiencies have been reported as high as 56% in RYGBP patients [15]. It has been suggested by several sources that homocysteine is the most sensitive marker of folic acid status in conjunction with serum folate. Vitamin B complex and folate deficiencies are fairly prevalent after bariatric surgery with Vitamin B12 deficiency ranging from 3–37% at 1 year after RYGBP and folate deficiency with an incidence of 9–35% after bypass operations [16]. In patients with severe Vitamin B12 and folate deficiency, megaloblastosis and megaloblastic anemia can occur, a condition that affects the nonhematopoietic cells, such as the gastrointestinal mucosal cells. The molecular basis for the occurrence of megaloblastosis is that folate and Vitamin B12 are required for the formation of S-adeno-sylmethionime, which is critical for the stabilization of DNA and many other proteins. Thus, deficiencies of these vitamins can contribute to poor cellular proliferation and repair in

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the postbariatric body contouring patient. Furthermore, the associated anemia will adversely affect circulation in the healing tissues [15]. Recommendations for postsurgical patients are 500 mg/day of Vitamin B12 and 800 mg of folate [7, 17].

65.10 Dietary Recommendations 65.10.1 Restrictive Procedures

65.8.11 Thiamine Thiamine deficiency occurs mainly secondary to persistent vomiting and/or inadequate dietary intake. A deficiency can occur in as little as 2 weeks if a patient is vomiting daily and not replenishing one’s store with food/and or supplementation. Because of the high likelihood of low dietary thiamine intake, it is suggested that patients be supplemented with thiamin. One of the authors has documented in the patients’ dietary histories that many RYGBP patients were consuming less than 50% of the recommended intake for all of the B vitamins after 1 year postop.

65.9 Recommended Vitamin/Mineral Supplementation

Restrictive Combination

Malabsorptive

Multivitamin

Yes

Yes

Yes

Calcium citrate

a

Yes

Yes

B12

a

Yes

a

Iron

a

b

a

Vitamin D

a

Yes

Yes

Vitamin A

a

a

Yes

Fish oil Yes a If indicated by labs or inadequate dietary intake b If anemic or menstruating a

surgeries should take fish oil regardless, since they are malabsorbing fat.

a

Recommended intake will vary by practice. Be sure to obtain your patient’s guidelines for nutrient intake. Calcium must be divided into doses of 500–600 mg at one time as the body cannot absorb more than that at one time. Calcium should not be taken with any product containing iron as it will block iron absorption. Leave at least 2 h between taking iron and calcium products. If patients do not eat fish, they should be taking fish oil supplements. Patients with malabsorptive

With restrictive procedures, patients will be able to consume ½ cup to 1 cup per meal lifelong. With the limited capacity to eat, it is imperative that these patients eat a well balanced diet with adequate protein intake. They should be taking a daily multivitamin and calcium (if dietary intake is inadequate). They initially may need other nutrients if they do not consume them from their diet such as protein, B12, vitamin D, and iron.

65.10.2 Restrictive/Mildly Malabsorptive With RYGBP, patients will be able to consume ½ cup to one cup per meal by 6 months postoperatively. The typical eating pattern for a meal is: • 2–3 oz of protein • ¼–½ cup of vegetables • ¼–½ cup of starch If patients need a planned snack, it will typically be protein based or a vegetable or fruit. They will need lifelong supplementation of the following vitamins/ minerals daily: • Multivitamin with iron • B12 (500 mg sublingual, monthly shot 1,000 mg or nasal spray) • 1,500 mg of calcium citrate daily split into three doses of 500 mg. This cannot be taken with iron/ iron containing supplements as calcium will block iron absorption at this dosage. Leave at least 2 h between calcium and iron supplements. • Iron (if a menstruating female or anemic). Typical dosage: 65 mg. A product compounded with vitamin C is suggested to increase absorption. Prescription iron may be needed if iron depletion is severe. • B50 complex

65 Nutrition Issues After Bariatric Surgery for Weight Loss

Long term, it is suggested that patients consume 1 g of protein per kilo of ideal body weight. Some may still need to consume a daily protein supplement if they are unable to consume adequate protein due to food intolerances. A suggested minimum daily protein intake regardless of height, weight, or sex is 70 g. Also consider an essential fatty acid supplement like fish oil as many patients do not consume fish in their diet. Some may need a vitamin D supplement lifelong if they consume adequate amounts or get it from the sun.

65.10.3 Restrictive/Predominantly Malabsorptive These patients typically have larger pouches to accommodate the extra malabsorption, so they tend to eat normal portions. Patients in this group are also fat malabsorbing which includes vitamin A, vitamin D, vitamin E, and vitamin K. Protein, zinc, and essential fatty acid deficiency can occur more often in this group also, so supplements and diet remain important to lifelong health. Required vitamins are the same for this group as the previous, with the addition of higher doses of vitamin D and vitamin A. Suggested minimum daily protein requirement is 90 g daily, so many may end up using a daily protein supplement long term.

65.11 Questionnaire for Prospective Postbariatric Patients 1. What type of bariatric procedure did you have? 2. What was the date of your surgery? 3. What was your starting weight? Lowest weight obtained? Current weight? 4. Please list all vitamins/minerals you take daily. 5. Have you been working with a Registered Dietitian (RD) pre and postoperatively? 6. When was the last time you had your labs done? 7. Do you currently have any nutrient deficiencies? If so, what and how are you correcting it? 8. How often do you exercise? What type of exercise are you doing?

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9. Please write down a typical day of eating. 10. How much fluid do you drink daily? What do you drink? 11. Do you drink alcohol? If yes, how much/how often? 12. Do you smoke? If yes, how much/how often? 13. Do you have any problems with food tolerations? If yes, what food? 14. Do you vomit when you eat? If yes, how often? 15. Do you chew your food and spit it out? If yes, how often? 16. Do you have any problems with hypoglycemia? If patients have not had their labs done, they will need to have them done to determine their nutrition status. If they are not compliant with their diet and/or vitamin/ mineral supplements, they should consult with a RD to work with until their nutrition is adequate and they have reestablished their required eating patterns and vitamin/mineral intake. A RD can outline what vitamins and minerals they should be taking, along with amounts and eating patterns.

65.12 Recommended Labs Restrictive

Combination Malabsorptive

Complete metabolic profile

Yes

Yes

Yes

CBC

Yes

Yes

Yes

Vitamin D OH

Yes

Yes

Yes

Serum retinol

a

a

Yes

Zinc

a

a

Yes

RBC folate

Yes

Yes

Yes

Ferritin

Yes

Yes

Yes

B12

a

Yes

Yes

Thiamin

a

Yes

Yes

Cholesterol panel

Yes

Yes

Yes

Thyroid panel

Yes

Yes

Yes

Parathyroid hormone

a

Yes

Yes

Zinc

a

a

Yes

Copper

a

a

a

(continued)

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G. J. Bitar and S. Myers

TIBC

Yesb

Yesb

Yesb

Serum iron

Yesb

Yesb

Yesb

Methylmalonic acid

a

b

b

CRP

a

a

a

a a Magnesium Yes Optional b Considered best test. If a nutritional deficit is suspected from noncompliance or inadequate intake, go ahead and test a

65.13 Plastic Surgery After Weight Loss Patients who undergo bariatric procedures witness dramatic changes in their body weight and contour in a relatively short period of time – 12–18 months. It is logical that when they see the resultant excess skin, they are discouraged and would like to get rid of it to enjoy their new body. These patients are appropriate plastic surgery candidates in the 1–2 year period after their bariatric surgery; however, this is also the period in which most patients have minimal nutritional reserves following months of continual malabsorption of proteins, vitamins, and mineral [18]. The plastic surgeon and the nutritionist who are managing the postbariatric patient have to confirm that the patient has reached his/her plateau weight for several months and is nutritionally optimized before plastic surgery should be offered. Postbariatric patients are usually prescribed a diet that contains adequate protein, vegetables, fruit, fiber, and essential fatty acids. Starches are often limited to two to three servings per day. Vitamin/mineral supplement guidelines are also given, as well as a discussion of food textures/tolerances and amounts. Increasing evidence shows that the postbariatric patients have fair to poor compliance with recommendations on nutrition that they receive from surgeons as evidenced by an article by Brolin and Leung [19], which noted that even when appropriate recommendations were made by surgeons to patients about multivitamin supplements, iron, protein, and calcium, compliance fell below 50%. Furthermore, some postbariatric patients can go the opposite direction and lose more than their excess weight to become malnourished after bariatric surgery,

possibly secondary to a loss of interest in food/eating. The criteria for a new eating disorder diagnosis have been proposed, “postsurgical eating avoidance disorder” (PSEAD) [2]. This group of patients can have a complicated postoperative course, so they need to reach appropriate weight and improve their nutrition before they can undergo plastic surgery. Preparing for plastic surgery after massive weight loss must be carefully undertaken from choosing the right board certified plastic surgeon, to discussing at length the procedures, to having a very good knowledge of the perioperative care and requirements [20]. When plastic surgery is undertaken after massive weight loss, protein malnutrition, coupled with vitamin and mineral deficiencies that have been asymptomatic, can lead to significant complications because now the stress of surgery is an added factor. In one study of postbariatric plastic surgery, complications relating to wound problems were noted in 66% of patients [21]! It has been well established in countless studies in the surgical literature that nutrition profoundly influences wound healing, with reports in the various surgical subspecialties of decreased postoperative hospital stay, infectious complications, morbidity, and mortality rates [22]. Measures should be taken to reduce stress after surgery, the nutrition optimized with the help of an RD, and frequent postoperative checkups done to insure that the healing is progressing as expected. If complications arise, early intervention, whether by draining a seroma, evacuating a hematoma, treating an infection with antibiotics, or administering appropriate wound care, while improving nutrition, will increase the success rate of postbariatric plastic surgery.

65.14 Conclusions The epidemic of obesity continues to grow in the U.S. [23]. Obesity not only affects adults, but now affects teenagers and children. It is important for medical professionals and patients to understand the different types of bariatric procedures to appreciate the possible nutritional deficiencies that can ensue. We have presented the common nutritional deficiencies that may occur after bariatric procedures. Nutrition needs to be addressed when patients are considering postbariatric plastic surgery to improve their body contour, removal of

65 Nutrition Issues After Bariatric Surgery for Weight Loss

excess skin, and tightening of the lax muscles that are resistant to hard work at the gym. By providing education, proactive care, and guidance, a partnership is created between the patient, the bariatric surgeon, the plastic surgeon, the dietitian, and the rest of the support staff. This partnership will help ensure a happy ending to the long journey that our patients have endured. Acknowledgment The authors would like to thank Dr. Osvaldo Anez, a compassionate skilled bariatric surgeon who has given hope to thousands of patients and inspiration to countless surgeons and medical professionals.

References 1. Aly AS. Body contouring after massive weight loss. St. Louis: Quality Medical Publishing; 2006. p. 4. 2. Kalarchian MA, Marcus MD, Courcoulas AP. Eating problems after bariatric surgery. Eat Disord Rev. 2008;19(4). 3. Christou NV, Sampalis JS, Lieberman M, Look D, Auger S, McLean AP, McLean AD. Surgery decreases long-term mortality, morbidity, and healthcare use in morbidly obese patients. Ann Surg. 2004;240(3):416–23. 4. Groff JL, Gropper SS. The digestive system: mechanism for nourishing the body. In: Groff JL, Gropper SS, editors. Advanced nutrition and human metabolism. 3rd ed. Belmont: Wadsworth Thompson; 2000. p. 24–49. 5. Madan AK, Orth WS, Tichansky DS, Ternovits CA. Vitamin and trace mineral levels after laparoscopic gastric bypass. Obes Surg. 2006;16(5):603–6. 6. Brolin RE, LeMarca LB, Henler HA, Cody RP. Malabsorptive gastric bypass in patients with super-obesity. J Gastrointest Surg. 2002;6(2):195–203. 7. Clements RH, Katsani VG, Palepu R, Leeth RR, Leeth TD, Roy BP, Vickers SM. Incidence of vitamin deficiency after laparoscopic roux-en-y gastric bypass in a university hospital setting. Am Surg. 2006;72(12):1196–202. 8. Ledoux S, Msika S, Moussa F, Larger E, Boudou P, Salomon L, Roy C, Clerici C. Comparison of nutritional consequences of conventional therapy of obesity, adjustable gastric banding, and gastric bypass. Obes Surg. 2006;16(8):1041–49. 9. Agha-Mohammadi S, Hurwitz DJ. Nutritional deficiency of post-bariatric body contouring patients: What every plastic

659 surgeon should know. Plast Reconstr Surg. 2008;122(2): 604–13. 10. Cohen IK, Diegelmann RF. Wound healing. In: Greenfield L, editor. Surgery: scientific principles and practice. Philadelphia: Lippincott; 1993. p. 86. 11. Mahan LK, Escott-Stump S. Medical nutrition therapy for anemia; krause’s food, nutrition, and diet therapy. 10th ed. Philadelphia: WB Saunders; 2000. p. 469. 12. Slater GH, Ren CJ, Seigel N, Willians T, Barr D, Wolfe B, Dolan K, Fielding GA. Serum fat-soluble vitamin deficiency and abnormal calcium metabolism after malabsorptive bariatric surgery. J Gastrointest Surg. 2004;8(1):48–55. 13. Prasad A. Acquired zinc deficiency and immune dysfunction in sickle cell anemia. In: Cunningham-Rundles S, editor. Nutrient modulation of the immune response. New York: Marcel Dekker; 1993. p. 393. 14. Ehrlich HP, Tarver H, Hunt TK. Inhibitory effects of vitamin E on collagen synthesis and wound repair. Ann Surg. 1972; 175(2):235–40. 15. Boylan LM, Sugerman HJ, Driskell JA. Vitamin E, vitamin B6, vitamin B12, and folate status of gastric bypass surgery patients. J Am Diet Assoc. 1988;88(5):579–85. 16. Brolin RE, Gorman JH, Gorman RC, Petschenik AJ, Bradley LJ, Kenler HA, Cody RP. Are vitamin B12 and folate deficiency clinically important after Roux-en-Y gastric bypass? J Gastrointest Surg. 1998;2(5):436–42. 17. Allied Health Services Section Ad Hoc Nutriton Copmmittee; Aills L, Blankenship J, Buffington C, Furtado M, Parrott J. ASMBS allied health nutritional guidelines for the surgical weight loss patient. Surg Obes Relat Dis. 2008;4(5 suppl): S73–108. 18. Agha-Mohammadi S, Hurwitz DJ. Potential impacts of nutritional deficiency of postbariatric patients on body contouring surgery. Plast Reconstr Surg. 2008;122(6):1901–14. 19. Brolin RE, Leung M. Survey of vitamin and mineral supplementation after gastric bypass and biliopancreatic diversion for morbid obesity. Obes Surg. 1999;9(2):150–4. 20. McNemar TB, Lomonaco J, Krieger MD. Bariatric plastic surgery: a guide to cosmetic surgery after weight loss. Omaha: Addicus Books; 2008. p. 28. 21. Hurwitz D, Agha-Mohammadi S, Ota K, Unadkat, J. A clinical review of total body lift surgery. Aesthetic Surg J. 2008; 28:294. 22. Dempsey DT, Mullen JL, Buzby GP. The link between nutritional status and clinical outcome: can nutritional intervention modify it? Am J Clin Nutr. 1998;47(2 Suppl):352–6. 23. Hurwitz D. Total body lift. New York, NY: MDPublish.com; 2005. p. 17.

The Body’s Aesthetic Units for Body Contouring Surgery in Massive Weight Loss Patients

66

Héctor J. Morales Gracia and Alberto Javier Coutté Mayora

66.1 Introduction The increase of morbid obesity has become one of the major health problems in most countries. Bariatric surgery has been increasing in the last decade in number and effectiveness, and so has the number of massive weight loss patients. Through the last 10 years, plastic surgeons have been developing new procedures or improving preexistent procedures, and different combinations of these based on Body’s Aesthetic Units to solve or correct as many of the different body contour deformities, or affected areas by skin laxity and redundancy [1–13]. Ideally, body contouring surgery in the post-bariatric surgery patients should only be performed after the patients’ weights are stable, and that could take around 18 months after the Bariatric surgery. As they have many body contour deformities and the intensity of these different deformities varies from patient to patient, we must evaluate each patient in order to make the best surgical plan, combining procedures to correct as many of the problems or body contouring deformities in each surgical stage without increasing surgical risk. The author regularly performs in the first stage a circular lipectomy with lateral thigh–buttocks lift in female patients that corrects all the lower body contour deformities except for the inner thigh, and also corrects the abdominal wall by tightening the muscles and the vertical skin excess, and the lower back [13]. This procedure can be combined with breast surgery. The author designed a procedure that can be regularly performed as a second stage in

females, but can be performed as a first stage in males. A reverse or upward abdominoplasty in “V” (or its variables) with pexy of the upper-back-torso and brachioaxilloplasty is performed (Fig. 66.1). This corrects the upper abdomen eliminating the horizontal skin excess by performing a “V” skin resection. The “V” design can be supra-umbilical in “v” or “T”, or suprapubic in “U” – “V” or “T”, or horizontal “H” in the cases where needed. This also corrects the lower abdomen and pubic area. The upward vertical abdominoplasty is combined with upper back and torso pexy and axillo-brachioplasty, and if needed, with breast surgery or pectoral plasty in males. One of the major concerns of male obese patients is the female breast look-like appearance of their chest that significantly lowers their self-esteem and prevents them from properly socializing, and most of the times, persists even after successful bariatric surgery. The author designed a male pectoral pexy and reshaping procedure, which gives the patient the body building pectoral shape and appearance that helps them recover self-esteem. This is a fast and easy technique that can be performed as a single procedure or in combination with all different reverse vertical abdominoplasties with upper-back-torsoaxillo-plasty (Fig. 66.2) and brachioplasty. There are patients with centripetal obesity whose major concern is the excessive abdominal skin and fat folds where the vertical abdominoplasty in inverted “V” with horizontal ellipse resection or “fleur-de lis” is the indicated procedure for their first stage (Fig. 66.3).

66.2 Preoperative Markings H.J. Morales Gracia (*) Cirugìa Plàstica Estètica y Reconstructiva, Belisario Domínguez No. 2501, Colonia Obispado, Monterrey, Nuevo León C.P. 64060, México e-mail: [email protected]

For pre-operative markings (Fig. 66.4), the patient could either be in supine or standing position, while the surgeon marks the abdominal mid-line from the

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_66, © Springer-Verlag Berlin Heidelberg 2010

661

662

H. J. Morales Gracia and A. J. Coutté Mayora

B A

A

a

a¢

b

b¢

c

c¢

Fig. 66.1 Vertical reverse–upward abdominoplasty with upper-back-torso-axillo-brachioplasty markings. Left: (a) Supraumbilical in “v”. (b) Suprapubic in “U” – “V”. (c) Horizontal “H”. Right: expected position of resultant scars

66 The Body’s Aesthetic Units for Body Contouring Surgery in Massive Weight Loss Patients

a

b

c

a¢

b¢

c¢

663

Fig. 66.2 (a) Sixteen-year-old male 14 months after bariatric surgery and loss of 120 pounds. (b) Preoperative parkings. (c) One week following vertical reverse upward suprapubic in “U”

abdominoplasty with upper-back-torso-axilloplasty and male pectoral pexy, contouring, and reshaping

pubis to the sternum, then the infra-mammary folds and breast or pectoral perimeter on both sides, then makes some pull-up manoeuvres of the lax tissues of one side of the abdomen in an oblique upward – contralateral direction – with one hand, and then with the other hand the lower abdominal flap is pulled in a horizontal contra-lateral direction, marking over the abdominal flap a vertical line where it meets the midline from the pubis to the infra-mammary line, then pulling up the flap in an upward direction, a horizontal line is drawn where it meets the sub-mammary or pectoral fold. The upper back and torso is pulled up in an upward medial oblique direction and a line is drawn where it meets the lateral aspect or perimeter of the pectoral muscle or anterior axillary line. The axilla and

arm are marked with the arm abducted and the elbow in 90° flexion, so the gravity pulls down the arm tissues and it makes it easy to mark the inner mid-line or bicipital groove from the epicondyle to the caudal limit of the axilla, then the arm tissue is pulled up and a line is drawn over the bicipital groove from the epicondyle to the axilla, then surrounding the lower–posterior edge of the axilla a “U” line is drawn, preserving part of the axillary glands and the axillary lymphatic nodes, until it meets with the upper back resection line or the lateral limit of the breast (Fig. 66.5). For pectoral pexy, contouring and reshaping pre-operative markings, the pectoral skin and tissues are pulled down with one hand, and with the other hand the tissues are also pulled laterally by the assistant, while the surgeon marks the

664 Fig. 66.3 Forty-seven-yearold female with centripetal obesity whose major concern was excessive abdominal skin and fat fronds. (a) Preoperative parkings for vertical abdominoplasty in inverted “V” with horizontal ellipse resection or “fleur-de-lis.” (b) One week postoperatively

H. J. Morales Gracia and A. J. Coutté Mayora

a

a¢

skin over the lower and lateral pectoral muscle’s perimeter, from the thoracic mid-line to the axilla, giving it a male pectoral shape (Fig. 66.6) that will be the future fixation suture line for both upper and lower flaps. Then the lower and lateral perimeter of the hypertrophied-ptotic gynecomastia pectoral tissue is marked, and a horizontal line is drawn 10–15 mm above the nipple–areola complex while pulling down the pectoral tissues from the mid-line to the lateral limit of the infra-mammary fold; all this area is going to be deepithelialized, if the areola is bigger than it should, and

b

b¢

an oval 20–23 mm horizontal by 18–20 mm vertical areola diameter is marked.

66.3 Surgical Technique An intravenous line is set, and the anaesthesiologist administers light intravenous sedation with 50 mg/kg of Midazolam, 1 mg/kg of Fentanest, 1 g of cephalotine every 6 h, 50 mg of ranitidine every 12 h, and 5,000 UI

66 The Body’s Aesthetic Units for Body Contouring Surgery in Massive Weight Loss Patients Fig. 66.4 Marking for contouring reshaping manoeuvres for vertical reverse upward suprapubic in “U” abdominoplasty with upper-back-torso-axilloplasty and male pectoral pexy

a

665

b

a-b

a

b

c

of subcutaneous heparin. The epidural catheter is introduced in a lateral decubitus position at the T8–T9 level where infra-umbilical lower abdomen and/or suprapubic area surgery is going to be performed along with upper abdomen, breast or pectoral, torso, axilla, or arm surgery. The patient is made supine and a Foleys catheter is set. The surgery starts with a supra-umbilical incision either in the abdominal mid-line (Fig. 66.7) or if it was possible to determine the exact amount of tissue to be resected with the pinch or pull manoeuvre, over the marked resection line of each side (in these cases undermining is minimal or not needed). If the incision is made on the abdominal mid-line regularly, there is only

d

a little lateral undermining of the flaps needed, exposing and marking the mid-line fascia and medial part of the rectus abdominis muscle aponeurosis, but it can be done as much as needed (tailor-made). It is important to avoid excessive or unnecessary undermining, given the excessive laxity and displacement of the abdominal, upper back, torso, axilla, breast or pectoral skin, subcutaneous, and connective tissues, then the incision is continued laterally as much as needed. For the cases where breast or pectoral, upper back, torso, infra-axillary, axillary, and arm surgeries are to be performed, the incision is made first over the infra-mammary or sub-pectoral fold or crease and around the lateral border or aspect of

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Fig. 66.5 (a) Markings for vertical reverse upward in “V” abdominoplasty with upper-back-torso-axillo-brachioplasty. (b) Brachioaxilloplasty markings (c) Immediate post-op result (c') One year post-op result

66 The Body’s Aesthetic Units for Body Contouring Surgery in Massive Weight Loss Patients

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Fig. 66.6 Contouring and reshaping parkings for male pectoral pexy. (a) Pectoral skin and tisúes pulled down and laterally to mask the pectoral muscle perimeter. (b) 1: Infra-mammary

fold and lateral perimeter of the ptotic gynecomastia pectoral tissue. 2: Horizontal supraareolar marking line. 3: Area of de-epithelialization. 4: Areola marking

the pectoral or breast exposing the pectoral’s aponeurosis on its lower and lateral edge and marking it. This marking of the aponeurosis or fascia is the ideal place for resultant scar as it is the abdominal mid-line. The undermining in this area is only as much as needed. The pull-up manoeuvre is started on each upper medial tip of the abdominal flap in an upward and oblique direction towards the previously anchored pectoral flap midline to the aponeurosis, until being sure of the amount of tissue needed to resect or cut, the same with the upper lateral abdomen in the upward direction, and the upper back in a oblique direction and infra-axillary flap in transverse direction. Once the amount of tissue to be resected is marked, perpendicular references are marked for suturing purposes. At this time, it is important to suture and fix the upper abdominal mid-line end and the upper lateral abdominal flap completely using Monocryl 3–0, taking the Scarpa’s fascia of the flap and fixing it to the muscle or the aponeurosis at the level that it was marked. At this time, if a pectoral or breast surgery is to be performed, it must be sutured completely before any abdominal mid-line tissue resection. Once upper tissues are fixed and sutured, the vertical infra-umbilical incision is completed and the flaps undermined, contralateral pull manoeuvre of the abdominal flaps is done to determine the correct amount of tissue to be resected. The abdominal mid-line is sutured in two layers with Monocryl 3–0, fixing and exteriorizing the umbilicus

through the suture; if abdominal muscles need to be plicated, first the rectus abdominis muscles must be plicated with two layers of Prolene 0, with separated stitches and a second layer of Prolene 0 running suture. Then it is checked if any oblique plication is needed. After the suture is complete, check if any pubic or lower abdomen skin excess remains, and if so, a horizontal compensatory incision over the suprapubic line is made, and the tissue is resected and sutured. When pectoral pexy and reshaping procedure is to be performed, the surgery starts with the de-epithelialization of the area within the previously marked infra-mammary fold and just above the areola line, preserving at all means the dermis of the flap (Fig. 66.8). Once the de-epithelialization is complete, the incision is made in the perimeter of this area, exposing the pectoralis muscle fascia. The upper pectoral flap is undermined 5–6 cm cephalad over the pectoralis fascia. The de-epithelialized flap is tailored eliminating lateral and medial tissue excess, being careful to preserve a wide central, upper, and lower pedicle in order to preserve the areola blood supply. As these tissues are ptotic and excessive, the flap must be tailored, reshaped and fixed at the proper height, giving it the male pectoral shape and anchoring the dermis of the lower aspect of the flap to the lower limit of the pectoralis muscle aesthetic unit previously marked, being careful to pull and fix the flap in the best position for the correct placing of the nipple–areola complex. Once the

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ANCHORING UPPER ABDOMINAL FLAP MID LINE

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Fig. 66.7 Surgical stops in vertical upward suprapubic in “U” abdominoplasty with upper-back-torso-axilloplasty and male pectoral pexy

flap is fixed, the upper pectoral flap is pulled down and laterally, skin resection line is marked, also marking perpendicular reference lines for suturing, and the areola coordinates over the flap, then skin resection is tailor-made, avoiding excessive tension. The flap is fixed with interrupted subdermal 3–0 Monocryl suture to the pectoralis muscle fascia, every 2 cm starting at thoracic mid-line. The areola is exteriorized through a horizontal incision, and sutured with subdermal inverted 5–0

Monocryl. If this is performed as a single procedure, the wound closure is done at this time with subdermal inverted 3–0 Monocryl. If it is combined with upper abdominal-back-torso-axilloplasty, then this flap is undermined just as much as needed, and once it is freed, the flap is pulled up in an upward oblique direction to assess or establish the amount of skin and subcutaneous tissue to be resected (Fig. 66.7). The resection is first done at the upper mid-line fixing both pectoral and

66 The Body’s Aesthetic Units for Body Contouring Surgery in Massive Weight Loss Patients

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Fig. 66.8 Contouring and reshaping surgical steps in male pectoral pexy (a) de-epithelialization, (b) cephalic major pectoralis muscle undermining, (c) y (d) pexia, remodeling and recontour-

ing of the mammary tissue into pectoral shape. (e) y (f) fixing and suturing of the pectoral skin flap. (g) Areola exteriorization

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Fig. 66.9 Thirty-four-year-old female post-bariatric with prior (first stage) “fleur-de-lis” abdominoplasty. Top: Markings for vertical reverse in “v” supra-umbilical abdominoplasty with

H. J. Morales Gracia and A. J. Coutté Mayora

upper-back-torso-axilloplasty. Middle: 6 months after surgery. Bottom: 6 months after mastopexy with silicone implants

66 The Body’s Aesthetic Units for Body Contouring Surgery in Massive Weight Loss Patients Fig. 66.10 Forty-year-old female post-bariatric surgery with prior “Fleur-de-lis” vertical reverse in “v” supra-umbilical abdominoplasty with upper-back-torsoaxilloplasty, augmentation mastopexy, and lateral thigh-buttock lift. (a, c, e) Pre-operative parkings for inner thigh vertical lipectomy and pubic pexy and reshaping. (b, d) Four months after surgery

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abdominal flaps at the thoracic mid-line over the sternum fascia. Once both flaps are fixed on mid-line, the abdominal-back-torso-axilla flap is pulled towards the previously marked pectoralis muscle fascia perimeter and the amount of skin resection is evaluated, marked, and resected (Fig. 66.7). Then, this flap is sutured in two layers, one taking the Scarpa’s fascia and the pectoralis muscle fascia, and the other taking the dermis of the pectoral and the abdominal-back-torso-axilla flap and the pectoralis muscle fascia (Fig. 66.7). Draining

tubes are left where needed, the wounds are covered with Neosporin and bandages. The patient wears a compressive girdle and vest. The patient spends one night at the clinic and receives autologous blood if needed. Ambulation is started the next morning and the patient is discharged at noon. The patient is examined on the seventh post-operative day when the drains and umbilicus stitches are removed. Examination is continued weekly for the first month, and then monthly for a year.

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abdominoplasty with upper-back-torso-axillo-brachioplasty. (f–h) One year post-operative with excellent results

66 The Body’s Aesthetic Units for Body Contouring Surgery in Massive Weight Loss Patients

Fig. 66.12 Body aesthetic units for body contouring surgery

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66.4 Results No major complications have occurred, all patients have had a fast and well recovery starting ambulation the morning after surgery, wearing a compressing girdle and vest when needed. Some patients indicated pain in the chest area, but were not prevented from walking and did not needstronger analgesia. In the cases where there was no remaining obesity, the results were excellent (Figs. 66.2, 66.3, 66.9–66.11). The goals were accomplished in all cases, except in one in which the patient did not want to have the vertical abdominal resultant scar, and the reverse abdominal resection by itself was not enough to correct the middle and upper back skin folds, although the patient was happy with the results. One patient presented with a seroma in one arm, and another presented with a small dehiscence in the centre of the lower T junction suture and a 2-cm dehiscence in the axilla. All these problems were spontaneously resolved.

66.5 Discussion Plastic surgery for massive weight loss patients offers a great deal of different procedures, It is imperative that plastic surgeons properly evaluate their patients, and have in mind all different previously described procedures and its combination possibilities, always placing the resultant scars strategically at the limits of the Body’s Aesthetic Units (Fig. 66.12) to correct as many body contour deformities in the less number of surgical stages without increasing surgical risk. Postbariatric or massive weight loss patients have many different body areas affected in different intensities,

H. J. Morales Gracia and A. J. Coutté Mayora

and in some patients skin retraction of some areas could be total and in other areas there could not be any retraction at all. That is why these cases must be planned according to their needs and focusing in solving in the first stage the deformities that cause the major concern to the patients so that they recover their self-esteem as soon as possible.

References 1. González-Ulloa M. Circular lipectomy with transposition of the umbilicus and aponeurolytic technique. Cirurgìa 1959; 27:394–409. 2. González Ulloa M. Belt lipectomy. Br J Plast Surg. 1961; 13:179. 3. Baroudi R, Keppke EM, Tozzi-Neto F. Abdominoplasty. Plast Reconstr Surg. 1974;54(2):161–8. 4. Regnault P. Abdominoplasty by the “W” technique. Plast Reconstr Surg. 1975;55(3):265–74. 5. Regnault P. Abdominal dermolipectomies. Clin Plast Surg. 1975;2(3):411–29. 6. Guerrero-Santos J. Brachioplasty. Aesthetic Plast Surg. 1979; 3:1–4. 7. Baroudi R. Body sculpturing. Clin Plast Surg. 1984; 11(3): 419–43. 8. Lockwood TE. Fascial anchoring technique in medial thigh lifts. Plast Reconstr Surg. 1988;82(2):299–304. 9. Baroudi R. Body contouring surgery. Clin Plast Surg. 1989; 16(2):263–77. 10. Lockwood TE. Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast Reconstr Surg. 1991; 87(6):1009–18. 11. Lockwood TE. Lower body lift with superficial fascial system suspension. Plast Reconstr Surg. 1993;92(6): 1112–22. 12. Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96(4):912–20. 13. Morales Gracia HJ. Circular lipectomy with lateral thighbuttock lift. Aesthetic Plast Surg. 2003;27(1):50–7.

Classification of Contour Deformities After Massive Weight Loss: Clinical Applications of the Pittsburgh Rating Scale

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Angela S. Landfair, Dennis J. Hurwitz, Madelyn H. Fernstrom, Raymond Jean, and J. Peter Rubin

67.1 Introduction In reaction to the immense surge in bariatric surgery over past two decades, body contouring surgery is undergoing a rapid evolution in technique and tactic. Contour deformities after massive weight loss are incredibly diverse and frequently unpredictable, and involve every corner of the body. The massive weight loss patient population has challenged the plastic surgery community to identify and catalog these unfamiliar contour deformities as well as invent new surgical techniques. The Pittsburgh Rating Scale, first presented in 2004, was the first all-inclusive and validated measure of contour deformities after massive weight loss [1, 2]. This classification system allows for systematic identification and quantification of the level of deformity in each area of the body, ensuing in a comprehensive evaluation of post massive weight loss surgical candidate. We have employed the Pittsburgh Rating Scale in our own practice, and consider it applicable and sufficiently universal in a variety of clinical settings. According to American Society of Plastic Surgeons (ASPS) statistics, 66,947 body contouring procedures were performed in massive weight loss patients in 2007 [3]. This is a considerable increase from 55,927 procedures performed in 2004. It was also estimated that 76% of the thigh and arm lifts performed in 2007 were in massive weight loss patients. Body contouring after massive weight loss has not only increased in number but also in sophistication. In the past 5 years,

A. S. Landfair (*) Division of Plastic Surgery, University of Pittsburgh, 3553 Terrace Street, Suite 6B, Pittsburgh, PA 15213, USA e-mail: [email protected]

we have witnessed a deluge of publications describing both innovations and refinements of established techniques. Both private and academic centers which focus their clinical practice on post massive weight loss body contouring surgery have emerged [4]. Today, bariatric surgeries produce successful and sustained weight loss with regularity [5, 6]. After massive weight loss, patients are often left with loose, ptotic skin envelopes and irregular bulges. The shapes and body distributions of these deformities are often difficult to predict, although it is generally agreed that younger patients, and patients with elastic skin, will suffer the least severe consequences. Postoperative deformity could only loosely be predicted based on preoperative appearance, degree of weight loss, and age. Some patients shed a much greater portion of their weight from one portion of their body, in comparison to other anatomic regions. Patients with comparatively slender buttocks, hips, and legs can have an enormous overhanging pannus that disrupts their silhouette. Not infrequently, patients with pleasing upper body contours including breasts and abdomen may have relatively adipocytic and ptotic lower bodies. Unexpected folds and creases materialize where previously there had been a large amount of adipose tissue and previously smooth contours cave into pleats and puckers. These post weight loss deformities are vast in scope and variety on even a single patient, and require an organized and systematic method of diagnosis. In approaching the postmassive weight loss patient with multiple problem areas, thorough preoperative planning and appropriate procedure selection are central to success. A classification system is a valuable tool in addressing each area of the patient’s body and quantifying the level of deformity in each region, and describing the deformities in a manner that is translatable among clinicians. A variety of existing

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_67, © Springer-Verlag Berlin Heidelberg 2010

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classification systems address contour deformities but have two specific drawbacks; first, they do not encompass the often unique deformities suffered by bariatric weight loss patients and second, they focus on a single region of the body and are thus insufficient in addressing multiple areas in a single patient [7–15]. The Pittsburgh Rating Scale is an inclusive and illustrative classification system that addresses the full range of post-weight loss deformities found in this unique population [1, 2]. The rating system can be used to perform a comprehensive assessment of a postbariatric patient. In validating our system for clinical use, a list of appropriate surgical intervention at each level of deformity was correlated. The scale has been utilized in clinical practice for initial assessment, surgical planning, and outcome analysis.

67.2 Technique Life after Weight Loss at University of Pittsburgh Medical Center, founded in 2003, is a major referral center for massive weight loss patients. From full body photographs of over 300 female patients, 25 patients who encompassed the full span of postweight loss appearances, ranging from normal to most severe deformities, were selected for further study. The study was limited to the female patients because this was representative of the gender predilection to seek plastic surgery after massive weight loss. Ten anatomic areas that were delineated for analysis were arms, breasts, abdomen, flank, mons, back, buttocks, medial thighs, hips/lateral thighs, and lower thighs/knees. A 4-point grading scale was designed to describe the common deformities found in each region of the body. Each scale ranged from 0 to 3, with 0 indicating an appearance within normal range, 1 indicating mild deformity, 2 indicating moderate deformity, and a grade of 3 indicating the most severe level of deformity (Fig. 67.1). The rating scale was customized for each region of the body. In general, a deformity considered “mild” would require a nonexcisional or minimally invasive procedure for correction. A moderate deformity would require an excisional procedure. A severe deformity would require combinations of excisional-lifting, tissue rearrangement, and noninvasive procedures, and frequently involve large areas of undermining.

A. S. Landfair et al.

The statistical validation of the Pittsburgh Rating Scale is detailed in our original publication [1]. Interobserver validity and test-retest reliability was determined using weighted kappa analysis. In all the ten categories, the kappa value was 0.6 or higher (0.6 = threshold for good validity), with a mean kappa of 0.68 (range 0.61–0.78) and an overall agreement of 69% over two sessions. When independently analyzed, each observer scored an individual mean kappa value of >0.6, indicating good interobserver validity, and a mean 67% agreement, indicating reasonable test-retest reliability. After the validation was complete, we employed the Pittsburgh Rating Scale in clinical practice. The authors use the scale to assess the level of deformity, plan appropriate procedures, and to grade pre and postoperative results. A series of recommendations were made for correlating a score on the Pittsburgh Rating Scale to a list of suitable surgical interventions. Mild deformities call for less invasive measures, and increasing levels of deformity for more invasive procedures of complex design to achieve adequate correction. For most anatomic regions, significant ptosis of adiposefilled rolls or obvious skin folds represent the most severe level of deformity that are best rectified by excisional lifting combined with tissue reshaping and augmentation procedures (Table 67.1). The same scale is used to grade preoperative deformity, choose appropriate corrective surgery, and assess the postoperative contour. In cases when the corrective procedure was successful, the postoperative rating on the scale would decrease, and often be restored to a 0, indicating normal contour. When used consistently, the Pittsburgh Rating Scale is a useful organizational tool for clinical studies. For further simplification, the regional scores can be combined into an “upper body”, “lower body”, and “total body” scores (Table 67.2). Such composite scores should be used for outcome analysis, and not for the dictation of therapy. The authors are applying the Pittsburgh Rating Scale in a prospective clinical registry of body contouring patients after massive weight loss.

67.3 Challenges The Pittsburgh Rating Scale, while widely applicable, does raise additional challenges. First and foremost, the current Pittsburgh Rating Scale represents

67 Classification of Contour Deformities After Massive Weight Loss Fig. 67.1 Pittsburgh rating scale. Ten anatomically defined areas were assessed using the following scale. Each subscale for each area was customized to describe the deformities most commonly seen in postbariatric weight loss patients. The scale ranges from 0, indicating normal, to 3, indicating the most severe deformity. (a0–3) Arms: scores 0–3. (b0–3) Breasts: scores 0–3. (c0–3) Abdomen: scores 0–3. (d0–3) Flank: scores 0–3. (e0–3) Back: scores 0–3. (f0–3) Buttocks: scores 0–3 (g0–3) Hips/lateral thighs: scores 0–3. (h0–3) Mons: scores 0–3. (i0–3) Medial thighs: scores 0–3. (j0–3) Lower thighs/knees: scores 0–3

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Table 67.1 The Pittsburgh rating scale Area

Scale

Preferred procedure

Arms

0 Normal

None

1 Adiposity with good skin tone

UAL and/or SAL

2 Loose, hanging skin without severe adiposity

Brachioplasty

3 Loose, hanging skin with severe adiposity

Brachioplasty ± UAL and/or SAL

0 Normal

None

1 Ptosis grade I/II or severe macromastia

Traditional mastopexy, reduction, or augmentation techniques

2 Ptosis grade III or moderate volume loss or constricted breast

Traditional mastopexy ± augmentation

3 Severe lateral roll and/or Severe volume loss with loose skin

Parenchymal reshaping techniques with dermal suspension, consider autoaugmentation.

0 Normal

None

1 Single fat roll or adiposity

UAL and/or SAL

2 Multiple skin and fat rolls

Excisional lifting procedures

3 Ptosis of rolls

Excisional lifting procedures

0 Normal

None

1 Redundant skin with rhytids or moderate adiposity without overhang

Mini-abdominoplasty, UAL and/or SAL

Breasts

Back

Abdomen

(continued)

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Table 67.1 (continued) Area Scale

Preferred procedure

2 Overhanging pannus

Full abdominoplasty

3 Multiple rolls or epigastric fullness

Modified abddominoplasty techniques, including fleur de lis and/or upper body lift

0 Normal

None

1 Adiposity

UAL and/or SAL

2 Rolls

UAL and/or SAL

3 Ptosis of rolls

Excisional lifting procedures

0 Normal

None

1 Mild to moderate adiposity and/or mild to moderate cellulite

UAL and/or SAL

2 Severe adiposity and/or severe cellulite

UAL and/or SAL ± excisional lifting procedure

3 Skin folds

Excisional lifting procedure

0 Normal

None

1 Excessive adiposity

UAL and/or SAL

2 Ptosis

Monsplasty

3 Significant overhang below symphysis

Monsplasty

Hips/

0 Normal

None

Lateral thighs

1 Mild to moderate adiposity and/or mild to moderate cellulite

UAL and/or SAL

2 Severe adiposity and/or severe cellulite

UAL and/or SAL ± excisional lifting procedure

3 Skin folds

Excisional lifting procedure

0 Normal

None

1 Excessive adiposity

UAL and/or SAL ± excisional lifting procedure

2 Severe adiposity and/or Severe cellulite

UAL and/or SAL ± excisional lifting procedure

3 Skin folds

Excisional lifting procedure

0 Normal

None

1 Adiposity

UAL and SAL ± excisional lifting procedure

2 Severe adiposity

UAL and SAL ± excisional lifting procedure

3 Skin folds

Excisional lifting procedure

Flank

Buttocks

Mons

Medial thighs

Lower thighs/knees

Ten regions are assessed on a scale ranging from 0 to 3. The presence of specific deformities determines the score. For each rating, the indicated surgical procedures are outlined. The procedures may be performed alone, or in combination

deformities found in our female patients, which reflects a clinical reality at the time; the vast majority of our patients are female. The contour deformities in male massive weight loss patients differ from our female subjects, and will no doubt need to be addressed in a separate study. The authors are seeing an increasing amount of male massive weight loss patients and a validated classification system for males is merely a matter of time and numbers.

While the Pittsburgh Rating Scale can effectively assess postoperative contour, it does not examine postsurgical scar quality or location. Extensive scarring is an undesirable component of skin excision, and successful surgical outcome is contingent on minimizing scar deformity. When appropriate, the Pittsburgh Rating Scale should be used in conjunction with a scar rating system in a comprehensive postoperative assessment.

67 Classification of Contour Deformities After Massive Weight Loss Table 67.2 Pittsburgh rating scale: composite scores Upper body: arms, breasts, abdomen, flank, back 0

Normal

1–5

Mild

6–10

Moderate

11–15

Severe

Lower body: mons, buttocks, hips/lateral thighs, medial thighs, lower thighs/knees 0

Normal

1–5

Mild

6–10

Moderate

11–15

Severe

Total body deformity score 0

Normal

1–10

Mild

11–20

Moderate

21–30

Severe

The individual ratings can be combined into upper body, lower body, and total deformity scores

The authors further recognize that in many instances, functional panniculectomies are performed in lieu complex excisional-lifting procedures. In these cases, the resulting contour cannot be held up to stringent aesthetic standards. In patients seeking optimal aesthetic outcome after weight loss deformity, surgeons should strive for normalization on the Pittsburgh Rating Scale. However, functional operations will always play a significant role in the post massive weight loss population, and in these instances, Pittsburgh Rating Scale may or may not show a significant improvement. Improvement in panniculitis, intertriginous rash, hygiene, and mobility are worthwhile clinical goals independent of improvement in contour. In the past several years, there has been a shift in emphasis from excisional lifting procedures to excisional lifting with tissue reshaping and autoaugmentation [16–19]. A single operation may address several different areas simultaneously [20, 21]. The breadth and variety of these surgical innovations are more thoroughly addressed elsewhere in the text. The categories in the Pittsburgh Rating Scale, as well as the recommended types of surgical interventions, still prevail. The continued innovation of body contouring after massive weight loss is the reason why broad categories

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of surgical intervention (i.e., excisional lifting) rather than a precise surgical procedure are recommended.

67.4 Discussion The Pittsburgh Rating Scale is a reliable and valid measure of contour deformities after massive weight loss. The scale is applicable to both preoperative planning and outcomes assessment. Rather than creating a laundry list of the deformities observed in this very complex patient population, the scale was made practical by limiting each subscale to four ordered classifications. We formulated appropriate treatment guidelines for each classification based on both literature search and expert opinion. Classification schemas in plastic surgery should be valid and reproducible, and serve several clinical purposes. First, it should provide a standardized classification that is also easily conveyed. A score should be compelling enough that a fellow surgeon who has not yet viewed the patient can potentially participate in surgical planning. The Pittsburgh Rating Scale has the potential to be an effective communication tool among colleagues and within surgical literature. The second purpose that our classification system serves is to correlate deformity to surgical strategy. In body contouring after massive weight loss, the successive grades of deformities should correlate to the degree of complexity of procedures. The highest grade of deformity is often an indication for a multifaceted procedure that adequately addresses the clinical severity. Multiple severe deformities in adjacent regions (i.e., a patient with a severe flank and buttock deformity) can aid the surgeon to decide on inclusive procedures to simultaneously address multiple regions. The third function that the classification system fulfills is to allow for numerical comparison of preoperative state to the surgical outcome. This will allow for objective quantification of improvement due to surgical manipulation. When we applied the scale to our body contouring patients, the postoperative score for the region that underwent surgery was often restored to normal. If the postoperative appearance is outside the normal range, the chosen surgical intervention may have been inadequate for the level of deformity, or additional procedures may have been necessary.

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Body contouring after massive weight loss continues to flourish in the plastic surgery community, but has entered an era of maturity. As the patient population and clinical experience grows, so does the plastic surgeon’s accountability. The Pittsburgh Rating Scale is a valid, accessible, and comprehensive rating system that allows for a standardized evaluation of the massive weight loss population.

67.5 Conclusions The Pittsburgh Rating Scale is easy to administer, demonstrates appropriate validity, displays acceptable reliability, and detects changes resulting from surgery, making it an appropriate outcome measure [22, 23]. The authors are confident that the scale appropriately detects changes from surgical intervention. Measurable success from surgical intervention will further guide us in polishing our body contouring repertoire. The Pittsburgh Rating Scale will provide consistent diagnosis and treatment recommendation even as surgical innovations continue to emerge. As both immediate and long-term outcomes in the massive weight loss patients are studied, the scale will aid in making a compelling argument for contour improvement from surgical interventions.

References 1. Song AY, Jean R, Hurwitz DJ, Fernstrom MH, Scott JA, Shestak KC, Rubin JP. A classification of contour deformities after bariatric weight loss: the Pittsburgh rating scale. Plast Reconstr Surg. 2005;116(5):1535–44. 2. Song AY, O’Toole JP, Jean RD, Hurwitz DJ, Fernstrom MH, Scott JA, Rubin JP. A classification of contour deformities after massive weight loss: application of the Pittsburgh rating scale. Semin Plast Surg. 2006;20:24–9. 3. American Society of Plastic Surgeons 2007. 4. Tang L, Song AY, Choi S, Fernstrom MH, Rubin JP. Completing the metamorphosis: building a center of excellence in postbariatric plastic surgery. Ann Plast Surg. 2007; 58(1):54–6.

A. S. Landfair et al. 5. Livingston EH. Obesity and its surgical management. Am J Surg. 2002;184(2):103–13. 6. AORN Bariatric Surgery Guideline. AORN J. 2004;79: 1026–52. 7. de Souza Pinto EB, Erazo, PJ, Matsuda CA, Regazzini DV, Burgos DS, Acosta HAP, do Amaral AG. Brachioplasty technique with the use of molds. Plast Reconstr Surg. 2000; 105(5):1854–60. 8. Bozola AR, Psillakis JM. Abdominoplasty: a new concept and classification for treatment. Plast Reconstr Surg. 1988; 82(6):983–92. 9. Matarasso A. Abdominoplasty: a system of classification and treatment for combined abdominoplasty and suction-assisted lipectomy. Aesthetic Plast Surg. 1991;15(2): 111–21. 10. Nahas FX. An aesthetic classification of the abdomen based on the myoaponeurotic layer. Plast Reconstr Surg. 2001; 108(6):1787–95. 11. Psillakis JM. Plastic surgery of the abdomen with an improvement in the body contour: pathophysiology and treatment of the aponeurotic musculature. Clin Plast Surg. 1984;11(3): 465–77. 12. Santos E, Muraira J. The waist and abdominoplasty. Aesthetic Plast Surg. 1998;22(3):225–7. 13. Young SC, Freiberg A. A critical look at abdominal lipectomy following morbid obesity surgery. Aesthetic Plast Surg. 1991;15(1):81–4. 14. Massiha H. Augmentation in ptotic and densely glandular breasts: prevention, treatment, and classification of doublebubble deformity. Ann Plast Surg. 2000;44(2):143–6. 15. Regnault P, Daniel R. Secondary thigh-buttock deformities after classical techniques: prevention and treatment. Clin Plast Surg. 1984;11(3):505–16. 16. Rubin JP. Mastopexy after massive weight loss: dermal suspension and total parencymal reshaping. Aesthetic Surg J. 2006;26:214–22. 17. Rubin JP, Khachi G. Mastopexy after massive weight loss: dermal suspension and selective autoaugmnetation. Clin Plast Surg. 2008;35(1):123–9. 18. Hurwitz DJ, Agha-Mohammadi S. Postbariatric surgery breast reshaping: the spiral flap. Ann Plast Surg. 2006;56(5): 481–6. 19. Centeno R. Autologous gluteal advancement with circumferential body lift in the massive weight loss and aesthetic patient. Clin Plast Surg. 2006;33(3):479–96. 20. Hurwitz DJ. Single-staged total body lift after massive weight loss. Ann Plast Surg. 2004;52(5):435–41. 21. Hurwitz DJ, Holland S. The L brachioplasty: an innovative approach to correct excess tissue of the upper arm, axilla, and lateral chest. Plast Reconstr Surg. 2006;117(2):403–11. 22. Ching S, Thomas A, McCabe RE, Antony MM. Measuring outcomes in aesthetic surgery: a comprehensive review of literature. Plast Reconstr Surg. 2003;111(1):469–80. 23. Hurwitz DJ, Agha-Mohammadi S, Ota K, Unadkat J. A clinical review of total body lift. Aesthetic Surg J. 2008;28(3): 294–304.

Facial Contouring in the Postbariatric Surgery Patient

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Anthony P. Sclafani and Vikas Mehta

68.1 Introduction Morbid obesity is a rising epidemic with 1.7 billion people considered overweight [1]. Approximately two-thirds of adults in the United States are overweight and half are obese [2]. In 1991, the National Institute of Health established guidelines for what has now become known as bariatric surgery for the morbidly obese patient (BMI > 40 or BMI > 35 with significant comorbidities). According to a recent meta-analysis, patients who undergo bariatric surgery lose 61.6% of their actual excess body weight and a majority of patients with diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea experience complete resolution or improvement of these comorbidities [3]. Despite the drastic improvement in health, two-thirds of massive-weight loss patients are unhappy with their appearance secondary to copious sagging skin [4]. According to the American Society of Plastic Surgeons, 47% of these (roughly 150,000) patients underwent body contouring procedures in 2007 after significant postsurgery weight loss [5]. Although the overall goal of bariatric surgery is massive weight loss, the same degree of fat reduction is not always desirable in the facial and cervical regions. The loss of cervicofacial fat often leaves the patient with noticeable soft tissue volume deficiencies and skin laxity. These postbariatric changes result in a “hollowed,” prematurely aged appearance (Fig. 68.1). Specifically, the patient will often present with prominent nasolabial

A. P. Sclafani (*) Department of Otolaryngology, Division of Facial Plastic Surgery, The New York Eye and Ear Infirmary, New York, NY, USA e-mail: [email protected]

and nasojugal grooves, lip atrophy, and a turkey-neck deformity. Although the truncal skin excess can be significantly more dramatic, patients may report that the facial changes are of greater concern as they can not easily be hidden with clothing. Often, these patients pursue cosmetic facial surgery prior to addressing other body contour issues. As greater numbers of Americans undergo weight loss surgery, it is prudent to identify and address the surgical challenges and perioperative issues that affect this unique population. The mechanics, physiology, and demographics of these patients differ significantly from the typical patient with an aging face. Understanding these variations is the key to a successful and safe cervicofacial rejuvenation in the massive weight loss patient.

68.2 Pathomechanics Fundamentally, postbariatric contouring surgeries focus on skin laxity and fat loss. An analysis of the biomechanical properties of skin following weight loss showed decreased stiffness, increased laxity, greater skin compliance, and increased elastic deformation [6]. In addition to these cellular abnormalities, there are location-specific trends in fat loss that contribute to esthetic concerns in the cervicofacial area. In the submental region, the expanded, stretched, and redundant skin is the principal cosmetic deformity. In contrast, deformities in the perioral and midface region are primarily due to the loss of fat volume. Within the midface, areas that are most notably affected by volume loss are the nasojugal groove, the malar eminence, the submalar region, and the nasolabial crease. Traditionally, age-related changes in the midface were attributed to a decrease in the suspension

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_68, © Springer-Verlag Berlin Heidelberg 2010

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a1

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Fig. 68.1 Postbariatric surgery patient. (a1–3) This patient appears prematurely aged, with significant malar flattening and mid facial volume loss, as well as lateral cheek and cervical skin redundancy. (b1–3) Six months after endoscopic brow lift, submental liposuction, and SMAS facelift with volume enhance-

ment of the midface. The natural structural features of the midface are highlighted postoperatively. A minor revision procedure was performed subsequently to further improve the lax cervical skin

properties of the fibrous tissue. Therefore, aesthetic surgery in this region was primarily focused on the techniques to lift and redistribute the fat compartments. Motivated by the desire for less invasive and more conservative techniques, recent trends place a greater emphasis on volume augmentation. Using various imaging techniques, connective tissue laxity, bone remodeling, and facial lipoatrophy have all been shown to play an important role in pathomechanics of the aging midface [7, 8]. This is an important point of difference between the aging and massive weight loss patients. Overall, postbariatric surgery (PBS) patients are relatively young. Similar to patients with HIV-associated

lipoatrophy, the suspension properties of the midfacial skin have not been altered drastically. Instead, it is the massive weight loss that creates a hollowed appearance in otherwise convex areas of the face [9]. Therefore, more traditional midface lifting techniques are usually not indicated, and a variety of temporary and permanent volume restoration options have been developed and applied to the midface, perioral complex, and lip of the PBS patient. In contrast to the midface, deformities in the jaw and neckline are caused primarily by skin excess and laxity, and therefore, are addressed solely by rhytidectomy techniques. Prior to bariatric surgery, pre- and

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subplatysmal fat accumulation leads to the stretching of the skin and platysma muscle. As in the rest of the body, postsurgical fat loss reveals stretched, inelastic, and redundant skin. In the neck, the anatomic area of interest is typically the anterior compartment between the sternocleidomastoid muscles. Again, however, a key difference between the aging patient and massive weight loss patient must be highlighted. The primary distinction lies in the pathomechanics, and subsequently, the treatment, of the platysma muscle. In the aging neck, the platysmal muscle undergoes a decrease in tone as well as an increase in diastasis. However, in the PBS patient, there is less muscle diastasis and greater skin excess that is the principal issue. More conservative treatment of the midline platysma by plication is performed in these patients.

68.3 Preoperative Evaluation As with all the patients seeking cosmetic surgery, a thorough preoperative consultation will include not only the patient’s particular aesthetic defect, but also their exact expectations, a complete history, and a quick assessment of their physical, psychological, and emotional well-being. In each of these areas, there are issues specific to the massive weight loss patient that must be addressed. First, timing of cosmetic surgery should be carefully planned. As mentioned previously, many PBS patients seek to correct their facial deformity prior to addressing other body contouring surgery. A recent meta-analysis has shown that the patient’s weight is likely to fluctuate within the first year and long-term weight loss is poorly described in the literature [10]. Additionally, it is well known that skin will undergo some degree of contraction after 60% of the body fat is lost. Therefore, it is prudent to wait for 6–12 months to allow the skin to reach its final position and the patient’s weight to stabilize to avoid overcorrection. Correction of midface deformities focuses on volume restoration. Areas of the midface that require particular attention are the tear trough/infraorbital rim, the malar eminence, the submalar region, and the nasolabial crease. These areas typically undergo the greatest volume loss. Additional areas of concern are the temporal fossa, jawline, and perioral region, and less commonly, the glabella and lateral brow. It is important to

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decide preoperatively (1) which areas to address (2) the specific type of filler to be used, and lastly, (3) the amount needed for effective volume replacement. There are scales described for both autologous fat transfer [11] and hyaluronic acid derivatives [12], but a universally accepted, standardized grading scale is yet to be established. If the surgeon is considering autologous fat, it is imperative to anticipate the amount of volume needed, so that an appropriate amount can be harvested. In the preoperative evaluation, there are unique anatomic considerations in each area of the face. Symmetry is of particular importance in the midface, as it is frequently variable and easily correctable. In the perioral region, restoration of the normal curves and convexities of the lip is essential to both redefine the shape of the lips as well as to reestablish the lip volume. With fat volume loss, the vermilion margin will flatten, and volume augmentation will allow the patient to regain the healthy, “pouty” look. Evaluation of the lower face focuses not only on the skin, muscle, and fat of the submental region, but also the bony substructure, including the strength of the anterior jaw projection and position of the hyoid bone. Anterior mandibular deficiency, unless corrected, will allow cervical skin to hang in unesthetic positions in the PBS patient. Failure to treat weak anterior bony projection seriously compromises the final results of rejuvenative surgery in these patients. Even in the PBS patient, a significant amount of submental fat may still be present, and cervical liposuction is generally necessary to adequately define the cervicomental angle and lower jawline. Fat removal should be thorough, and should also be feathered peripherally. Excessive liposuction should be avoided, but “cobra neck” deformity [13] is uncommon because of the relatively lower incidence of midline platysma diastasis. Finally, the overall degree of skin laxity must be assessed in order to counsel the patient set appropriate postoperative expectations. In cases of severe skin laxity, a truly youthful appearing neck and jawline may be impossible or require several revisions to fully redrape the skin. Other preoperative considerations specific to the PBS patient include those related to their extensive comorbidities. While weight loss surgery can have a positive impact on related diseases, such as diabetes, the literature is controversial. Several authors have reported large cohorts of weight loss patients with

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s ignificant reductions in comorbidities [14, 15] and mortality over time [16, 17] (up to 89% reduction at 5 years). However, a meta-analysis [10] which included only those studies with greater than 3 years postoperative follow-up noted several flaws in the above-mentioned studies’ claims, as well as a statistically significant regain in weight for all of the series included at 10 years. For the cosmetic surgeon, the key to this controversy lies in the possibility that despite the initial weight reduction, many patients may return to obesity and retain their comorbidities, especially diabetes. It is important, therefore, that any contouring surgery be deferred for at least a year and extensive preoperative medical screening is performed on every PBS patient. Other well-documented issues in treating the PBS patient include cardiac arrhythmias and nutritional deficiencies. Up to 10% of patients will develop new cardiac arrhythmias after bariatric surgery, and if any anomalies are identified on a preoperative electrocardiogram, a complete cardiac evaluation is warranted. PBS patients may develop hypokalemia and hypomagnesemia, and appropriate electrolyte evaluation should be performed preoperatively. Massive weight loss patients are at a significant risk for caloric and nutritional deficiencies in vitamin A, vitamin B12, folate, vitamin C, iron, selenium, zinc, and protein [18]. For the facial plastic surgeon, important considerations are anemia, problems with wound healing, and poor immune response optimization. Many of these patients who reach normal weight or begin at a body mass index of <40 kg/m2 are at a much higher risk for malnourishment [19]. It is imperative to recognize these patients preoperatively as they are at a high risk for poor wound healing and immunodeficiency. In an outcomes analysis of 139 patients undergoing contouring procedures after massive weight loss, 14.4% had wound complications [20]. To avoid these and other potential complications, preoperative screening and supplementation are recommended: 600 mg vitamin B12, 400 mg folate, 60 mg vitamin C, 25,000 IU vitamin A, 100 mg iron, 20 mg zinc, 100 mg selenium, and 1–2 mg/kg of protein per day [19]. Also common among these patients is gastroesophageal reflux, especially if any alteration has been made to the GE junction. Some pre- or perioperative reflux medication may be indicated when operating on these patients. Finally, these patients should be assessed for obstructive sleep apnea and potential difficulties with

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intubation, both of which are extremely common in all obese individuals. As with any patient seeking plastic surgery, it is imperative to assess the patient’s psychological wellbeing. This is especially true in the massive weight loss patient. Studies have found a high rate of psychological abnormality among persons with extreme obesity that pursue bariatric surgery. Between 20 and 60% of patients have been diagnosed with axis I psychiatric disorders, the most common of which are mood and anxiety disorders [21, 22]. Additionally, binge eating is common among this population and can return at any time despite the massive weight loss. Patients should undergo preoperative psychological screening, such as a questionnaire to assess the potential psychological pathology, especially eating disorders, body dysmorphic disorder, and emotional instability. Positive screening or suspicions should be referred to a mental health professional prior to any cosmetic surgical procedure. Finally, patients may have unrealistic expectations of their final results based on popular figures that have undergone bariatric surgery with contouring. These should be identified preoperatively and realistic expectations should be discussed explicitly with the patient preoperatively.

68.4 Treatment 68.4.1 Rhytidectomy in the Post Bariatric Patient In tailoring a procedure for the PBS patient, it should be kept in mind that the laxity, excess, and ptosis of the skin generally exceed those of the superficial musculoaponeurotic system (SMAS). Rhytidectomy in these patients is still a standard procedure with appropriate modifications. The important considerations and modifications to a standard SMAS rhytidectomy necessary in PBS patients, rather than the complete procedure, are described here. The skin incision can enter the temporal hairline above the helical root only if the vector of the planned facial elevation is predominantly posterosuperiorly, not superiorly, oriented; if the vector of flap movement is mostly superior in direction, the incision should course around the sideburn pretrichially to avoid the elevation of the temporal hair tuft. It should be remembered that postbariatric rhytidectomy patients

68 Facial Contouring in the Postbariatric Surgery Patient

are generally younger than the traditional patient with an aging face, and are undergoing facial surgery to match their facial appearance with their rejuvenated body; these patients are often reluctant to commit to a specific hairstyle to camouflage an occipital scar. The vector of elevation in the neck can be mostly superior in direction, and with care, the incision across the mastoid skin and into the hairline can be avoided. Patients appreciate the absence of this obvious portion of the scar, especially when seeking to resume a more active and athletic lifestyle. In patients with severe skin laxity, it may not be possible to contour the postauricular area smoothly without the occipital portion of the skin incision. The skin may “bunch” along the postauricular scar, but this can be redraped if the incision is extended into the hairline, or the scar can be revised 6–8 weeks after surgery as a planned, second stage. These options should be discussed preoperatively with the patient and a plan of action determined before surgery (Fig. 68.1). Suction-assisted or direct lipectomy, or both, in the submental triangle and jowl areas can be judiciously performed to assist in creating a smooth, contoured, sculpted neckline. In the midline, paramedian platysmal bands are identified and the edges undermined from the submental crease inferiorly to a point 1 cm above the thyroid cartilage. If the bands are particularly thick or prominent, a vertical strip of muscle is excised from the medial edge of each platysmal band. The platysmal edges are then sutured from superior to inferior with a running 3–0 polydiaxone suture, which then returns superiorly with wider tissue bites to be tied in the submental region. This creates a sturdy sling for the support of the submentum. Correction of the deformity requires significantly more skin undermining than the typical rhytidectomy to redrape the elevated skin smoothly. Particularly in the patient with massive weight loss, the inelasticity of the skin increases the chance of a “lateral sweep,” and it is important that the skin flap be elevated and redraped in a smooth, tensionfree fashion. If poor chin projection is present, a chin implant should be placed to assist in defining the cervicomental angle. Occasionally, modest transverse skin excision from the posterior border of the submental incision may be necessary. SMAS elevation and imbrication are performed in the standard fashion, although, as stated earlier, relatively less elevation of this layer is necessary than in the typical rhytidoplasty. The skin is then redraped and trimmed appropriately. We now treat

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all the flaps with platelet rich fibrin matrix (SelphylTM, Aesthetic Factors, Englewood, NJ) to aid in hemostasis and wound healing. No drains are used, all incisions are closed, and a compressive dressing applied. Postoperatively, early ambulation of the PBS patient is essential, as Aly et al. [23] noted a 9% incidence of pulmonary embolism in a PBS patient undergoing abdominoplasty. Later, the patient should be assessed for residual skin redundancy. A “tuck-up” procedure may be necessary as early as 2–3 months postoperatively to address this additional skin excess; it is preferable to address this severe skin excess at a later date rather than over tighten the skin during the primary procedure, so as to minimize a “lateral sweep deformity”. At the same time, contour irregularities in the postauricular sulcus (not uncommon if the occipital portion of the incision is not used) can be treated with conservative resection.

68.4.2 Volume Restoration of the Lower Two-Thirds of the Face Volume loss out of proportion to skin redundancy is the primary element of acute midfacial aging after bariatric surgery. As such, aggressive skin redraping can easily lead to a “pulled” or “windswept” look, especially in the midface. Appropriate volume augmentation, especially in the submalar area can rejuvenate the face and reduce the chance of a “lateral sweep deformity” [24]. A measured approach to midfacial rejuvenation is essential to maximize the results. Moreover, perioral volume loss, particularly in the lips, also ages the PBS patient’s appearance, and a comprehensive treatment plan is critical to success in this area as well. Midfacial fat atrophy after PBS will lead to signs of aging out of proportion to the patient’s chronological age. Infraorbital hollowing and nasojugal troughs will lead to a “tired” and “sad” periorbital expression, and may also “unmask” lower eyelid fat pseudoherniation. Fat transposition blepharoplasty can be considered, but the volume of fat available is generally inadequate to correct the severe degree of volume loss. Midface lifting provides inadequate volume, as the midface is atrophied and not descended. Volume augmentation with extrinsic material is generally necessary to allow

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the skin envelope to properly drape over the midface skeleton. True bony deficiencies should be corrected with skeletal augmentation. Alloplasts (such as tear trough or malar/submalar implants) can be considered for additional midface volume, but should be used with caution, as a thinned soft tissue envelope will fail to camouflage the implant’s edges. Perioral volumizing is performed in the nasolabial crease, marionette folds, and lips. Relatively speaking, nasolabial crease treatment is less critical in the PBS patient than in the typical aging patient. The nasolabial fold is highlighted by the lateral depression caused by malar soft tissue atrophy. Once malar volume is restored, conservative filling of the nasolabial crease is generally sufficient. However, volume restoration of the labiomandibular groove can further smoothen the natural convexities of the lower face. Finally, restoring the volume of the lips not only effaces lip rhytids, but also reestablishes proper balance of the lower face. Given the younger age of PBS patients, long-term correction is desirable. Additionally, larger volumes are generally required, which will also have a significant financial implications. In light of this volume/persistence need, autologous fat transfer, long-lasting hyaluronic acid derivatives (HA), calcium hydroxylapatite, and poly-l-lactic acid should be considered. A complete description of each filler is beyond the scope of this chapter; however, a brief review of the materials and their uses is reasonable. Hyaluronic acid products are glycosaminoglycans (GAGs) that are found extensively in the native extracellular matrix of the connective tissues. The hydrophilic composition of GAGs attracts water into the extracellular matrix conferring a degree of turgor to the tissue, which acts as a hydrating agent and increases its effect as a volumizing agent. Hyaluronic acid has the unique property of being identical in all species; therefore, its derivatives should not be antigenic across species. Lowe et al. [25] published a series of 709 patients who underwent injections of Hylaform or Restylane without preoperative skin testing. In three patients (0.4%), a delayed inflammatory reaction was observed at the site of injection. After transplantation, the hyaluronic acid derivatives undergo local degradation by hydrolysis and eventual metabolism by the liver. Commercially available injectables consist of hyaluronic acid derivatives that have been cross-linked to form a gel matrix which prolongs their degradation in vivo. Several large series have confirmed the duration

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of the augmentation achieved with these compounds to be approximately 6–9 months [26–30]. These fillers are approved for mid-deep dermal injection; however, they may be used in an “off-label” fashion to provide large volume augmentation with both deep dermal and subcutaneous placement. Two to six ml per side may be necessary, and care should be taken to blend the edges of the treated areas, especially in the nasojugal grooves, where these fillers need to be deposited in a supraperiosteal plane. Being similar in action to hyaluronic acid derivatives that rely solely on their own volume to augment soft tissues, a cross-linked porcine collagen has recently been introduced to use in the United States which can be similarly used and may persist longer [31]. Two other fillers are available that rely in part or fully on the body’s response to the injected material. Injectable calcium hydroxylapatite beads are suspended in a mixture of glycerin, water, and cellulose (Radiesse, Bioform Medical, Inc., San Mateo, CA). Once injected subdermally, collagen deposition around the beads and provides additional volume correction which can last for 12–18 months [32]. Even and smooth subdermal distribution is important; placement in the suborbital grooves should in general be avoided, as the thin overlying skin and soft tissues provide little camouflage or blending to the injected material, which may then be visible as a distinct mass. Similarly, injectable poly-l-lactic acid (PLLA, Sculptra, Dermik Laboratories, Inc., Berwyn, PA) is a suspension of PLLA beads that are injected subdermally. A progressive fibrosis around the individual beads ultimately generates a thickening of the dermis and volume augmentation, but multiple treatments are generally needed [33]. PLLA recently received FDA approval for cosmetic uses. However, the longevity of effect of 2 years or more makes PLLA a reasonable option for volume augmentation in PBS patients. Autologous fat transfer remains the large volume facial filler of choice when a permanent solution is desired. In 1893, Neuber [34] first used autologous fat for soft tissue augmentation. Over the years, the use of adipose grafts in soft tissue augmentation has wavered due to the high rate of graft resorption, as well as the unpredictable degree of volume loss. With the advent of liposuction in the 1970s, autologous fat grafting increased in popularity due to the increased ease of harvest. Various other techniques for obtaining adipose tissue, including syringe extraction and open harvest

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have been proposed. Once extracted, the fat must be pretreated to remove the inflammatory mediators and isolate the components necessary for implantation. Many authors have described the techniques of fat washing, centrifugation, and filtration; however, no methodology is widely accepted as superior. Harvested and prepared adipose grafts are generally injected with a large-bore (14–18-gauge) needle or cannula just below the dermis. Unlike the hyaluronic acid derivatives, a substantial overcorrection is required due to the large degree of resorption with time. Authors report that anywhere between 30 and 60% of the injected fat will be resorbed [35, 36]. However, mixing the adipocytes with an appropriate platelet rich plasma [37] has been shown to enhance graft survival.

68.4.3 Postoperative Care and Complications Postoperative care of the massive weight loss patient following cosmetic surgery is relatively straightforward with a few exceptions. The postrhytidectomy patient is typically observed overnight and discharged in the morning after a dressing change. The incidence of minor hematoma following rhytidectomy is relatively low (approximately 0.4 to 3%) and has recently been shown to improve with the use of fibrin glue prior to closure [38], and this is expected to be similar with the use of a platelet rich fibrin matrix. Due to the severity of the skin laxity, the skin may have a tendency to bunch along the incision lines. The patient must be instructed to massage these areas and the surgeon must note these on early postoperative visits to observe for possible revision. The patient may experience inflammation and ecchymosis for up to 2 months, but typically feel comfortable going out in public after 2 weeks [13]. There is a strong possibility of the need for minor revision procedures, which should be discussed with the patient postoperatively. The patients injected with volume fillers must be continually assessed for significant absorption of the injected material and an irregular contour once the edema has subsided. Injection site swelling and minor bruising is common, but typically last no more than 4–7 days [39]. If a subcutaneous nodule is prominent (particularly with the use of particulate fillers like calcium hydroxylapatite or PLLA), it may require

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excision if conservative measures (such as massage or corticosteroid injection) fail. This is especially common in the thin skin of the nasojugal groove if the injection accidentally infiltrates the orbicularis muscle. If hyaluronic acid products have been used, enzymatic degradation with hyaluronidase may be employed. Additionally, if a temporary filler is used, the patient will require a periodic follow-up to assess for repeat augmentation; additional injections may be necessary as early as 4 months after the initial treatment, depending on the location, with highly mobile areas such as the lips typically requiring earlier retreatment. Nutritional deficiencies are common in this patient population and should be suspected if poor wound healing is encountered. In these cases, diet modification, nutritional consultation, and even addition of a daily multivitamin may improve the outcome.

68.5 Conclusions Massive weight loss results in an overall improvement in the quality of life, but can cause significant facial cosmetic deformity. The loss of volume in the midface and severe skin laxity of the cervicofacial junction often leads PBS patients to seek facial contouring procedures. It is important for the cosmetic surgeon to understand the pathomechanics behind these esthetic defects in order to appropriately address them. The midfacial and perioral volume loss is easily correctable with injectable fillers. The excess skin laxity can be fixed using the modified rhytidectomy technique. To achieve an optimal result in a safe manner, a good understanding of the special pre- and postoperative needs of the PBS patient is imperative.

References 1. Deitel M. Overweight and obesity worldwide now estimated to involve 1.7 billion people. Obes Surg. 2003;13(3): 329–30. 2. National Center for Health Statistics NHANES IV Report. Available at: http://www.cdc.gov/nchs/ product/pubs/pubd/ hestats/obes/obese99.html. 2002. 3. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, Schoelles K. Bariatric surgery: a systematic review and meta-analysis. J Am Med Assoc. 2004;292(14): 1724–37.

694 4. Kinzl JF, Traweger C, Trefalt E, Biebl W. Psychosocial consequences of weight loss following gastric banding for morbid obesity. Obes Surg. 2003;13(1):105–110. 5. American Society of Plastic Surgeons. 2007 National plastic surgery statistics. Arlington Heights, IL: American Society of Plastic Surgeons; 2008. 6. Smalls LK, Hicks M, Passeretti D, Gersin K, Kitzmiller WJ, Bakhsh A, Wickett RR, Whitestone J, Vissher MO. Effect of weight loss on cellulite: gynoid lypodystrophy. Plast Reconstr Surg. 2006;118(2):510–6. 7. Gosain AK, Klein MH, Sudhakar PV, Prost RW. A volumetric analysis of soft-tissue changes in the aging midface using high-resolution MRI: implications for facial rejuvenation. Plast Reconstr Surg. 2005;115(4):1143–52. 8. Ascher B, Katz P. Facial lipoatrophy and the place of ultrasound. Dermatol Surg. 2006;32(5):698–708. 9. Ascher BA, Coleman S, Alster T, Bauer U, Burgess C, Butterwick K, Donofrio L, Engelhard P, Goldman MP, Katz P, Vleggaar D. Full scope of effect of facial lipoatrophy: a framework of disease understanding. Dermatol Surg. 2006; 32(8):1058–69. 10. Shah M, Simha V, Garg A. Review: long-term impact of bariatric surgery on body weight, comorbidities, and nutritional status. J Clin Endocrinol Metab. 2006;91(11):4223–31. 11. Le Louarn C, Buthiau D, Buis J. The face recurve concept: medical and surgical applications. Aesthetic Plast Surg. 2007;31(3):219–31. 12. Raspaldo H. Volumizing effect of a new hyaluronic acid subdermal facial filler: a retrospective analysis based on 102 cases. J Cosmet Laser Ther. 2008;10(3):134–42. 13. Adamson PA, Litner JA. Surgical management of the aging neck. Facial Plast Surg. 2005;21(1):11–20. 14. Sugerman HJ, Wolfe LG, Sica DA, Clore JN. Diabetes and hypertension in severe obesity and effects of gastric bypassinduced weight loss. Ann Surg. 2003;237(6):751–6. 15. Puzziferri N, Austrheim-Smith IT, Wolfe BM, Wilson SE, Nguyen NT. Three-year follow-up of a prospective randomized trial comparing laparoscopic versus open gastric bypass. Ann Surg. 2006;243(2):181–8. 16. Christou NV, Sampalis JS, Liberman M, Look D, Auger S, McLean AP, MacLean LD. Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients. Ann Surg. 2004;240(3):416–23. 17. Flum DR, Dellinger EP. Impact of gastric bypass operation on survival: a population-based analysis. J Am Coll Surg. 2004;99(4):543–51. 18. Agha-Mohammadi S, Chir SB, Hurwitz DJ. Nutritional deficiency of post-bariatric surgery body contouring patients: what every plastic surgeon should know. Plast Reconstr Surg. 2008;122(2):604–13. 19. Agha-Mohammadi S, Chir SB, Hurwitz DJ. Potential impacts of nutritional deficiency of postbariatric patients on body contouring surgery. Plast Reconstr Surg. 2008;122(6): 1901–14. 20. Shermak MA, Chang D, Magnuson TH, Schweitzer MA. An outcomes analysis of patients undergoing body contouring surgery after massive weight loss. Plast Reconstr Surg. 2006;118(4):1026–31. 21. Sarwer DB, Cohn NI, Gibbons LM, Magee L, Crerand CE, Raper SE, Rosato EF, Williams NN, Wadden TA. Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates. Obes Surg. 2004;14(9):1148–56.

A. P. Sclafani and V. Mehta 22. Rosenberger PH, Henderson KE, Grilo CM. Psychiatric disorder comorbidity and association with eating disorders in bariatric surgery patients: a cross-sectional study using structured interview-based diagnosis. J Clin Psychiatry. 2006;67(7):1080–5. 23. Aly AS, Cram AE, Chao M, Pang J, Mckeon M. Belt lipectomy for circumferential trunkal excess; the University of Iowa experience. Plast Reconstr Surg. 2003;111(1):398–413. 24. Lambros V, Stuzin JM. The cross-cheek depression: surgical cause and effect in the development of the “joker line” and its treatment. Plast Reconstr Surg. 2008;122(5):1543–52. 25. Lowe NJ, Maxwell CA, Lowe P, Duick MG, Shah K. Hyaluronic acid skin fillers: adverse reactions and skin testing. J Am Acad Dermatol. 2001;45(6):930–3. 26. Rohrich RJ, Ghavami A, Crosby MA. The role of hyaluronic acid fillers (Restylane) in facial cosmetic surgery: review and technical considerations. Plast Reconstr Surg. 2007;120(6 Suppl):41S–54S. 27. Bousquet MT, Agerup B. Restylane lip implantation: European experience. Operat Tech Oculoplast Orbital Reconstr Surg. 1999;2:172–6. 28. Cantisano-Zilkha M, Bosniak S. Hyaluronic acid gel injections for facial rejuvenation: a 3-year clinical experience. Operat Tech Oculoplast Orbital Reconstr Surg. 1999;2:177–81. 29. Carruthers A, Carey W, De Lorenzi C, Remington K, Schachter D, Sapra S. Randomized, double-blind comparison of the efficacy of two hyaluronic acid derivatives, restylane, perlane and hylaform, in the treatment of nasolabial folds. Dermatol Surg. 2005;31(11 Pt 2):1591–8. 30. Lupo MP, Smith SR, Thomas JA, Murphy DK, Beddingfield FC III. Effectiveness of Juvéderm ultra plus dermal filler in the treatment of severe nasolabial folds. Plast Reconstr Surg. 2008;121(1):289–97. 31. Narins RS, Brandt FS, Lorenc ZP, Maas CS, Monheit GD, Smith SR. Twelve-month persistency of a novel ribose-crosslinked collagen dermal filler. Dermatol Surg. 2008;34(Suppl 1): S31–39. 32. Graivier MH, Bass LS, Busso M, Jasin ME, Narins RS, Tzikas TL. Calcium hydroxylapatite (Radiesse) for correction of the mid- and lower face: consensus recommendations. Plast Reconstr Surg. 2007;120(6 Suppl):55S–66. 33. Salles AG, Lotierzo PH, Gimenez R, Camargo CP, Ferreira MC. Evaluation of the poly-l-lactic acid implant for treatment of the nasolabial fold: 3-year follow-up evaluation. Aesthetic Plast Surg. 2008;32(5):753–6. 34. Neuber F. Fettransplantation. Chir Kongr Verhandl Deutsche Gesellsch Chir. 1893;22:66. 35. Chajchir A, Benzaquen I. Fat-grafting injection for soft tissue augmentation. Plast Reconstr Surg. 1989;84(6):921–34. 36. Bucky LP, Kanchwala SK. The role of autologous fat and alternative filler in the aging face. Plast Reconstr Surg. 2007;120(6 Suppl):89S–97S. 37. Azzena B, Mazzoleni F, Abatangelo G, Zavan B, Vindigni V. Autologous platelet-rich plasma as an adipocyte in vivo delivery system: case report. Aesthetic Plast Surg. 2008; 32(1):155–8. 38. Zoumalan R, Rizk SS. Hematoma rates in drainless deepplane face-lift surgery with and without the use of fibrin glue. Arch Facial Plast Surg. 2008;10(2):103–7. 39. Cohen JL. Understanding, avoiding, and managing dermal filler complications. Dermatol Surg. 2008;34(Suppl 1):S92–9.

Total Body Lift After Massive Weight Loss

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Nestor Veitia and Dennis J. Hurwitz

69.1 Introduction The medical advantages of massive weight loss (MWL) are well documented and often include the improvement or resolution of comorbidities like diabetes, sleep apnea, asthma, and hypertension to result in a much healthier and fit individual. Unfortunately, the anatomic hallmark of MWL can include widespread areas of tissue ptosis, including the face, arms, breasts, torso, buttocks, and legs. This sequelae has spawned a subspecialty of plastic surgery, termed “body contouring after massive weight loss”. Related terms include the general “body lift” and the comprehensive “total body lift” (TBL). The myriad of techniques, both functional and aesthetic, that are encompassed within these terms have actually existed for decades. While these procedures are continually being modified, what is relatively new is the evolving understanding of how the plastic surgeon should approach the MWL patient. The modern era of body lift surgery began with the high lateral-tension abdominoplasty and lower body lift developed by the plastic surgeon Ted Lockwood [1]. He showed the method and value of the excision of broad transverse bands of skin and fat followed by high tension closure using the superficial fascial system (SFS). Most of the disagreement that exists today among plastic surgeons performing these procedures is not whether they should be performed, but rather, in what order, manner, and magnitude they should be undertaken. Thus, the term total body lift is worth examining closely. TBL surgery is a comprehensive aesthetic rehabilitation of the upper and lower

N. Veitia (*) 3109 Forbes Avenue, Suite 500, Pittsburgh, PA 15213, USA e-mail: [email protected]

body in as few stages as safely possible. To some plastic surgeons, the term represents an accurate, ideal, descriptive surgical goal. To others, the term is unrealistic, oversimplified and even dangerous. To the patients seeking out these operations, the term holds great promise since it seems to imply that all of their surgical concerns can be addressed in a single-stage. The reality of the situation is much more complex and needs to be individualized to patients.

69.2 Defining Total Body Lift The most common misconception surrounding the TBL is that it is synonymous with a single-stage procedure. Actually, only a small portion of patients interested in having a TBL will be appropriate candidates for a single-stage procedure [2]. There are several variables to consider. When considering a patient for single-stage TBL, it is best to separate these variables into preoperative, intraoperative, and postoperative elements. Table 69.1 lists the ideal patient criteria for a TBL. Patients that do not meet these preoperative criteria should be counseled to consider staged procedures. However, in practical terms, some leeway is given. The authors will accept mildly obese patients if they are young. Older patients are accepted if they have a normal BMI. The intraoperative considerations are based on the surgical team that will carry out the operation. The ideal surgical team for a single-stage TBL should consist of an experienced team leader supported by a team of surgeons and assistants that can operate with minimal direction. The goal of this team is to operate in concert to expediently produce a harmonious surgical result that maximizes surgical efficiency while

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_69, © Springer-Verlag Berlin Heidelberg 2010

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696 Table 69.1 Ideal candidates for single-stage total body lift BMI less than 30 Age less than 50 Physically and mentally healthy and fit Highly motivated (accepts theoretical increased risks of infection, thromboembolism, and blood transfusions)

minimizing operative times. There are several logistical barriers to organizing this type of surgical team. In an academic surgical setting, a primary surgeon may have the support of a fellow, residents, and a physician assistant. In the private practice setting, the surgical team may be composed of an experienced plastic surgeon and a physician assistant and/or an experienced surgical scrub tech, possibly with a fellow. The postoperative considerations that must be considered before offering a patient a single-stage TBL revolve around the expected recovery course. It is reasonable to assume that a patient that undergoes both upper and lower body contouring procedures simultaneously will have a more demanding postoperative recovery course. Patients that have gone through it point out frequently the burden of limited arm mobility coupled with abdominal and lower extremity pain. Additionally, patients should be told that the common postoperative complications that can exist after staged procedures, like wound-healing issues, seromas, and recurrent tissue ptosis, are perhaps even more likely to occur after a single-stage procedure. The ideal patient for a single-stage TBL should meet the stated preoperative criteria for the operation, have the operation performed by an experienced team of surgeons and support personnel, and be prepared for a prolonged recovery.

69.3 Special Considerations

N. Veitia and D. J. Hurwitz

anticipating how the collection of procedures will complement each other to create an anatomically harmonious result. Staging can increase the difficulty of achieving that goal. Conversely, offering too many procedures simultaneously in the poorly-selected patient is predictive of poor outcomes. Patient requests or even insistence for single-stage operations should never outweigh sound surgical judgment on the part of the surgeon. Concessions to this rule can lead to compromised patient care and increases in postoperative morbidity.

69.3.2 Preoperative Marking Before discussing the preoperative markings for a TBL, it should be noted that an increasing number of surgeons prefer to mark their patients the evening before surgery. This offers several potential advantages, including a more contemplative marking period free of the numerous interruptions by perioperative personnel typical of the preoperative holding area. There is also the added safety advantage of not exposing the patients to hypothermia immediately before a long procedure. Finally, it provides an opportunity for the patients to question their surgeon about incision patterns and expected outcomes while they are less anxious than they might otherwise be immediately before their surgery. They also have approximately 12 hours to think about the planned incisions and can question the surgeon immediately before their operation. Surgeons who elect to mark their patients the night before surgery should be advised to use heavyduty, permanent marker that will not easily fade due to cleansing before the next day.

69.4 Abdominoplasty

69.3.1 The “Whole Patient” Approach

69.4.1 Panniculectomy vs. Abdominoplasty Before delving into the individual techniques that contribute to the contouring of the body after MWL, it should be stressed that some of these procedures can be carried out simultaneously or they can be broken up into stages. Even if these procedures are staged, their design should still take into account the entire patient,

For many patients that have experienced MWL, the abdomen will be a focus of aesthetic dissatisfaction. It can also be an area of functional compromise, especially for the patient that has developed a significant

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Fig. 69.1 Typical appearance of a patient requiring a functional panniculectomy

abdominal pannus. A ptotic abdominal pannus is usually associated with significant intertriginous dermatitis. At times there is an abdominal hernia, which may be difficult to detect. Additionally, the sheer mass of the pannus can interfere with daily activities and impede further weight loss (Fig. 69.1). For this special class of patients, abdominal contouring is usually viewed less as a cosmetic measure and more as a functional surgical intervention. The operation of choice is usually not abdominoplasty, but rather a panniculectomy. Since a panniculectomy involves only the excision of fat and skin between the umbilicus and mons pubis without abdominal wall undermining, plication of diastasis recti or translocation of the umbilicus, the result is functional, limited, and rarely aesthetic. Some surgeons and patients consider this step as a prelude to future aesthetic surgical contouring of the abdomen, usually after the patient has lost more weight. A further consideration when performing a panniculectomy without a complete abdominoplasty is the involvement of a third-party payer for the operation. This is a point worth mentioning because many patients interested in plastic surgery after weight loss are under the impression that the procedures will be covered by their health insurance carriers. While this may be the case in some instances, surgeons need to be transparent in their dealings with both the patients and insurance carriers. Patients need to be told that they will be held financially responsible for any portion of a procedure that is deemed cosmetic by their insurance provider.

Insurance carriers need to be billed appropriately, which can mean that only a portion of a given procedure, that is, the noncosmetic portion, is submitted for reimbursement. The consequences of not complying with these guidelines can include investigations of insurance fraud and unanticipated costs to the patient. Additionally, in dealing with insurance carriers, surgeons and their office staff should be aware that as requests for covered plastic surgical procedures have increased in recent years, insurance carriers have revised their criteria and imposed stricter guidelines for the coverage of these procedures. Recently, panniculectomy has been assigned the CPT code of 15830 to aid in billing separate from abdominoplasty (CPT code 15847). One study demonstrated that the standard surgical charge for a medical panniculectomy was $3,086, while the range of reimbursements was zero to the full amount with the mean reimbursement of $615 and the median being $899 [3]. This type of perceptual devaluation of plastic surgery services among MWL patients is reflected in the fact that these patients tend to undervalue the estimated costs for plastic surgery by up to 60% [4].

69.4.1.1 Technique Aesthetic surgical contouring of the abdomen after MWL usually begins with full abdominoplasty including abdominal flap undermining, plication of diastasis

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recti, and translocation of the umbilicus. To that procedure, one can add a vertical excision component, or a so-called Fleur-de-lis abdominoplasty, and a variety of adjuvant procedures, including suction-assisted lipectomy of the abdomen and/or flanks as well as surgical contouring of adjacent structures like the mons pubis. Extension of the abdominoplasty incision beyond the midaxillary line, a so-called “extended” abdominoplasty, can add a powerful contouring component to the operation. This incision can also be carried into a circumferential excision, or a so-called “belt lipectomy,” which can be modified to address the various lower truncal deformities that can occur after MWL [5]. The lateral extensions of an abdominoplasty incision can also be merged with the lateral extensions of lower body lift incisions. For those patients with considerable excess upper abdominal skin, a reverse abdominoplasty, which involves an inframammary incision and upward traction of the abdominal tissue, may be called for. A review of this procedure has concluded that there is a clear, though limited, indication for the reverse abdominoplasty in a selected group of patients with redundant upper abdominal wall tissue

after a previous abdominoplasty or liposuction, preferably with preexistent submammary scars [6]. The authors have been more liberal in their indications for the reverse abdominoplasty, because frequently a standard abdominoplasty alone fails to fully correct the abdominal skin excess in the MWL patient. While the traditional markings for an abdominoplasty are performed entirely with the patient standing, we have found that the awkwardness of the hanging pannus makes it easier to begin with the patient supine. Beginning with the inferior incision, and as the patient is pulling up on her lower abdomen to simulate the anticipated tension of closure, a mark is made in the midline from 6 to 9 cm (relating to the height of the patient) above the vulvar anterior commissure (or base of the penis). A vertical midline hash mark is made on the mons pubis as a later intraoperative guide to incision closure and alignment of the umbilicus. A straight transverse incision is drawn along the superior margin of the mons pubis from 5 to 7 cm on either side of the midline. From the ends, the incision lines are drawn to the easily palpable anterior superior iliac spines (Fig. 69.2). The incisions are then symmetrically continued laterally

Fig. 69.2 Markings for abdominoplasty, which were made as described in the text and extended circumferentially into a lower body lift. In addition, there are markings for the upper inner thighplasty, the upper body lift, Wise pattern mastopexies, spiral flap reshaping of her breasts, and L brachioplasties. The abdominoplasty markings begin with identifying the midline between the lower abdomen and mons pubis about 8 cm from the labial

commissure. A 12-cm transverse line is centered over the median hatch mark. Rising lines are drawn to the anterior superior iliac spines and then continued transversely across the top of the buttocks. The superior incision line is at the level of the umbilicus with the width of excision determined by the grasp and pinch test. There are closure guiding hatch marks. The pentagonal cut out of the umbilicus is not seen

69 Total Body Lift After Massive Weight Loss

or superior laterally depending on the goals of the abdominoplasty. The superior incision line of the transverse excision is drawn at this point and usually extends in a curvilinear fashion from the established lateral excision points to a line just superior to the umbilicus. Many surgeons will only use this superior transverse line as a guideline not to be committed to until the abdominal flap is raised intraoperatively and a safe excision pattern can be determined that will allow for the closure of the abdominoplasty incision without undue tension. In the MWL patient, there is often a transverse line of thin subcutaneous tissue in the mid abdomen which forms an adherence to the abdominal wall fascia. Ideally, the superior incision line is drawn on a fold of skin superior to this depression. In such cases, the operation begins with an incision in this line followed by the elevation of the superior flap. The flap is then advanced toward the lower line and only incised where safe reach is possible. The preoperative surgical marking period is also the appropriate time to determine and mark any areas that will undergo suction-assisted lipectomy as well as any other areas deemed for excision and contouring, such as the mons pubis. Care must be taken to preserve abdominal wall perforating vessels, especially if suction-assisted lipectomy is to be added to the abdominoplasty procedure. The need for plication of the anterior rectus fascia will depend on the degree of rectus diastasis. Translocation of the umbilicus is customary. The timing of abdominoplasty in relation to other body contouring procedures that may be occurring simultaneously, such as thighplasty, is important because the abdomen is the keystone of the body. The tension of the abdominoplasty affects both the upper thighs and the lower chest and breasts. Operationally, flexion of the patient during abdominoplasty closure should be timed to minimally interfere with the work occurring in adjacent areas.

69.4.1.2 Complications A study assessing weight loss surgery (WLS) patients who underwent either abdominoplasty or panniculectomy found that the overall wound complication rate in these patients was 34% (seroma 14%, wound infection 12%, healing-disturbance 11%, and hematoma 6%) [7]. The same study also compared WLS patients to non-WLS patients undergoing these procedures

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and found that the WLS patients had an overall increase in wound complications (41% vs. 22%; P < 0.01) and in all categories of wound complications compared with non-WLS-patients by univariate methods of analysis. The development of seromas after abdominoplasty can be minimized by the appropriate use of drains. There are reports, however, of modified abdominoplasty techniques that may minimize the formation of seromas and even the need for drains. These techniques involve the preservation of a subscarpal lymphatic tissue bed on the paramedial anterior rectus fascia [8]. These techniques are reported to be associated with minimal seroma formation and even the avoidance of abdominal drains. Our experience with the preservation of lower abdominal subscarpal fascia has virtually obviated seromas, and we have seen reduced drainage output and more rapid removal of vacuum drains. More conventionally, drains are used and remain in place for a period of 5–10 days or until their output diminishes to an acceptable level. Another widely-reported complication of abdominoplasty in this patient population relates to wound healing. The vast majority of skin dehiscences are 1–2 cm in length, occur more than 2 weeks after surgery and very rarely require surgical intervention [9]. Most of these wounds are amenable to local wound care. In rare instances, these dehiscences can be large and deep enough to warrant more aggressive means of wound care, such as a vacuumassisted closure, or VAC (Kinetic Concepts, Inc., San Antonio, Texas). A less common but significant complication of abdominoplasty is damage to the lateral femoral cutaneous nerve, which can potentially lead to the condition, meralgia paraesthetica, which is numbness or pain in the outer thigh caused by injury to the lateral femoral cutaneous nerve. This can usually be avoided by keeping the dissection of tissue superficial in the area just medial to the anterior superior iliac spine. Treatment of this unfortunate condition is not standardized, with studies reporting comparable high improvement rates following local injection of corticosteroid and surgical interventions (either nerve decompression or neurectomy), but similar outcomes without any intervention in a single natural history study [10]. Finally, a rare but almost completely avoidable complication related specifically to abdominoplasty in the postbariatric patient relates to patients that have undergone the placement of a lap band

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device. Injury to either the extra-abdominal port or its tubing can inadvertently commit the patient to an intraabdominal operation to repair or replace the lap band device. A careful preoperative history can avoid this complication. Plastic surgeons should also be familiar with these devices because these patients are increasingly requesting exchange of their ports to lower profile ports at the time of abdominoplasty. This relatively simple procedure can either be coordinated with a bariatric surgeon or done by an appropriatelytrained plastic surgeon. Abdominoplasty in the MWL patient is an apparently simple procedure, which in fact suffers a high rate of complications [11].

69.4.2 Lower Body Lift The primary goal of a lower body lift is to address tissue laxity and ptosis of the buttocks and the posterior and lateral thighs. There can be a small amount of secondary tightening effect on the medial thighs with this operation; however, patients should be counseled that this effect may be minimal or short-lived and does not replace procedures that directly address the medial thigh. Controversy exists regarding the timing of this operation with a medial thighplasty. The argument for staging these procedures centers around the concept of avoiding the creation of competing vectors of pull on the lateral and medial thighs. Advocates of combining these procedures point out that the vectors of pull for both of these procedures are mostly vertical vectors [12]. Since a full vertical medial thighplasty (VMT) has two elliptical patterns of excision, one vertically-oriented and one horizontally-oriented, that come together at a “T-closure” point (Fig. 69.3), one could argue that the upper, horizontally-oriented ellipse is a vertically-oriented closure that does not represent a competing vector to the lower body lift closure. In general, these vector considerations need to be applied to individual patients, and single-stage lower body lift with medial thighplasty should only be considered in patients that have a moderate amount of thigh and buttock fat accompanied by significant skin laxity. For patients presenting for lower body lift and thighplasty that have excessively sized thighs, surgeons should consider staging these operations and adding suction-assisted lipectomy of the thighs to the first stage.

N. Veitia and D. J. Hurwitz

69.4.2.1 Technique The term “lower body lift” is conventionally applied to the excision and suspension of tissues of the buttocks and the posterior and lateral thighs. It often includes the creation and preservation of an adipofascial flap of the medial and paramedial lower back tissue. This flap is usually deepithelialized and can range in size from 30 to 40 cm transversely to 15–20 cm in its widest vertical dimension. A variety of techniques have been described regarding the ultimate placement of this flap; from leaving it in-situ to aggressively undermining the flap and transposing its lateral wings inferiorly to contribute to the desired final contour of the buttocks. This flap, which is thought to be a superior gluteal artery perforator flap, serves as a form of autoaugmentation. While speculation exists as to how safely it can be undermined and manipulated, studies have demonstrated how these flaps can be raised lateral to medial, and transferred to the inferomedial quadrant of the buttocks safely [13]. Ultimately, the surgeon needs to judge the adequacy of the vascularity of this flap against the decision to manipulate its position. The preoperative markings for a lower body lift are shown in Fig. 69.4. Notice that the inferior incision line begins just above the buttock cleft and then takes a curvilinear course toward the midaxillary line. The superior incision line is based on the preoperative pinching and pushing of the tissue and is indicative of a conservative removal of tissue. The senior author routinely commits to it at the beginning of the case. The central, paramedial tissue is marked out to delineate the adipofascial flap. Once the patient is intubated and placed in the prone position, this area will be deepithelialized with an electric dermatome. Residual islands of epithelium are removed with scissors or scalpel. This is followed by an incision along the inferior incision line and dissection down to the level of the gluteal fascia. A suprafascial plane is then developed inferiorly for 6–8 cm along both the buttocks. As this plane is developed laterally, the fascia lata is encountered. At this point, the legs are abducted, either on armboards or side utility tables. Lower body lift wounds closed during full thigh abduction have been shown to have a significantly lower deformity severity scores for the hip/thigh complex when compared with patients treated without full thigh abduction [14]. While abducted, a 45-cm Lockwood dissector (Byron Medical, Tucson, Ariz.) is passed inferiorly over the

69 Total Body Lift After Massive Weight Loss Fig. 69.3 This 48-year-old woman lost 220 pounds after gastric bypass and presented with a considerable skin laxity of her lower body and thighs. (a) As she lies on the gurney completed drawings for her vertical thighplasty can be seen. The pinch and grasp technique decided the width of the vertical limb. The horizontal limb starts with a line between the labia and medial thigh. The width of resection is determined by pushing down on the skin with the leg abducted. (b, c) Patient standing and pulling up on her abdominal and then thigh skin reveal the impact of the markings

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a

b

fascia lata in the lateral thigh to create discontinuous undermining. Once this is accomplished, we routinely place three to six quilting sutures in the trochanteric region from the fascia lata to the lateral thigh tissue as it is lifted [15]. This step prevents recurrence of tissue ptosis along the lateral thigh, or the so-called “saddle bag deformity.” Next, attention is turned to the proposed superior incision line. With the legs abducted, it should be possible to approximate how far superiorly the newly-created buttock-thigh flaps will migrate, thereby simulating the ultimate closure of the lower body lift. Further excision of the skin can be performed.

c

Determining the size and the lateral extent of the adipofascial flap depends on several factors, including how robust the vascularity to the flap appears to be, how aggressively the flap will be moved and how much flap volume is felt to be necessary to create buttock projection. After the careful removal of any retained epithelium, the mobilized flaps are then sutured into the gluteal pocket. The wound is then approximated using a series of towel clips. If the closure appears satisfactory from the standpoint of tension and contour, it is closed in layers, including the approximation of the superficial fascial system (SFS), usually with #2 PDO, Quill SRS (Angiotech, Vancouver, BC).

702 Fig. 69.4 The lower body lift marking continuation of the abdominoplasty drawing of Fig. 69.2 is seen. The superior line is a posterior extension of the superior abdominoplasty line. The width is determined by the grasping of tissues, leading to the inferior line along the mid buttocks and across the intergluteal crease. Again care is taken to obtain symmetry. Markings for the upper body lift and spiral flap harvest are also seen

N. Veitia and D. J. Hurwitz

a

b

69.4.2.2 Complications

69.4.3 Thighplasty

Early studies on the lower body lift reported that it required 5–6 h of operating time, 2 units of autologous blood, 2 nights of nursing care, and 3 weeks off from work [16]. Today, as the operation is performed with epinephrine solution infusion and bilaterally through a simultaneous team approach, both the operative time and the need for transfusion have decreased. The need for diligent postoperative care and recuperation, however, still remain. Additionally, postoperative complications associated with lower body lift surgery remain common. Complications are in keeping with other body contouring operations after weight loss, including wound dehiscences, seroma formation and, very rarely, flap tip skin necrosis [14]. Complications related to the adipofascial flap must also be considered, and can range from fat necrosis to partial or complete flap loss. Additionally, buried, chronic cysts can develop as a result of incomplete de-epithelialization of the adipofascial flap. Given the fact that patients tend to lay on a lower body lift incision, complications are not surprising. Attention should therefore be paid to the avoidance of undue postoperative pressure on the lower body lift closure. This can be accomplished through the use of a turning protocol or even a low-pressure hospital bed with an automatic turning capacity.

The topic of thighplasty was briefly mentioned in the section on lower body lift, because that operation treats the lateral thigh saddle bag deformity. In addition, the anterior and inner thighs are frequently a source of aesthetic disappointment for the MWL patient and a surgical challenge to the plastic surgeon. Perhaps more than any other area of the body, thigh contouring presents the greatest challenge and morbidity. A thoughtful discussion of obtainable and sustainable surgical goals for the thighs must take place. This discussion should include a staging protocol that is appropriate for the patient, the role, if any, of suction-assisted lipectomy, and the anticipated morbidity. Once the patient decides to proceed with a medial thighplasty, the first basic consideration is whether the patient’s thighs are obese enough to warrant a staged approach of suction-assisted lipectomy followed by an excisional thighplasty some months later. Another important consideration is whether the surgeon needs to address the full medial thigh or can limit the operation to the proximal medial thigh alone. This decision must take into account not only the deformity to be addressed, but the patient’s willingness to accept the increased morbidity associated with a full VMT.

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69.4.3.1 Technique If the medial thigh contour abnormality is limited to the proximal third or half of the thigh, a medial upper thighplasty may be appropriate. The great advantage of this type of thighplasty is that the incision can be well masked in the inner groin crease. Unfortunately, many patients will not be appropriate for this type of thighplasty because their deformities extend into the distal medial thigh. Patients that are poor candidates for a medial upper thighplasty but still proceed with the operation in the hopes of avoiding the prominent scar associated with a VMT will likely be disappointed with the outcome because the distal thigh deformity remains unaddressed. The technique for a medial upper thighplasty involves designing a large crescent-shaped ellipse that has its proximal margin adjacent to the inner groin crease. In females, this line should be made far enough away from the vulvar area so as not to cause distortion of the labial structures. Care should also be taken not to place this line so distal on the upper thigh that the resulting incision and scar become visible beyond underwear or a bathing suit. The placement of the curved distal margin of the crescent-shaped ellipse will depend on the amount of excess tissue to be removed in the upper medial thigh. Additionally, if the patient is undergoing simultaneous body contouring operations, such as a lower body lift or an abdominoplasty, this inner groin incision may merge with incisions around the mons pubis. For the crescent inner thighplasty, we have followed Lockwood’s admonition of a permanent suture suspension of thigh tissue to Colles fascia during a medial upper thighplasty. The suspension appears to limit the inferior drift of the scar and spreading of the labia. Closure of the wound normally involves a 2-layer closure with the incorporation of the SFS in the deep layer. If the medial thigh contour abnormality involves the majority of the medial thigh and perhaps even the area where the distal thigh meets the proximal knee, a VMT may offer the best contouring solution. A major drawback to a VMT is the resulting scar, which can be prominent and difficult to camouflage. The healing environment of a VMT incision is precarious due to the thin SFS for closure, dependency with edema, ambulation, and rubbing of garments. Additionally, the proximal portion of the incision

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tends to be an area that is covered with clothing and prone to moisture and exposed to high perineal bacterial counts. The excision pattern for a VMT is drawn first with the patient supine. The pattern is drawn in the form of two perpendicular ellipses that meet at a “T” junction in the upper third of the thigh (Fig. 69.3). The proximal ellipse is similar in fashion to that described for an upper medial thighplasty. The distal ellipse is much lengthier than the proximal ellipse and will include a vertical excision pattern that removes excess thigh tissue with a resulting scar position similar to the inner seam of a pair of pants. After drawing the anterior limb, the width of the excision is determined by pinching the tissues together. Symmetry is aided by imprinting the ink of one drawn leg onto the other. There are two basic approaches to VMT: excisiononly and excision with suction-assisted lipectomy. The former approach involves a sequential excision approach, where the anterior excision margin is carried down to a level above the adductor fascia and dissection proceeds posteriorly until the posterior excision margin can safely be committed to. Care must be taken to avoid inadvertent injury to the saphenous vein during this dissection. Also, any apparent injury to the lymphatic vessels, which can be difficult to identify, must be addressed with either ligature clips or sutures. Over the past 5 years, we favor the second approach, which incorporates suction-assisted lipectomy into the excision. Aggressive liposuction, usually in the form of ultrasonic-assisted lipectoplasty (UAL), is limited to the site of excision. More limited cosmetic UAL may be performed elsewhere in the thigh. The excision site liposuction (ESL) involves the removal of as much fat as possible in the proposed area of excision. Then, only the skin of the excision site is removed. This technique spares the neurovasculature and connective tissue. The preservation of the larger lymphatics reduces late lymphoceles and chronic edema. No drains are used as the legs are wrapped in elastic tights. Regardless of the excisional technique used during VMT, the point of greatest wound closure tension tends to be at the “T” junction of the horizontal and vertical ellipses. The tissues at this point can be reinforced by suspension to Colles fascia, but that appears to be superfluous. Again, the closure of the wound normally involves a 2-layer closure with the incorporation of the SFS.

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69.4.3.2 Complications Surgical contouring of the thighs, perhaps more than any other area of the body, poses challenges and is associated with morbidity that must be clearly explained to prospective patients. Complications associated with thighplasty include scar migration, vulvar distortion, delayed wound healing, and recurrence of tissue ptosis and lymphatic system alterations. With regard to the last point, a study that evaluated the effect of thighplasty on the lymphatic system by performing lymphoscintigraphy after thighplasty in patients that had had normal preoperative lymphoscintigraphy revealed abnormal lymphoscintigraphy in 30.8% of patients, resulting in significant functional and anatomic alterations in the lymphatic system [17]. Unfortunately, there is no standardized algorithm to treat lymphatic system alterations, and the treatments range from observation to compression, elevation, percutaneous drainage, and catheter ablation [18]. If a lymphocele is identified and can be localized to a certain area of the thigh like the groin, techniques including lymphatic mapping have been described to treat these collections [19]. Finally, the development of chronic lymphedema after thighplasty represents one of the most difficult treatment challenges related to lymphatic system alterations. This is a dreaded complication of thighplasty and can be especially difficult to treat.

N. Veitia and D. J. Hurwitz

breast deformity is characteristically different from what is normally recognized as breast ptosis in the non-weight loss population. Addressing MWL breast deformities requires special techniques that have evolved in recent years. The profound loss of superior pole fullness as well as the descent of breast parenchyma pose a special challenge to the plastic surgeon. A mere mastopexy, with or without augmentation mammoplasty, cannot typically address the deformity adequately. Techniques have evolved that not only build upon traditional mastopexy techniques but also recruit adjacent flaps of tissue that can lend form and support to the mastopexy as well as techniques that allow for a more secure suspension of the descended breast tissue.

69.4.5.1 Technique The two mastopexy techniques that are essentially unique to the post-weight loss population are the Spiral Flap reshaping and the dermal suspension mastopexy (DSM). These techniques evolved out of the difficulty in addressing breast ptosis in the post-weight loss patient as well as a necessity to develop procedures that could lend autologous bulk and internal strength to the mastopexy.

69.4.4 Brachioplasty

69.4.6 Spiral Breast Flap

Upper arm ptosis is a frequent source of dissatisfaction for the MWL patient. Brachioplasty is requested often by this patient population and it represents an integral part of a TBL. There are several special considerations when performing brachioplasty in the MWL patient, including the ideal position of the scar, the pattern of excision, the need for incorporating axillary and/or lateral chest tissue into the brachioplasty excision, and the advantage of excision site suction-assisted lipectomy (see Chap. 82).

When recruitment of a large amount of neighboring tissue is desirable, then the spiral flap reshaping is chosen. This flap combines a deepithelialized central breast pedicle with a lateral thoracic flap and inferior breast extensions. Nourished by trans-serratus muscle intercostal perforators, the lateral thoracic flap is advanced into a tunnel beneath the superior pole of the breast to augment and suspend, while the inferior extension is flipped up to augment the inferior pole of the breast. The spiral flap takes advantage of the ptotic, redundant tissue in the lateral chest to add form and contour to the breast during the time of mastopexy (Fig. 69.5). This lateral chest tissue, which is a lateral intercostal artery perforator (LICAP) pedicled flap, is raised and recruited into the mastopexy in a lateral to medial direction. The blood supply to the flap is typically

69.4.5 Mastopexy For females that have undergone MWL, the breasts are typically a focus of aesthetic dissatisfaction. This

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upper or lower breast poles. When more tissue is needed, saline or silicone breast implants can also be used, preferably during a second stage [20]. The placement and fixation of the flap will depend on where it can most safely rotate and effectively add contour. An added benefit of performing this flap is the improvement in the appearance of the lateral axillary-thoracic region.

69.4.6.1 Complications

Fig. 69.5 De-epithelialized spiral flap that includes the lateral thoracic flap and epigastric extension

Besides common complications like minor wound dehiscence, these operations are associated with very few major morbidities. Spiral flaps, by virtue of the fact that they require the dissection and rotation of a long deepithelialized flap, can be associated with flap vascular compromise. When this occurs, it usually manifests as fat necrosis. Since these flaps can sometimes run a course across the chest to the parasternal region, their compromise can be quite serious. Debridement is not always necessary, but may be if enough of the flap is involved. Cases involving a large amount of debridement may require the addition of a breast implant to achieve contouring goals [20].

69.4.7 Dermal Suspension Mastopexy

Fig. 69.6 De-epithelialized spiral breast flap in place for augmentation and suspension

robust, likely explained in part by the fact that largecaliber blood vessels, which are a common remnant in the postweight loss patient, can be observed in the area of this flap. The lift is essentially a reverse abdominoplasty that ends along the inframammary fold incision of the Wise pattern mastopexy and continues laterally along the back roll. The excess lateral chest tissue is deepithelialized and spiraled around the breast for augmentation, shaping, and suspension (Fig. 69.6). The flap can be placed either along the

The dermal suspension mastopexy takes advantage of one of the hallmark characteristics of breast ptosis after weight loss. The severely ptotic breasts in these patients typically appear deflated, with seemingly little to no appreciable breast parenchyma along their prolonged course. It is not unusual for these flattened breasts to rest on the abdomen as they descend. The operation addresses two aspects of the breast deformity: parenchymal reshaping and dermal suspension. The operation builds on the classic Wise pattern mastopexy but elegantly expands on the concept by incorporating large, thin, deepithelialized wings of dermal tissue adjacent to the central inferior pedicle. These dermal flaps are used to build up the breast once it is suspended to the deep pectoral muscle and periosteal rib. The operation requires diligence, patience, and an aesthetic sense of how thin dermal flaps, through a process of suspension and tailoring, can help create a convincing and stable

706 Fig. 69.7 One year after single-stage total body lift and 4 years after 100 pound weight loss from gastric bypass in this 48-year-old woman. Over 10 h she had bilateral L brachioplasties, upper body lift with spiral flap reshaping of her breasts, abdominoplasty, lower body lift, and upper inner thighplasties

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breast mound. The technique is extremely versatile for restoring an aesthetic and youthful breast shape in the patient who has lost a massive amount of weight [21].

69.4.7.1 Complications Overall, complication rates with this operation are low. One study reported that the operation carries an extremely high rate of patient satisfaction despite the disadvantages of a lengthy scar and the need for extensive intraoperative tailoring which may increase the operative time [21]. Mastopexy is frequently performed concomitantly with other body contouring procedures and the time required to appropriately address this complex type of breast deformity must be taken into consideration. Although patients with massive weight loss are likely to present for longer procedures and have a higher rate of wound-healing complications, these complications occur most frequently in areas other than the breast [22]. The broad obligatory undermining of the Wise pattern flaps leave the vertical limbs ischemic sometimes resulting in peripheral skin necrosis. There is some loss of superior pole fullness with time. Severe bottoming out of the breast has not been a problem.

69.4.7.2 Conclusions The well-documented medical advantages of MWL result in a much healthier and fit individual who, unfortunately, is commonly burdened by widespread areas of tissue ptosis, including the face, arms, breasts, torso, buttocks, and legs. Body contouring techniques have evolved rapidly in recent years to address these concerns (Fig. 69.7). The order, manner, and magnitude

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of surgical planning, however, remain an area of debate. The concept of the TBL, which does not commit to a single-stage procedure, encompasses a surgical goal that frequently requires a continuum of procedures to be performed before the “total body” can be considered “lifted.” This is certainly the goal for most patients searching for a surgical solution to their anatomic predicament. The decision to proceed with body contouring surgery in any patient is a highly individualized process that begins with an honest assessment of goals, transparent discussions of expected outcomes, and a candid conversation about realistic expectations and risks These operations are marked by a high rate of complications. The individual morbidity associated with different procedures has been outlined, and to that list can be added the universal risks of deep vein thrombosis and thromboembolism, including pulmonary embolism and death. There is no consensus regarding prophylaxis against venous thromboembolism in this patient population, although it is generally agreed that risk factors should be strongly considered and appropriate steps be taken in obese patients with a body mass index greater than 35 [23]. When one considers the less serious but significant and common need for revisionary surgery on these patients, it is remarkable that the patients undergoing these procedures frequently report a high rate of postoperative satisfaction. This is likely because of the fact that many of these patients are fully willing to trade widespread tissue ptosis for extensive scarring. In this way, this patient population distinguishes itself from some other cosmetic patient populations, and indeed, can be an extremely satisfying population to work with. As techniques in this field of plastic surgery continue to evolve, we can look forward to decreasing morbidity with improved and sustainable patient outcomes.

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References 1. Lockwood TE. Maximizing aesthetics in lateral-tension abdominoplasty and body lifts. Clin Plast Surg. 2004; 31(4): 523–37. 2. Hurwitz DJ, Agha-Mohammadi S, Ota K, Unadkat J. A clinical review of total body lift surgery. Aesthet Surg J. 2008;28(3):294–303; discussion 304–5. 3. Sati S, Pandya S. Should a panniculectomy/abdominoplasty after massive weight loss be covered by insurance? Ann Plast Surg. 2008;60(5):502–4. 4. Gusenoff JA, Pennino RP, Messing S, O’Malley WE, Boss TJ, Langstein HN. Post-bariatric surgery reconstruction: patient myths, perceptions, cost, and attainability strategies. Plast Reconstr Surg. 2008;122(1):1e–9. 5. Aly A, Cram A. The Iowa belt lipectomy technique. Plast Reconstr Surg. 2008;122(3):959–60. 6. Halbesma GJ, van der Lei B. The reverse abdominoplasty: a report of seven cases and a review of English-language literature. Ann Plast Surg. 2008;61(2):133–7. 7. Greco J, Castaldo, E, Nanney LB, Wendel JJ, Summitt JB, Kelly KJ, Braun Sa, Hagan KF, Shack RB. The effect of weight loss surgery and body mass index on wound complications after abdominal contouring operations. Ann Plast Surg. 2008;61(3):235–42. 8. LeLouarn C, Pascal JF. High superior tension abdominoplasty. Aesthetic Plast Surg. 2000;24(5):375–81. 9. Nemerofsky R, Oliak DA, Capella JF. Body lift: an account of 200 consecutive cases in the massive weight loss patient. Plast Recon Surg. 2006;117(2):414–30. 10. Khalil N, Nicotra A, Racowicz W. Treatment for meralgia paraesthetica. Cochrane Database Syst Rev. 2008; 16(3): CD004159. 11. Fraccalvieri M, Datta G, Bogetti P, Verna G, Pedrale R, et al. Abdominoplasty after weight loss in morbidly obese patients: a 4-year clinical experience. Obes Surg. 2007;17(10): 1319–24.

N. Veitia and D. J. Hurwitz 12. Hurwitz D. Medial thighplasty. Aesthetic Surg J. 2005; 25:180–91. 13. Colwell AS, Borud LJ. Autologous gluteal augmentation after massive weight loss: aesthetic analysis and role of the superior gluteal artery perforator flap. Plast Reconstr Surg. 2007;119(1):345–56. 14. Hurwitz D, Rubin JP, Risin M, Sajjadian A, Sereika S. Correcting the saddlebag deformity in the massive weight loss patient. Plast Reconstr Surg. 2004;114(5):1313–25. 15. Pascal JF, LeLouarn C. Remodeling bodylift with high lateral tension. Aesthetic Plast Surg. 2002;26(3):223–30. 16. Lockwood T. Lower body lift with superficial fascial system suspension. Plast Reconstr Surg. 1993;92(6):1112–22. 17. Moreno CH, Neto HJ, Junior AH, Malheiros CA. Thighplasty after bariatric surgery: evaluation of lymphatic drainage in lower extremities. Obes Surg. 2008;18(9):1160–4. 18. Borud LJ, Cooper JS, Slavin SA. New management algorithm for lymphocele following medial thigh lift. Plast Reconstr Surg. 2008;121(4):1450–5. 19. Stadelmann WK. Intraoperative lymphatic mapping to treat groin lymphorrhea complicating an elective medial thigh lift. Ann Plast Surg. 2002;48(2):205–8. 20. Hurwitz DJ, Agha-Mohammadi S. Postbariatric surgery breast reshaping: the spiral flap. Ann Plast Surg. 2006;56(5): 481–6. 21. Rubin JP, Khachi G. Mastopexy after massive weight loss: dermal suspension and selective auto-augmentation. Clin Plast Surg. 2008;35(1):123–9. 22. Rubin JP, Gusenoff JA, Cood D. Dermal suspension and parenchymal reshaping mastopexy after massive weight loss: statistical analysis with concomitant procedures from a prospective registry. Plast Reconstr Surg. 2009;123(3): 782–9. 23. Shermak M, Chang D, Heller J. Factors impacting thromboembolism after bariatric body contouring surgery. Plast Recon Surg. 2007;119(5):1590–6.

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Transaxillary Breast Augmentation/ Wise-Pattern Mastopexy in the Massive Weight Loss Patient George John Bitar

70.1 Introduction For obese women, losing a lot of weight is a great achievement as it requires willpower, determination, and sacrifice. Women can either undergo massive weight loss (MWL) by dieting and exercising or via bariatric surgery such as laparoscopic banding or gastric bypass surgery. MWL after a bariatric procedure requires about a year to 18 months. Changes occur in the process of weight loss with respect to family dynamics, romantic relationships, social interactions, work habits, self-esteem, and other life issues that may be unique to each individual patient. Ideally, plastic surgery on MWL patients provides enormously positive results for their self-image, self-esteem, attitude, and – ultimately – their health. There is disappointment after the MWL because instead of having a fabulous, sexy body as part of those welcome changes, a woman usually ends up with a lot of excess unwanted skin. A typical MWL female patient can go from having macromastia to significantly ptotic, empty breasts. The most effective answer to improve the volume and shape of the postweight loss breasts is a breast augmentation/mastopexy.

70.2 Initial Consultation Preparation for plastic surgery after MWL must be very carefully undertaken, from choosing the right board-certified plastic surgeon and discussing the

G. J. Bitar Bitar Cosmetic Surgery Institute, 8650 Sudley Rd. #203, Manassas, VA 20110, USA e-mail: [email protected]

procedures at length, to having a very good knowledge of the perioperative care and requirements [1]. A plastic surgeon has to be clear about what can be realistically and safely achieved via plastic surgery, in what time frame, and with what potential complications. Sometimes a long-term plan is discussed to address multiple areas with which a patient is not happy. For example, the decision can be made to proceed with performing an abdominoplasty and brachioplasties in an initial operation, wait a year, and then perform the thigh plasties and mastopexies/breast augmentations. This is a common and realistic scenario because it addresses multiple areas to be improved in a safe approach in patients with a high rate of complications. In one study of postbariatric plastic surgery, complications relating to wound problems were noted in 66% of patients [2]. The medical history is reviewed, a physical exam performed, and the patient is also asked to get medical clearance from her own physician, as well as basic labs, to ensure that the patient will undergo the procedure safely. The patient should have the opportunity to discuss the procedure with an experienced nurse, the plastic surgeon who will perform the procedure, and to talk to patients who have had the same procedure performed by the same surgeon.

70.3 Breast Evaluation for Cosmetic Surgery After Massive Weight Loss It is important for a patient to understand what a breast augmentation, a mastopexy, is, and what a breast augmentation/mastopexy will accomplish. Different techniques, limitations, risks, benefits, and postoperative expectations should be discussed in detail. Because a

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_70, © Springer-Verlag Berlin Heidelberg 2010

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woman may end up with unsightly scars as well as a long-term prosthesis in her breasts, it is important to discuss long-term consequences. A woman who has undergone MWL may have enough breast tissue to make her a good candidate for a mastopexy, with or without augmentation. The surgeon needs to address what would be the most appropriate mastopexy in her case and what is the best augmentation procedure, and, a myriad of choices have to be made. The best approach is to offer the patient the choices, but guide them in the direction that is optimal.

70.4 Augmentation, Mastopexy, or Both? The decision to have a breast augmentation, mastopexy, or mastopexy-augmentation may not be as straightforward as it would seem. Every plastic surgeon handles the situation a little differently. One way to address it is by asking the patient what bothers them about their breasts. If the size is too small, then an augmentation is sufficient. If they are not happy with the ptosis, but are happy with the size, then a mastopexy is appropriate. If they are not happy with the ptosis and the size, then a mastopexy and augmentation is in order (Fig. 70.1). Sometimes, the lines are not clearly drawn. If a patient has mild ptosis, but their main complaint is hypomastia, then it is a judgment call as to whether a mastopexy should be performed with an augmentation, or to wait a year and maybe the breast will settle nicely, thus avoiding a mastopexy. If a patient has ptosis and a decent sized breast, then they may be happy with just a mastopexy, as opposed to a mastopexy/augmentation. These options and the possibility of requiring future surgery should be discussed thoroughly with the patient.

70.5 Mastopexy Techniques Differing views on what is the optimal mastopexy are certainly not in shortage! With MWL patients, the typical presentation is that of a woman with a wide chest circumference, long inframammary fold extending sometimes to the back, suboptimal skin quality with striae, laxity of muscles and skin, with varying fat volume and severe

G. J. Bitar

ptosis. Because of this typical anatomical presentation, a minimal lift that may offer some benefit in women with mild ptosis such as a crescent mastopexy or a Benelli mastopexy, will fall short of achieving a long-term desirable result either due to the nipple–areolar complex (NAC) stretching, distorting, the breast bottoming out, or because of not achieving enough lift. A Wise pattern mastopexy with an inferior pedicle and anchor lift incision technique is a reliable technique, provided appropriate dissection is undertaken and enough of a lift is achieved to minimize the “bottoming out” effect. The reason for that choice is that in a MWL patient, this technique addresses and corrects the anatomical problems listed above. Variations of the vertical mastopexy technique, which should also be considered, are discussed elsewhere.

70.6 Breast Augmentation Technique Breast augmentation has become one of the most popular cosmetic surgery procedures in the U.S.A. with a variety of techniques with which it is performed. The literature describes the evolution of various techniques of breast implant placement in the submuscular vs. subglandular plane, silicone vs. saline implants, transaxillary vs. transumbilical, inframammary, or periareolar placement of the incision [3–5]. Even, within each technique, these is a myriad of nuances and variations between surgeons. Like everything in cosmetic surgery, a surgeon has to choose an operation that works well in his or her hands, makes the patient happy, and has a relatively low complication rate. There is no such thing as the “perfect breast augmentation technique,” and thus opinions differ and debates are heated among plastic surgeons as to what is the best way to perform a breast augmentation. I believe that the transaxillary breast augmentation with saline implants and via a blind dissection technique, i.e., without an endoscope, is a simple procedure with a high level of satisfaction and a low rate of complications. The main indication for a breast augmentation is hypomastia or breast asymmetry or both. The decision by a woman to have a breast augmentation should be explored in the initial consultation. The best reasons to accept to perform a breast augmentation is for a woman to feel better about herself in a decision which was well thought out and arrived at without external forces. Typically, a woman like that will have the highest likelihood of success and happiness with the operation.

70 Transaxillary Breast Augmentation/Wise-Pattern Mastopexy in the Massive Weight Loss Patient Fig. 70.1 (a1,2) Preoperative 38-year-old woman who had undergone a gastric bypass with resultant massive weight loss. (b1,2) One year postoperative after an axillary breast augmentation/mastopexy, simultaneously performed with an abdominoplasty. (c1,2) The arrow is pointing to the patient’s virtually imperceptible underarm scar

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Furthermore, she will be in the best position to handle a complication appropriately, should there be one.

implants achieve a very natural, long lasting result, with minimal complications.

70.7 Breast Augmentation in MWL Patients

70.8 Technical Details-Transaxillary Breast Augmentation/ Wise-Pattern Mastopexy

In addition to the traditional debate on whether saline or silicone should be used in breast augmentation, MWL patients offer additional opportunities. Autol ogous breast augmentations, either with fat transfer or with the lateral breast tissue, are the options. The author has felt that a Wise pattern mastopexy with a transaxillary breast augmentation and smooth saline

70.8.1 Preoperative Work-Up A patient should get a routine medical clearance and a psychiatric clearance when needed [6]. In case of MWL patients, a nutritional consultation is recommended due

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to the advantage in outcome from cosmetic surgery when nutrition is optimized [7]. A history of medications that can interfere with a good outcome, such as medications that increase the likelihood of bleeding, should be stopped before surgery. A pregnancy test should be ordered preoperatively. Also a complete blood count and INR gives a general idea of the hematological state of the patient. A urinalysis is important, since a positive test may warrant treatment before inserting prosthesis in a patient with an ongoing infection. A mammogram should be obtained in women at a higher risk for breast cancer, based on the recommendations of the American Cancer Association. Patients should also stop smoking for at least 2 weeks prior to the operation and 2 weeks after the operation to improve the surgical outcome. Two specific circumstances are worth mentioning. If a woman seeking breast augmentation is planning on getting pregnant shortly after the procedure, especially since bariatric surgery is being performed on women of child-bearing years, the prospective patient should understand that pregnancy can create changes in breast shape and size. Also, there is a small chance that a breast augmentation operation may have complications that can render a woman unable to breast-feed. A future operation, either to change the size of the breast implant, remove it, or perform a mastopexy, may be warranted, and a patient should be well aware of these possibilities. It is also important to address the history of breast cancer in the woman seeking a breast augmentation or in her family. Whether silicone or saline implants are placed, submuscular or subglandular, the issue of breast cancer detection should be discussed with the patient.

70.8.2 Surgical Marking The patient is marked while standing. The inframammary folds, the superior border of where the implant should lie, and the midline are marked. A 2-cm line is drawn at the lower aspect of the hair-bearing area of the axilla. A Wise pattern mastopexy is also marked initially, with the expected new location of the NAC, the amount of skin to be deepithelialized centrally, and the amount of skin to be resected both medially and laterally. Those amounts depend on the shape and size of each individual breast.

G. J. Bitar

70.8.3 Surgical Prep The patient is initially given prophylactic antibiotics, DVT (deep vein thrombosis) prophylaxis, and is intubated with general anesthesia, LMA, or intravenous sedation given as a surgeon’s choice. The arms of the patient are at right angle to the body and wrapped around the arm-rest. The breasts are infiltrated in a fashion similar to a liposuction area with about 75–120 mL on each side of tumescent solution for a total of 150–240 mL (500 mL of saline, 50 mL of lidocaine 1% plain, and 1 ampule of epinephrine 1:10,000). The technique with which to inject is important so as to achieve two goals: hydrodissection in the submuscular plane and vasoconstriction of the area to be dissected. A pneumothorax is much less likely if the surgeon lifts the breast with the nondominant hand and injects the tumescent fluid with the dominant hand in a fashion that is parallel to the rib cage in the submuscular plane. The patient is then prepped in a usual sterile fashion from the neck to below the umbilicus, including the axillas, while the tumescent fluid is allowed to take effect.

70.8.4 Surgical Technique After the tumescent solution takes effect, a 2-cm incision is made in the lower pole of the hair-bearing area of the axilla. With a curved Mayo scissors, a pocket is created in the axilla. Next, digital dissection is carried out to establish an intermuscular plane between the pectoralis major and minor muscles. Care is taken to avoid trauma to vessels and musculature; however, the tumescent solution helps to minimize bleeding to the point that electrocautery is seldom used with this technique, since it is almost a bloodless procedure. When the intermuscular plane has been established, a blunt curved dissector such as a Van Buren or a uterine sound dissector is used to complete the subpectoral pocket. After the submuscular pocket is created, implant sizers are inserted through the axillary incision and are filled to the size on which the patient and the surgeon have agreed. It is important to choose a breast implant size that augments the breast in a natural way and not exceed the diameter of the breast [8]. The back of the operative table is then elevated, so that the patient

70 Transaxillary Breast Augmentation/Wise-Pattern Mastopexy in the Massive Weight Loss Patient

is assessed in the sitting position. Implant pocket adjustment can be accomplished by either finger dissection or blunt sound dissection until the surgeon is satisfied with the size and shape of the augmented breasts. This is probably the step where experience helps the most. Medially, the muscle should be elevated enough to create nice cleavage, but not excessively to create symmastia. Inferiorly, insufficient dissection may lead to a “high-riding” implant, and aggressive dissection may lead to a “double-bubble” sign. Laterally, the breast should have a nice fullness, but if the dissection is too aggressive, then, in the future, the patient will complain that the implant ends up in the axilla when she lies down. Proper dissection of the breast pocket may initially be learned with direct visualization by the endoscopic guided method, but once a surgeon feels comfortable with the boundaries of the dissection, a blind technique is less costly, more efficient, simpler, and – at least with comparable results, in my opinion.

70.8.5 Replacing the Sizers with the Real Implants Next, one sizer implant is removed and the surgeon changes gloves, the axillary incision site is cleaned with Betadine and the assistant places an army–navy retractor to open the pocket for the surgeon. The surgeon empties the air from the saline implant, rolls it, and inserts it through the incision without it touching the skin, and with the valve facing anteriorly. When the implant has been completely inserted, it is filled with saline to the desired amount with a one-way stop-cock closed system to ensure the sterility of the saline. The sizer in the contralateral breast is kept to ensure hemostasis until the time to place the real implant in the contralateral pocket. At that time, the sizer implant is removed, and the saline implant is placed in an identical fashion in the contralateral pocket. Then the implants and the general shape of the breast are inspected as the patient is sitting up. When the shape and size are deemed appropriate by the surgeon, the filling tubes are removed. The incisions are then closed with 3.0 Vicryl interrupted sutures for the dermis and a 4.0 Vicryl subcuticular closure is performed.

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70.8.6 Mastopexy-Augmentation Performed Simultaneously If a patient wishes to have a mastopexy performed simultaneously with a breast augmentation, I prefer to perform a mastopexy–augmentation in the following way: First, a breast augmentation is performed in the way described above through an axillary approach, up to the step where the implant sizers are in place. The implant sizers are left in place and a Wise pattern mastopexy is performed in the traditional way by deepithelializing the central aspect of the breast, leaving the NAC intact, and resecting the excess skin of the lateral and medial segment leaving a healthy inferior pedicle for the neurovascular supply of the NAC. The skin is stapled closed. The patient is sat up and symmetry is assessed. At this time, adjustments are made for the skin envelop if necessary. Also, the new location of the NAC is marked, the skin carefully excised, and the NAC is brought out into its new location and stapled in place. Next, the dermal incisions are closed with 3.0 Vicryl, and the subcuticular layer is closed with 4.0 Vicryl with the sizers in place. When the mastopexy is completed, the sizers are removed from the axillary incision. Excellent hemostasis is achieved. Next, the permanent implants are placed through the axillary incision, and the patient is sat up for a final inspection. When the shape and size of the breasts are satisfactory, the filling tubes are removed, and the axillary incisions are closed with 3.0 and 4.0 Vicryl sutures.

70.8.7 Postoperative Care The incisions are covered with Steri-Strips, and foam tape is placed around the breasts to ensure healing in the proper position. The patient is then placed in a bra and dressings are placed to cover the axillary incisions. The patient is recovered in the ambulatory surgery center or hospital for an hour or two and given antiemetic medicine if needed. The patient is asked to sleep supine with the head elevated and take the appropriate antibiotic and analgesic medications.

714 Fig. 70.2 (a1,2) Preoperative 55-year-old woman. (b1,2) Three months postoperative after a breast augmentation/mastopexy. (c) Three months after surgery showing early healing results of the axillary and Wise pattern mastopexy scars. Arrow pointing to axillary scar

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The patient is seen the following day and the incisions are inspected as well as the over-all appearance of the patient and the breasts. Any early problems are addressed in a timely fashion. Most patients heal uneventfully (Fig. 70.2) and have

mild to moderate ecchymosis and edema. The tape is removed after a week. Daily activity is resumed in a few days, work can be resumed in about a week, and exercise after the fourth week in most cases.

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Fig. 70.3 Examples of the virtually imperceptible axillary scar

70.9 Advantages of a Two Incision Approach for a Breast Augmentation/Mastopexy The advantages of this technique in creating two separate surgical sites for the axillary breast augmentation and mastopexy outweigh the advantages of a “single surgical site” traditional augmentation-mastopexy with the insertion of the implants through the periareolar or anchor incision: 1. The pectoralis major muscle is minimally manipulated, since the implant is inserted in the submuscular plane, and the mastopexy is performed in the dermal and glandular planes. The dissection as such decreases postoperative inflammation and pain, also preserving intact muscle coverage for the implant, in case of an infection or dehiscence of the mastopexy anchor incision. 2. The option to adjust the implant size based on the tension on the NAC exists without difficulty, by inflating or deflating the sizer implants to achieve

the desirable volume, before committing to the final implant size. 3. There is no prolonged handling and exposure of the implant, which may decrease the chance of infection of the implant. 4. Precious intraoperative time is saved because suturing of the breast incisions can proceed faster without having to worry about puncturing the implant. The major disadvantage of this approach is the placement of an additional axillary scar in addition to the anchor incision performed, which is usually imperceptible (Fig. 70.3) and so the patient has to consent after a thorough discussion of the available options.

70.10 Complications With this technique, pain has been limited to the first few days and controlled with analgesic medications. Return to daily activity has occurred within 1 week to 10 days.

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Exercise is usually encouraged after the third week. The complications have been limited to hematomas (2%), capsular contracture (4%), DVT (2%), high-riding implants (2%), implant deflation (less than 1%), and a few patients (3%) who were unsatisfied for reasons of asymmetry. It is important to note that there were no implant infections, “double-bubble” signs, pneumothorax, and loss of ability to breast-feed, permanent loss of nipple sensation, major medical complications, or mortality.

70.10.1 Avoidance of Common Complications: 1. Postoperative hematoma A small hematoma may be observed, but if the hematoma is significant or is enlarging, then operative drainage is necessary. The rate of hematomas, or bleeding after a breast augmentation is reported to be about 2%, in 2006; Handel et al. reported 1.50–2.89% depending on the method of augmentation used [9]. Before surgery, our patients are evaluated by their own physicians, and blood tests obtained include an INR and a CBC. I use tumescent solution in breast augmentations. The key is to inject the tumescent solution and wait for about 7 min to start the operation. This technique plus minimal dissection, for the breast pocket and the mastopexy flaps, gentle handling of the muscle during the procedure, and creating the appropriate pocket size for the implant, all contribute to keep the postoperative hematomas rate low, less than 1%. 2. Infection Breast implant infections occur in general in about 1–2% of cases; a study from 2005 reports 2–2.5% [10]. The most important step in avoiding infections is to perform the surgery at a first-rate surgical facility where principles of sterility are applied regularly. Patients are given the appropriate intravenous antibiotic coverage throughout the actual surgery. I change gloves multiple times during the operation, and remain the only one who handles the implants in the operating room to ensure total sterility and avoidance of infection. After the procedure, patients are prescribed a 1-week course of antibiotics to minimize infection.

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3. Capsular contracture Capsular contracture occurs in 10–15% of women with breast implants, depending on what study is quoted. In 2004, the FDA reports a rate of 10–11%, at 5 years, for augmentation patients [11]. Capsular contractures may be caused by a subclinical infection, significant bleeding during the operation, or time and collagen remodeling alone. In the previous sections, there was a discussion about how to minimize the risk of infection or bleeding. The rate of capsular contractures in my mastopexy/breast augmentation patient population has been about 4%. 4. Rippling Rippling, especially with saline implants, can lead to patient dissatisfaction in up to 10% of breast augmentation patients. Handel et al. also reported the rate of rippling to be 5.7–14.15% depending on the technique and type of implant used [9]. Rippling can be avoided or minimized by giving the breast implant maximum coverage with breast tissue and muscle. For that specific reason, rippling is minimized by placing an implant under the pectoralis major muscle and by selecting an implant size that would be covered almost completely by the muscle. As a result, the implant cannot be felt from the lateral edge of the breast. 5. Deflation or rupture It is difficult to quote the rates of breast implant rupture or deflation because it is a function of time. The best way to minimize this risk is by paying attention to each step in the preoperative evaluation of a patient, the actual surgical procedure, and the follow-up care. If an implant ruptures or deflates, it needs to be exchanged. 6. High riding implants The shape and look of the augmented breasts should be very natural. Critics have cited “high-riding” implants as a result of this technique [12]. With the use of proper surgical technique as described and good muscle dissection, the rate of high-riding implants is reduced. If that were to happen, then it is prudent to wait until about a year, when the healing has taken its course, and reoperate to fix the problem at that time.

70 Transaxillary Breast Augmentation/Wise-Pattern Mastopexy in the Massive Weight Loss Patient

70.11 Discussion Patients who have had mastopexy/augmentations after MWL in my practice have ranged in age from 25 to 66 years. Some have had simultaneous procedures such as liposuction, abdominoplasty, or facial rejuvenation procedures. The overall satisfaction rate has been very high with a very low rate of complications. It is critical to address the controversy of performing transaxillary breast augmentations with the “blind approach” instead of the endoscopically-assisted approach. The results of the blind approach are excellent. The critics’ view that this technique will yield a high percentage of “high-riding” implants has not been true in my breast augmentation patients. The advantages of this technique over the endoscopically-assisted technique is the shorter time in which the operation can be performed safely (the actual surgical time is 25–40 min), which is significantly less than the endoscopic approach. The second advantage is the lack of reliance on endoscopic equipment, the cost involved, and potential added variables to an operation that is otherwise very simple.

70.11.1 Choosing the Right Breast Implant Size In the initial consult, the patient is asked to place a known-sized silicone breast implants in her bra and wear a shirt that would reveal her silhouette clearly. The patient tries on different size implants until she finds the size she likes. We offer our patients the option to try sizes again on a second consultation. Usually they come up with either the same size or a very close size to the one of the initial consultation. I encourage my MWL patients to choose implants in the range of 200–550 ccs, with exceptions in certain situations.

70.11.2 Silicone or Saline Breast Implants The choice of implant type affects the type of surgery to be performed. It is difficult to perform a

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silicone breast augmentation through an axillary approach. The incision has to be 5 cm with a silicone implant [13] instead of 2 cm with a saline implant. The technique discussed in this chapter is limited to saline implants inserted through an axillary incision. Silicone implants are advantageous in certain situations. Silicone breast implants feel more natural than saline implants when a woman has had many breast procedures and has very little breast tissue or muscle remaining in the breast. Silicone implants may be preferable also when a woman is very thin, in which case, silicone implants may feel more natural. In these two situations, the author will offer the patients silicone breast augmentation. The advantages of saline implants are as follows: 1. Scar location: They are more easily inserted from the transaxillary incision. 2. Scar length: The scar is about 2 cm vs. 5 cm for a silicone implant. 3. Cost: Silicone implants are significantly more expensive in the short and long-term than saline implants. 4. Long-term follow-up: No need for MRI scans biannually to determine if there is a silicone rupture, as recommended by FDA for silicone implants. MRI costs $2,000–$3,000.

70.12 Conclusions The “blind” technique of transaxillary breast augmentation is a safe, effective, and simple way to perform breast augmentations. In MWL patients who frequently require a mastopexy, and would sometimes like to combine a mastopexy with an augmentation, an axillary breast augmentation/Wise pattern mastopexy provides a safe, effective, and reproducible technique which yields excellent results with low level of complications and a happy patient. Like any procedure, a learning curve is always expected, but it is truly an elegant, simple, and highly effective procedure with a minimal rate of complications.

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References 1. McNemar TB, Lomonaco J, Krieger MD. Bariatric plastic surgery: a guide to cosmetic surgery after weight loss. Omaha, NA: Addicus Books; 2008. p. 28. 2. Hurwitz D, Agha-Mohammadi S, Ota K, Unadkat J. A clinical review of total body lift surgery. Aesthetic Surg J. 2008, 28(3):294–303. 3. Momeni A, Padron NT, Fohn M, Bannasch H, Borges J, Ryu SM, Stark GB. Safety, complications, and satisfaction of patients undergoing submuscular breast augmentation via the inframammary and endoscopic transaxillary approach. Aesthetic Plast Surg. 2005;29(6):558–64. 4. Dowden R. Keeping the transumbilical breast augmentation safe. Plast Reconstr Surg. 2001;108(5):1389–400; discussion 1401–08. 5. Hendricks H. Complete submuscular breast augmentation: 650 cases managed using an alternative surgical technique. Aesthetic Plast Surg. 2007;31(2):147–53. 6. Bitar G. Breast augmentation: axillary approach. In: Shiffman MA, editor. Breast augmentation: principles and practice. Berlin: Springer; 2009. p. 231–40.

G. J. Bitar 7. Bitar G, Myers S. Nutrition issues after bariatric surgery for weight loss (in press). 8. Hurwitz D. Total body lift. USA: MD Publish.com; 2005. p. 107. 9. Handel N, Cordray T, Gutierrez J, Jensen JA. A long-term study of outcomes, complications, and patient satisfaction with breast implants. Plast Reconstr Surg. 2006;117(3):757– 67; discussion 768–72. 10. Pittet B, Montandon D, Pittet D. Infection in breast implants. Lancet Infect Dis. 2005;5(2):94–106. 11. FDA Breast Implant Consumer Handbook – 2004. Retrieved 30 May 2007, Web site: http://www.fda.gov/cdrh/breastimplants/handbook2004/localcomplications.html. 12. Troilius C. A ten-year evaluation following corrections of implant ptosis subsequent to transaxillary subpectoral breast augmentation. Plast Reconstr Surg. 2004;114(6):1638–41; discussion 1642–3. 13. Serra-Renom J, Garrido MF, Yoon T. Augmentation mammaplasty with anatomic soft, cohesive silicone implant using the transaxillary approach at subfascial level with endoscopic assistance. Plast Reconstr Surg. 2005;116(2):640–5.

Mastopexy with Extended Chest Wall-Based Flap After Massive Weight Loss

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Ruth Maria Graf, Daniele Pace, and Alexandre Mansur

71.1 Introduction Nowadays, obesity is epidemic all around the world. Statistics of some studies report the prevalence of obesity in more than 1.7 billion people in the world. In the United States, around 5% of people have morbid obesity. This health problem has a lot of causes that include the sedentary life and the foods habits [1]. An important aspect of body contouring after massive weight loss is the reshape of the breast and the upper body. The treatment requires the correct diagnoses and understanding of the anatomy. There are a lot of different types of breast after the patient lost weight. Usually, the ptosis and the laxity of the skin are extensive and is common the decreased inframammary crease in continues with the upper back roll. Some patients have an adequate quantity of fat and glandular tissue to perform the mastopexy. But in general, despite excess skin, the breast lose majority of fat, and has excess of skin and tissue in the lateral aspect of the breast and the back (the upper back roll). The deformities of the breast include profound and asymmetric breast volume loss with flattening of the parenchyma against the chest wall, a redundant and inelastic skin envelope, grade 3 nipple ptosis, medialization of the nipple–areola complex, and a prominent axillary roll of skin that extends from the lateral breast [2]. The necessity to remove the lateral skin excess and reshape the breast in the same procedure to have good

R.M. Graf (*) Department of Hospital de Clínicas, Federal University of Paraná (UFPR), Curitiba-PR, Brazil e-mail: [email protected]

results encourages the use of that tissue as a flap to improve the volume of the breast. If we have this option, it is not necessary to use implants. Otherwise some thin patients will need implants. Besides the utilization of the chest wall-based flap to fill the upper pole, it was demonstrated that passing the flap under a sling of pectoralis major muscle promotes longer maintenance of breast shape. Mastopexy using an extended thoracic wall flap associated with a loop of pectoralis muscle provides an upper body lift for recontouring of the breast and chest.

71.2 Surgical Technique The patient is marked in an upright position (Fig. 71.1). A line from the sternal notch to the xyphoid process is drawn in the midline. The meridian line is drawn from

Fig. 71.1 Schematic drawing of the markings

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the mid-clavicle to the nipple–areola complex, and continues vertically crossing the infra-mammary crease (“E” point) at about 12 cm from the midline. Point “A” is marked at 17–20 cm from the sternal notch depending upon the projected size of the breast and the length of the chest. Moving the breast laterally, a medial vertical line is drawn in the projection of the meridian line. Similarly, pulling the breast medially, a lateral line is drawn through breast meridian projection. Both vertical lines start at point A and join ending 2–4 cm above the point E, characterizing the point “D.” Points “B” (medial subareolar point) and “C” (lateral subareolar point) are marked over the vertical lines, 5–7 cm above the point D. Point B is located about 9 cm from midline, and point C about 12 cm from anterior axillary line. A periareolar curved line is marked in an oval shape, passing through points B-A-C. Five to seven centimeters from point B, a line is drawn medially until it reaches the inframammary fold (point F) and the same is done laterally (point G) according to the skin excess to be removed. The marked area is deepithelialized. The dermis is incised along the marked lines, up to 1.5–2 cm superior to points “B” and “C,” sparing the upper portion of the areola, which is the pedicle for the nipple–areola complex. Dermis is also incised horizontally 1 cm inferior to the areola and subcutaneous tissue is incised perpendicular to the plane of the thoracic wall, reaching the pectoral fascia at the level of the 4th intercostal space. Great care must be taken not to incise in a caudal direction so as to protect the vascular supply. To create the chest wall-based flap, medial and lateral vertical incisions are made obliquely through the breast parenchyma down to the pectoralis fascia, leaving enough breast tissue on either side to preserve breast pillars (Fig. 71.2). Above this flap, breast tissue is undermined from pectoral fascia up to the level of 2nd intercostal space. The lower portion of the parenchyma flap is dissected carefully down to the original infra-mammary crease, leaving breast skin flaps 0.5–1 cm thick. This maneuver widens the inferior portion of the breast flap, taking all of the lateral deepithelialized flap. The pectoralis strip consists of a 2-cm wide bipedicled flap, which includes the fascia and partial thickness of the pectoralis major muscle. It is dissected just superiorly to the base of the dermolipoglandular flap, long enough to accommodate the breast flap under it, without causing any compression. The usual length of the muscle sling is 8–10 cm. The donor area of the

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Fig. 71.2 The roll flap elevated

Fig. 71.3 The chest wall-based flap undermined under the pectoralis strip

muscle is closed by two interrupted sutures of 2–0 nylon. Then, the central and lateral flaps are passed under the muscle sling (Fig. 71.3) and fixed to the pectoralis fascia by a running suture of 2–0 nylon, reaching the 2nd intercostal space, starting with the lateral part of the flap and continuing with the central portion of the flap, and finishing the suture medially, superiorly to the sling (Fig. 71.4). The size of this flap is similar to a 100–200-mL implant, and adds volume to the upper pole of the breast. Because tension on the pedicle is modest, strangulation of the flap has never been encountered. No breast tissue is removed. It is important not to resect tissue from the medial pillar to avoid flattening

71 Mastopexy with Extended Chest Wall-Based Flap After Massive Weight Loss

Fig. 71.4 The lateral aspect of the flap sutured in the high portion of the central flap

the medial part of the breast (Fig. 71.5). The upper part of the breast is then suspended and sutured to the pectoralis muscle at the level of the 2nd intercostals space, just above the most superior part of the chest wallbased flap. This maneuver also helps to correct breast tissue ptosis, restoring the upper pole fullness, bringing together the medial and lateral pillars, and improving the breast shape. The medial and lateral pillars are sutured together in an inferior to superior fashion using 2–0 nylon sutures. To close the skin and reduce wound tension around the areola, a round block suture is made all the way around the periareolar skin. This is a running suture passing through the deep dermis of the outer skin and the areolar deep tissue (Fig. 71.6). Deep dermis of the vertical wound is sutured placing together

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Fig. 71.5 The gland with the flap in the correct position

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Fig. 71.6 Final suture of the inverted T scar

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the subareolar points “B” and “C.” A suture is done joint the points E-F-G. A running intradermal suture with 4–0 Monocryl closes the skin. No suction drainage is used.

71.3 Postoperative Care Postoperatively, it is recommended to use a molding compressive brassiere for 1–2 months. Lymphatic drainage massage for the operated areas is done from the third postoperative day throughout the fourth week. Special care with the scars is necessary to improve wound healing. Topical antibiotic ointment maintains the local humidity and helps with the cell migration to accelerate wound closure. To avoid hypertrophic scars, sterile strips and silicone gel or sheets can be used when the scar is completely dry, and is utilized for 2 months. Walking is encouraged the first day after surgery and physical activities are resumed after 3 weeks. a1

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71.4 Discussion Mammaplasty with the thoracic wall flap, including the lateral aspect of the breast associated with a loop of pectoralis muscle is a good choice to patients after massive weight loss. The patient achieved better upper pole fullness, better shape, absence of a lateral roll and minimal bottoming out (Fig. 71.7). Morbid obesity is growing in huge proportions in the United States and around the world. In U.S., it is estimated that 144,000 gastric bypasses were performed in 2004 [3]. The increase of body contouring surgery runs in the same proportion. The actual weight loss and the body contouring surgery after weight loss have beneficial effects on self-esteem and body image [4–6]. For women, the breast is an important aspect and represents the femininity image. Autologus tissue can give a more natural aspect to the breast as to appearance and touch. The postoperative aspect of the breast gives a more natural shape. When an implant is used, it is possible to a3

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Fig. 71.7 (a1–3) Preoperative 35-year-old patient after massive weight loss. (b1–3) One year postoperative following mammaplasty with the thoracic wall flap, including the lateral aspect of the breast associated with a loop of pectoralis muscle

71 Mastopexy with Extended Chest Wall-Based Flap After Massive Weight Loss

notice the double contour of the breast shape because of the tissue relaxation that occurs in these patients. The implant stays in a high position and the relaxed skin and subcutaneous tissue stays down (snoopy breast). A significant aspect of the anatomy in patients after massive weight loss is the decreased inframammary crease in continuation with the upper back roll [4, 7]. Because of this, the regular techniques of mammaplasty would not treat all the deformities and the results are poor [8]. The surgeon has to think about the chest and back as a unit that needs to be reshaped. The Wise pattern is chosen because the design maximizes skin removal [9]. The skin excess is vertical and horizontal and in these patients, the remaining skin is unable to contract. The extended thoracic wall flap is undermined and fills out the deficient upper pole while removing the lateral roll, and gives a better reshaping of the upper body. The fat is very lengthy and is probably assisted by the generous subcutaneous vasculature found in the weight loss patient. The loop of pectoralis helps to prevent the descent of the fat. It is an essential detail of the technique in performing the pectoralis muscle loop not to squeeze so that there is no difficulty with the blood supply of the flap [10–13]. The history of vertical mastopexy dates back to Arié [14] and Lassus [15, 16]. Using adjustable markings for an upper pedicle for the areola and central breast reduction, Lassus has employed vertical reduction mammaplasty in a wide range of breast hypertrophies. It was then modified and popularized by Lejour [17, 18] and other authors [19, 20]. In cases where the breast flaccidity is evident, a small horizontal component is indicated as described by Marchac [21]. In massive weight loss patients, the lateral component goes until the back in order to remove the skin and subcutaneous tissue and used as a flap to improve the lateral and superior projection of the breast. In order to avoid a long vertical component of the scar, a fixed vertical length of 5–7 cm is marked. Once the vertical limbs are established, a curved line is drawn from the proposed superior edge of the areola to the upper point of the vertical limbs, which incorporates the remaining skin redundancy, which will be closed around the areola with a purse string suture. The upper pole fullness is improved using a nonareolar dermolipoglandular flap. This flap is based centrally over the pectoralis major muscle, receiving its blood supply through perforator vessels at the level of 4th and 5th

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intercostal spaces. This flap is held in place by passing it under a loop of pectoralis muscle and some sutures from the dermis of the flap to the pectoralis fascia. Using the lateral breast tissue to increase the chest wall-based flap helps to reshape the superior lateral aspect of the breast, giving projection and better breast contour. At the same time, with the excess skin resection of the back roll, the great improvement of the lateral thoracic area is observed with this technique described above. In order to obtain a better long-term outcome, it is mandatory to redefine breast shape with internal tissue, not only with skin sutures, which is mandatory in massive weight loss patients [22].

71.5 Conclusions The main purpose of the mastopexy with thoracic wall flap, including the lateral aspect of the breast associated with a loop of the pectoralis muscle, is to give the best shape to the breast just with local flaps. The use of a chest wall-based flap is a strategy created to achieve better upper pole fullness. The flap can be used with all types of incisions, including inverted T mammaplasties, which can be used in massive weight loss patients associated with the deepithelialized lateral back roll flap. The uppermost advantage of the breast flap held by the pectoralis sling is to promote longer maintenance of breast shape.

References 1. Roldan EO. Obesity: a worldwide health care epidemic. In: Aly AS, editor. Body contouring after massive weight loss. St Louis: Quality Medical Publishing; 2006. 2. Hurwitz DJ, Agha-Mohammadi S. Postbariatric surgery breast reshaping the spiral flap. Ann Plast Surg. 2006;56(5): 481–6. 3. Wolfe BL, Terry ML. Expectations and outcomes with gastric bypass surgery. Obes Surg. 2006;16(12):1622–9. 4. Aly AS, Cram AE, Chao M, Pang J, McKeon M. Truncal body contouring surgery in massive weight loss patient. Plast Reconstr Surg. 2003;111(1):398–413. 5. Rubin JP, Agha-Mohammadi S, O’Toole J. Breast reshaping after massive weight loss. In: Aly AS, editor. Body contouring after massive weight loss. St Louis: Quality Medical Publishing; 2006.

724 6. Song A, Rubin JP, Thomas V, Dudas JR, Marra KG, Fernstrom MH. Body image and quality of life in post massive weight loss body contouring patients. Obesity (Silver Spring) 2006;14(9):1626–36. 7. Soliman S, Rotemberg SC, Pace D, Bark A, Mansur A, Cram A, Aly AS. Upper body lift. Clin Plast Surg. 2008;35(1): 107–14. 8. Graf R, Mansur A, Tenius FP, Ono MC, Romano G, Cruz GA. Mastopexy after massive weight loss: extended chest wall-based flap associated with a loop of pectoralis muscle. Aesthetic Plast Surg. 2008;32(2):371–4. 9. Wise RJ. A preliminary report on a method of planning the mammaplasty. Plast Reconstr Surg. 1956;17(5):367–75. 10. Graf R, Biggs TM, Steely RL. Breast shape: a technique for better upper pole fullness. Aesthetic Plast Surg. 2000;24(5): 348–52. 11. Graf R, Biggs TM. In search of better shape in mastopexy and reduction mammoplasty. Plast Reconstr Surg. 2002; 110(1):309–17. 12. Graf R, Reis de Araujo LR, Rippel R, Neto LG, Pace DT, Biggs D. Reduction mammaplasty and mastopexy using the vertical scar and thoracic wall flap technique. Aesthetic Plast Surg. 2003;27(1):6–12. 13. Graf R, Mansur A, Tenius FP, Ono MC, Romano G, Cruz GA. Mastopexy after massive weight loss: extended chest

R. Graf et al. wall-based flap associated with a loop of pectoralis muscle. Aesthetic Plast Surg. 2008;32(2):371–4. 14. Arié G. Una nueva téchnica de mastoplastia. Rev Lat Am Cir Plast. 1957;3:22. 15. Lassus C. A technique for breast reduction. Int Surg. 1970; 53(1):69–72. 16. Lassus C. Breast reduction: evolution of a technique – a single vertical scar. Aesthetic Plast Surg. 1987;11(2): 107–12. 17. Lejour M, Abboud M. Vertical mammaplasty without inframammary scar and with breast liposuction. Perspect Plast Surg. 1990;4:67–90. 18. Lejour M. Vertical mammaplasty and liposuction of the breast. Plast Reconstr Surg. 1994;94(1):100–14. 19. Chen CM, Warren SM, Isik FF. Innovations to the vertical reduction mammaplasty: making the transition. Ann Plast Surg. 2003;50(6):579–87. 20. Pallua N, Ermisch C. “I” Becomes “L”: modification of vertical mammaplasty. Plast Reconstr Surg. 2003;111(6): 1860–70. 21. Marchac D, Olarte G. Reduction mammaplasty and correction of ptosis with short scar. Plast Reconstr Surg. 1982;69(1): 45–55. 22. Ribeiro L. A new technique for reduction mammaplasty. Plast Reconstr Surg. 1975;55(3):330–4.

Medial Thigh Lift Free Flap for Breast Augmentation After Bariatric Surgery

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Thomas Schoeller and Georg M. Huemer

72.1 Introduction Obesity and its associated medical morbidities carry a substantial health risk. While massive weight loss allows improvement in health status and lifestyle, physical sequelae due to symptomatic skin redundancy result in typical deformities that require operative treatment [1]. In the upper body, these deformities include rolls of redundant tissue on the back and lateral thorax, moderate to severe laxity of the upper arms, a displaced posterior axillary fold and, in many cases, of most concern to the patient, various deformities of the female breast [2]. One of the key features for an optimal operative plan for the MWL-patient is to stage various body contouring procedures. Often, more than one area can be addressed within a single operation. This approach offers many advantages such as fewer operative steps in order to reach the patient’s goal, less down time, and the possibility to utilize autologous tissue for augmentation purposes. In the postbariatric patient, the breast displays a unique problem, which cannot be compared to the typical mastopexy patient. In general, there are three different types of breast deformities: • A very large breast with tissue excess. Here, regular breast reduction techniques will yield good results, depending on the individual surgeon’s preferences. • A ptotic breast with sufficient volume but an excessive skin envelope. Here mastopexy techniques

T. Schoeller (*) Department for Handsurgery, Microsurgery and Reconstructive Breast Surgery, Marienhospital Stuttgart, Böheimstraße 37, 70199 Stuttgart, Germany e-mail: [email protected]

such as the total parenchymal reshaping technique [3] are able to restore a youthful breast shape. • A ptotic breast that also lacks volume. Here an augmentation procedure needs to be carried out in conjunction with mastopexy to achieve a satisfactory outcome. • A sufficient firm skin envelope, but deficient breast volume. Here just autologous augmentation is recommended. Although some breasts need further reduction, most benefit from mastopexy plus augmentation. Patients who have achieved massive weight loss (MWL) are left with significant areas of redundant skin and subcutaneous tissue secondary to fat atrophy. The morbid obesity acted like a tissue expander and left the breast with a significant loss of volume and severe breast ptosis after MWL has been achieved. Due to the volume loss, standard mastopexy alone is frequently inadequate in reconstructing an aesthetically pleasing breast, and augmentation is required. However, these “pancake” breasts often provide poor soft tissue coverage to camouflage an implant. The result is a breast with a round, unnatural appearance that transitions poorly onto the chest and an obvious “augmented” look. In addition, concerns about the long-term behavior and complications of breast implants, as well as their feeling to the touch make some of these patients inquire about the possibility of autologous augmentation. Thus, the use of autologous tissue in augmentation has a particular appeal in this group of patients. These demands are emphasized by the generally accepted superiority of autologous breast reconstructions compared with implants. Since implants are associated with these disadvantages, several patients would profit from autologous implants utilizing the otherwise discarded redundant

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tissue during body contouring procedures. Abdom inoplasty flaps (either in form of DIEP-, SIEA-, or PUP-flaps) are a well-established procedure for regular breast reconstruction with maximally diminished donor site morbidity, which can also be used for breast augmentation. In some cases, however, this tissue from the lower abdomen is not available for various reasons such as previous abdominal surgery or simply too less volume, and alternatives such as the tissue from the medial thigh would be helpful. This chapter describes a technique utilizing tissue from the medial thigh through a conventional thigh lift with simultaneous harvesting of a gracilis free flap for breast augmentation in a single-stage procedure.

72.2 Surgical Technique 72.2.1 Flap Harvest The patient is placed in the supine position similar to a thigh lift procedure, with the knee and hip flexed and the draped leg slightly rotated outside (Fig. 72.1). After determining preoperatively the amount of redundant skin and soft tissue similar to the marking technique for a horizontal thigh lift, the marking lines of the skin island are infiltrated with local anesthetics plus vasoconstrictor to reduce unnecessary bleeding from the skin edges.

Fig. 72.1 Intraoperative positioning of the patient for bilateral breast augmentation with redundant tissue from the medial thigh. The knees and hips are slightly flexed and the leg is rotated outwards. The amount of skin redundancy, which equals the skin island of the transverse myocutaneous gracilis flap is outlined preoperatively in a standing position

T. Schoeller and G. M. Huemer

The skin island is incised starting from the palpable origin of the adductor longus tendon running backwards in the groin crease toward the infragluteal fold. The endpoint is the lateral end of the infragluteal fold or the lateral two third of the posterior thigh. The lower incision line is dependent on the laxity of the inner thigh skin. The width of the island is estimated by means of a pinch technique of the skin to ensure tension-free closure (approximately 10–12 cm skin island width in MWL patients). These lines, landmarks for harvesting the myocutaneous gracilis flap, are nearly identical to the preoperative markings of a classic medial thigh lift. The skin island can be extended anterior into the groin area to correct the loose skin in that area if required. The raising of the adipocutaneous portion of the flap is started close to the groin where the tendon of the adductor longus muscle is palpated. The skin island is harvested with the underlying fascia. At the dorsal border of this muscle, a first view of the vascular pedicle of the TMG flap is possible. With the surgical assistant lifting the leg and flexing it in the hip, the posterior part of the skin island extending into the gluteal crease is incised down to the musculature. Care has to be taken not to injure the branches of the posterior femoral cutaneous nerve. The fascia at the caudal border of the island overlying the gracilis muscle is opened and the muscle is bluntly freed. This maneuver facilitates the closure of the thigh and reduces tension and therefore the tendency of widening of scars postoperatively. The minor pedicle to the muscle should be identified and ligated or clipped. During dissection of the tendon of the gracilis muscle, care has to be taken not to injure the saphenous nerve. Using extra-long scissors, the tendon is cut after palpating it between two fingers. Then, the origin of the muscle is separated from the pubic bone using electrocautery. In cases in which a horizontal thigh lift is combined with a vertical excision, the initial incision can be carried out toward the tendon of the gracilis muscle, which facilitates transecting the tendon and clipping of the minor vascular pedicle (Fig. 72.2). The branch of the obturator nerve supplying the gracilis muscle is ligated and the vascular pedicle is dissected free up to its origin from the deep femoral vessels. Freeing the space lateral to the adductor magnus muscle facilitates dissecting the pedicle origin and is used routinely in our hands for flap elevation. Care has to be taken to either clip or ligate all side branches into adjacent muscles. The adductor longus muscle is then retracted medially and the pedicle dissected close

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applied and kept on for approximately 10 days together with compression stockings. Mobilization of the patient is started on postoperative day 2 with walking, and sitting with slightly flexed hips is allowed on day 4. Typically, the patient is dismissed from the hospital after 7 days.

72.3 Management of the Breast

Fig. 72.2 Flap harvest with the forceps in close proximity to the minor vascular pedicle. In this patient, a vertical thigh lifting procedure was also planned and, thus, the incision was carried out running over the gracilis muscle caudally. In patients, in which a vertical extension of the thigh lift is not necessary, flap harvest is carried out solely from the horizontal incisions

Fig. 72.3 Appearance of the donor site immediately after wound closure. On both legs, a TMG-flap was harvested and a vertical skin component was excised in order to achieve a circumferential thigh tightening

to its origin. The flap is transferred to the recipient site and the donor site is closed primarily in a typical medial thigh lift fashion, avoiding dog-ears by advancing the lower wound edge to the midline of the wound. If there is additional circumferential skin laxity after closure of the recipient site, an additional vertical skin island can be excised in order to achieve a circumferential tightening. In this manner, a horizontal thigh lift is combined with a vertical extension (Fig. 72.3). Flap elevation takes an average of 40 min and closure another 20 min in pure horizontal excisions. A compression garment, typically used for liposuction patients but with a hook and loop fastener is

Depending on the degree of ptosis that needs to be corrected, the breast is either accessed by an inverted T approach or in cases where just volume is needed, by an inframammary incision. In case of an inverted T approach, the nipple areola complex can either be pedicled inferiorly or superiorly, depending on the surgeon’s preferences. The authors normally use the inferior pedicle that has the safer blood supply. The dissection is carried out as in a regular mastopexy operation. When the pectoralis fascia is freed, the muscle is spread at the fourth rib lateral to the sternal edge. For microvascular anastomosis, the cartilage of the fourth rib and all adjacent tissue between the third to fifth rib is removed to gain access to the internal mammary vessels. Both the artery and vein from the dominant gracilis pedicle are anastomosed to the internal mammary vessels in an end-to-end fashion. The flap should be secured with 2–3 resorbable sutures at the pedicle entry point to the pectoralis muscle and the thoracic wall to avoid any uncontrolled shifting force to the flap’s pedicle. The best projection can be achieved by suturing the crescent shaped skin island together into the form of a cone with the suture line cranially (Figs. 72.4 and 72.5). A part of the skin island can be used for flap monitoring for the first days and later deepithelialized and submerged (Fig. 72.6). After initial closure of the breast over the flap, the shape of the breast has to be reevaluated. If there is some residual ptosis, further skin reduction has to be undertaken. Care has to be taken not to make the skin envelope too tight to avoid compression of the flap’s circulation. Light bandages are applied in order to be able to check the flap perfusion on a regular basis just as in regular free flap surgery. After 1 week, a sport bra can be applied to the breast and should be worn for approximately 6 weeks postoperatively.

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Fig. 72.4 Shape of the harvested TMG-flap with a large adipocutaneous skin island that is typically available in the massive weight loss patient

Fig. 72.5 The shape of the flap after coning the skin island by suturing the cranial wound edge of the flap together. This maneuver results in a very nicely projecting flap resembling an anatomically shaped implant

72.4 Complications Complication encountered are typically related either to microvascular compromise of the flap or wound breakdown at the donor site. In order to avoid problems with flap perfusion, state-of-the-art microvascular technique should be applied. Since this technique is surgically

Fig. 72.6 Above: preoperative. Below: postoperative. Comparison of preoperative appearance with immediate postoperative result after breast augmentation with bilateral TMG-flaps in a massive weight loss patient. The patient previously underwent inverted T mastopexy but was dissatisfied with the size of her breasts. Thus, breast augmentation in conjunction with thigh rejuvenation was offered to her. On the picture below, one can see the small monitoring skin island located in the submammary fold

demanding, it should be carried out only by a surgeon who is familiar with standard microsurgical technique. Wound breakdown of the donor site may be related to excessive width of the skin island with resulting tension on the skin closure. Thus, the skin island should be harvested in a conservative manner to avoid such tension problems.

72 Medial Thigh Lift Free Flap for Breast Augmentation After Bariatric Surgery

Urinary catheters are regularly used that will be removed after the patient is fully ambulatory again for hygiene reasons. In general, the same complications are encountered as in a regular medial thigh lift, such as prolonged seroma formation, lymphocele, or sensory disturbances.

72.5 Discussion The MWL necessarily results in body contour deformities associated with physiological and psychological problems. Plastic surgery performed to improve the patient’s body image and self-respect, in case of typical breast emptiness and disfiguring ptosis, regularly includes the evaluation for options of autologous augmentations. The author’ technique of breast augmentation with a bilateral myocutaneous gracilis free flap in patients who had experienced MWL represents a method to perform a breast augmentation with a simultaneous medial thigh lift as a one-stage procedure (Figs. 72.7–72.9). The transverse orientation of the skin island in the proximal third of the gracilis muscle, which was first introduced by Yousif [4] indicates an incision, which is very similar to an incision of a regular horizontal thigh lift. As we raised flaps with skin paddles up to 12 cm in width and up to 30 cm in length, the amount of resected skin in the thigh region is very similar to a conventional thigh lift. The donor site of the gracilis flap is negligible regarding the expected functional loss in contrast to other myocutaneous flaps such as the transverse rectus abdominis flap (TRAM). The gracilis muscle is expandable without a discernable loss of adductor function [5, 6], and there is no additional scar to the regularly performed medial thigh lift. In addition, vascular anatomy of this flap is highly consistent with the known anatomy (there were some variations in the number of minor pedicles, but this was not relevant to the reconstructive procedure). The average pedicle length was 6–8 cm, the arterial diameter was 1.5 mm, and the venous diameter was 3.2 mm. We observed that the diameter was slightly bigger in the MWL-patients compared to TMG-cases used in reconstructive patients [7, 8]. This observation is similar to other authors who describe bigger perforators in MWL patients on the abdomen. The idea of using excess tissue for the breast in patients who had undergone MWL has been described by our group previously, where we used redundant

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abdominal tissue for breast reconstruction [9] as well as the TMG-flap [10]. Although using abdominal tissue for breast reconstruction is the gold standard nowadays and this might be also true for microvascular autologous breast augmentation in the MWLpatient, there are indications in which a TMG-flap is the superior choice: 1. The patient had already undergone a contouring procedure on the abdomen and therefore this tissue is not available anymore. 2. Patients who have experienced a tremendous amount of MWL. In these cases, it is possible that the tissue on the lower abdomen is deflated to such an extent that there is not enough volume for bilateral breast augmentation. Here the gracilis muscle is the first choice for breast augmentation in our experience, because it is the only donor site, which offers adequate volume for an aesthetic breast augmentation. 3. If performing a perforator-based abdominal flap, such as a DIEP, is beyond the surgical capabilities of the surgeon, violating the abdominal musculature in order to raise such a flap will result in much more donor site morbidity such as abdominal bulging or hernia due to denervation of the rectus abdominis muscle compared to a conventional gracilis flap. Here the flap dissection is much more straightforward and technically easier. A general advantage of the gracilis myocutaneous flap and an abdominal flap is their use as an autologous tissue for breast augmentation. There are no long-term complications to be expected in these cases, whereas the regularly used silicone implants are associated with formation of a capsule around the implant, resulting in a contracture of various degrees. There are relatively few reports on the real longtime outcome of breast augmentation surgery using silicone implants, considering the relatively young age at which the interventions are usually performed. When one considers the lifelong aspect of breast augmentation, even the use of free flaps seems warranted, if the procedure is safe enough and donor site morbidity is low and acceptable to the patient. Especially in the MWL-patient, the concept of autologous tissue augmentation seems particularly appealing. Compared to reconstructive patients, the MWL-patient will profit from taking donor tissue since this tissue will be excised and probably discarded during the body contouring procedure anyway. It seems only logical to utilize this tissue for augmentation

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Fig. 72.7 Left: preoperative 38-year-old female patient after a weight loss of approximately 55 kg. Right: the result after breast augmentation with bilateral TMG-flaps. Apart from that, she underwent fleur-de-lis abdominoplasty in a different operation

purposes. The main disadvantage of this procedure is the added length of a microvascular operation. But even if the operation fails and the flap is lost, the patient has the benefit of a newly contoured donor site. In the worst case, the failed flap has to be exchanged for a silicone implant.

However, the authors strongly believe that an individualized approach to each patient is the key to ultimate patient satisfaction [11]. Not every MWL-patient will profit from a TMG-flap for breast augmentation to the same extent. As described above, if there is the case of a ptotic breast with a lack of volume, we first

72 Medial Thigh Lift Free Flap for Breast Augmentation After Bariatric Surgery Fig. 72.8 (a, b) Left: preoperative 32-year-old female patient after a weight loss of approximately 100 kg. The patient underwent previously breast reshaping with a spiral flap from the lateral thorax but was not satisfied with the size of the breast due to insufficient tissue gain from the lateral thorax. Right: the result after bilateral breast augmentation with redundant tissue from the medial thigh (TMG-flap)

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evaluate the possibility of utilizing local tissue. If there are sufficient back rolls or redundant tissue on the lateral thorax, we perform either a spiral flap [12] or pedicled perforator flaps [13, 14]. This approach offers the same advantages by using autologous tissue without the demanding need for microsurgery. However, if the patient does not have redundant tissue in this region, we believe that tissue harvest from there will result in an unnecessary donor scar that can be prevented. Next, if the patient has sufficient lower abdominal tissue and

no other contraindications, such as prior liposuction or big abdominal scars, we would use a split DIEP-flap during the abdominal contouring procedure to augment the breast. By performing a DIEP-flap in a faulty manner, the problems associated with denervation of the abdominal musculature by far outweigh the benefit of harvesting autologous tissue. In such a case, a TMGflap offers the much better donor site, since the loss of the muscle is functionally negligible when compared to the rectus abdominis muscle.

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Fig. 72.9 (a, b) Focusing on the donor site. Together with flap harvest, a vertical thigh lifting procedure was undertaken concomitantly in order to rejuvenate the thigh in a circumferential fashion. The patient also underwent a lower body lift in a prior operation. Left: preoperative. Right: postoperative

72.6 Conclusions Performing autologous breast augmentation with a free myocutaneous gracilis flap in the MWL population offers an interesting option in the selected patient.

Although this procedure is time consuming and demanding, it will reward the patient and the surgeon with an optimal aesthetic outcome with a youthful and projecting breast as well as a maximally improved medial thigh donor site.

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References 1. Huemer GM, Dunst KM Massive weight loss after bariatric surgery: friend or foe? Plast Reconstr Surg. 2004;114(6):1663–4. 2. Song AY, Jean RD, Hurwitz DJ, Fernstrom MH, Scott JA, Rubin JP A classification of contour deformities after bariatric weight loss: the Pittsburgh Rating Scale. Plast Reconstr Surg. 2005;116(5):1535–44. 3. Rubin JP, Khachi G Mastopexy after massive weight loss: dermal suspension and selective auto-augmentation. Clin Plast Surg. 2008;35(1):123–9. 4. Yousif NJ. The transverse gracilis musculocutaneous flap. Ann Plast Surg. 1993;31(4):382. 5. Carr MM, Manktelow RT, Zuker RM Gracilis donor site morbidity. Microsurgery 1995;16(9):598–600. 6. Deutinger M, Kuzbari R, Paternostro-Sluga T, Quittan M, Zauner-Dungl A, Worseg A, Todoroff B, Holle J Donor-site morbidity of the gracilis flap. Plast Reconstr Surg. 1995; 95(7):1240–4. 7. Wechselberger G, Schoeller T The transverse myocutaneous gracilis free flap: a valuable tissue source in autologous breast reconstruction. Plast Reconstr Surg. 2004;114(1):69–73. 8. Schoeller T, Huemer GM, Wechselberger G The transverse musculocutaneous gracilis flap for breast reconstruction:

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guidelines for flap and patient selection. Plast Reconstr Surg. 2008;122(1):29–38. 9. Wechselberger G, Haug M, Schoeller T, Nehoda H, PizaKatzer H Breast reconstruction facilitated by vertical banded gastroplasty. Obes Surg. 2000;10(5):460–4. 10. Schoeller T, Meirer R, Otto-Schoeller A, Wechselberger G, Piza-Katzer H Medial thigh lift free flap for autologous breast augmentation after bariatric surgery. Obes Surg. 2002;12(6):831–4. 11. Huemer GM. Upper body reshaping in the female massive weight loss patient: an algorithmic approach. Aesth Plast Surg. in press. 12. Hurwitz DJ, Agha-Mohammadi S Postbariatric surgery breast reshaping: the spiral flap. Ann Plast Surg. 2006;56(5): 481–6. 13. Kwei S, Borud LJ, Lee BT Mastopexy with autologous augmentation after massive weight loss: the intercostals artery perforator (ICAP) flap. Ann Plast Surg. 2006;57(4): 361–5. 14. Hamdi M, Van Landuyt K, Blondeel P, Hijjawi JB, Roche N, Monstrey S Autologous breast augmentation with the lateral intercostal artery perforator flap in massive weight loss patients. J Plast Reconstr Aesthetic Surg. 2009;62(1): 65–70.

Rotation-Advancement Superomedial Pedicle Mastopexy Following Massive Weight Loss

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Albert Losken

73.1 Introduction Bariatric surgery continues to offer the greatest degree of sustained weight loss to the morbidly obese patient [1]. As plastic surgeons embrace the growing need for body contouring procedures, we are beginning to recognize the complexity of the contour deformities following massive amounts of weight loss [2, 3]. Although the breast represents only one aspect of the MWL patient, the deformity is often complex, blending into the upper abdomen, lateral chest, and arm. The long, deflated ptotic breast following MWL is still poorly understood, and although we are familiar with intricacies related to breast ptosis as the result of age, pregnancy, and gravity, those following MWL pose additional challenges. Numerous physiological and anatomical factors exist, and the traditional mastopexy reduction techniques are often insufficient. In order to best manage these patients, it is crucial to examine and understand the deformity to best achieve the goals. The two main issues following MWL are that the breast has an unstable envelope with significant skin laxity and an unstable mound with loss of volume and form. The breast is often very ptotic, laterally displaced, and with a flat upper pole. The chest can be wide, with ill-defined landmarks and a loose inframammary fold (IMF). The patient’s body habitus is also a contributing factor. These are some of the reasons why management of the breast following MWL is challenging and often requires additional steps in order to maintain shape and size expectations, and minimize recurrence of the defor-

A. Losken Emory Division of Plastic and Reconstructive Surgery, 550 Peachtree Street, Suite 84300, Atlanta, GA 30308, USA e-mail: [email protected]

mity. The superomedial technique is an option for managing the massive weight loss breast. Various authors have employed central or inferior pedicle techniques and designed vascularized attachments to provide suspension of the breast mound, and autoaugmentation mainly in the upper pole where volume is often desired [4, 5]. Although the majority of surgeons still used the inferior pedicle breast reduction technique [6], there is a growing trend toward the more superiorly based pedicle designs. It is felt that the superomedial pedicle technique can afford more reliable cosmetic outcomes, shorter operating times, and less pseudoptosis [7, 8]. The superomedial pedicle is a relatively short, well-vascularized pedicle that can easily rotate into position. All breast reduction and mastopexy techniques rely on repositioning the nipple–areolar complex (NAC) on a vascularized pedicle, resecting tissue as needed, and reshaping the breast mound with the pedicle and residual breast tissue. Extension flaps and autoaugmentation techniques are relatively new and are slightly more involved. The rotation advancement technique is essentially a superomedial pedicle extension flap that rotates lower pole dermatoglandular tissue attached to the NAC to remote areas in the breast where additional volume is required (Fig. 73.1).

73.2 Patient Selection It is important that the patient is healthy and has stabilized at his or her desired weight prior to body contouring surgery. Screening mammography is performed as indicated. The patient’s desires are then discussed, focusing on size and shape. Breast volume, nipple position, skin quality is assessed. The typical breast following weight loss is long and deflated with

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Fig. 73.1 Top: This 29-year-old woman lost over 125 pound weight and had significant breast deflation with relatively long, ptotic breasts. Bottom: Postoperatively after the extended superomedial approach was used to augment the volume void in her outer quadrant without the need for implants. Breast projection and definition was restored

significant ptosis. Results are best if the skin quality is good and breast has sufficient lower pole volume (Fig. 73.2). If breast volume is insufficient despite significant ptosis, and additional volume is desired, then implant augmentation is required in addition to the rotation advancement technique. Smoking will increase the risk of complications and is not preferred. This technique, however, does not involve extensive undermining of skin flaps, which minimized the incidence of skin flap necrosis.

73.3 Markings The patient is marked preoperatively in the standing position. The midaxial line of the breast and the existing IMF is marked. The proposed nipple location is determined just above the projected level of the IMF.

This typically results in a suprasternal notch to nipple distance of 20–23 cm, depending on the height of the patient, level of the IMF, and desired size after the mastopexy (depending on implant use and autoaugmentation). The IMF is often loose and subsequently lower than desired, which needs to be taken into consideration when determining nipple height. A mosque-shaped areolar pattern is then drawn [9, 10], with a diameter of about 5 cm and length of the periareolar scar of less than 16 cm. Markings are then completed in the standard Wise and vertical fashion. The SM pedicle is then drawn from the superior or medial aspect of the new areolar opening depending on the length of the pedicle and the amount of rotation necessary. Conservative vertical medial and lateral pillar markings are drawn to determine the width of the extended pedicle. This marking is tapered down to about 2–3 cm above the IMF. Wise markings will allow more definition of lateral breast contour addressing the excess skin in that location.

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Fig. 73.2 Top: This 45-year-old women with post pregnancy breast ptosis desired as much upper pole fullness as possible without the need for implant augmentation. Bottom: She had an extended superomedial pedicle transferred from the lower-pole to autoaugment the superior aspect of her breast

73.4 Operative Technique (Fig. 73.3) The NAC is incised and the superomedial pedicle as well as the extended pedicle is deepithelialized down to just above the IMF. The dermis is then released, creating the outline of the pedicle. The pedicle is back-cut medially only as much as is necessary to minimize restriction of rotation while keeping the pedicle base as wide as possible. Parenchyma is then incised almost down to the level of the chest wall with no undermining inferiorly. The lateral parenchymal extension is then transected from the lateral pillar up to the superior markings and minimal undermining is performed superiorly above the proposed nipple position to create a pocket for the autoaugmentation. Elevation of the pedicle off the chest wall is required inferiorly for rotation into the upper pole, however, central attachments are left intact to maximize pedicle viability. This allows for safe pedicle back-cut for nipple inset when necessary. Once the dermatoglandular pedicle has been created, the excess skin and parenchyma is resected depending on size and shape desired. The pedicle is then rotated superiorly and suspended as needed to fill

the upper pole. It is important to minimize excessive tension or torsion on the pedicle, which could impair perfusion of the extension. The advancement component involves bringing the lateral breast in and plicating the medial and lateral pillar together with 2–0 polydioxanone suture to reshape, and narrow the lower pole of the breast. This can also redefine and tighten the IMF at a higher elevation if necessary. Lateral parenchymal plication is performed in a horizontal orientation as needed. Once the breast mound has been shaped, the skin envelope is redraped and any excess skin removed. Lateral breast skin is advanced medially to redefine the lateral breast and eliminate the lateral breast roll. Although this can often be performed through a vertical only skin take out patter, the horizontal component is usually required in the massive weight loss breast to redefine the lateral mound and remove the excess skin. When implant augmentation is performed at the time of mastopexy, the subglandular pocket is created by undermining the SM pedicle. The width of the extended SM pedicle drawn preoperatively is more conservative to minimize the risk of over resection of

738 Fig. 73.3 (a) The deepithelialized superomedial pedicle is illustrated demonstrating location of the medial perforators. Note inferior extension of the pedicle and small back-cut to allow rotation if necessary. (b) The pedicle is dissected and the excess skin removed, usually in the Wise pattern. The superomedial pedicle is deepithelialized and extended down to the IMF and chest wall. Medial and lateral pillars are dissected, creating the extended pedicle. (c) The breast parenchyma is transected from the lateral pillar to above the proposed nipple position and a pocket is created for the pedicle. (d) The rotation advancement technique showing rotation of the extended superomedial pedicle superiorly and suspended for autoaugmentation. The lateral breast is advanced medially to allow for parenchymal plication and closure of the vertical pillars. Note the lower pole parenchymal defect once pedicle has been rotated superiorly. (e) Parenchymal reshaping using the rotation advancement technique. (f) The pedicle is suspended superiorly for improved upper pole fullness and preservation of shape. Lower pole glandular plication is performed by reapproximating the medial and lateral pillars, and lateral gland if necessary. (g1,2) Skin is redraped over the shaped breast mound. (Illustrations reprinted with permission from ref. [8])

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Medial perforators

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De epithelized pedicle extended down to IMF

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Defect from extended superiomedial pedicle

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f Suspension sutures Auto augmentation

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Fig. 73.4 Top: Preoperative 36-year-old female with 185 pound weight loss. She has wide, atrophic breasts, with inelastic skin, grade IV ptosis and asymmetry. Bottom: Eighteen months after

s uperomedial mastopexy, parenchymal plication, and a 300-mL subglandular implant augmentation. Shape and size have been preserved with time, breast has been narrowed, with improved definition

lower pole skin. Autoaugmentation techniques are still employed, and parenchymal reshaping is performed prior to implant placement. Once the desired breast size has been determined, the skin is redraped over the mound. The final step is to resect the excess skin only once the mound has been shaped and the implant has been placed (Fig. 73.4).

and fat necrosis has occurred in patients at the distal most portion of the flap, however, this did resolve with time. Recurrent ptosis is another issue that is minimized using this technique, however, not prevented. Despite overcorrection and extensive glandular manipulation, revision rate is up to 10%, especially in the massive weight loss breast when implants are also used [8]. This is easily accomplished by glandular plication and skin envelope tightening. Revision is more likely when a mastopexy augmentation was performed.

73.5 Complications The rotation advancement technique is relatively safe with minimal morbidity in carefully selected patients. The author has previously reported favorable results in a series of 35 MWL patients with complications, including minor wound dehiscence with delayed healing (n = 3), hypertrophic scarring (n = 1), wound infection (n = 1), and capsular contracture (n = 1). There were no patients with significant long-term fat necrosis, or loss of nipple viability. Fat necrosis remains a concern, especially when length is required for the extended pedicle. This is minimized by keeping the superomedial pedicle as wide as possible, and preserving central perforating vessels if the arc of rotation allows. Some early edema

73.6 Discussion As management of patients who have undergone massive weight loss continues to evolve, techniques will invariably be adapted and refined to best manage these complex deformities. The superomedial technique evolved into a rotation-advancement pattern to reshape the ptotic deflated breast following massive weight loss. This technique was inspired by necessity and applied to the MWL patient, based on many of the basic concepts and principles as discussed by Lejour and Hall Finlay [9–11].

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The goals of both reconstructive and aesthetic breast surgery are to meet size and shape expectations, preserve function, symmetry, and minimize scars. In massive weight loss patients, the delineation between reconstructive and aesthetic surgery becomes less well defined, and the patients not only seek alleviation of skin symptoms, but are also interested in more definition to the breast, and alleviation of significant ptosis and volume loss with the associated physical and emotional ramifications. This is often a challenging endeavor and it becomes crucial that the patient and surgeon have realistic expectations regarding results and potential outcome. The types of breast deformities seen following MWL are relatively new, and in order to best manage these patients and access outcomes, it is crucial that we understand the defect. Classification systems exist for breast ptosis, however, are mainly based on nipple position. The degree of ptosis following MWL has both a glandular component and a true ptosis component, stressing the importance of evaluating not only the nipple position, but the gland and skin envelope as well [12, 13]. The Pittsburgh Rating Scale [14] has recently been developed to measure contour deformities following weight loss, with potential applications in preoperative planning and evaluating results. However, accessing the breast deformities and evaluating longterm results remains a challenge and will always have a certain degree of subjectivity. The maintenance of shape over time might best be demonstrated by longitudinal evaluation of results through a combination of three-dimensional images of the breast [15, 16] and comprehensive, yet easy-to-use rating scales. The superomedial technique is a reliable and versatile technique, with the benefits being numerous in how they relate to various aspects of the MWL breast deformity. The dermatoglandular pedicle is often short and well vascularized. Nipple viability has not been an issue and the superior medial orientation allows for safe placement of a subglandular or submuscular implant through the traditional approach without jeopardizing blood supply. The subglandular implant location is preferred as it provides better projection and a more natural appearance. The ability to use the vascularized extension of the superomedial pedicle to autoaugment the upper pole provides fullness to an area that is often devoid of volume, and otherwise difficult to fill without implants. Rotation of this extended SM pedicle provides a parenchymal

A. Losken

defect in the inferior pole that is then amenable to parenchymal plication and lateral breast advancement. This creates an internal support sling that will theoretically maintain breast shape with upper pole fullness, and minimize recurrence of ptosis. The importance of this is especially magnified in the MWL patient where any relying on the inelastic skin envelope for breast reshaping will invariably contribute to recurrence of breast ptosis. The skin envelope is very relaxed with the skin being thin and atrophic. These principles are not new, as Lejour [9] recognized the importance of such glandular suturing. Another benefit to this type of glandular plication and parenchymal advancement is that it helps narrow the base of an otherwise wide breast deformity, as well as redefining a blunted or occasionally lower IMF, and helps reposition the laterally displaced breast mound on the chest wall. Although this technique is applicable through the vertical pattern in patients with lesser deformities and relatively good skin quality, the majority will require a Wise pattern skin takeout to address the lateral chest wall deformity and axillary skin rolls. The issue regarding simultaneous mastopexy augmentation is yet to be answered in the massive weight loss breast. Although the safest approach might be a staged mastopexy, glandular reshaping, followed by implant augmentation if necessary, this is not always desired or financially feasible for the patient. Patients with extremely long, deflated breast will benefit from an initial mastopexy for concerns of breast shape, recurrent ptosis, and nipple viability. If implants are desired, minor revisions in the skin envelope can be performed at that time to improve the final outcome. However, when an implant is placed at the time of mastopexy, it is important to finalize mound adjustments through glandular shaping and implant augmentation prior to skin takeout and tightening of the skin envelope. The vertical pillars in this technique help support the implant, and smaller implants are preferable, as the heavier implants might contribute to the risk of scar widening and recurrent ptosis. The extended portion of the pedicle is kept narrow to allow for safe closure, which is reasonable since the upper pole fullness relies less on the autoaugmentation when an implant is used. A certain degree of recurrent ptosis in the MWL patient is expected, however, this is often magnified when implants are used, leading to the higher revision rate in that category in our series.

73 Rotation-Advancement Superomedial Pedicle Mastopexy Following Massive Weight Loss

The combined approach is now used with caution in the MWL patient, and it is crucial that the patient understands the potential risks preoperatively. Attempts are continually being made to improve long-term shape following mastopexy and reduction mammaplasties. Ritz et al. [17] recently described a technique using a lower thoracic parenchyma flap tunneled underneath the prepectoral fascia, providing a fascial suspension component to their mastopexy. Other techniques have been described to maintain shape following mastopexy using different suspension type sutures, parenchymal flaps, and muscle slings [18–21]. Although these concepts are not unique to the MWL patient, their importance is magnified given the underlying anatomy and physiology. One of the main goals with this procedure is to eliminate breast ptosis and maintain shape over time. Despite proactive attempts to minimize ptosis, we realize that in this patient population, a certain degree of recurrent ptosis is almost inevitable. The goal is to minimize it to the point where both patient and surgeon satisfaction is sufficient to eliminate the need for revisional surgery (Fig. 73.5). Over the next few years, there will undoubtedly be numerous techniques in the

a

b

Fig. 73.5 Longitudinal evaluation of results. (a) Preoperative 39-year-old woman after a 148-pound weight loss. (b) Four weeks postoperative after superomedial pedicle Wise pattern

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literature describing ingenious ways to reshape the MWL breast, using some degree of glandular shaping, parenchymal suspension, and autoaugmentation. The rotation advancement technique addresses and corrects many of the above problems familiar to the massive weight loss breast. It is not without limitations and won’t necessarily be the technique of choice for all breasts. These deformities are complex and the management of which is similarly involved. As the incidence of bariatric surgery continues, the number of women seeking aesthetic and reconstructive breast surgery and body contouring will continue to rise.

73.7 Conclusions The rotation advancement technique utilizing the superomedial pedicle with certain modifications is safe, reliable, and reproducible. It is relatively easy to apply to all types of breast ptosis, and the majority of MWL breast deformities. The goal is to maintain shape and symmetry over time while minimizing the need for revisional surgery.

c

mastopexy with autoaugmentation and parenchymal plication. (c) One year postoperatively shows some maintenance of shape (Reprinted with permission from ref. [8])

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References 1. Livingston EH. Obesity and its surgical management. Am J Surg. 2002;184(2):103–13. 2. O’Connell JB. Bariplastic surgery. Plast Reconstr Surg. 2004;113(5):1530. 3. Gastric Bypass Surgery popularity leads to jump in plastic surgery procedures. Press Release: American Society of Plastic Surgeons; 10 March 2003. 4. Rubin JP, Khachi G. Mastopexy after massive weight loss: dermal suspension and selective autoaugmentation. Clin Plast Surg. 2008;35(1):123–9. 5. Hurwitz DJ. Single-staged total body lift after massive weight loss. Ann Plast Surg. 2004;52(5):435–41. 6. Rohrich RJ, Gosman AA, Brown SA, Reisch J. Mastopexy preferences: a survey of board-certified plastic surgeons. Plast Reconstr Surg. 2006;118(7):1631–8. 7. Davison SP, Mesbahi AN, Ducic I, Sarcia M, Dayan J, Spear SL. The versatility of the superomedial pedicle with various skin reduction patterns. Plast Reconstr Surg. 2007;120(6): 1466–76. 8. Losken A, Holtz DJ. Versatility of the superomedial pedicle in managing the massive weight loss breast: the rotation-advancement technique. Plast Reconstr Surg. 2007;120(4):1060–8. 9. Lejour M. Vertical mammaplasty and liposuction of the breast. Plast Reconstr Surg. 1994;94(1):100–14. 10. Hall-Finlay EJ. A simplified vertical reduction mammaplasty: shortening the learning curve. Plast Reconstr Surg. 1999;104(3):748–59.

A. Losken 11. Lassus C. A 30-year experience with the vertical mammaplasty. Plast Reconstr Surg. 1996;97(2):373–80. 12. Brink R. Management of true ptosis of the breast. Plast Reconstr Surg. 1993;91(4):657–62. 13. Regnault P. Breast ptosis. Definition and treatment. Clin Plast Surg. 1976;3(2):193–203. 14. Song AY, Jean RD, Hurwitz DJ, Fernstrom MH, Scott JA, Rubin PJ. A classification of contour deformities after bariatric weight loss: the Pittsburgh Rating Scale. Plast Reconstr Surg. 2005;116(5):1535–44. 15. Galdino GM, Nahabedian M, Chiaramonte M, Geng JZ, Klatsky S, Manson P. Clinical applications of three-dimensional photography in breast surgery. Plast Reconstr Surg. 2000;110(1):58–70. 16. Losken A, Seify H, Denson DD, Paredes AA, Carlson GW. Validating three-dimensional imaging of the breast. Ann Plast Surg. 2005;54(5):471–6. 17. Ritz M, Silfen R, Southwick G. Fascial suspension mastopexy. Plast Reconstr Surg. 2006;117(1):86–94. 18. Ribeiro L. A new technique for reduction mammaplasty. Plast Reconstr Surg. 1975;55(3):330–4. 19. Graf R, Biggs TM. In search of better shape in mastopexy and reduction mammaplasty. Plast Reconstr Surg. 2002;110(1): 309–17. 20. Caldeira AM, Lucas A. Pectoralis major muscle flap: a new support approach to mammaplasty, personal technique. Aesthetic Plast Surg. 2000;24(1):58–70. 21. Lockwood T. Reduction mammaplasty and mastopexy with superficial fascial support system suspension. Plast Reconstr Surg. 1999;103(5):1411–20.

Flank Reshaping

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Keith Robertson and Bilal Gondal

74.1 History Patients with localized fat accumulations often desire removal for aesthetic reasons, whereas patients with large accumulations desire removal for both aesthetic and functional reasons [1]. Since the beginning of the twentieth century, many surgeons have tried to model the body contour so that it adheres to the generalized notion of “beauty.” Historically, various approaches have been used to remove fatty deposits during lipoplasty. In 1921, Dujarrier attempted to remove the subcutaneous fat from a dancer’s calves and knees using a uterine curette. However, a complication led to the amputation of one of the dancer’s legs [2]. The next major advance in body contouring was not for over 40 years. Procedures like those performed by Pitanguy resulted in long and poorly placed scars [3]. In the 1970s, Schrudde used a delicate curette to remove fat from the lower leg through a small incision. The next advance was brought about by Arpad and Giorgio Fisher in 1976. They developed a fat-removing system using hollow cannulas equipped with suction (motor-driven suction cannula). They also developed the criss-cross tunnel formation technique, which consisted of tunneling from multiple incisions; this technique is currently used for more uniform results. In 1978, Meyer and Kesselring developed sharp curettage aided by the suction technique. This technique, however, was not widely accepted because of frequent residual seromas that caused irregularities [4, 5].

K. Robertson (*) Whitfield Clinic, Waterford, Ireland e-mail: [email protected]

In 1977, Illouz used a negative pressure device with high suction power connected to a cannula. He developed the wet technique in which a hypotonic saline solution that contained hyaluronidase was infiltrated in the subcutaneous tissue before aspiration. He believed that the solution would perform a dissecting hydrotomy that facilitated the removal of fat and diminished the blood loss and surgical trauma. This technique is now known as standard lipoplasty [6]. Hetter reported that the use of diluted epinephrine solutions reduced blood loss to 15–30% of the aspirate. Fodor expanded the concept of wetting solutions to the superwet technique, in which larger volumes of infiltration were used. In 1987, Klein reported his development of the tumescent technique, in which even higher volumes were infiltrated until the point that the tissue developed significant turgor [7]. De Souza Pinto et al. compared cannulas with different diameters, lengths, tips, and aspiration efficiency for a given suction negative pressure [8]. Chalekson et al. felt that cannula size and shape were of little importance in fibrous areas such as the flank. They noted minimal change with respect to surgeon fatigue, blood loss, and postoperative ecchymosis [5]. Further advancement in lipoplasty involved the addition of techniques that used energy-based devices, such as external ultrasonic-assisted lipoplasty (UAL), and power-assisted lipoplasty. Power-assisted lipoplasty devices work with a blunt avulsion/aspiration mechanism, but the procedures are performed by mechanically reciprocating cannulas [7]. In the late 1980s, Zocchi developed UAL, which was based on the emission of continuous ultrasound energy that caused selective fragmentation/emulsification of fat before its aspiration [9]. This technology was first popularized by Scuderi after his experience with a firstgeneration UAL device, which delivered continuous

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_74, © Springer-Verlag Berlin Heidelberg 2010

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ultrasound through blunt, solid, thick probes (4–6 mm diameter) to pretreat fat [9, 10]. Newer machines featured hollow cannulas for simultaneous fat fragmentation and aspiration, but the internal narrow lumen diameter (only 2 mm) did not allow an efficient evacuation of the fragmented tissue [7]. Several complications arose, especially related to the inadvertent excessive exposure of the treated tissues to ultrasound energy, prompting surgeons to strive to develop more efficient and safe ultrasound-based lipoplasty technology [11]. Kelly was one of the first to discuss the direct excision of excess skin and fat of the abdomen [12]. This is often necessary when the person has a poor skin tone or requires excision of a large amount of fat. Lewis first described the circumferential excision of thigh skin and fat with a vertical closure [13]. Farina performed direct lateral excision that improved the contour of the lateral thigh, but produced large visible scars [14]. An improvement to this was made by Pitanguy who described a thigh lift incision that was hidden within the bathing suit line [15]. Through the years, many variations have dealt with the location of the lateral (flank) scar. Baroudi kept his lateral incisions low [16]. Regnault et al. brought the incision higher, onto the buttock. Grazer and Klingbeil raised the incisions to the level of the mid buttock to conceal the scar beneath normal clothing [17]. The authors prefer to keep the incision in one of the natural folds of the body. This is marked with the patient sitting in a chair and leaning forward.

74.2 Pathophysiology The structural organization of fat in the trunk and extremities has been characterized as having both a superficial and deep fatty layer. The superficial layer is composed of small dense pockets of fat separated by vertical well-organized fibrous septa. The deeper fat layer is organized more loosely, with looser areolar fatty tissue interspersed with less regular fascial septae intervening between the pockets. The vertical septa originate from the fascia and extend upward toward the dermis. These layers become important in avoiding potential complications during liposuction. An estimated 30–50% of the variability in body fat is determined genetically. Environmental and nutritional factors are also important determinants of body

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fat stores. Drugs, including phenothiazines, antidepressants, antiepileptics, steroids, antiandrogens, and antihypertensives, have also been associated with increased body weight. Women are more likely to demonstrate gynoid pattern collections, which are characterized by increased deposits over the outer thigh, buttock, hips, and truncal region. Men more frequently exhibit android pattern collections that center around the truncal and abdominal regions. However, accumulation patterns vary by race and age patterns as well as by sex. As age increases, a significant decrease in the subcutaneous fatty layer and elevations in intraabdominal fat contents occur. In men, percent body fat may increase from 20% in young men to 25% in older men. For women, the percentage increases from 30 to 35%. At all ages after puberty, women have a higher percentage of body fat than men [1]. The “flanks” are the two areas of fatty excess that run above the pelvic brim on the lateral and lateralposterior part of the trunk. Contour disturbances of the flanks, (so-called “love handles”), can be seen in isolation or may be found in conjunction with lower abdominal lipodystrophy. The contour problem resulting from the continuous sweeping of the lower abdominal fatty excess into the flank, is referred to by many as a “spare tire.” Male flanks are located just above the crest of the hip bone, whereas most women tend to display localized fat deposits in the area below the bra strap, the back below the shoulders, and the slightly lower “hip” areas (overlying and below the pelvic brim). However, individual females with a more “android” (male-like) physiognomy can have “love handles,” and may have hip and flank fat blend imperceptibly into one another. A prominent flank may blend into the upper buttock and obscure the projection of the buttocks.

74.3 Candidates The best candidates for liposuction are of relatively normal weight with firm elastic skin, but have pockets of excess fat in certain areas. Good candidates should be physically healthy, psychologically stable, and realistic in their expectations. Most important, having firm, elastic skin will result in a better final contour. The amount and thickness of the adipose layer in areas that concern the patient need to be appraised critically. Stretch marks are a strong indication of

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poor elasticity, as is delayed rebound after manual stretching. Significant skin overhang is also a prime indicator of the need for excisional procedures (e.g., flankplasty, abdominoplasty, and thigh lift), because the removed fat accentuates the redundant skin, forming an unsightly pannus. These adjunctive procedures decrease the risk of contour deformities and possible skin irregularities. However, flank reshaping is also done on patients who are moderately obese with loose skin or who have lost massive amounts of weight. Patients with massive weight loss frequently have large amounts of excess skin making suction-assisted lipectomy of fatty areas inadequate. In such cases, excisional surgery is needed to correct these problems. However, for patients with fair-to-moderate skin tone, a large amount of skin contraction can be achieved by using superficial liposuction with a 2.5-mm cannula. Patients with poor skin tone are best served by excision. When excisional surgery is needed in addition to the liposuction procedure, it is important to analyze the patient’s motivation level because of the extensive nature of recovery and the need for frequent followup. Large amounts of skin and subcutaneous fat are excised, leaving long, occasionally wide, and permanent scars. The patient must have realistic ideas of what can be accomplished, the location of scars, and the amount of postoperative care that is required. The location of the scar will vary from one person to the next. It is short sighted to place the scar where it will be hidden by one style of clothing. This style will probably not be in vogue a few years down the line. Age is not a major consideration when choosing a likely candidate for the surgery. Older patients may have diminished skin elasticity and may not achieve the same results as a younger patient with tighter skin but they are more tolerant of longer scars. Hanging skin will not shrink and must be resected. Surgery that removes excess skin will leave visible scars. Furthermore, liposuction carries a greater risk if the patient has had recent surgery near the area to be sculpted, has poor blood circulation in that area, or has significant medical problems such as diabetes, heart, or lung disease. If the patient falls under any of these categories, the procedure may become complicated. A thorough preoperative history and physical examination allows surgeons to pick suitable candidates. Patients should be in either American Society of Anesthesiologists (ASA) class I (healthy with no medical problems) or ASA class II (medical problems well

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controlled on medications) in order to have the procedure. Patients with uncontrolled medical problems are not candidates for flankplasty by either excisional or liposuction methods. Failure to detect the underlying cardiovascular, pulmonary, renal, hepatic, or thyroid disease can lead to fatal complications. A patient with a history of sleep apnea is at an increased risk of fatal complications during the postoperative period. Patients must have an adequate cardiopulmonary reserve to handle the large volumes of wetting solution that are typical with large volume liposuction. A personal or family history of coagulopathies or bruising tendencies should be elicited. Candidates for flank reshaping should be in a healthy state both physically and mentally. Weight should be stable or decreasing with diet and exercise. Patients who are experiencing rapid or persistent weight gain should be started on a program of exercise and nutritional modification before being accepted as surgical candidates [18]. I will not usually perform the procedure on someone over 200 lb (90 kg).

74.4 Preoperative Details As with all major surgical procedures, perform a thorough history and physical examination. • Specifically investigate dietary habits, history of weight gain or loss. • Note the medical problems, especially diabetes, as well as smoking habits and drug use (prescription, nonprescription). • Carefully document previous surgical procedures, especially gynecologic, orthopedic, vascular, or cutaneous. • Measure the circumference under the breasts, at the narrowest point and at the widest point. Record the patient’s weight on the weighing scales in the clinic. Self-reported weights are not accurate. Conduct detailed discussions with the patient regarding areas of concern and the patient’s aesthetic goals. • Give the patient a realistic idea of whether the deformity can be treated with a local resection or a regional resection would be better. • Emphasize the location and expected quality of the scars. • Counsel the patient regarding postoperative care. Discuss the presence of drains (if any) and the

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p ossibilities of hematoma, infection, wound dehiscence, and their treatment. Patients with poor skin tone are at a high risk for recurrent seroma. Discuss the difficulties that the patient will have with walking and sitting for up to 3 weeks. The patient should be shown beforehand how to get out of bed and how to use the bathroom with minimal flexion of the torso. • Schedule a second, and if necessary, a third consultation to ensure that the patient understands the magnitude of this operation. Where excisional surgery is concerned, the surgeon should: • Perform a thorough medical history with particular emphasis on medications. Patients frequently do not volunteer information regarding certain drugs they are taking (prescription or nonprescription (e.g., homeopathic, over-the-counter) weight loss drugs, drugs that can promote obesity), so carefully question them and meticulously document the answers. • Note previous surgery. Examine the patient without clothing in the standing and in the lying position. Note the location of any previous surgical scars and the presence of multiple skin folds and rolls. • Assess the elasticity of the skin. • If possible, a full-length mirror should be available. Draw the planned excisions and locations of the scars on the patient while the patient observes. • Obtain a complete laboratory workup. Obtain a complete blood count, complete metabolic panel, and ECG. Carefully investigate any abnormal value prior to surgery. Spend a significant amount of time obtaining informed consent. Impress the magnitude of this operation upon the patient. Thoroughly discuss postoperative complications and their responsibilities in the postoperative phase. Inform the patient as to where the scars will be located and that these scars almost assuredly will not fade into fine white lines. Wound healing problems, marginal skin necrosis, and seromas occur frequently. As with thigh and buttock surgery, deep venous thrombosis and pulmonary embolism are rare but real considerations. Patients should be aware that skin that has been stretched severely by obesity has lost much of its elasticity. Therefore, tight, smooth contours cannot always be obtained with these procedures, especially if the patient gains weight or continues to lose weight,

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which is why the patient’s weight should remain stable for at least 18 months before surgery. Inelastic stretched skin continues to age, frequently requiring revisional or “touchup” surgery. This is true in most patients.

74.5 Wetting Solutions While certain patients with flank disturbances may be the candidates for broad excisions of skin and fat, (e.g., the massive weight loss patient needing body lift), most contour problems of the flanks will be treated using suction lipectomy. Four types of wetting solutions have been used for liposuction: dry, wet, superwet, and tumescent. The main difference between these techniques is the amount of infusate into the tissues and the resultant blood loss as a percentage of aspirated fluid. The dry technique involves no infused fluid and results in approximately 25–40% blood loss of the volume removed. The wet technique uses an infusion of 100–300 mL of fluid (with or without epinephrine) into each site to be treated, resulting in a reduction in blood loss of 10–30% of aspirate without epinephrine and 15% with epinephrine. However, due to the large volumes of blood loss resulting from these techniques, they have been widely replaced by the superwet and tumescent techniques. The superwet technique involves a 1:1 ratio between the instillation of fluid with epinephrine and the amount of supranatant fat to be removed. Ranges of blood loss have been reported at 1–4% of aspirate. The tumescent technique involves infusions of fluid with epinephrine until the targeted tissue is tense with fluid. Blood loss estimates with this technique have been approximated at 1% or less. The American Society of Plastic Surgeons Practice Advisory Committee has recommended the use of the superwet technique to reduce the need for infiltrating solutions and the surgical risk. Approximately 50–70% of the infused fluid is estimated to remain at the end of the lipoplasty procedure. The two major formulas for tumescent infiltration for liposuction are the tumescent formula (Klein, Hunstad) and modified tumescent formula (Hunstad). The tumescent formula combines 1 L of normal saline with 50 mL of 1% lidocaine, 1 mL (1 amp) of 1:1,000 epinephrine, and 2.5 mL of 8.4% sodium bicarbonate. In this formula, the bicarbonate is added to counteract the acidic nature of the saline solution to decrease the pain of the injection and increase analgesic potency.

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The modified tumescent formula is composed of 1 L of lactated Ringer solution with the same lidocaine and epinephrine solution as in the standard formula. Because the pH of the LR solution is higher than that of the saline solution, the need for the bicarbonate is obviated. In both concentrations, a final concentration of lidocaine of 0.05% and epinephrine of 1:1,000,000 is created. Some surgeons omit the lidocaine component of the solution when the patient is undergoing general anesthesia to further reduce potential lidocaine toxicity issues.

74.6 Liposuction Techniques Suction-assisted liposuction (SAL): the traditional method of removing fat by inserting a small, hollow tube (cannula) connected to a vacuum pressure unit, directing the cannula into areas to be suctioned through tiny incisions. Ultrasound-assisted liposuction (UAL): sound waves are transmitted to the tip of the cannula to liquefy fat before it is removed by suction. External ultrasound-assisted liposuction (E-UAL): external ultrasound waves alter fat cells. The area is injected with a fluid containing a local anesthetic to transmit ultrasonic energy, and liquefied fat is removed by suction. Power-assisted liposuction: a cannula with a back and forth motion of the tip passes through the tissue to suction out fat and fibrous or scarred tissue with reduced effort. It is used with the traditional liposuction technique. VASER®-assisted liposuction: intermittent or continuous bursts of ultrasonic energy can be used to break up fat cells, which are then removed by suction. There is little or no consensus among plastic surgeons as to which technique is superior. There is slightly less blood loss and a greater ability to remove fat in difficult areas with ultrasonic liposuction, but it is also associated with greater complications than tumescent liposuction such as burning and/or tingling, swelling, skin burns, and seromas (fluid collecting under the skin). Because this process can create significant amounts of heat, two concepts are essential in the treatment with this method of lipoplasty: (1) use only in the presence of a wet environment or solution (for control of temperature and the improvement of cavitation), and (2) apply ultrasonic energy to the

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cannula only while the cannula is in motion to avoid thermal burns/injury. Many surgeons believe that UAL is best considered not as a replacement for SAL, but rather as a compliment to decrease the effort during the procedure. The authors prefer the standard method because of its low complication rate, the large variety of cannulas available, and the ability to perform both superficial and deep liposuction. The infiltration begins by creating a small stab incision, just enough to accommodate the infiltration needle. Blunt-tipped cannulas of varying lengths are used to infiltrate the fluid into the deep subcutaneous adipose layer of the flank. When using the tumescent technique, the fluid is infused until the skin is firm at the operative site. After 10 min, the skin should become blanched from the vasoconstriction. Pretunneling can help increase cannula control by establishing desired planes of fat removal before suction is activated. This concept, delineated by Mladick, involves using a larger cannula (6 mm on the trunk/ extremities and 3–4 mm on the face) that is passed many times without suction into the most superficial layer of the desired area of removal. I use much smaller cannulas – 3 mm on the body and 2 mm on the face and neck. This helps prevent inadvertent removal in the subdermal fat layer, which can result in contour irregularities. Cross tunneling is an additional technique helpful in improving cosmetic results of lipoplasty. The technique of cross tunneling involves the use and creation of at least two port sites at right angles to treat an area of adiposity. The use of multiple port sites provides for better contouring and feathering of edges and allows for more thorough treatment of problem areas. I place one incision in the umbilicus, another in the groin crease or abdominoplasty incision line. In the prone position, I add incisions at the top of the gluteal cleft, on either flank. Sometimes the flank can be suctioned through an incision at the lateral end of the gluteal-thigh fold. Fat layers generally are treated from deep to superficial in sequence. Parallel tracks are developed in standard fashion, and as the procedure is moved more superficially, cannula size can be decreased along with suction intensity to help decrease risk of irregularity to surface layers. I use a 4-mm cannula in the deep layer and a 2.5-mm cannula in the superficial layer. Care is taken to keep the tip openings facing downward or deep to prevent suction of superficial fat near the dermis, which can result in dimpling. Additionally, moving the tip more rapidly helps prevent dermal deformity. If any dimpling is noted intraoperatively, fat

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is harvested from the other side of the body using a hand held 60-cc syringe. This fat is reinjected in multiple layers until the defect is no longer seen. A technique called mesh undermining can also be used to recontour transition and treatment area edges. A blunt cannula is used without suction and is passed laterally into surrounding transition areas, loosening adjacent tissue and softening the edge of treated and untreated areas. This causes some cutaneous contraction in adjacent areas which will help to take up some laxity in the suctioned areas.

74.7 Special Considerations Many complications arise when dealing with large volume liposuction. These are mainly related to fluid delivery and lidocaine/epinephrine dosing. With large volume liposuction, defined by the American Society of Plastic Surgeons as greater than 5 L, significantly greater fluid shifts occur as a result of tumescent fluid infusion and fat removal. Some have estimated the amount of infusate that is absorbed by the body to be 1 mL/1 mL fat removed and that 20% of the tumescent fluid is removed through suction. The recommendations for perioperative intravenous (IV) fluids also have varied in the literature. Some have recommended no additional IV fluids when using the tumescent technique, others suggest only maintenance fluids, and yet others a total infusion volume of 2–3 mL (including infusate, IV, and postoperative fluids) per milliliter aspirate removed. Other recommendations using the superwet technique involve maintenance fluids and wetting solution if less than 5 L are to be aspirated, and maintenance fluids, wetting solutions, and 0.25 mL IV crystalloid per each milliliter aspirated after 5 L. Recent research has utilized the intraoperative fluid ratio (superwet solution volume infused divided by aspiration volume) to further assess fluid administration and patient safety. Small volumes (less than 5 L) showed safety with ratios of 1.8 and 1.2 in large volume (more than 5 L) reduction. Average urine output was 1.5 mL/kg/h for the small volume and 1.7 mL/kg/h for the large volume patients. When epinephrine is used for the tumescent fluid, it can be used safely in much higher dosages than traditionally recommended. The maximum safe dose of

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epinephrine is <0.7 mg/kg. Doses for lidocaine approximating 35 mg/kg body weight have been suggested as safe, with peak plasma concentrations occurring at approximately 12 h post procedure when infused into subcutaneous fat for a liposuction procedure. These concentrations usually occur at less than 2 µg/mL, which is lower than that observed with doses of 3–5 µg/mL with which toxicity can be observed. Cannula shaft lengths also vary significantly to allow for proper access to the area to be treated. Areas such as the face and neck are best treated by shorter lengths, while the thighs, hip, back, and abdomen often are treated by longer length cannulas to obtain sufficient reach. Smaller cannula sizes and openings allow for more controlled fat removal with less opportunity for the development of contour deformities. Generally, for larger treatment areas, such as the truncal area, 2.5–4 mm cannulas are used, while in areas that require the removal of smaller amounts, such as the face and neck, 1.5, 2.0, and 2.5 mm cannulas are frequently used. Several indications help determine when to stop liposuction to an area. Assessment of symmetry (if bilateral), shape, and overall smooth contour helps determine the end points of the procedure. As more adipose tissue is removed, skin pinch testing should become less than an inch and also should be symmetric between sides. If both sides were fairly equal prior to surgery and infusate was similar, the amount of aspirate should also be close in volume on both sides. With removal of more and more of the remaining fat, stroking of the cannula changes to a grittier feel as it passes against the remaining fibrous septa.

74.8 Anesthesia Liposuction of the flanks is sometimes done under local anesthetic, so that the patient can roll over and allow the surgeon access to the back of the flanks. Some feel that it is dangerous to roll a patient who is under general anesthesia because the movement can interfere with the placement of the endotracheal tube. However, general endotracheal anesthesia is the preferred method of anesthesia for large volume liposuction (lidocaine may be eliminated from the wetting solution if the patient is under general anesthesia) A balanced anesthetic consisting of narcotic, midazolam, propofol, and

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an inhalational agent is used for most patients. Intraoperative monitoring includes noninvasive blood pressure monitoring, ECG, pulse oximetry, temperature, and end-tidal carbon dioxide measurement is routine on all patients under general anesthesia. Monitoring of urine output with Foley catheter is advisable in those receiving more than 4 L of wetting solution. Constant monitoring of the patient’s fluid balance is essential. The anesthesiologist should be provided with a running balance of wetting solution infused, fat and saline aspirated, blood loss, and urine output. Careful monitoring of these variables and of IV fluid gives the anesthesiologist an accurate idea of the patient’s fluid balance and should avoid the problem of fluid overload or hypovolemia.

74.9 Multistage Surgery The fundamental principle of flank reshaping is the removal of bulges around the “love handle” area so as to give the back and sides a slightly concave appearance. Multiple procedures may be required for patients who are obese and require extensive liposuction, or those whose skin may not be elastic. During the past few years, morbid obesity has increasingly been treated, quite successfully, with gastric bypass surgery. Massive weight loss is associated with loose skin and overhanging pannus, making body contouring necessary to improve mobility and body image. The risk of recurrent skin infections (Intertrigo) and skin breakdown – particularly in the abdomen area – makes it a problem that it may be covered by insurance companies. The presence of a large pannus prevents patients from having active lifestyles. In such cases, an excisional procedure is needed to remove the excess skin and fat. Techniques for these procedures have been refined and the results are usually very satisfying for the patients. The surgeries are based on a concept popularized by Lockwood who described the superficial facial system (SFS) [19]. The superficial system is a network of connective tissue that begins with the subdermal plane and continues down to the underlying muscle fascia. This system is composed mainly of a single or many slender, horizontal membranous sheets divided by fluctuating amounts of fat with adjoining vertical or oblique

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fibrous septae. The anatomy of the superficial fascial system changes with sex, adiposity, and body region. The superficial fascial system’s function is thought to be to support and shape the fat of the torso and extremities while adhering the skin to the underlying tissues. This system can contribute to, and even be held responsible for, many of the creases, bulges, valleys, and other skin contour irregularities [20]. With this method, a very narrow cannula is used to make multiple closely spaced passes in the subdermal fat to undermine the affected tissue. The procedures aim to excise loose skin and subcutaneous tissue and anchor it to the SFS for resuspension. Repair of the SFS with permanent sutures provides a more secure wound closure with a decreased risk of hypertrophic scarring and scar widening [21]. The procedure for reshaping the flanks using excisional flankplasty is as follows: 1. The patient is marked in the sitting and standing positions. The markings are explained and the probable location of the final scar is shown. Long vertical lines are placed every 10 cm around the body to aid with the closure of the wound. 2. The patient is placed in the prone position with appropriate padding of the body. Liposuction is performed if needed. 3. A nerve block is placed using 0.25% Marcaine with Adrenaline 30 mL per side. Then an incision is made along the reference line, followed by the elevation of the superior flap in the plane deep to the SFS. Undermining the inferior flap is performed to the greater trochanter level. 4. In the inguinal region, undermining should include the area parallel and inferior to the inguinal ligament for improved lifting of the anterior thigh. 5. Redundant tissue is removed from the superior and inferior flaps, and the wound is repaired in a moderately overcorrected position. 6. The wound is closed in layers, including SFS. The SFS is sutured to the underlying fascia anterior to the anterior superior iliac spine. Liposuction can be used to equalize the thickness of the flaps. 7. Superiorly or inferiorly based deepithelialized flaps may be useful to correct supratrochanteric depressions producing a more youthful rounded contour. 8. Flexion and extension of the torso should be minimized for 4 weeks in order to reduce tension on the suture line.

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74.10 Postoperative Course Following surgery, pain is minimal to moderate. The intraoperative nerve block is usually very effective for the first 24 h. Oral narcotics are usually all that is required for the following week. Antibiotics are prescribed to prevent infection. Most patients are completely ambulatory immediately following surgery. Patients are usually able to return to normal activities within a few days, although vigorous physical activity is discouraged immediately following surgery. Most patients experience swelling after the procedure. This is usually in the most inferior areas treated. Good results can be seen within about 3–4 weeks and final results within 3–6 months. While it does take a while for the swelling to go down, there is minimal to no pain involved. A compression garment is to be worn following the surgery. These garments are specifically designed to be used with superabsorbent pads and to provide firm compression to encourage maximum drainage of residual blood-tinged anesthetic solution. The garments should be worn day and night for 6 weeks. Discontinuing the use of the garments too early may result in prolonged swelling. Some patients will have drainage for more than a week. One should expect a large volume of blood-tinged anesthetic solution to drain from the small incisions during the first 24–48 h following tumescent liposuction. In general, if there is more drainage, then bruising and swelling will be less. For the first 24–48 h, bulky superabsorbent pads are worn overlying the treated areas, and under the compression garments. After most of the drainage has stopped, patients need only place absorbent pads over the incision sites that continue to drain. Nurses and care givers need to be informed of this beforehand since they can become very alarmed. Oozing from the gluteal incision may be misinterpreted as rectal bleeding.

74.11 Complications Overall, the procedure is safe. However, the removal of large amounts of fat requires longer operating times. Other risks are of delayed healing, fat clots, excessive fluid loss, friction burns to skin or nerves, and perforation injury. Scars are placed parallel to the natural folds of the body, but despite this they may become wide or

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thick. Skin pigmentation, numbness or an irregular “baggy skin” appearance can develop especially in the older age group. This might require additional surgery. Long-term complications can include the development of disharmonious obesity [22]. This is more obvious in those who are moderately obese and have poor self control. They do not regulate their caloric intake and quickly gain weight after surgery. The most commonly affected areas are the back and sometimes the buttocks and the pubic mound. One portion of body’s fat cells are removed and other fat cells pick up the burden of fat storage, and this may lead to unusual areas of fat bulging. Other possible complications include: 1. Abnormal body contour 2. Anesthesia reaction 3. Bleeding 4. Burning 5. Death (approximately 1 in 10,000) 6. Depression (mild depression is normal following elective surgery) 7. Dimples 8. Discoloration 9. DVT or blood clot 10. Fat embolus (less than 0.1%) 11. Heart failure 12. Hematoma 13. Hypothermia 14. Infection 15. Keloid formation 16. Nerve damage 17. Perforation of bowel or abdominal wall 18. Permanent numbness (risk is less than 1%) 19. Puckers 20. Reactions to medications 21. Seroma formation 22. Shock 23. Skin irregularities 24. Skin death (necrosis) 25. Slow healing 26. Swelling 27. Tingling 28. Visible scar Deaths related to liposuction surgery can occur for a number of reasons; blood clot, perforation of the abdominal wall or bowels, shock and hemodilution (blood dilution), and possibly excess amounts of lidocaine. Shock and blood dilution can occur after a

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patient has had excessive amounts of fluid injected and then excessive amounts of fat and body fluid removed (over 5,000 mL, about 11 lb). Lidocaine use poses particular hazards, especially since experts do not agree on safe injectable levels. At least one study links possible lidocaine toxicity to liposuction deaths. People with less than normal liver function or those who have been drinking alcohol may not be able to metabolize lidocaine well. Unlike the situation with buttock plasties, the complications of hematoma, seroma, infection, wound dehiscence, widened scars, scar migration, sensory nerve damage, and lymphedema are far more common with flankplasty procedures, often approaching 15%. Revision surgery may be necessary when the skin fails to contract. While rare in moderately obese patients, it is required in virtually all patients with massive weight loss. This should be explained to people contemplating these procedures so that they see their surgery as the first of several stages.

Zook was able to standardize the procedure by describing the following individual procedures and their sequence: patient marking (in the standing position), long S-shaped incisions, and preservation of veins and lymphatics [26]. As Regnault indicates, the problem is more of a resection of redundant skin and subcutaneous fat rather than a resection to cure obesity. It has been seen that when combined with abdominoplasty, liposuction of flanks in conjunction with abdominoplasty does not appear to increase the risk of seroma formation, although overweight or obese patients present a statistically higher risk for developing seromas than that of normal weight patients [27]. Reiger et al. state that liposuction of the flanks does not increase the rate of complications of the abdominoplasty procedures. They also find a tendency toward shorter scars in patients who underwent abdominoplasty combined with liposuction of the flanks [28]).

74.13 Case Studies 74.12 Combined Procedures 74.13.1 Flank Asymmetry Flankplasty is rarely performed alone. It is most often combined with abdominoplasty and thighplasty procedures. Somalo described the circumferential “dermolipectomy” [23]. In 1960, Gonzalez-Ulloa wrote about the “belt lipectomy,” with a vertical wedge resection [24]. While belt lipectomy is usually indicated for obesity or excess skin from massive weight loss, partial belt lipectomies can produce dramatic results [22]. McCraw first described multiple procedures on a patient with massive weight loss, combining abdominoplasty, brachioplasty, mastopexy, and thigh lift [25].

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Fig. 74.1 Preoperative views (a) anterior and (b) posterior of a 26-year-old nulliparous woman complaining of unsightly bulges over the top of her jeans and moderate flank asymmetry. Marked for flank reshaping

This 26-year-old nulliparous woman complained of unsightly bulges over the top of her jeans (Fig. 74.1). She was noted to have a waist to hip ratio of 0.7, mild scoliosis, asymmetry of the pelvis and soft tissues of the waist and flank as well as fullness in the area above the gluteal fold. The asymmetry of the waist (narrowest area) is marked in red. The asymmetry of the widest area is marked in green. The surgical plan is to make incisions (transverse lines black) and perform liposuction (crosshatched area blue). A larger

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volume will be removed from her left, but the goal is to under correct rather than over correct.

74.13.2 Circumferential Body Lift This 68-year-old mother of four had an abdominoplasty 10 years earlier (Fig. 74.2). Now the fat that was

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Fig. 74.2 Left: Preoperative views (a), (c), (e), (g) of a 68-year-old mother of four who had an abdominoplasty 10 years previously. Right: Postoperative views (b), (d), (f), (h) four weeks after circumferential body lift including flank reshaping. Over 1 kg of tissue was removed by excision and a further 2,000 mL by liposuction

stored in the resected lower abdomen is seen on the lower back. This is an example of disharmonious obesity. She underwent a circumferential body lift including flank reshaping. Over 1 kg of tissue was removed by excision and a further 2,000 mL by liposuction. Four weeks postoperatively she has a circumferential scar, but a greatly improved waist, flank, and abdominal contour after fat transfer from flank to buttocks, buttock implants, flankplasty, and abdominoplasty.

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74 Flank Reshaping Fig. 74.2 (continued)

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74.13.3 Buttock Contouring This 48-year-old mother of two wanted projecting buttocks and a flatter abdomen (Fig. 74.3). Liposuction of the lower abdomen and flanks was performed in the supine position. She was then placed prone. The

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flanks and back were liposuctioned. Buttock implants (250 mL) were then placed. The fat was processed and 400 mL was injected into each buttock. She was then returned to the supine position for the abdominoplasty. After her surgery, she has a very large buttock which will be more obvious because of the evacuation of fat

754 Fig. 74.3 (a) Preoperative view. 48-year-old mother of two wanted projecting buttocks and a flatter abdomen. (b) She has had an abdominoplasty with excisional flankplasty and liposuction of the back and flanks. Buttock Implants (250 ml) were placed through a midline buttock cleft incision. 400 ml of autologous fat was injected into each buttock

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from the flank. She also has a flatter abdomen. Because she has undergone fat transfer, she is less likely to develop disharmonious obesity. The adipocytes that would have enlarged her waist with weight gain will now enlarge her buttocks.

74.14 Conclusions The goal of flankplasty should be to achieve a pleasing “midsection.” In a woman, this will usually mean a waist to hip ratio of about 0.8. The convexity of the buttock should transition into a concavity in the lumbar region of the back. This concavity should be seen on the lateral view as well as on the frontal view. Reshaping of the flank is performed with liposuction and/or resection of a wedge of skin and fat around the waist and flank. Tension on the incision can be minimized by undermining and careful approximation of fascia. The procedure has a short learning curve and is a useful adjunct to abdominoplasty and circumferential body lift.

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References 1. Robertson K, Freeman BG. Body contouring, flankoplasty and thigh lift. www.emedicine.com (2008). 2. Flynn TC, Coleman WP, Field LM, Klein JA, Hanke CW. History of liposuction. Dermatol Surg. 2000;26(6): 515–20. 3. Pitanguy I. Trochanteric dystrophy. Plast Reconstr Surg. 1964;34:280–6. 4. Fischer G. Liposculpture: the “correct” history of the liposuction. Part I. Dermatol Surg Oncol. 1990;16(12):1087–9. 5. Chalekson C, Wilhelmi BJ, Neumeister M. Liposuction, techniques. http://www.emedicine.com (2006). 6. Avelar JM, Illouz YG. Historico da tecnica lipolise: lipoaspiracao. Lipoaspiracao. In: Illouz YG, editor. Lipoaspiracao, 1st ed. Sao Paulo: Hipócrates; 1986. p. 24–31. 7. Jewell ML, Fodor PB, Souza Pinto EB, et al. Clinical application of VASER-assisted lipoplasty: a pilot clinical study. Aesthetic Surg J. 2002;22(2):131–46. 8. de Souza Pinto EB, Saldanha OR, da Rocha RP, et al. Metologia experimental para testar canulas de lipoaspiracao. Revista Soc Bras Cir Plast. 2005;20(1):30–5. 9. Zocchi M. New perspective in lipopplasty: the ultrasonicassisted lipectomy (UAL). Presented at the Annual Congress of the French Society of Aesthetic Surgery. Paris; 1988. 10. Scuderi N, Devita R, D’Andrea F, et al. Nuove prospective nella liposuzione la lipoemulisificazone. Giorn Chir Plast Ricoster ed Estetica. 1987; 2:33–9.

74 Flank Reshaping 11. de Souza Pinto EB, Abdala PC, Maciel C M, dos Santos Fde P, de Souza RP. Liposuction and VASER. Clin Plast Surg. 2006;33(1):107–15. 12. Kelly HA. Excision of the fat of the abdominal wall lipectomy. Surg Gynecol Obstet. 1910;10:229. 13. Lewis JR Jr. The thigh lift. J Int Coll Surg. 1957;27(3):330–4. 14. Farina R. Riding trousers-like type of pelvicrural lipodystrophy (trochanteric lipomatosis). Br J Plast Surg. 1971; 13:174. 15. Pitanguy I. Surgical reduction of the abdomen, thigh, and buttocks. Surg Clin North Am. 1971;51(2):479–89. 16. Baroudi R. Thigh lift and buttock lift. In: Courtiss E, editors. Aesthetic surgery trouble – how to avoid it and how to treat it. St. Louis: Mosby; 1978. 17. Grazer FM, Klingbeil JR. Body image: a surgical perspective, St. Louis: Mosby; 1980. 18. Vistnes MD. Liposuction: large volume: safety and indications. http//www.emedicine.com. (2006). 19. Lockwood T. Lower body lift with superficial fascial system suspension. Plast Reconstr Surg. 1993;92(6): 1112–25. 20. Karnes J, Salisbury M, Schaeferle M, Beckham P, Ersek RA. Hip lift. Aesthetic Plast Surg. 2002;26(2):126–9.

755 21. Santoro TD, Hedrick MH. Body contouring and excisional surgery. In: Greer SE, editor. Handbook of plastic surgery. Informa Health Care, London, UK; 2004. 22. Fulton JE, Kerendian F. Disharmonious obesity following liposuction. In: Shiffman MA, Di Giuseppe A, editors. Liposuction: principles and practice. Berlin: Springer; 2006. p. 342–6. 23. Somalo M. Cruciform ventral dermolipectomy, swallowshaped incision. Prensa Medica Argent. 1964;33:75. 24. Gonzales-Ulloa M. Belt lipectomy. Br J Plast Surg. 1960; 13:179. 25. McCraw LH Jr. Surgical rehabilitation after massive weight reduction. Case report. Plast Reconstr Surg. 1974;53(3): 349–52. 26. Zook EG. The massive weight loss patient. Clin Plast Surg. 1975;2(3):457–66. 27. Kim J, Stevenson TR. Abdominoplasty, liposuction for flanks, and obesity: analyzing risk factors for seroma formation. Plast Reconstr Surg. 2006;117(3):773–9. 28. Rieger UM, Erba P, Wettstein R, Schumacher R, SchwenzerZimmerer K, Haug M, Pierer G, Kalbematten DF. Does abdominoplasty with liposuction of the love handles yield a shorter scar? An analysis with abdominal 3D laser scanning. Ann Plast Surg. 2008;61(4):359–63.

Perforator Sparing Abdominoplasty: Indications and Operative Technique

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Ulrich M. Rieger and Martin Haug

75.1 Introduction The obesity pandemic in western countries is becoming a major health problem. In recent years, a growing number of obese patients is seeking a surgical solution for their weight problem. Bariatric surgery is an effective treatment modality resulting in substantial and long-term weight reduction [1]. Consecutively, the number of patients being referred to plastic surgeons for body contouring procedures after massive weight loss following gastrointestinal bypass surgery [2] is steadily increasing. Abdominoplasty often is among the first procedures to be performed in these patients. Depending on the incisions used for bariatric surgery by the visceral surgeon, abdominoplasty procedures have to be adapted according to patient needs as well as to the remaining blood supply of the abdominal skin flap. Some surgeons consider the left oblique or left and right oblique incision to be standard incisions for bariatric surgery due to a very low rate of incisional hernia compared to vertical midline incisons [3–5]. In these patients, these transverse supraumbilical or subcostal scars severely compromise the blood supply from the superior epigastric arteries [6]. Therefore, often a limited abdominoplasty of the low transverse type with limited undermining only up to the level of the umbilicus is performed in order not to compromise blood supply in the zone between the old transverse scar (resulting from the gastric bypass) and the new transverse scar (resulting from the abdominoplasty).

U. M. Rieger (*) Department of Plastic and Reconstructive Surgery, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria e-mail: [email protected]

While limitation of mobilization of the abdominal flap itself leads to preservation of vascular zones [7] and therefore is a safe procedure, it does not yield an aesthetically acceptable result. These patients, following gastrointestinal bypass surgery need full abdominoplasty by extensive lifting also above the umbilicus. In the following, our perforator sparing abdominoplasty technique [8] is described as a means to achieve both, aesthetically pleasing results and a high degree of safety of the procedure by preserving sufficient blood supply to the abdominal flap.

75.2 Relevant Anatomy The blood supply of the abdominal fat and skin overlying the rectus muscles is mainly supplied by vessels derived from the deep superior and inferior epigastric vessels coursing within the rectus muscles. Perforators originating from the vessels run through the rectus fascia, the overlying fat, and then supply the skin. Further blood supply is derived from the superficial superior and inferior epigastric vessels as well as from the superficial iliac circumflex vessels. Minor blood supply is derived from the lateral intercostals and subcostal vessels, including the lumbar vessels running from back to front within the fatty tissue. When performing a traditional full abdominoplasty with wide undermining up to the xiphoid process, including umbilical transposition as described by Pitanguy, the remaining blood supply of the abdominal flap only consists of these minor lateral vessels as well as the superficial superior epigastric vessels. In the presence of transverse supraumbilical or subcostal scars, as may be encountered after open gastrointestinal bypass surgery, scarring and subsequent

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_75, © Springer-Verlag Berlin Heidelberg 2010

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subdermal fibrosis after these incisions represent a great limitation to the remaining blood supply to the abdominal flap as the blood supply by the superficial superior epigastric vessels is additionally jeopardized. Performing full abdominoplasty in presence of these scars is associated with a higher risk of postoperative complications [6], including partial or complete tissue necrosis.

75.3 Patient Presentation Patients presenting for abdominal body contouring after gastrointestinal bypass surgery or gastric banding may present with little stab incisions resulting from laparoscopic access ports or with vertical or horizontal scars from open bypass surgery. The vertical scar often does not limit blood supply of the abdominal flap in abominoplasty procedures at all, nor do the laparoscopic access ports. However, patients with transverse abdominal scars do need individualized approaches [9] for abdominal body contouring due to the limitations in blood supply of the abdominal flap. All of these massive weight loss patients present with excess abdominal wall laxity above and below the umbilical region. Undoubtedly, these patients do need full abdominoplasty by extensive lifting also above the umbilicus. As the weight loss deformities increase with additional excess tissue extending from the abdomen to the lateral and posterior trunk, more extensive procedures such as circumferential body lifting may be required.

75.4 Patient Selection Abdominal body contouring after massive weight loss is often the initial step of an extensive series of body contouring procedures that are needed to restore a functional and pleasing body contour. Therefore, it is mandatory that the patient has achieved a stable body weight after bariatric surgery for a minimum of 1 year. Although massive weight loss leads to a significant decrease of medical comorbidities such as heart disease, hypertension, diabetes, or hypercholesterolemia [10], these medical problems must be under control before postbariatric surgery is carried out. Tobacco

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abuse has deleterious effects on microcirculation and blood supply, leading to postoperative tissue necrosis in the long term. Since abdominoplasty procedures are associated with relatively high complication rates of up to 50% with obese patients being associated with the highest rates of complications [11], the authors think that cessation of smoking is mandatory before carrying out extensive body contouring in order minimize complications.

75.5 Operative Technique One gram of cephazoline is administered intravenously 1 h preoperatively for antibiotic prophylaxis. The abdominoplasty procedure is performed under general anesthesia and muscle relaxation. Basically, the operative procedure is done according to Pitanguy et al. [12]. However, in order to prevent hypoperfusion of the flaps 1–3, abdominal wall perforator vessels are selectively dissected and preserved. Perforator vessels can be visualized preoperatively by color duplex imaging. Vessel tunneling through the rectus sheaths and rectus muscles and ligation of the cranial perforator branches provides sufficient flap mobility without perforator tension or traction. Flap undermining is then performed around those perforator vessels (Figs. 75.1 and 75.2). The abdominal flap is then further elevated to the xiphoid processes centrally and the costal margins laterally, and excess of skin and subcutaneous tissue is excised. Hereby, the lifting effect can be extended all over the abdominal flap up to the xiphoid. The umbilicus is circumcised and reinserted in a triangular incision on the abdominal flap. In presence of true diastasis of the rectus muscle, midline suture plication of the fascia is performed, beginning below the xiphoid process and continuing down to the pubis. Layered closure of the abdominal wound is performed over two suction drains.

75.6 Discussion Extended flap undermining is considered as the surgical standard in abdominoplasty. Nine out of ten surgeons reported that they performed complete undermining up

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Fig. 75.1 Perforator sparing abdominoplasty technique. Area of undermining, the rectus abdominis muscles with one dissected perforator with ligated ascending branch (with permission from [8])

Fig. 75.2 Two dissected paraumbilcal perforator vessels (arrows) and umbilicus (asterisk)

to the costal margin [13]. Reports describing limited dissection of the abdominal flap in triangular shape from the xiphoid to anterior superior iliac spine [14] and discontinuous undermining by dissecting the supraumbilical flap by liposuction [15] have been described to improve flap perfusion before. The major risk factor that is responsible for jeopardizing the blood supply of the abdominal flap after

gastrointestinal bypass surgery with transverse scars is the existence of subdermal fibrosis around these scars. The described perforator sparing abdominoplasty turns the random pattern abdominal flap into an axial pattern type flap, thus increasing flap blood supply despite presence of subdermal fibrosis. However, basic microsurgery skills are required. Preoperative marking of the perforators in proximity to the umbilicus by color duplex imaging can help identifying the necessary perforator vessels [8, 16], which may be of great use to a less experienced microsurgical surgeon. In some cases only insufficient flap mobility may be achieved despite extensive perforator dissection. The limiting factors hereby are the actual lengths of the dissected perforators, because they may be disrupted by too much traction when pulling the abdominal flap caudally for good tightening. In these cases, alternative procedures, such as an abdominoplasty with cranial (submammary folds) and caudal incisions (low transverse down to inguinal folds and suprapubic region) with preservation of a circumcised paraumbilical skin island may be used, or two-staged procedures may be warranted [9]. In cases with excess tissue extending from the abdomen to the lateral and posterior trunk, more extensive procedures such as circumferential body lifting or fleur-de-lys abdominoplasty [17] may be warranted.

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In such cases, perforator preservation can be used in circumferential body lifts as well, to enhance tissue perfusion of the abdomen in the presence of scars. The concept of perforator sparing is applicable to a variety of indications. From an aesthetic point of view, we have to state that the resulting new scar is positioned low in the inguinal folds, but that the old scar from the gastric bypass is moved caudally and often to the central part of the abdomen. Suture plication of the rectus muscles can be performed easily, thus achieving an excellent abdominal tightening effect. However, the bypass scar can become even more accentuated. The method yields excellent results in terms of abdominal skin sensibility (Figs. 75.3 and 75.4). Adjunct procedures such as liposuction e.g., of the flanks for “fine-tuning” of the

contour can be performed safely with no apparent additional risk of complications [18, 19].

75.7 Conclusions The perforator sparing abdominoplasty represents a valuable technique in the armamentarium of postbariatric surgeons to perform full abdominoplasty with wide undermining without jeopardizing abdominal flap blood supply. The concept of perforator preservation can be applied in more extensive procedures, such as circumferential body lifts, as well, in order to preserve abdominal blood supply in the presence of transverse abdominal scars.

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b1 Fig. 75.3 A 32-year-old female patient underwent gastrointestinal bypass surgery with bilateral subcostal incision for morbid obesity (height 160 cm, weight 130 kg, body mass index 50.8 kg/m2). (a1,2) Two years later, preoperatively for abdominoplasty and excess skin resection (weight loss 58 kg, weight 72 kg, body mass index 28.1 kg/m2). (b1,2) Postoperative views

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75 Perforator Sparing Abdominoplasty: Indications and Operative Technique Fig. 75.4 A 37-year-old female patient underwent gastrointestinal bypass surgery with bilateral sub-costal incision for morbid obesity (height 175 cm, weight 106 kg, body mass index 42 kg/m2). (a1,2) Preoperative 7 years later for abdominoplasty and excess skin resection (weight loss 23 kg, weight 83 kg, body mass index 34 kg/m2). (b1,2) Postoperative views

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References 1. Spivak H, Hewitt MF, Onn A, Half EE. Weight loss and improvement of obesity-related illness in 500 U.S. patients following laparoscopic adjustable gastric banding procedure. Am J Surg. 2005;189(1):27–32. 2. Savage RC. Abdominoplasty following gastrointestinal bypass surgery. Plast Reconstr Surg. 1983;71(4):500–9. 3. Alvarez-Cordero R, Aragon-Viruette E. Incisions for obesity surgery: a brief report. Obes Surg. 1991;1(4):409–11. 4. Jones KB Jr. The superiority of the left subcostal incision compared to mid-line incisions in surgery for morbid obesity. Obes Surg. 1993;3(2):201–5. 5. Jones KB Jr. The left subcostal incision revisited. Obes Surg. 1998;8(2):225–8. 6. de Castro CC, Aboudib Junior JH, Salema R, Gradel J, Braga L. How to deal with abdominoplasty in an abdomen with a scar. Aesthetic Plast Surg. 1993;17(1):67–71. 7. Huger WE Jr. The anatomic rationale for abdominal lipectomy. Am Surg. 1979;45(9):612–7. 8. Rieger UM, Aschwanden M, Schmid D, Kalbermatten DF, Pierer G, Haug M. Perforator-sparing abdominoplasty technique in the presence of bilateral subcostal scars after gastric bypass. Obes Surg. 2007;17(1):63–7. 9. Rieger UM, Erba P, Kalbermatten DF, Schaefer DJ, Pierer G, Haug M. An individualized approach to abdominoplasty in the presence of bilateral subcostal scars after open gastric bypass. Obes Surg. 2008;18(7):863–9.

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10. Taylor J, Shermak M. Body contouring following massive weight loss. Obes Surg. 2004;14 (8):1080–5. 11. Neaman KC, Hansen JE. Analysis of complications from abdominoplasty: a review of 206 cases at a university hospital. Ann Plast Surg. 2007;58(3):292–8. 12. Pitanguy I, Mayer B, Labrakis G. Abdominoplasty – per sonal surgical guidelines. Zentralbl Chir. 1988;113(12): 765–71. 13. Grazer FM, Goldwyn RM. Abdominoplasty assessed by survey, with emphasis on complications. Plast Reconstr Surg. 1977;59(4):513–7. 14. Baroudi R, Keppke EM, Netto FT. Abdominoplasty. Plast Reconstr Surg. 1974;54(2):161–8. 15. Illouz YG. A new safe and aesthetic approach to suction abdominoplasty. Aesthetic Plast Surg. 1992;16(3):237–45. 16. Chang BW, Luethke R, Berg WA, Hamper UM, Manson PN Two-dimensional color Doppler imaging for precision preoperative mapping and size determination of TRAM flap perforators. Plast Reconstr Surg. 1994;93(1): 197–200. 17. Dellon AL. Fleur-de-lis abdominoplasty. Aesthetic Plast Surg. 1985;9(1):27–32. 18. Matarasso A. Liposuction as an adjunct to a full abdominoplasty. Plast Reconstr Surg. 1995;95(5):829–36. 19. Rieger UM, Erba P, Wettstein R, Schumacher R, SchwenzerZimmerer K, Haug M, Pierer G, Kalbermatten DF. Does abdominoplasty with liposuction of the love handles yield a shorter scar? An analysis with abdominal 3D laser scanning. Ann Plast Surg. 2008;61(4):359–63.

Abdominal Lipectomy and Mesh Repair of Midline Periumbilical Hernia After Bariatric Surgery Sparing the Umbilicus

76

Antonio Iannelli

76.1 Introduction Abdominal lipectomy is a common procedure among patients with massive weight loss especially following bariatric surgery. With the recent epidemic of obesity and the wide diffusion of bariatric surgery, this procedure has become even more frequent. Patient’s satisfaction is generally high because of the good cosmetic results that can be obtained in experienced hands. One of the most feared complications is the necrosis of the umbilicus that has been reported as high as 28% after abdominoplasty. The problem is more prevalent when a midline hernia around the umbilicus coexists with the pendulous abdomen. The incision around the umbilicus and the dissection of its insertion on the linea alba to approximate the anterior sheaths of the rectus muscles would result in complete avulsion of the umbilicus itself. On the other hand, the retromuscular mesh repair approach for midline incisional hernia offers several advantages over other techniques such as the intraperitoneal mesh repair either by laparoscopy or laparotomy. First, it allows for a direct repair of the defect that is left open when the mesh is only stapled or sutured over its peritoneal face, leaving the hernia sac in place. The patient still feels the defect and the partial inefficacy of his or her abdominal muscles that, especially in the case of large midline defect, remain lateral to the defect. Furthermore, the persistence of the hernia sac may increase the risk of seroma and Morel Lavallé syndrome (soft tissue traumatic injury consisting of a closed A. Iannelli Chirurgie Digestive et Centre de Transplantation Hépatique, Hôpital L’Archet 2, University of Nice Sophia Antipolis, 151 Route Saint Antoine de Ginestière, BP 3079, Nice, Cedex 3, France e-mail: [email protected]

internal degloving of the subcutaneous tissue creating a cavity filled by bloody serous fluid), compromising the cosmetic results. The retromuscular repair allows approximating the muscles and the aponeuroses in the midline, reshaping the muscular belt of the abdomen. The risk of umbilical necrosis is higher in obese patients and those with other risk factors for wound healing such as diabetes, hypertension, and smoking. The surgical artifice that is described herein allows performing a retromuscular incisional hernia repair, associating the abdominoplasty with umbilicus transposition.

76.2 Surgical Technique Marking of the skin resection is done preoperatively with the patient in the standing position. The abdominal lipectomy is performed as follows. A low transverse suprapubic incision is done as low as possible at no more than 7 cm from the upper pole of the external genitals. Patients are given antibiotic prophylaxis with Augmentin 2 g intravenously at anesthetic induction. Antithrombotic prophylaxis with subcutaneous low molecular weight heparin (5,000 IU) is given to all patients throughout the hospital stay. The abdominal flap is undermined upward, taking care not to open laterally the Scarpa’s fascia. Leaving the Scarpa’s fascia intact avoids the division of the inguinal lymphatic trunks that drain the hypogastrium into the inguinal nodes. In fact, the divided lymphatic trunks may leak postoperatively, giving rise to one of the most common complication of the abdominoplasty, the seroma. Medially, the dissection plane is on the rectus aponeurosis to facilitate the midline medial plication. The dissection is then carried out up to the hernia sac, which is dissected free on the side where it is

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_76, © Springer-Verlag Berlin Heidelberg 2010

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Fig. 76.1 The umbilicus is cored out on the opposite side with a generous layer of fat around it (2.5–3 cm)

Fig. 76.2 The remaining part of the sac is dissected free and the flap is undermined up to the costal margins in the preaponeurotic plane

more developed laterally. A circular skin incision around the umbilicus is done without attempting to dissect the deeper planes. The hernia sac is opened on the side where it has been previously dissected free without attempting to dissect it all around the umbilicus. The umbilicus is cored out on the opposite side with a generous layer of fat around it (2.5–3 cm) (Fig. 76.1). The remaining part of the sac is dissected free and the flap is undermined up to the costal margins in the preaponeurotic plane (Fig. 76.2).

A. Iannelli

Fig. 76.3 The retromuscular plane is created on each side anterior to the posterior rectus sheath above the arcuate line and in the preperitoneal space below it

At this stage of the procedure, the plane for the mesh is dissected with particular care not to jeopardize the epigastric vessels that give origin to the vascular supply to the umbilicus. The retromuscular plane is created on each side anterior to the posterior rectus sheath above the arcuate line and in the preperitoneal space below it (Fig. 76.3). On the side of the umbilicus, the posterior plane is started a few centimeters laterally to the insertion of the umbilical stalk and only the peritoneal layer is dissected until the aponeurosis is reached. Particular care was taken to avoid any injury to the epigastric vessels during dissection of the retromuscular plane (Fig. 76.4). The dissection is carried out about 5 cm beyond the hernia defect in consideration of the mesh shrinkage due to the healing process. At the level of the umbilicus, the posterior plane is closed by approximating the aponeuroses whenever possible – as in the case of small hernias or when the hernia is above or below the umbilicus, and the dissection is carried out below or above the umbilicus, respectively in order to place the mesh beyond the limits of the hernia – or by approximating part of the sac to the contralateral aponeurosis. Once the posterior layer is closed (Fig. 76.3), the mesh is put in place and fixed with interrupted 2/0 Prolene® sutures (Fig. 76.5). At the level of the umbilicus, only the remaining part of the hernia sac that was still in continuity with the umbilicus is approximated to the anterior sheath of the rectus muscle of the opposite side. The anterior aspect of the rectus muscle sheath is then approximated with running sutures. The need for the

76 Abdominal Lipectomy and Mesh Repair of Midline Periumbilical Hernia

Fig. 76.4 Avoid any injury to the epigastric vessels during dissection of the retromuscular plane

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The new umbilicus site is determined a few centimeters above the projection of the umbilical stalk. The skin incision for the recipient of the new umbilicus can be done in several different forms such as heart shaped, circular, and triangular according to the preference of the surgeon. Several quilting sutures are placed at this stage between the superficial fascia of the flap and the anterior aponeurotic plane. This allows, on one side, to avoid dead spaces that predispose to complications such as seromas and hematomas, which may become infected. On the other side, the quilting sutures are placed in the epigastrium, pulling at the same time on the flap downward in order to obtain the major tension in the epigastrium. This translates into minimal tension at the suprapubic area at the level of the skin wound and avoids the insufficient skin tightening, which is often seen at the epigastrium. The umbilicus is re-sited and additional quilting sutures are placed in the suprapubic area and laterally in the iliac fossa. Two aspiration drains are generally left in place in the subcutaneous plane. Complete closure of dead spaces reduces sensibly fluid discharge from drains, as the two main factors responsible for fluid production are the dead space and the friction that occurs between the flap and the aponeurotic plane when the patient moves. The drainage of the retromuscular plane is avoided by most because of the fear of mesh infection. The skin is approximated with subcuticular interrupted sutures.

76.3 Discussion

Fig. 76.5 Once the posterior layer is closed, the mesh is put in place and fixed with interrupted 2/0 Prolene® sutures

plication of the anterior rectus sheath remains at the discretion of the surgeon. In fact, if the hernia defect is large, closing the aponeurosis in the midline may be difficult and the plication impossible. Indeed, in case of excessive tension on the umbilicus, vertical relaxing incisions can be made on the anterior aspect of the rectus sheath on each side. The abdominal flap is redraped, the excess tissue resected.

The rational behind the technique relies on the fact that the vascular supply to the umbilicus is symmetric on the midline, and sparing the vessels of one side only is enough for an effective vascularization of the umbilicus. Vascular supply to the umbilicus depends on epigastric vessels that show a rhomboid or hourglass course pattern around the umbilicus. The main trunks of epigastric arteries split into two main branches that anastomose with each other at about 4–5 cm above the umbilicus. The lower intercostals arteries also anastomose with branches of the epigastric arteries. Two arteries on each side come from the inferior epigastric arteries to nourish the umbilicus. These arteries have an axial course around the

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umbilicus, making any traction or torsion on the umbilicus potentially hazardous to the umbilical flap during abdominal lipectomy. A wide periumbilical incision (2.5–3 cm) is advised to core out the umbilicus during abdominoplasty at the level of the tip as well as at the level of the base, given the diverging pattern of its axial vascularization. The wide base is supposed to stabilize the umbilicus, while the subcutaneous tissue around the umbilical stalk ensures the integrity of the vessels that run along it in a diverging pattern. The dissection of the retromuscular plane must be achieved with particular care especially on the side where the vascular supply to the umbilicus has to be spared. The epigastric vessels lie laterally in the rectus muscles sheath and can be easily identified during the dissection of the posterior aponeurotic rectus muscles sheath. It is generally recommended to place the mesh 5 cm beyond the aponeurotic defect due to the partial retraction of the mesh that can be observed with the healing process. Thus, it is advisable to divide the vascular supply of the umbilicus on the side where the defect is more developed, needing a more lateral dissection that may result in advertent injury to the epigastric vessels. On the side where the vascular supply has to be spared, the lateral dissection can be done at a lesser extent, reducing the risk of jeopardizing the epigastric vessels. Placing the mesh in the retromuscular plane has several advantages such as the reinforcement of the posterior plane and the solidity of the mesh repair. This, in turn, allows the partial closure of the anterior aponeurotic plane, avoiding the dissection of the umbilical stalk. In case of large midline incisional hernia, including the umbilicus, care must be taken not to resect the hernia sac that may be used to approximate the anterior and/or the posterior plane. A good strategy is to divide the sac, leaving the larger part for the repair of the posterior plane that may be more difficult to accomplish in the case of a very large midline defect. Other technical artifices can be used to close the anterior aponeurotic plane such as the relaxing incisions on the rectus muscles sheaths that release the tension on the midline and particularly on the umbilicus. Care must be taken to avoid any torsion of the umbilicus on its vertical axis when it is fixed to the recipient of the new umbilicus. The cutaneous flap is anchored to the anterior aponeurotic plane to avoid any tension on the umbilicus.

A. Iannelli

The potential complication of the technique is the risk of necrosis of the umbilicus, and the patient must be extensively informed of the advantages as well as the risks inherent to the retromuscular mesh repair. The author’s point of view is that the incisional hernia repair is the key element in the complex condition that associates the pendulous abdomen and the hernia defect. In fact, the latter may become complicated by life-threatening conditions such as bowel obstruction and strangulation. The retromuscular approach seems to be the more appropriate technique. In any case, there is always the possibility to reconstruct a new umbilicus if the final result is not cosmetically satisfying. The other point that may be a matter of debate is the possibility to split the procedure into two steps: the incisional hernia repair fist, followed later by the abdominal lipectomy. If this strategy is preferred, the mesh repair must be accomplished with the same technique herein reported i.e., the vascular supply to the umbilicus must be spared on one side. If this is not done, the risque of necrosis of the umbilicus when it is cored out at the time of abdominal dermolipectomy is extremely high. The technique presented may allow sparing the umbilicus while achieving an effective incisional hernia repair. The careful selection of the candidates to this procedure on the basis of risk factors such as obesity, smoking habits, diabetes, and hypertension, as well as the accurate preoperative imaging work-up with CT scan may be helpful for the final functional and cosmetic results.

Further Reading 1. Flegal KM, Carrol MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among U.S. adults, 1999–2000. J Am Med Assoc. 2002;288(14):1723–7. 2. Kroll SS. Necrosis of abdominoplasty and other secondary flaps after TRAM flap breast reconstruction. Plast Reconstr Surg. 1994;94(5):637–43. 3. Vastine VL, Morgan RF, Williams GS, Gampper TJ, Drake DB, Knox LK, Lin KY. Wound complications of abdominoplasty in obese patients. Ann Plast Surg. 1999;42(1):34–9. 4. Velanovich V. Ponderal index as a predictor of postoperative complication. Ann Surg. 1990;56(11):659–61. 5. Postlethwait RW, Johnson WD. Complications following surgery for duodenal ulcer in obese patients. Arch Surg. 1972;105(3):438–40. 6. Iannelli A, Bafghi A, Patrono D, Sautot-Vial N, Gugenheim J. Use of Plasma Jet™ System in patients undergoing abdominal lipectomy following massive weight loss resulting

76 Abdominal Lipectomy and Mesh Repair of Midline Periumbilical Hernia from bariatric surgery: early experience. Obes Surg. 2006; 16(4):1504–7. 7. O’Dey DM, Heimburg DV, Prescher A, Pallua N. The arterial vascularization of the abdominal wall with special regard to the umbilicus. Br J Plastic Surg. 2004;57(5):392–7. 8. Iannelli A, Bafghi A, Negri C, Gugenheim J. Abdominal lipectomy and mesh repair of midline periumbilical hernia

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after bariatric surgery: how to spare the umbilicus. Obes Surg. 2007;17(9):1189–92. 9. Luijendijk RW, Hop WC, van den Tol MP, de Lange DC, Braaksma MM, Ijzermans JN, Boelhouwer RU, de Vries BC, Salu MK, Wereldsma JC, Bruijninckx CM, Jeekel J. A comparison of suture repair with mesh repair for incisional hernia. New Engl J Med. 2000;343(6):392–8.

Combined Abdominoplasty and Medial Vertical Thigh Reduction Following Severe Weight Loss

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Mohammed G. Ellabban and Nicholas B. Hart

77.1 Introduction The common perception of beauty in the human body has shown a dramatic change over the past few decades culminating in a preoccupation not only with body weight, but also with body image [1]. Obesity is becoming prevalent in our society, and yet generalized redundancy of skin following massive weight reduction can be a similar affliction [2, 3]. Localized fat deposits in one or more regions of the trunk, upper arms, and thighs are common and are virtually impossible to correct by diet, weight loss, or exercise [4]. Body contouring procedures advocated in the excision of the excess pendulous skin and/or the localized fat deposits are able to reduce or even eliminate the physical problems associated with the condition and contribute significantly to patient self-esteem [3]. These procedures are usually multiple and extensive [2, 5, 6]. Any means of combining and reducing the number of such procedures while obtaining optimal results would be most beneficial to both the surgeon and the patient [2].

77.2 Technique Selected patients are the ones who achieved long-term (more than a year) severe weight loss by diet control and exercise alone or with the help of vertical banded gastroplasty with stable body mass index (BMI) of

M.G. Ellabban (*) 43, Parklands Ave, Lillington, Royal Leamington Spa, Warwickshire, CV32 7 BH, UK e-mail: [email protected]

around 35 and present with excessive redundant skin, lipodystrophies, or resistant localized fatty areas in the lower abdomen and medial thighs. Routine preoperative evaluation and complete laboratory profile are carried out for all patients to assess fitness for surgery. Smoking is a contraindication to surgery due to associated high complications rate. Selected patients should be either nonsmokers or had stopped smoking 6 months prior to surgery. Antiembolism measures in the form of low molecular weight heparin (Fragmin® 2,500 U, subcutaneously, once daily) and thrombo embolic deterrent (TED) stockings start preoperatively, while intermittent calf compression (Flowtron®, Huntleigh Healthcare) is used in the operation theater. Prophylactic antibiotics are given in the operating room before the start of the procedure. Preoperative skin markings are done with the patient in the standing position with the thighs slightly abducted. A low transverse “Regnault type” [7] abdominoplasty incision and a straight vertical medial thigh reduction incision running from the medial thigh crease to just proximal to the knee area along the adductor longus muscle is used. Care is taken to mark all the excess skin and fat in the lower abdomen and medial thighs and still to be able to close the wound with the minimal possible tension. Intraoperatively, with the patient in the supine position, the abdominoplasty operation is done first. The skin and fat flap is lifted off the muscle fascia and mobilized up to the costal margins, the umbilicus is circumcised on its pedicle and later reinset after skin redraping. The rectus fascia is plicated using a 0-Nylon® continous suture, then the abdominal flap redraped after excision of the lower excess fat and skin. The wound is drained with suction drains and closed with subcutaneous 3/0 Vicryl® in layers and subcuticular 3/0 Monocryl®.

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With the knee flexed and the hip flexed and abducted, easy access to the medial thigh is achieved without the need to change the patient position in the operating theater. A vertical ellipse of the medial thigh skin and superficial subcutaneous fat is excised, the dimensions of which vary from one patient to the other to allow excision of all the excess redundant tissues and easy wound closure without tension. Care is taken to preserve the integrity of the long saphenous vein if encountered in the resection field. The thigh wound is drained with suction drains and closed in layers using subcutaneous 3/0 Vicryl® and subcuticular 3/0 Monocryl®. Postoperative hemoglobin check is done the next morning and the patient is gently mobilized on the second postoperative day. Heparin is stopped on full mobilization of the patient and the drains are removed when clinically appropriate. Patients are usually discharged home on the fourth or fifth postoperative day.

77.3 Complications Out of the 14 consecutive patients in the study, five patients (35.7%) had postoperative complications (Table 77.1). All ultimately resolved without the need for surgical intervention. Four patients (28.6%) had trivial lower leg swelling that was treated conservatively by leg elevation, compression stockings, and massage, and that eventually resolved. One patient (7.1%) had an infected seroma of the right thigh that was treated with oral antibiotics and aspiration of the seroma fluid. Another patient (7.1%) had a superficial wound infection around the umbilicus that was treated with oral antibiotics and dressings.

77.4 Discussion Obesity and poor cosmetic appearance after weight loss may cause the individual to have severely devalued selfimage, to face difficulty in fitting of clothing and suffer from physical affliction such as intertrigo, abdominal and back pain, or reduced mobility associated with large amounts of overhanging redundant skin [3].

M. G. Ellabban and N. B. Hart Table 77.1 Patient complications Patient no.

Complications

Management

1

None

2

Right leg swelling

3

None

4

Bilateral leg swelling

Conservative

5

Infected seroma right thigh Right leg swelling

Seroma drained and conservative treatment of leg swelling

6

Swelling of legs

Conservative

7

None

8

None

9

None

10

None

11

None

12

None

13

None

14

Umbilical wound infection

Conservative

Antibiotics and dressings

One of the complex aesthetic distortions of the body contour involves the abdomen, flanks, and inner thighs, which are often specifically more affected by heavy fat accumulation than the rest of the body. Flabbiness and loss of turgor of the skin, especially of the upper inner thigh region lead to more ptosis of the tissues that contribute more to the aesthetic problem [4]. These areas can be improved to a limited degree by dieting and exercise. Suction lipectomy is of limited benefit and usually yields poor results due to the redundant skin and lack of fill. Classical abdominoplasty and medial thigh reduction are performed to correct these deformities [8–11]. Traditionally obese patients have not been considered good candidates for body contouring procedures because of the high morbidity of obesity and associated surgical procedures. In recent years, rapid improvements in surgical and anesthetic techniques have allowed significant body contouring procedures to be performed safely in obese patients [12]. Combined procedures can be performed safely and successfully without any added morbidity, provided that proper patient selection and good surgical techniques are applied [6, 13].

77 Combined Abdominoplasty and Medial Vertical Thigh Reduction Following Severe Weight Loss

Body contouring for patients who have experienced massive weight loss requires extensive and multiple procedures [2, 5, 6]. Combined body contouring procedures have several advantages: 1. Enhance patient satisfaction in that it simultaneously corrects several aesthetic problems 2. Reduce the length of hospital stay and its cost 3. Reduce the risk of multiple anesthetics 4. Decrease interference of scars with intended future procedures 5. There is no difference in occurrence of clinical complications [2, 5, 6] The fundamentals of success in achieving the planned results in combined procedures are based on the harmony of four main factors: (1) experienced surgeon, (2) highly qualified surgical team, (3) an anesthesiologist specifically acquainted with combined surgical procedures, and (4) proper patient selection [6]. Combined body contouring procedures have been commonplace for years in plastic surgery. Combined mammoplasty with abdominoplasty, deep planed torsoabdominoplasty with buttock-pexy, brachioplasty with thoracoplasty and mammoplasty, and multiple facial procedures all have been done successfully without any added morbidity [2, 5, 6, 13, 14]. In the authors’ technique, abdominoplasty is combined with medial vertical thigh reduction as sagging

a1

a2

Fig. 77.1 (a1–3) Preoperative. (b1–3) Postoperative

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of the lower abdominal skin and fat and friction of the inner thighs with their associated problems were the two main distressing complaints of the massive weight loss patients. Using a vertical medial thigh reduction as opposed to the procedure described by Lewis [16] provides the advantages of being an easy technique that can be performed effectively and rapidly without adding much extra time to the original abdominoplasty operation. It is performed with the patient in the supine position with no need to change the patient position in theater. It directly tackles the problem of the redundant skin and fat of the upper inner thighs and alleviates the mechanical friction that these patients encounter, and the resultant wound usually heals well with linear scar that is hidden in the inner aspects of the thigh. The commonest complication (35.7%) was a transient leg swelling that was due to the sacrifice of the long saphenous vein in the early cases with the resected medial thigh skin and fat that carries some of the leg lymphatics. A change of the technique was adopted with the careful preservation of the long saphenous vein, and this complication was not encountered in the subsequent cases in the study. Patients’ recovery was uneventful and all were pleased with the overall result at the end of our followup of 12 month (Figs. 77.1–77.3).

a3

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b1

M. G. Ellabban and N. B. Hart

b2

b3

Fig. 77.1 (continued)

a1

Fig. 77.2 (a1,2) Preoperative. (b1–3) Postoperative

a2

77 Combined Abdominoplasty and Medial Vertical Thigh Reduction Following Severe Weight Loss

b1

b2

b3

Fig. 77.2 (continued)

a1

Fig. 77.3 (a1,2) Preoperative. (b1,2) Postoperative

a2

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774 Fig. 77.3 (continued)

M. G. Ellabban and N. B. Hart

b1

77.5 Conclusions Combined abdominoplasty with vertical medial thigh reduction is effective in correcting common aesthetic and physical problems after massive weight reduction, which are not corrected by other less invasive measures such as dieting, exercise, or liposuction. It is safe and easy to perform with excellent predictable outcome. The procedure is recommended as a routine in carefully selected patients.

References 1. Rohrich RJ. Body contouring. SRPS. 1995;7(38):1–32. 2. Hallock GG, Altobelli JA. Simultaneous brachioplasty, thoracoplasty and mammoplasty. Aesthetic Plast Surg. 1985; 9(3):233–5. 3. Schechner SA, Jacobs JS, O’loughlin KC. Plastic and reconstructive body contouring in the postvertical banded gastroplasty patient: a retrospective review. Obes Surg. 1991;1(4): 413–7. 4. Baroudi R. Body contour surgery. Clin Plast Surg. 1989; 16(2):263–77.

b2

5. Hauben DJ, Benmeir P, Charuzi I. One-stage body contouring. Ann Plast Surg. 1988;21(5):472–9. 6. Pitanguy I, Ceravolo M P. Our experience with combined procedures in aesthetic plastic surgery. Plast Reconstr Surg. 1983;71(1):56–63. 7. Regnault P. Abdominoplasty by the W technique. Plast Reconstr Surg. 1975;55(3):265–74. 8. Matarasso A. Abdominoplasty. Clin Plast Surg. 1989;16(2): 289–303. 9. Lookwood TE. Medial thighplasty. In: Hetter GP, editor. Lipoplasty the theory and practice of blunt suction lipectomy. 2nd ed. Boston: Little Brown; 1990. p. 375–83. 10. Kesselring UK. Regional fat aspiration for body contouring. Plast Reconstr Surg. 1983;72(5):610–9. 11. Vilain R, Dardour JC. Aesthetic surgery of the medial thigh. Ann Plast Surg. 1986;17(3):176–83. 12. Hustad JP. Body contouring in the obese patient. Clin Plast Surg. 1996;23(4):647–70. 13. Grazer FM. Abdominoplasty. In: McCarthy JG, editor. Plastic surgery. Philadelphia: WB Saunders; 1990. p. 3929–63. 14. Barrett BM Jr, Kelly MV. Combined abdominoplasty and augmentation mammaplasty through a transverse suprapubic incision. Ann Plast Surg. 1980;4(4):286–91. 15. Gonzalez M, Guerrerosantos J. Deep planed torso-abdominoplasty combined with buttocks pexy. Aesthetic Plast Surg. 1997;21(4):245–53. 16. Lewis JR Jr. The thigh lift. J Int Coll Surg. 1957;27(3): 880–4.

Complications in Abdominoplasty Patients After Bariatric Surgery

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Mikko Larsen and Peter W. Plaisier

78.1 Introduction

78.2 Defining Complications

Body contouring is an important aspect of the overall treatment of the morbidly obese patient [1]. Quality of life improves after bariatric surgery and is significantly enhanced after further body contouring, with improved body image [2–4]. Bariatric surgery, as opposed to dietary or lifestyle changes or pharmacologic interventions, offers sustained long-term weight reduction. After massive weight loss, the pannus can interfere with clothing, physical activity, and hygiene, as well as be a cause for recurrent infection. There are, therefore, clear advantages to the excision of remaining excess tissue. The literature is reviewed with the results from our institution to evaluate the incidence and types of complications that occur after abdominoplasty following bariatric surgery. Specifically, the aim was to find the commonly cited correlations between complications and known pre-operative risk factors and to find whether the post-bariatric surgery population is more susceptible to post-operative complications than the general population seeking abdominal body contouring. The results are summarized from the largest published series and provide an overview on the current debate surrounding the question of whether there is evidence that the post-bariatric surgery patient is at a higher risk for post-operative complications.

A complication is any adverse or undesired result of disease management. There are a variety of definitions and classifications found in the literature on post- bariatric surgery abdominoplasty patients. This makes it more difficult to form a clear comparison of complication rates across various studies. For example, “wound complication” has been used simply to encompass those easily documented outcomes that required debridement or drainage [5], which is arguably a broad definition as it includes the loss of the umbilicus, which some may rather classify as a major (cosmetic) complication. Another way of defining complications is by saying that a major complication is one that leads or may lead to death, or that requires more than 6 months of wound care [6]. Those authors grouped all other complications into the minor category. Others define major complications in similar terms: life threatening, extend hospital stay or are not easily managed as an outpatient; and all others as minor [7]. Complications are also divided into local and systemic, and further into major and minor categories [8]. Intermediate severity complications (including haemorrhages) are cited in another paper [9]. However in general, in the body contouring literature, complications are often subdivided into minor complications including seromas, hematomas, surgical site infections (SSIs), fat necrosis or transfusions [9]. An SSI could be further defined as any superficial wound infection that requires a period of outpatient antibiotic therapy [10]. Scar hypertrophy is not reported as a potential complication in abdominoplasty as it is for other body contouring procedures [11]. Cosmesis and/or patient

P. W. Plaisier () Department of General Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands e-mail: [email protected]

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satisfaction is seldom an item reviewed in the post-bariatric surgery abdominoplasty literature, and adverse patient satisfaction is consequently not mentioned as a complication as such. One reason for this of course is that post-bariatric body contouring lends such dramatic results that minor complications and cosmetic imperfections are generally well-tolerated by patients. Major complications include wound breakdown, from approximately 3 cm, including large areas of wound dehiscence, abscesses or fistulae requiring wound care for a period of time [10]. Re-exploration might be indicated for massive wound haematoma, flap necrosis, and deep SSI, or to explore a chronic non-healing wound bed. Even seromas, among the most frequently encountered complications, may necessitate operative treatment. Other major complications include fatalities and perioperative (<30 days) myocardial infarctions or deep venous thromboses with pulmonary embolism and acute anaemia. Wound infections and complications can be described using a published and validated system of wound classification known as ASEPSIS, developed for prospective studies, but occasionally applied to retrospective studies. This system assigns numerical scores to a wound based on external characteristics such as erythema, exudate, purulence and differing amounts of dehiscence [12]. There was one article in the postweight loss abdominoplasty literature using this system, so that comparisons with other papers are difficult to make [13]. Other ways of documenting and classifying wound complications could be through the measurement of bacterial contamination, varying levels of required wound management from antibiotic therapy to local debridement, and hospital admission with or without surgical intervention [13]. Complications described in the literature also include drain removal under anaesthesia, deep suture abscess requiring surgical removal, pain requiring consultation and bleeding ulcer within weeks of surgery requiring transfusion [14].

78.3 Prevalence of Complications The first reports on complications in abdominoplasty patients were described by Grazer and Goldwyn [15]. This paper surveyed the results of over 10,000 abdominoplasties performed by 958 plastic surgeons, and found an overall complication rate of 14.6%. A

M. Larsen and P. W. Plaisier

survey published in 2001 recorded 32% complications (including 1.4% major complications) in a 15-year follow-up of 199 abdominoplasty patients [7]. Other large series reporting on the general population seeking abdominoplasty report complication rates varying from 16% (N = 153 [18] and 18% (N = 278) [16] to 24% (N = 86) [17] and 37% (N = 206) [18]. Comparing these series to the post-obese or post-bariatric surgery population is difficult because the type of procedure the latter undergo is often far more extensive. Arguably, the complication profile of a circular or belt lipectomy (or midbody contouring) is not comparable to a series of pure abdominoplasties. Indirect support for this hypothesis may be derived from some authors’ experience that the amount of tissue removed during abdominoplasty functions as a strong risk factor for complications [14, 18]). The post-bariatric surgery population is at a high risk for post-abdominoplasty complications, with morbidity ranging from 20% to more than 50% [9, 10, 18, 20, 21] and complications occurring in up to 80% of the obese patients [18]. It has been noted anecdotally that there is a trend towards higher complication rates in the postbariatric surgery population (even when they are close to their ideal weight at the time of body contouring) than in patients with the same body mass index (BMI) whose weight was always stable [9]. In groups with and without prior weight loss surgery, and without significant differences in pre-abdominoplasty BMI, Greco et al. found that the post-weight-loss-surgery group had a higher complication rate (41 vs. 22%) [13]. Some hitherto unknown mode of risk transfer in the postobese, even after significant weight loss, may explain the discrepancy in complication rates between these patients and those whose weight has always been stable. An important determinant of the risk rate may be the maximum weight ever achieved by the patient [9, 21, 22). There may be an underlying biological mechanism because of which the pre-bariatric condition of increased risk does not reverse, and this merits further study [9]. These authors hypothesize that vascular and metabolic changes occurring during obesity do not reverse despite rapid weight loss, but further studies are necessary to elucidate this, as some authors find no evidence that prior bariatric procedures are a sole risk factor for the development of complications [19]. There may be an element of risk attributable to the amount of weight loss as described by Sanger et al. [20], who in a group of 26 patients found that excessive weight loss (>50 lb) before body contouring was a risk factor for

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ound-related complications. Other factors that may w differentiate weight loss patients from non-weight loss patients and have an effect on post-abdominoplasty outcome are the findings that the former group are more likely to be active/former patients with diabetes or smokers, and are more likely to be categorized in a higher American Society of Anesthesiologists (ASA) class [13]. Other factors may be the greater skin redundancy presented, nutritional deficiencies or continued obesity often manifested in weight loss surgery patients. Nevertheless, as in other operations, the BMI at surgery has a significant influence on the risk of complications [11, 13, 18, 19, 21, 23]. By stratification, authors have found an increasing risk with increasing BMI [24]. Some studies find no such correlation (N = 132) [25], but do report a significant improvement in wound healing with pre-operative weight loss [7, 17, 25]. BMI stratification has also yielded interesting data concerning the lack of linearity in correlation with complication risk. In 1999, Vastine et al. [18] reported no difference in the complication rates between borderline obese and non-obese patients, but a significantly increased complication rate of 80% in their obese patients. The actual extent to which the BMI at the time of body contouring, as well as the history and type of weight loss surgery and other clinical parameters such as diabetes, affect wound complication rates is generally poorly understood; moreover, the extent to which these factors should be involved in pre-operative planning and informed consent is open to debate [13]. Smokers asked to stop 4 weeks before abdominoplasty still had a relative risk of 14 (p < 0.0001) to develop a post-operative infection, with a cut-off of 8.5 pack years in a relatively small study comparing 30 smokers to 30 non-smokers [22]. This does leave to debate the smoke-free window that should be maintained before body contouring can safely be performed. The BMI threshold at which surgery should be refused is not clear either [26], despite clear evidence that higher BMIs are associated with increased complications [10, 18, 24].

78.4 Literature Series and Discussion on Complication Risk Factors Chart review of 123 consecutive panniculectomies was performed by Acarturk et al. [27]. They compared 21 patients who underwent simultaneous bariatric surgery

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and panniculectomy to 102 patients who sustained a period of weight loss (17 ± 11 months, average BMI reduction of 19 kg/m2) after the bariatric procedure. There were significantly more wound infections, dehiscence and respiratory problems in the simultaneous procedure group. There were three deaths in the combined procedure group. All three had significant comorbidities, the largest specimen weights (45 ± 9 kg), the highest body weights (280 ± 21 kg) and large open abdominal wounds as a result of dehiscence. Deaths were due to myocardial infarction, renal failure and massive pulmonary embolism at 3–30 days post-operatively. It is concluded by these and other authors that panniculectomy at the same time as bariatric surgery carries substantially increased operative risk and a high rate of post-operative complications [27, 28], and that weight stabilization should be obtained for 1 year following bariatric surgery before body contouring is performed [11, 18]. Some go so far as to say that body contouring should only be performed in the still obese or non-weight-stabilized population when there is a medical indication such as recurrent infection or severe functional disability [11]. The extent to which the operative times affect the outcome in abdominoplasty is unclear from the literature. When there is a statistical relationship, the odds ratio is generally small, leaving the clinical significance to be debated [13]. We agree with Greco et al., that to err in favour of a dogma is recommendable, especially in the light of general surgical literature supporting the reduction of operating time as a high priority along with safety and meticulousness. The type of anterior trunk body contouring procedure performed, being a simple excision of excess tissue in an ellipse (panniculectomy), excision with undermining to the xyphoid process (abdominoplasty) or other type of excision such as the fleur-de-lis pattern [29], potentially has an influence on the complication profile. Care must be taken to account for reduced tissue perfusion due to scars from previous abdominal surgery. A standard abdominoplasty may devascularize the region caudal to a subcostal scar. Panniculectomy may be performed, but with inferior cosmesis. Another option is to incorporate a vertical component in a (a) symmetrical fleur-de-lis pattern, depending on the angle the subcostal incision takes to the vertical. There is a concomitant high risk of wound complications at the junction of the inverted T scar, especially in patients with prior Kocher incisions, smokers and patients with

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large ventral hernias [17, 28, 30]. It is important in this procedure, as arguably in any abdominoplasty, to preserve the large perforators in the xyphoid and subcostal region, to trim the poorly vascularized sub-scarpa fat and to minimize the trimming of subcutaneous tissue near the neoumbilicus [30]. A full abdominoplasty can also be performed in patients with transverse subcostal scars by the preservation and caudal dissection of abdominal perforators [31]. When resorting to panniculectomy alone, the cosmetic results are often disappointing, but may be significantly improved when this is combined with liposuction [32]. In an analysis of 76 consecutive cases, these authors report very few complications: no seromas, one small area of skin necrosis <1 cm, minimal post-operative pain and return to work within 1 week. The preservation of all perforators was noted as an advantage, but no further mention of patient characteristics was made. Seroma formation requires an average of 2.4 aspirations [19]. Prevention may be obtained through methods such as the quilting suture technique as described by Baroudi and Ferreira [33] and the use of progressive tension sutures as described by Pollock and Pollock [34]. Layered closure over multiple drains after minimal undermining followed by sandbag compression works well in others’ hands [28]. Fibrin glue may also be an effective means of reducing seroma formation. So far, however, fibrin sealing has not found much application in the body contouring literature, and compression has been found to be ineffective in preventing seroma formation in the breast surgery literature [35]. Sealing of capillaries as well as lymphatic vessels using excited argon gas coagulation (PlasmaJet™) has also been suggested as a means to reduce post-operative bleeding and seroma formation [36]. When minimizing dead space, maintaining lymphatic integrity and treatment of high risk patients conservatively fail to prevent seroma formation, treatment may be initiated consisting of aspiration, drainage, and injection of sclerosant agents such as doxycycline and bleomycine [14]. Multiple applications of drainage combined with sclerosis may be necessary, and occasionally surgery may be necessary to excise the lining and close the pocket using quilting sutures over multiple drains [14, 34]. A retrospective study was conducted by chart review and a questionnaire sent to the 39 patients who had undergone laparoscopic adjustable gastric banding (LAGB) and abdominoplasty (LAGB only, N = 631) at our hospital between 1995 and 2004 [37]. The LAGB

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and abdominoplasty procedures were performed by the same surgeons, respectively. All the patients were morbidly obese before LAGB (mean BMI: 47), but still obese both before and after abdominoplasty (BMI 30 and 31, respectively, range 24.9–39.3), despite 60% having undergone additional body contouring procedures. Eleven patients (44%) experienced a form of complication. The only major complication was wound breakdown in two patients. The most frequent complication was seroma formation, occurring in 25% of patients. Those who experienced a complication had a slightly higher BMI (31.1) pre-abdominoplasty than patients who did not (30.1), although this was not significant (p = 0.53). Pre-operative risk factors encountered were smoking (28%), diabetes (4%), depression (40%), varicose veins (24%), recurrent panniculitis (56%) and hypertension (20%). The likelihood ratio X2 test found no statistical relationship between any of these factors and the incidence of complications. LAGB procedures lead to a significant improvement in the quality of life, weight reduction and marked decrease in co-morbid conditions [38]. The LAGB procedure is the safest bariatric operation, with a 0.05% mortality rate, and carries less risk of protein, vitamin, mineral or other nutrient deficiency [39]. Potentially, this will have an effect on wound healing after body contouring procedures, although we do not have data from other bariatric procedures or from the literature to verify this. When 126 post-bariatric panniculectomies were retrospectively reviewed, 40% of the patients experienced a complication, and only pre-panniculectomy BMI was an independent predictor for developing a post-operative complication (odds ratio 3.3, confidence interval 1.2–8.4, p < 0.01) [10]. In this study, age, pre-panniculectomy BMI > 25, ASA classification, weight loss, secondary procedures, operating room time, specimen weight and blood loss had no significant impact on the patients developing a post-operative complication when subjected to logistic regression analysis. Although the patients lost an average of 50 kg and made significant improvements in their co-morbidities, those still obese at presentation for panniculectomy are subjected to an additional perioperative risk. Another retrospective review found a complication rate of 50% in 117 post-bariatric surgery panniculectomies [9]. This complication rate was higher than that of abdominoplasties in the general population [7]. These authors note that complications are generally

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well tolerated, largely due to the benefit patients experience in terms of both function and aesthetics, which is also our experience. This series reported an average BMI change of 14–28.7 kg/m2 after medical or surgical bariatric intervention. The actual BMI at the time of body contouring was not mentioned. Combining ventral hernia repair in patients with panniculectomy after massive weight loss may predispose to the loss of the umbilicus (in 11 of 71 patients reviewed, compared to 0 of 29 patients) [5]. Circular abdominoplasty was evaluated in a psychological review [40]. Only immediate post-operative complications were reported: serous fluid collections (18.8%) and anaemia (6.3%). This group of patients (N = 16) was evaluated using the Adaptive Operationalized Diagnostic Scale (AODS). The 31 items on this questionnaire evaluate physical and mental health, social adjustment, body image, self-concept, self-esteem, mood and feelings, and emphasizes the ability to adapt to change. There was an unnamed prevalence of complications seen in outpatient clinic, but the patients were evaluated after these had resolved, with 43.8% showing good adaptation and 37.5% mild adaptation. There was no correlation provided to post-operative complications. In a study comparing abdominoplasty results in 139 patients with prior weight loss surgery to 83 patients without, and with statistically similar characteristics in terms of age, BMI, specimen weight and operative time, Greco et al. [13] found a much higher complication rate (41%) in the weight loss surgery group than the non-weight loss surgery group (22%) (p < 0.01). Their results showed that prior weight loss surgery and obese patients were at an increased risk for wound complications by univariate analysis (these were not independent predictors of risk by logistic regression). They found that weight loss surgery patients who lost ³40% of body weight before body contouring did not have higher rates of wound complications (in contrast to Sanger and David [21]), but did have significantly higher rates of seroma formation. Others report that circular abdominoplasty is not necessarily more likely to result in seromas [14]. In a review documenting the results in 128 postweight loss abdominoplasty procedures, male gender and hypothyroidism were found to be significant predictors of wound dehiscence. There was one patient with Ehlers–Danlos syndrome in this cohort, and not surprisingly, wound dehiscence occurred in this patient [35].

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In a review of 200 body lift patients, Nemerofsky et al. [24] found an overall complication rate of 50%, with skin dehiscence occurring in 32.5%, seromas in 16.5%, skin necrosis in 9.5%, infection in 3.5%, bleeding in 3%, deep vein thrombosis in 2% and pulmonary embolism in 1%. Interestingly, BMI before massive weight loss was predictive of complications (p < 0.01), but not the BMI at the time of body lift (p < 0.1). Patients with larger changes in BMI as a result of massive weight loss after bariatric surgery had higher risks of complications (p < 0.03). Smokers had a significantly higher rate of skin dehiscence and necrosis (p < 0.05). Although complications described in the literature are frequently mild, with seroma formation being the most frequently mentioned in most series and in our population, major complications do occur. The most relevant of these, due to the fact that it is life-threatening, is deep venous thrombosis with pulmonary embolism. Matarasso et al. [8] recently reported a US national survey on over 20,000 abdominoplasties, and a decreasing complication rate of deep venous thrombosis (0.04%) and pulmonary embolism (0.02%). More extensive contouring and the addition of liposurgery to abdominal contouring did not change the complication profile. Other less frequent major complications include necrotizing infections of the abdominal flap caused, for e.g. by Pseudomonos aeruginosa [24].

78.5 Prevention of Complications As is evident from the above, despite adequate cohort sizes, there is often contradictory evidence in the literature on the relative risk incurred by different factors in this population. However, there is enough evidence from the general surgery literature to support preventative strategies based on reducing pre-morbid risk factors such as age, BMI, ASA classification, smoking, diabetes, hypothyroidism, coronary artery disease, autoimmune disorders, thromboembolism history, psychiatric disorders, asthma and hypertension, and reduction of surgical risk factors such as excessive operative time, undermining, adjunctive liposuction and over resection due to poor procedure planning. Patients require aggressive management from the pre-operative consultation to the late post-operative period [14]. Male patients may be less compliant, and according to some

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studies, show less collagen deposition than women with age [41], leading some authors to advocate more conservative treatment in this population [35]. When less aggressive surgery and more aggressive perioperative care are combined with the knowledge of known or potential risk factors, results may be improved [21]. Thus informed, a group of 128 abdominoplasties showed no correlation between complications and age, hypertension, cardiac diseases, diabetes, history of thromboembolism, depression, tobacco use and BMI at the time of body contouring [14]. Some surgeons will not operate on patients who are smokers, and others incorporate extensive nutritional analysis, and if necessary, additional diet and weight loss programs in their pre-operative management in order to reduce complication risk [11]. It is also important to monitor the patients depending on the type of weight loss procedure performed. Protein levels need to be monitored in patients with a distal gastric bypass or biliopancreatic diversion due to the risk of protein loss in the stool, and proximal gastric bypass procedures can lead to deficiencies of iron, folate, calcium, vitamin B12 and vitamin D1 [21]. A recent prospective study compared the complication profile in abdominoplasty patients with massive weight loss obtained through diet and exercise (N = 34) to bariatric surgery patients (N = 477) [42]. The groups did not differ in terms of age, gender, co-morbidities or BMI. Interestingly, diet and exercise patients had higher absolute complication rates (53 vs. 41%, p = 0.18) with statistically more infections (18 vs. 7%, p = 0.03). An explanation may be the fact that the diet and exercise patients were more likely to have multiple procedures performed at the same time. Statistical significance was lost when 1:1 matched groups of 34 patients were controlled for BMI, gender, age and additional procedures performed, but the trend towards more complications in the diet and exercise group was still present. In one study, no additional risk of post-operative wound infection was found in patients undergoing different types of bariatric surgery compared to obese patients undergoing general elective surgery procedures of similar invasiveness [43]. By contrast, wound complication rates in obese patients undergoing abdominoplasty are more than doubled when compared to non-obese patients, irrespective of any previous bariatric surgery [18]. General surgical procedures on obese patients also result in more complications [6].

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A complication such as wound infection or dehiscence does not amount to surgical failure, and abdominoplasty is a procedure with a high success rate that provides adequate improvement to the quality of life. However, the post-bariatric surgery population is at an increased risk for post-operative complications, so that maximal reduction in BMI should be stressed to these patients before undergoing abdominoplasty [10, 37]. This is all the more important as the bariatric population often presents with a persistently elevated BMI despite massive weight loss [19]. An essential aspect in preparing the patients for body contouring procedures is their education on the potential complications and the severity of these complications. A realistic idea about the frequency and treatment required for specific complications may have an impact on patient satisfaction and reducing outpatient follow-up visits [19]. Patients are often not aware of the fact that body contouring is a ‘real’ operation with associated complications [11]. Patients may be better guided through the course of treatment for their complications using preand post-operative photographs. When they raise concerns about seromas, scar asymmetry, minor wound healing problems and other minor complications, they can be shown the dramatic change from the pre-operative situation [26].

78.6 Uncertainties Questions that come to mind when comparing literature on this subject include the impact of specific weight loss procedures on post-abdominoplasty complications [10]. Conceivably, the midline incision contributes to some complications in a series reporting on patients with open Roux-en-Y gastric bypass procedures. It would be interesting to know whether the rates of wound complication are significantly different in patients who underwent a laparoscopic gastric bypass with no prior midline incision. Other interesting points are whether impaired nutrition from more malabsorptive procedures would result in more wound complications or less weight lost from a laparoscopic band procedure would result in a higher BMI at the time of panniculectomy and thereby a higher rate of complications. Patients who used exercise and lifestyle modification as a means of weight reduction have strengthened their cardiopulmonary status over time

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and potentially reduced their post-operative risk [21], although this is contended by the results from Gusenoff et al. [42]. What the authors fail to mention is the clinical impact of a 40–50% complication rate. The subjective impact could be expressed in terms of parameters such as length of hospital stay, time to wound healing or time away from work [10]. There is currently a trend towards a younger patient population and a more even distribution of males undergoing bariatric surgery and body contouring procedures [9]. This may have a future impact on the complication profile also.

References 1. Schechner SA, Jacobs JS, O’Loughlin KC. Plastic and reconstructive body contouring in the post-vertical banded gastroplasty patient: a retrospective review. Obes Surg. 1991;1(4):413–7. 2. Datta G, Boriani F, Obbialero FD, VErg M. Body contouring after weight loss in morbid obesity: gain in health and leap in psychosocial functioning. Obes Surg. 2006;16(5):673. 3. Song AY, Rubin JP, Thomas V, Dudas JR, Marra KG, Fernstrom MH. Body image and quality of life in post massive weight loss body contouring patients. Obesity (Silver Spring). 2006;14(9):1626–36. 4. Pecori L, Serra Cervetti GG, Marinari GM, Migliori F, Adami GF. Attitudes of morbidly obese patients to weight loss and body image following bariatric surgery and body contouring. Obes Surg. 2007;17(1):68–73. 5. Saxe A, Schwartz S, Gallardo L, Yassa E, Alghanem A. Simultaneous panniculectomy and ventral hernia repair following weight reduction after gastric bypass surgery: is it safe? Obes Surg. 2008;18(2):192–5; discussion 196. 6. Rogliani M, Silvi E, Labardi L, Maggiulli F, Cervelli V. Obese and nonobese patients: complications of abdominoplasty. Ann Plast Surg. 2006;57(3):336–8. 7. Hensel JM, Lehman JA Jr, Tantri MP, Parker MG, Wagner DS, Topham NS. An outcomes analysis and satisfaction survey of 199 consecutive abdominoplasties. Ann Plast Surg. 2001;46(4):357–63. 8. Matarasso A, Swift RW, Rankin M. Abdominoplasty and abdominal contour surgery: a national plastic surgery survey. Plast Reconstr Surg. 2006;117(6):1797–808. 9. Fraccalvieri M, Datta G, Bogetti P, Verna G, Pedrale R, Bacchioti MA, Boriani F, Obbialero FD, Kefalas N, Bruschi S. Abdominoplasty after weight loss in morbidly obese patients: a 4-year clinical experience. Obes Surg. 2007; 17(10):1319–24. 10. Arthurs ZM, Cuadrado D, Sohn V, Wolcott K, Lesperance K, Carter P, Sebesta J. Post-bariatric panniculectomy: prepanniculectomy body mass index impacts the complication profile. Am J Surg. 2007;193(5):567–70; discussion 570. 11. Borud LJ, Warren AG. Body contouring in the postbariatric surgery patient. J Am Coll Surg. 2006;203(1):82–93.

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12. Byrne DJ, Malek MM, Davey PG, Cuschieri A. Postoperative wound scoring. Biomed Pharmacother. 1989;43(9):669–73. 13. Greco JA III, Castaldo ET, Nanney LB, Wendel JJ, Summitt JB, Kelley KJ, Braun SA, Hagan KF, Shack RB. The effect of weight loss surgery and body mass index on wound complications after abdominal contouring operations. Ann Plast Surg. 2008;61(3):235–42. 14. Shermak MA, Rotellini-Coltvet LA, Chang D. Seroma development following body contouring surgery for massive weight loss: patient risk factors and treatment strategies. Plast Reconstr Surg. 2008;122(1):280–8. 15. Grazer FM, Goldwyn RM. Abdominoplasty assessed by survey, with emphasis on complications. Plast Reconstr Surg. 1977;59(4):513–7. 16. Stewart KJ, Stewart DA, Coghlan B, Harrison DH, Jones BM, Waterhouse N. Complications of 278 consecutive abdominoplasties. J Plast Reconstr Aesthetic Surg. 2006; 59(11):1152–5. 17. van Uchelen JH, Werker PM, Kon M. Complications of abdominoplasty in 86 patients. Plast Reconstr Surg. 2001; 107(7):1869–73. 18. Vastine VL, Morgan RF, Williams GS, Gampper TJ, Drake DB, Knox LK, Lin KY. Wound complications of abdominoplasty in obese patients. Ann Plast Surg. 1999;42(1):34–9. 19. Neaman KC, Hansen JE. Analysis of complications from abdominoplasty: a review of 206 cases at a university hospital. Ann Plast Surg. 2007;58(3):292–8. 20. Taylor J, Shermak M. Body contouring following massive weight loss. Obes Surg. 2004;14(8):1080–5. 21. Sanger C, David LR. Impact of significant weight loss on outcome of body-contouring surgery. Ann Plast Surg. 2006;56(1):9–13; discussion 13. 22. Gravante G, Araco A, Sorge R, Araco F, Nicoli F, Caruso R, Langiano N, Cervelli V. Pulmonary embolism after combined abdominoplasty and flank liposuction: a correlation with the amount of fat removed. Ann Plast Surg. 2008; 60(6):604–8. 23. Deitel M. How much weight loss is sufficient to overcome major co-morbidities? Obes Surg. 2001;11(6):659. 24. Nemerofsky RB, Oliak DA, Capella JF. Body lift: an account of 200 consecutive cases in the massive weight loss patient. Plast Reconstr Surg. 2006;117(2):414–30. 25. Manassa EH, Hertl CH, Olbrisch RR. Wound healing problems in smokers and nonsmokers after 132 abdominoplasties. Plast Reconstr Surg. 2003;111(6): 2082–7; discussion 2088–89. 26. Gusenoff JA, Rubin JP. Plastic surgery after weight loss: current concepts in massive weight loss surgery. Aesthet Surg J. 2008;28(4):452–5. 27. Acarturk TO, Wachtman G, Heil B, Landecker A, Courcoulas AP, Manders EK. Panniculectomy as an adjuvant to bariatric surgery. Ann Plast Surg. 2004;53(4):360–6; discussion 367. 28. Manahan MA, Shermak MA. Massive panniculectomy after massive weight loss. Plast Reconstr Surg. 2006;117(7): 2191–7; discussion 2198–99. 29. Dellon AL. Fleur-de-lis abdominoplasty. Aesthetic Plast Surg. 1985;9(1):27–32. 30. Borud LJ, Warren AG. Modified vertical abdominoplasty in the massive weight loss patient. Plast Reconstr Surg. 2007; 119(6):1911–21; discussion 1922–1923.

782 31. Rieger UM, Aschwanden M, Schmid D, Kalbermatten DF, Pierer G, Haug M. Perforator-sparing abdominoplasty technique in the presence of bilateral subcostal scars after gastric bypass. Obes Surg. 2007;17(1):63–7. 32. Duncan TD, Mangubat AE. A new abdominoplasty approach for patients following massive weight loss surgery. Surg Obes Relat Dis. 2007;3:299–344. (Abstracts: 2007 Poster Session). 33. Baroudi R, Ferreira CA. Seroma: how to avoid it and how to treat it. Aesthetic Surg J. 1998;18:439–41. 34. Pollock H, Pollock T. Progressive tension sutures: a technique to reduce local complications in abdominoplasty. Plast Reconstr Surg. 2000;105(7):2583–6; discussion 2587–2588. 35. Shermak MA, Chang D, Magnuson TH, Schweitzer MA. An outcomes analysis of patients undergoing body contouring surgery after massive weight loss. Plast Reconstr Surg. 2006;118(4):1026–31. 36. Iannelli A, Bafghi AR, Patrono D, Sautot-Vial N, Gugenheim J. Use of PlasmaJet system in patients undergoing abdominal lipectomy following massive weight loss resulting from bariatric surgery: early experience. Obes Surg. 2006;16(11):1504–7. 37. Larsen M, Polat F, Stook FP, Oostenbroek RJ, Plaisier PW, Hesp WL. Satisfaction and complications in post-bariatric

M. Larsen and P. W. Plaisier surgery abdominoplasty patients. Acta Chir Plast. 2007; 49(4):95–8. 38. Champault A, Duwat O, Polliand C, Risk N, Champault GG. Quality of life after laparoscopic gastric banding: prospective study (152 cases) with a follow-up of 2 years. Surg Laparosc Endosc Percutan Tech. 2006;16(3):131–6. 39. Salameh JR. Bariatric surgery: past and present. Am J Med Sci. 2006;331(4):194–200. 40. Modolin M, Cintra W Jr, Gobbi CI, Ferreira MC. Circumferential abdominoplasty for sequential treatment after morbid obesity. Obes Surg. 2003;13(1):95–100. 41. Lenhardt R, Hopf HW, Marker E, Akca O, Kurz A, Scheuenstuhl H, Sessler DI. Perioperative collagen deposition in elderly and young men and women. Arch Surg. 2000; 135(1):71–4. 42. Gusenoff JA, Coon D, Rubin JP. Implications of weight loss method in body contouring outcomes. Plast Reconstr Surg. 2009;123(1):373–6. 43. Topaloglu S, Avsar FM, Ozel H, Babacan M, Berkem H, Yildiz Y, Hengirmen S. Comparison of bariatric and nonbariatric elective operations in morbidly obese patients on the basis of wound infection. Obes Surg. 2005;15(9): 1271–6.

Quality of Life After Abdominoplasty Following Bariatric Surgery

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Wilson Cintra, Miguel Luiz Antonio Modolin, Joel Faintuch, Rolf Gemperli, and Marcus Castro Ferreira

79.1 Introduction Postoperative assessment for plastic surgery interventions, especially those that follow massive weight loss induced by antiobesity procedures, is not complete with aesthetic criteria only. Quality of life is a variable that should not be overlooked because it mirrors the personal, social, and emotional impact that patients cherish. Surgically treated morbid obesity is a representative example of serious body dysmorphism, often encompassing skin laxity and enormous dermal folds asymmetrically distributed over abdomen, breasts, face, upper, and lower limbs [1]. Such redundancies interfere with daily routines as they impair dressing, washing, and walking, may trigger postural changes, and are susceptible to ulceration or repeated bouts of intertrigenous infection or panniculitis. Moreover, they damage body image [2].

79.2 Plastic Techniques and Outcomes Multiple plastic procedures have been indicated within this context, such as abdominoplasty, mammaplasty, mastopexy, rhytidoplasty, brachioplasty, and thigh lift, aiming to remove excessive skin and adipose tissue and to enhance body contour. Plastic surgery tends to increase self-esteem, at the same time that it removes functional barriers preventing normal physical and professional performance, thus patients become again productive members of the society [3].

The number and extent of the operations correlate with subsequent changes in quality of life. For instance, a much better response is noticed after circumferential abdominoplasty or upper body lift than after simple brachioplasty. In our experience, abdominoplasty is the most requested intervention, as approximately 90% of subjects with postoperative massive weight loss who come to the Plastic Service undergo such intervention [4].

79.3 Quality of Life For the World Health Organization (WHO), quality of life is an individual perception, within a context of culture and values, and taking in account objectives, expectations, standards, and concerns [5]. The recent medical literature grants much importance to this concept in a variety of illnesses and conditions, including surgical diseases and procedures. As remotely as half a century ago, some attempts to add subjective variables to standard morbidity and mortality rates, in the assessment of surgical outcome, could already be identified. Nevertheless, it was basically in the 1980s that a theoretical framework was established, and tools for measuring quality of life were devised and gained acceptance [6].

79.4 Criteria and Variables W. Cintra (*) Plastic Surgery Service, Hospital das Clínicas, São Paulo, SP, Brazil e-mail: [email protected]

Grading of this outcome does not entirely overlook classic clinical symptoms, limitations, and dysfunctions. However, it focuses on the domains of happiness,

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_79, © Springer-Verlag Berlin Heidelberg 2010

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social indicators, and standards of health. Depending on the circumstances, tools for psychological and emotional health are emphasized, including self-esteem, depression, loneliness, sexual life, anxiety, and stress. Mortality, life expectancy, comorbidities, disabilities, and other objective outcomes are more meaningful to the surgeon than to the patients. Subjective feelings loom higher in their mind. The WHO recognizes that health is much more than the absence of disease, embodying complete physical, mental, and social well-being. Improved body shape and function and restoration of distorted anatomical profile are unquestionably worthwhile. Nevertheless, in order to unveil the full picture, particularly from the vantage point of the patient, new tools were designed since the 1970s, nominally Sickness Impact Profile, Nottingham Health Profile, Short-Form Quality of Life Questionnaire (SF-36), and others. The target here is to document the effect of disease and treatment on the ability of the patient to perform, enjoy life, and cope with his or her usual challenges, stresses, and dreams [7].

79.5 Objective vs. Subjective Response The depth of the concept of quality of life can be gauged by the views of Gill and Feinstein [8]. Instead of a mere description of health standards, it mirrors how the individual perceives and reacts to both medical and nonmedical reality. For Calman [9], the fundamental variable is the distance between the subject´s expectations and achievements. The closer they are, the better the quality of life. It is essential to grasp that in nearly all definitions, quality of life represents a set of subjective responses by the patient, in face of objective facts and events pertaining to daily life and environment, as well as to family, social and professional relationships. A general theoretical framework correlating objective conditions with subjective perceptions is useful to correctly interpret the key findings of quality of life assessment.

79.6 Body Shape and Self-Image Plastic surgery measurably influences self-image. Actual impact depends on psychological stability of the subject, as well as on the speed and degree of produced

W. Cintra et al.

changes. Mammary implants are examples of immediate satisfaction of the patient’s desire, with response to body image following in the next weeks or months. Corrective maneuvers aiming to remove local or regional abnormalities and to restore a normal anatomical profile modify less body image, and improved psychological well-being takes longer to occur. Nevertheless, patients do acknowledge the benefits and are mostly grateful for the intervention. Procedures for body contour have to take in account length and complexity of the operation, duration of obesity, and amount of weight loss. Emotional and interpersonal relationships need to be carefully questioned in order not to indicate the procedure for the wrong reasons, and psychological stability is absolutely required [3].

79.7 Clinical Approach to Quality of Life For specific investigation of quality of life, a variety of tools may be employed. Some address life in general and are appropriate for healthy subjects (World Health Organization Quality of Life-WHOQOL, Quality of Life Questionnaire-QOLQ, Client Quality of Life InterviewCLQI, and Quality of Life Interview Scale-QOLIS). In recent years, many have been developed with a view on ill people, either hospitalized or in the outpatient setting (Sickness Impact Profile, Nottingham Health Profile, Medical Outcomes Study-Short FormMOS SF-36, and Quality of Well-Being). The most accurate and recommended, but not many of this category are available, target a single disease, and how its natural history and complications undermine quality of life [10]. Obviously some questionnaires such as the SF-36 have become classic, however many others enjoy widespread use and strong practical validation. A few are less well known but may prove invaluable for defined populations. Qualitative answers cannot always be avoided, and are actually convenient to become familiar with the inner feelings of the patient. Still, numerical techniques are ideal for population studies, as well as for routine interviews in the office or the outpatient service, as they can be conducted by a trained technician and are promptly interpreted, according to the corresponding scores.

79 Quality of Life After Abdominoplasty Following Bariatric Surgery

The Operationalized Adaptive Diagnostic Scale (EDAO) measures how a given individual adapts to a new situation and copes with this reality, and was thus applied to plastic surgery patients [11]. Extensive validation is not available yet, but this should be sought whenever one examines quality of life and other subjective items.

79.8 Experience with Postbariatric Abdominoplasty Body dysmorphism that follows weight loss in excess of 30% is not usually amenable to full correction by standard abdominoplasty. Dermal excesses and dogears in the flanks may become more prominent after conventional transverse infraumbilical abdominoplasty, thus extension of the incision to the posterior regions will be required. Other challenges are patients with vertical laparotomy scars and large epigastric skin folds, or eventually with gluteal ptosis, who will benefit from compound abdominoplasty, “anchor” incision, and other tailormade adaptations [2, 12]. Not all of these concerns are immediately relevant for the patient, who typically complains only about the conspicuous abdominal overhang. Indeed, resection of loose skin in the lower abdomen tends to be the first request of postbariatric subjects [13]. Still, patients do become aware of residual or secondary abnormalities and quality of life will not be optimized unless these are addressed as well, preferably during the first operation.

79.9 Clinical Results A great number of reports can be found about psychosocial impact and quality of life after abdominoplasty for massive weight loss. Stuerz et al. [14] evaluated 34 patients by means of Strauss and Appelt’s Questionnaire, Body Perception Questionnaire by Paulus, and Questionnaire for Satisfaction of Life by Fahrenberg. Compared to control cases, operated individuals exhibited improved self-confidence and felt more charming and attractive.

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The series of Chahraoui et al. [15] encompassed 19 patients submitted to augmentation mammaplasty and six others to abdominoplasty. The methods included Subjective Quality of Life Profile-SQLP and General Health Questionnaire-GHQ12. Accordingly, both quality of life and general mental health increased after intervention. In other protocols, both nonspecific assessment by Short Form SF-36 and more focused questionnaires such as EuroQol were selected for plastic surgery populations. Again, advances in quality of life, emotional stability, and a tendency toward extroversion and sociability were documented [16, 17]. The authors’ recent study covered 16 females undergoing either standard circumferential abdominoplasty (n = 5) or combined circumferential abdominoplasty (n = 11). A trained psychologist administered the Operationalized Adaptive Diagnostic Scale (EDAO). Advantage for social and cultural adaptation was unveiled in 81.3% of the subjects, along with remarkable benefits also in the domains of organic health, productivity, and affectivity – relationship traits [18]. Table 79.1 reproduces the list of questions of EDAO. Answers are divided in categories in order to attribute scores according to the protocol [11]. For correct interpretation, three qualitative criteria need to be considered: how effectively is the problem solved, how happy is the patient with the solution, and how much psychological or environmental conflict, if any, does that approach generate. As a result, items are described as adequate, slightly inadequate, or severely inadequate (Table 79.2). The scoring system establishes that in agreement with the above classification, affective-relationship indicators receive 3, 2, and 1 points, respectively, and productivity items 2, 1, and 0.5, respectively. Within this context, in the first block (affective- relationship), good, reasonable and poor responses corresponded to, respectively, 62.5, 31.3, and 6.3% of the registered population. For productivity, the proportion did not change much, with the majority displaying adequate findings (62.5%), and only 12.5% very inadequate adaptation. Sum total of all given scores is another index. In 43.8%, it reached the highest value (5.0), another 37.5% remained in an acceptable range (4.0 points), and just 18.75% stayed at or below the 3.0 threshold. As summarized in Table 79.3, a good outcome corresponds to score 5.0, it is deemed mildly inadequate

786 Table 79.1 EDAO questionnaire (items 1–3 are merely technical) 1. For how long have you been receiving treatment for obesity?

W. Cintra et al. Table 79.2 Definitions for the answers according to adaptive criteria Adequate (+++)

Solve the problem (+) Are satisfactory (+) Create no psychological or environmental conflict (+)

Mildly inadequate (++)

Solve the problem (+) Are satisfactory (+) Create conflict (+)

Severely inadequate (+)

Solve the problem (+) Not satisfactory (+) Create conflict (+)

2. And for how long in the plastic surgery service? 3. How did you come to us? 4. Do you link your obesity to any given fact or event in your life? 5. What is your current job or activity? 6. Are you happy with the job? Why? 7. Do you have plans for your professional future? 8. Did the plastic operation change your professional life? How? 9. What do you do during leisure time? 10. Do you appreciate company during leisure time? Why?

Table 79.3 Quantitative classification of adaptation Group Diagnosis Sum total

11. Did plastic surgery change your social life? How?

1

Good adaptation

5

12. How do you feel physically after the plastic operation/surgery?

2

Mildly inadequate

4

13. What did this procedure change in your body?

3

Moderately inadequate

3/3.5

14. How do you feel in regard to such changes?

4

Severely inadequate

2/2.5

15. Do you sleep well since this operation? Why?

5

Very severely inadequate

1.5

16. Do you eat well after the plastic operation/surgery? Why? 17. Did your eating habits change since you were operated? How? 18. Did your habits of personal hygiene change since operation? How? 19. Did your personal relationships change after operation? How? 20. Are you happy with your personal relationships? Why? 21. Did your emotional relationships change after plastic surgery? How? 22. Are you happy with your emotional relationships? Why? 23. Did your sexual relationships change after plastic surgery? How?

with 4.0, moderately inadequate at 3.0, and severely or very severely inadequate at values 2.0 and 1.0, respectively. The interest of a semistructured interview should not be overlooked. Whereas standard questionnaires are indispensable, the possibility of spontaneous comments by the patients often brings precious insights about their inner feelings. Furthermore, some degree of dialogue is essential to establish mutual trust and good communication with them.

24. Are you happy with your sexual relationships? Why? 25. What pleased you in the plastic intervention? Why? 26. Are the results of plastic surgery close to your expectations? Why? 27. What would you change in your operation? Why? 28. Which result of the operation made you most happy? Why? 29. Which result was most disappointing for you? Why? 30. What changed in your life after this procedure? 31. General comments

References 1. Gusenoff JA, Rubin JP. Plastic surgery after weight loss: current concepts in massive weight loss surgery. Aesthet Surg J. 2008;28(4):452–5. 2. Modolin M, Cintra Junior W, Gobbi CIC, Ferreira MC. Circumferential abdominoplasty for sequential treatment after morbid obesity. Obes Surg. 2003;13(1):95–100. 3. Black J, Morgan M. Body contouring and weight loss surgery for obesity. Nurs Clin North Am. 1991;26(3):777–88. 4. Favre S, Egloff DV. Body contouring surgery after massive weight loss. Rev Med Suisse. 2005;1(28):1863–7.

79 Quality of Life After Abdominoplasty Following Bariatric Surgery 5. WHOQOL-BREF. Introduction, administration, scoring and generic version of assessment. Geneva: WHO. 2009. http:// www.who.int/mental_health/media/en/76.pdf. 6. Lehman AF, Ward NC, Linn LS. Chronic mental patients: the quality of life issue. Am J Psychiatr. 1982;139(10): 1271–6. 7. Barge-Schaapveld D, Nicolson N, Delespaul P, de Vries M. Assessing quality of life with the experience sampling method. In: Katsching H, Freeman H, Sartorius N, editors. Quality of life in mental disorders. New York: Wiley; 1997. p. 95–107. 8. Gill TM, Feinstein AR. A critical appraisal of the quality of life instruments. J Am Med Assoc. 1994;272(8):619–26. 9. Calman KC. Quality of life in cancer patients – a hypothesis. J Med Ethics. 1984;10(3):124–7. 10. Fleck MP. Avaliação de qualidade de vida. In: Fráguas RJ, Figueiró JA, editors. Depressões em Medicina Interna e em Outras Condições Médicas-Depressões Secundárias. São Paulo: Atheneu; 2000. p. 33–43. 11. Simon R. Psicologia Clínica Preventiva: Novos Fundamentos. 1st ed. São Paulo: EPU; 1989. p. 13–91.

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12. Carwell GR, Horton CE Sr. Circumferencial torsoplasty. Ann Plast Surg. 1997;38(3):213–6. 13. Fraccalvieri M, Datta G, Bogetti P, Verna G, Pedrale R, Brocchiotti MA, Boriani F, Obbialero FD, Fefalas N, Bruschi S. Abdominoplasty after weight loss in morbidly obese patients: a 4-year clinical experience. Obes Surg. 2007;17(10):1319–24. 14. Stuerz K, Piza H, Niermann K, Kinzl JF. Psychosocial impact of abdominoplasty. Obes Surg. 2008;18(1):34–8. 15. Chahraoui K, Danino A, Frachebois C, Clerc AS, Malka G. Aesthetic surgery and quality of life before and four months postoperatively. Ann Chir Plast Esthet. 2006;51(3):207–10. 16. Iwuagwu OC, Walker LG, Stanley PW, Hart NB, Platt AJ, Drew PJ. Randomized clinical trial examining psychosocial and quality of life benefits of bilateral breast reduction surgery. Br J Surg. 2006;93(3):291–4. 17. Freire M, Neto MS, Garcia EB, Quaresma MR, Ferreira LM. Quality of life after reduction mammaplasty. Scand J Plast Reconstr Surg Hand Surg. 2004;38(6):335–9. 18. Cintra W Jr, Modolin MLA, Gemperli R, Gobbi CIC, Faintuch J, Ferreira MC. Quality of life after abdominoplasty in women after bariatric surgery. Obes Surg. 2008;18(6):728–32.

Algorithm for Surgical Plane in Brachioplasty After Massive Weight Loss

80

Claudio Cannistrà

80.1 Introduction During weight evolution after bariatric surgery, brachioplasty is a frequent surgical procedure. This is caused by loss of elasticity of the superficial fascia after loss of deep adipose tissues and by excess of the skin. These modifications are increased by age with dermosenescence that causes skin thickness and a loss of elasticity usually on the medial side of the proximal arms. Posse [1] in 1946 proposed an elliptical incision on the medial side of the arm to reduce the excess of the skin. The procedure correction of the brachial lipodystrophy was first described by Correa-Iturraspe and Fernandez in 1954 [2]. Clarkson and Jeffs [3] advocated a curved suprascapular incision that passes around the posterior aspect of the arm to correct the thoracic wall and the deformity of arms. Pitanguy and Matta [4] proposed an S-shaped incision extended onto the anterior axillary pillar to the inframammary sulcus. The scar is positioned at the level of the posterior border of the biceps muscle. Franco and Rebello [5] published a similar approach for resculpturing of the arm using a separate L-shaped incision between and below the scapulae to contour the thorax. In 1979, Juri et al. [6] published a report on a quadrangular flap reduction with T closure. The use of a straight axillary line with a large T closure and axillary suspension may give some axillary retraction. Contemporaneously, Guerrerosantos [7] described a

C. Cannistrà Department of Surgery, Plastic Surgery Unit, Bichat C.B. University Hospital, 75008 Paris, France e-mail: [email protected]

smaller Z-plasty to restore axillary contour and to lengthen the scar. Borges [8] proposed a W-plasty technique, but this is very complicated. Regnault [9] proposed an M axillary incision to modify the Juri technique to reduce the problems of the retraction scars. Goddio [10] proposed deepithelialization of the posterior flap and repositioning to create a bicipital sulcus. After anatomical description of the arm’s superficial fascial system, Lockwood [11] proposed a brachioplasty procedure that provided secure anchoring of the arm flap to the axillary fascia along with strong superficial fascial system repair of incision. The scar is positioned anteriorly at the level of the medial bicipital sulcus. Teimourian and Malekzadeh [12] described four categories of upper arm problem to make the surgical approach easier. de Souza Pinto et al. [13] proposed an acrylic mold during the surgical marking to make a brachioplasty using the italic double S-shaped incision on the bicipital sulcus associated with liposuction. Richards [14] described a minimal incision brachioplasty technique associated with lipoaspiration and half ellipse incision at the level of axillary area. Strauch et al. [15] proposed a treatment algorithm based on four treatment zones to help the surgeon evaluate upper extremity contour deformities. He analyzed the problem of the scar location and recommended an undulating scar and placing the scar well posterior to the medial bicipital groove, to minimize the visibility of the final scar from the frontal position. In an alternative to brachioplasty, Gilliland and Lyos [16] proposed circumferential paraaxillary superficial tumescent liposuction in the aging female with excess arm fat and poor skin. However, the current brachioplasty techniques are somewhat unpredictable and are commonly associated with significant untoward results such as misplaced,

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Fig. 80.1 Skin graft after excessive skin resection during brachioplasty

widened, or hypertrophic scars, contour deformities due to over correction centrally and under resection proximally and distally (Fig. 80.1), transverse cutaneous folds, delayed wound healing due to marginal skin necrosis, and suture dehiscence. It is necessary to define one’s preoperative marking that reduces over correction problems and makes the surgical technique easier for the young surgeons and to evaluate an ideal position of the residual arm scar.

80.2 Technique Modification of the upper arm can be divided into four general categories by the classification of Teimourian and Malekzadeh [12]. Group 1: Minimal to moderate subcutaneous fat with minimal skin laxity. Group 2: Excessive accumulation of subcutaneous fat moderate skin laxity. Group 3: Obesity and extensive skin laxity. Group 4: Minimal subcutaneous fat and extensive skin laxity. It is preferable to perform liposuction with local anesthesia 3–5 months before to reduce the excess of subcutaneous fat. This delayed procedure permits the evaluation of the skin retraction capacities, reduces the patients’ number with primary indication for surgery, and reduces the surgical skin dissection and resection. The scar should be placed well posterior to the medial bicipital groove, along the line between the

C. Cannistrà

Fig. 80.2 The first line is traced along the axis of the arm at the coracoid articulation (point A) to the lateral epicondyle of the humerus (point B)

medial axillary line and the olecranon because that is not visible to a patient in front of a mirror. The patient is marked before surgery in the standing position. The procedure is performed under general anesthesia. The patient is positioned with the arms abducted to 90°. The first line is traced along the axis of the arm at the coracoid articulation (point A) to the lateral epicondyle of the humerus (point B) (Fig. 80.2). This line is between 28 and 32 cm. The A–B line is divided into three or four segments, creating the points C, D, and E. This first line serves as reference for two incision lines that are planned on either side of the excess skin fold. After this marking, two incision lines are made in the anterior and posterior arm face after the pinching test to value the skin excess (Fig. 80.3). Note the distance between the points C, D, and E, the anterior and posterior skin line incision, and the length between the anterior and posterior arm incision lines (Fig. 80.4).

Fig. 80.3 Pinch test

80 Algorithm for Surgical Plane in Brachioplasty After Massive Weight Loss

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Fig. 80.4 Note the distance between the points C, D, and E, the anterior and posterior skin line incision, and the length between the anterior and posterior arm incision lines Fig. 80.6 Perform infiltration at the level of the dissection plane

On the contralateral arm, the line A–B is marked with the C, D, E points that are the same distance between these points and the incision line and the anterior and posterior incision lines that are marked (Fig. 80.5). Normally, the lengths between the anterior and posterior lines at the level of the C, D, and E points are identical on the two arms. These correspond to the new circumference of the arms. Subcutaneous infiltration of a solution of 1 L of physiologic solution consisting of 1 mg of epinephrine and 20 mg of lidocaine is made by the small incision on the excess of the skin. It is important to perform infiltration at the level of the dissection plane (Fig. 80.6).

Fig. 80.5 On the contralateral arm, the line A–B is marked with the C, D, and E points that are the same distance between these points and the incision line and the anterior and posterior incision lines that are marked

After the skin incision, dissection is performed on the superficial fascial system suspension because the subcutaneous resection has been previously made by liposuction. This procedure reduces the risk of vascular and nerve injury damage. Before resection of the skin excess, the skin tension is evaluated around the arms (Fig. 80.7). If the tension is very tight, it is possible to change the position of the skin incision (Fig. 80.8). These modifications should be done on the other arm to make a symmetrical shape (Fig. 80.9). The superficial fascial system is plicated at level of the inferior arm margin. The scar is located on the inferior margin of the arm where the gravitational tension is absent (Fig. 80.10). The laxity of the remaining skin should permit easy closure. At the level of the axillary fold, the author prefers a Z-plasty closure to preserve the axillary fold (Fig. 80.10).

Fig. 80.7 Before resection of the skin excess, the skin tension is evaluated around the arms

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C. Cannistrà

A Redon drainage is positioned for 48 h. An elastic bandage is utilized for 15 days to reduce the tissue edema and scar traction.

80.3 Complications Large scars are observed in 20% of patients. There has not been any skin under resection or over resection with unnatural postoperative contours or lymphedema. No seromas have been observed.

Fig. 80.8 If the tension is very tight, it is possible to change the position of the skin incision

Fig. 80.9 The modifications should be done on the other arm to make a symmetrical shape

Fig. 80.10 The scar is located on the inferior margin of the arm where the gravitational tension is absent

80.4 Discussion Literature analysis has shown that the technical procedure is carefully explained every time. The younger surgeons are easily exposed to skin resection errors with over and under resection of tissue and nonaesthetic unnatural contours. There is the possibility of nerve and vascular damage during this procedure, and it is important to make the surgical procedure easy and, if possible, with local assisted anesthesia. Experience with patients after extensive weight loss showed that it is very important to prepare preventively the subcutaneous layers before molding the superficial skin layers. The patient’s weight should be allowed to stabilize to near ideal body weight prior to any surgical procedure. The most skin flaccidity and ptosis, are best the result. The circumferential lipoaspiration proposed by Gilliland and Lyos [16] was thinned by the author in order to modify the normal disposition of the fat. Normally, the located adiposity is positioned on the inferior level of the arms. When you perform a circumferential lipoaspiration during weight loss, after completing weight loss, there is asymmetric distribution of the fat with senescent appearance of the arms. In 20% of the author’s patients, preventive lipoaspiration was not performed because the author observed skin ptosis in zone II of the upper extremity [12–15]. In these cases, there is no subcutaneous fat excess. The transverse axillary minimal incision [14] does not correct the morphological problems of the arms. In patients following extensive weight loss, the excess of the skin on the arms is circumferential and is not in length. This technique proposed a reduction of the length of the arm skin, and it is possible to cause a

80 Algorithm for Surgical Plane in Brachioplasty After Massive Weight Loss

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a1

a2

Fig. 80.11 Hypertrophic and retracted scar after skin resection limited to arm

retracted scar with limitation of the arm abduction (Fig. 80.11) and easily damage the axillary lymphatic vessels, causing lymphatic edema of the arms. The technical procedure described by Lockwood [11] is very dangerous for young surgeons during the exposure of the axillary vein and the brachial cutaneous nerve in the axillary fold to obtain suspension of the axillary fold. The algorithm [17] to mark a surgical plan is important to avoid postoperative arm asymmetry and to reduce surgical complications. Plication of the superficial fascial system permits a circumferential arm reduction at level of the zone II. Z-plasty [7] at level of the aponeurosis and axillary skin permits correction of the zone III axillary deformity. The scar positioned parallel to the axillary lymphatic vessels reduces the possibility of lymphatic arm

a1

b1 Fig. 80.13 (a1,2) A 65-year-old woman with extensive arm laxity after weight loss of 50 kg. (b1,2) Twelve months postoperative after brachioplasty

b1

b2

Fig. 80.12 (a1,2) A 45-year-old woman with important arm laxity after weight loss 50 kg. Lipoaspiration had been performed 6 months before. (b1,2) Twelve months postoperative after brachioplasty

edema. The scar located between medial humeral epicondyle and the medial axillary line is positioned without gravitational tension. The quality of scar is good and the localization is better accepted by the

a2

b2

794

a

b1

b2

Fig. 80.14 (a) A 42-year-old woman with extensive arm laxity after weight loss of 45 kg. (b1,2) Eighteen months postoperative following brachioplasty

patient because it is not visible when the patient looks in the mirror.

80.5 Conclusions The algorithm to mark the surgical plane during brachioplasty is carefully explained and planned. This technique is very easy and adapted for the younger surgeons to simplify the method and to prevent postoperative arm asymmetry. Scar revision is necessary 1 year postoperatively in 10% of patients.

C. Cannistrà

References 1. Posse P. Cirugia Estética. Bueno Aires: EI Ateneo; 1946. 2. Correa-Iturraspe M, Fernandez JC. Dermolipectomia braquial. Prensa Med Argent. 1954;34(34):2432–36. 3. Clarkson P, Jeffs J. The contribution of plastic surgery to the treatment of obesity. In: Gibson T, editor. Modern trends in plastic surgery, 2nd series. Washington: Butterworths; 1966. 4. Pitanguy I, Matta SR. Correcao da lipodistrofia da regiae lateral do torax, face interna do braco e da dermosenescencia do cotovelo. Rev Bras Cir. 1975;65:277–9. 5. Franco T, Rebello C. Cirugia Estetica. Rio de Janeiro: Ateneu; 1977. p. 336. 6. Juri J, Juri C, Elias J. Arm dermolipectomy with a quadrangular flap and T closure. Plast Reconstr Surg. 1979;64(4): 521–6. 7. Guerrerosantos J. Brachioplasty. Aesthetic Plast Surg. 1979; 3:1. 8. Borges AF. W-plastic dermolipectomy to correct “batwing” deformity. Ann Plast Surg. 1982;9(6):498–501. 9. Regnault P. Brachioplasty, axilloplasty and preaxilloplasty. Aesthetic Plast Surg. 1983;7(1):31–36. 10. Goddio AS. Brachioplasty: new technique. Ann Chir Plast Esthet. 1990;35(3):201–208. 11. Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96(4):912–20. 12. Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg. 1998;102(2):545–51. 13. de Souza Pinto BE, Erazo P, Matsuda CA, Regazzini DV, Burgos DS Acosta HA, do Amaral AG. Brachioplasty technique with the use of molds. Plast Reconstr Surg J. 2000;105(5): 1854–60. 14. Richards ME. Minimal incision brachioplasty: a first choice option in arm reduction surgery. Aesthetic Surg J. 2001;21(4): 301–8. 15. Strauch B, Greenspun D, Levine J, Baum T. A technique of brachioplasty. Plast Reconstr Surg J. 2004;113(4): 1044–48. 16. Gilliland MD, Lyos AT. CAST liposuction: an alternative to brachioplasty. Aesthetic Plast Surg. 1997;21(6): 398–402. 17. Cannistrà C, Valero R, Benelli C, Marmuse JP. Brachioplasty after massive weight loss: a simple algorithm for surgical plane. Aesthetic Plast Surg. 2007;31(1):6–9.

81

L Brachioplasty Following Massive Weight Loss Daron Geldwert and Dennis J. Hurwitz

81.1 Introduction The upper arm, axilla, and lateral chest are appreciated for their femininity, beauty, and erotic sensuality. Massive weight loss patients often suffer severe arm deformities that extend into the axilla and chest. Although there is considerable variability in the presentation based on the amount of preexisting adiposity, skin elasticity, and age, there are five consistent distortions. Upper body deformities usually consist of hanging upper arm skin, oversized and deep axilla, descent of the posterior axillary fold (PAF), and flattening and elongation of the anterior axillary fold (AAF) with extension onto the lateral chest wall. These women are embarrassed by their appearance and cover up their arms with long sleeves. They disdain sleeveless tops and are distressed by lateral skin rolls that overhang the top edge of their bra. The authors have found that classic operations inadequately address these problems [1–5]. The senior author (DJH) developed a technique of continuous excision of excess skin from the arm to the axilla and onto the chest. The sweeping scar across the axilla resembles the letter “L” on its side. The “L” represents the shape of the excision, with the long limb along the medial axis of the upper arm and the short limb meeting at right angles across the axilla and then extending along the midlateral chest. The deformities should be corrected leaving attractive new contours with acceptable scars. Since 2001, the authors have used this technique successfully in over

D.J. Hurwitz () Hurwitz Center for Plastic Surgery, Pittsburgh, PA 15213, USA e-mail: [email protected]

50 patients with few complications in aesthetically reshaping the arm, axilla, and lateral chest.

81.2 Patient Presentation and Analysis Although there is significant variability in the presentation of patients, there exist five consistent distortions that range from moderate to bizarre in the massive weight loss patient [5]. The most outstanding of these deformities is the canopy-like axilla-to-elbow sagging of upper arm skin. Through the intermuscular septum, the bicipital groove divides the arm into the anterior and posterior compartments. Unlike the anterior arm skin where there are lesser effects of gravity and a generalized anatomical adherence, the posterior arm deformity can range from loose and deflated to a thick and heavy dangling mass. The groove is usually well defined medially with strong dermofascial adherence between the biceps and biceps brachii muscles groups. Laterally, a lesser defined adherence is present between the biceps and triceps muscles. Skin anterior to the groove is firmly adherent to the underlying muscular fascia, whereas skin posterior has weak attachments. These anatomical landmarks are important when planning scar placement. A scar placed along the medial intermuscular septum can lead to retraction and depression of the scar line. A scar placed along the posterior margin tends to flatten the natural curvature of the posterior arm. The second deformity is descent of the PAF. This inferior displacement broadens the attachment of the arm to the chest, leading to the classic bat-wing appearance of the upper arm. The inadequately suspended PAF contrasts greatly from the tight skin adherence of the axillary dome and the elongated and flattened AAF.

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The third deformity is the oversized and deeply concaved axilla, which we call hyperaxilla. As the axillary skin is directly adherent to the clavipectoral fascia, with massive weight loss there is relative retraction of the clavipectoral fascia with deepening of the axilla. This leads to an enlargement of the normal hairbearing axillary skin, an unnatural appearance, and difficulty in shaving. The fourth deformity is a flattened and elongated AAF. The AAF is a ridge that forms along the lateral border of the pectoralis major muscle. It begins at its humeral insertion and ends along the superior lateral border of the breast. Ptosis of the breast, which is common, accentuates the deformity. The desirable “S” shaped curve created by the AAF and lateral breast is stretched to an unappealing “J.” The last component is lateral chest skin laxity that leads into a mid-transverse torso roll. The short limb of the L brachioplasty addresses this deformity either alone or it can be integrated into an upper body lift breast reshaping procedure.

81.3 Patient Selection and Treatment Goals The optimal candidate has ptotic and loosely hanging skin of the upper arm. Arms that are oversized and tensely full are often best treated with a preliminary lipoplasty. The visibility and unpredictability of the scar appearance is discussed in detail. The patient needs to understand the trade-off between the deformity and the scars along the arms, axilla, and chest. The medial arms scars usually take several years to mature with the most distal end the last to flatten. Moreover, the risk for delayed healing, seromas, under- and overresection, wound dehiscence, infection, and lymphoceles should be discussed. The patient is advised that there is an anticipated 80–90% correction rate because a more aggressive resection can result in limb threatening constriction secondary to postoperative swelling or skin necrosis followed by suture line dehiscence. Inadequate correction can be redone on a more limited basis, usually as an office procedure. Hypertrophic scars or axillary contracture that was not amenable to medical management can be treated by surgical revision, which may include a Z-plasty.

D. Geldwert and D. J. Hurwitz

81.4 Operative Planning The plan to excise the excess skin and fat of the upper arm, axilla, and lateral chest is drawn in the form of an inverted “L” with the closed angle at the dome of the axilla. The long hemi-ellipse is situated along the medial aspect of the arm with the shorter ellipse along the lower half of the axilla and lateral chest. Consistent arm position during marking is imperative. The markings are made with the patient sitting. The arm is abducted 90° from the chest and the forearm is flexed 90° with the palms forward as if taking an oath. Extension of the arm at the elbow distorts the skin by putting more tension on the mid medial than the posterior arm skin. The goal of the markings is to have confidence in them so that the surgeon can accurately and expeditiously excise the appropriate amount of excess skin and fat in a symmetrical fashion (Fig. 81.1). The marking commences with setting the midpoint along or slightly inferior to the bicipital groove. A line is then drawn from the most distal portion of the excision at the medial elbow through the midpoint dot and then proximally to the deltopectoral groove at the axilla. By gathering and pinching excess tissue at the widest portion in the midarm, the width of the mid-arm excision is determined and marked. A straight line is then drawn from that point to intersect the distal marking at the medial elbow. A point is then chosen along the inferior border that can be pinched and approximated across the axilla to the deltopectoral groove. The critical location of this point can often take several attempts to properly localize. Approximation of this point should raise the ptotic PAF and equalize the lengths of the superior and inferior lines. The inferior line then angles acutely to descend inferiorly through the axilla. From the deltopectoral groove, the superior line descends vertically through the axilla. The area between these two lines comprises the resection of axillary and lateral chest skin. The chest portion of the ellipse often needs to be coordinated with the transverse removal of upper back rolls during an upper body lift. Next, the arms and forearms are fully extended above the head and the marking are reevaluated. The distance of the superior line from the elbow to the deltopectoral groove is equal to the distance of the curving inferior line from the elbow to the advancement point on the PAF. The incision lines are then crosshatched for proper alignment. The result 5 years after markings were made and the operation performed is seen in Fig. 81.2.

81 L Brachioplasty Following Massive Weight Loss

Fig. 81.1 Marking for the L brachioplasty. (a) The superior incision line extends from the deltopectoral groove along the bicipital groove to the mid point of the medial elbow. (b) The width of the skin excision is marked along the midpoint of the arm by pinch approximation of the tissues. (c) From that central point, a straight line is drawn to the medial elbow and on the

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other end, a second line is drawn toward the axilla. (d) From that point, a line is drawn along the PAF to the upper lateral chest. The final line joins the superior line at the deltopectoral groove to the inferior line ending at the midlateral chest. (e, f ) The final excision lines with cross hatching is shown for both the right and left arms

81.5 Operative Technique

Fig. 81.2 Five years after L brachioplasty. The faded longitudinal scars lay symmetrically along the bicipital grooves. While the arms are still large, there is no hanging skin

The patient is placed supine on the operating room table with the arms draped on arm boards as seen in another patient (Fig. 81.3). Forty milliliters of 1% xylocaine and 1 mg of epinephrine is added to a liter of saline and is infused until the excision site tissues are firm. Additional infiltration of the arm is performed if cosmetic liposuction is planned. Thorough liposuction, preferably ultrasonic assisted, of the excision incision is completed so that only skin with minimal underlying fat need be removed (Fig. 81.3). After the excision site liposuction, the premarked lines of skin excision are approximated with skin staples or towel clamps to confirm the width of resection. Adjustments are drawn and then the incisions are made through to the subcutaneous

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Fig. 81.3 Operative technique part 1. (a) The oversized marked right arm lies 90° abducted from the shoulder on an arm board, circumferentially prepped and ready for the brachioplasty. (b) The posterior arm fold is advanced to the deltopectoral groove by pinch approximation. One can confirm the equal distances of the superior and inferior incisions. (c) After infusion with saline containing xylocaine and epinephrine, the arm will undergo ultrasonic emulsification with VASER, using a double-ringed probe within the excision site until there is no further resistance

to the strokes. (d) Aggressive liposuction is completed when no further fat can be removed from the excision site. There is a cookie-cutter like depression of the excision site indicative of the near complete fat removal. Once the fat is removed, the width of the excision site is checked by staple approximation (not shown). (e) The inferior incision is made first followed by 2 cm of undermining. (f) After complete perimeter incision, the skin excision is started distally near the elbow

fascia with only several millimeters of undermining (Fig. 81.3). Starting distally at the elbow, the redundant medial skin is excised with a multi pronged rake retracting it and the surgeon’s helping hand pushing down the subcutaneous connective tissue (Fig. 81.4). The excision continues just under the dermis across the axilla and is completed with full thickness removal of skin and subcutaneous tissue along the lateral chest (Fig. 81.4). The previously placed hatch marks are aligned (Fig. 81.4). The closure begins a 2–0 braided absorbable suture approximating the subcutaneous tissue of the PAF triangular flap to the deltopectoral fascia across

the axilla. Then the first running suture of the two-layer closure is started with 0 or 2–0 PDO double armed Quill SRS (Angiotech Pharmaceuticals, Vancouver, British Columbia, Canada) (Fig. 81.4). The suture is placed in as a horizontal mattress and doubled back at the ends for several throws to be cut short in the suture line. The dermis is aligned with a running 2–0 Monoderm. Skin glue completes the closure (Fig. 81.4). No drains are placed. The suture line is covered with a large ABD dressing, which is secured with an ace wrap just short of the axilla. This dressing is changed for elastic sleeves 2–3 days later. The before and 3-year result of the cases are in Fig. 81.5.

81 L Brachioplasty Following Massive Weight Loss

Fig. 81.4 Operative technique part 2. (a, b) A composite excision of skin and subdermal fat is sharply dissected from the subcutaneous tissue of the arm, leaving behind the elastic connective tissue and neurovascular. With preservation of the lymphatics, there has no longer been a problem with lymphoceles. (c) The excision bed has a fairly uniform bed of fat, with no chance of injury to major cutaneous nerves. (d) The previously placed

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hatched marks are approximated with staples or towel clamps as seen here. Further excision is performed as needed. The first suture approximates the triangular flap to the deep fascia at the deltopectoral groove. (e) Then the two-layer closure begins with a running closure using absorbable sutures through the subcutaneous fascia. (f) The intradermal running suture completes the curvilinear closure

b

Fig. 81.5 (a) Preoperative. (b) Three years postoperative. There has been maintenance of the arm reduction with aesthetic contour. Despite primary healing of all incisions, the right scar has widened

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81.6 Discussion Patients following massive weight loss often develop severe deformities involving not only the arms, but the axilla and lateral chest. We have found traditional fulllength brachioplasties inadequate to treat these issues [1–4]. Moreover, the placement of a straight-line scar along the bicipital groove is conspicuous even when broken up by axillary T closures or Z-plasties. The design of the L brachioplasty addresses the deformities of the arms, axilla, and chest as a continuum. This approach can be applied both for the massive weight loss and the aged arm. Because both types of patients have loose hanging skin with poor elasticity, excess skin needs to be removed along the entire arm. The challenge is how to do this simply, symmetrically, and reliably while leaving aesthetic contours and inconspicuous scars. Short scar techniques to address both moderate to severe arm deformities are inadequate [6–8]. The width of the excisions through the arms and chest wall is addressed through meticulous preoperative assessment of excess skin through anatomic point locations followed by pinch-and-gathering maneuvers. Confidence in the planning and experience permits an expeditious removal of excess skin. In the full-sized arms, the resection width is difficult to determine unequivocally, especially, and a more conservative resection is undertaken initially that later might require further resection. As pinch and gather techniques are the most reliable means to determine width of resection, preformed skin excision patterns play no role [9]. The geometry of the L brachioplasty is uniquely designed to deal with the uneven lengths of the superior and posterior incision lines and the advancement of the PAF triangular flap into the axilla. Due to the hanging skin along the posterior border of the arm, the superior incision line is predictably shorter than the inferior incision line. Moreover, in the axilla, the posterior axillary line is more ptotic than the anterior axillary line. The arm skin excision is therefore more of a hemi-ellipse than a full ellipse. Interspersed, between the arms and chest is an inverted V-shape of skin that is to be removed from the axilla. Excision of this axilla tissue allows for cephalic advancement of this triangular flap of tissue into the deltopectoral junction. Advancement of this flap equalizes the superior and inferior limb lengths. There are those that advocate use of a Z-plasty or a T-pattern closure to recreate the axillary dome and

D. Geldwert and D. J. Hurwitz

retard axillary contracture [1, 3, 10–13]. This is a conceptual error because the axillary deformity is addressed secondarily. The ill fit relates to the static Z-shaped scar in a dynamically reshaped axilla and the subtle coning at each closed angle of the Z-plasty. The Z-plasty can also interpose different skin types (hair vs. nonhair; thick vs. thin) and lead to a cobblestonelike appearance of the axilla. The Z-shape of the scar is subtle only if it fails to become hypertrophic. T-pattern excisions in which the axillary and arm scars meet at right angles in the dome of the axilla can provide only limited elevation of the descended PAF [3, 14]. Tip necrosis with widening of scars and contracture do occur. The T-junction scar can also drift into the arm. The appropriate recognition of the aesthetic landmarks of the axilla allows for the proper restoration of these at the time of the brachioplasty. The axilla is a dome-shaped structure that is formed by the tight adherence of the thin, mostly hair-bearing axillary skin to the clavipectoral fascia. The axilla is bordered by the inner arm, lateral chest, and axillary folds. The AAF is created by the firm skin adherence to the lateral border of the pectoralis major muscle. The gentle concavity of the AAF turns abruptly convex around the lateral border of the breast. The posterior border is formed by the PAF, which is formed by the firm skin adherence along the lateral border of the latissimus dorsi muscle. Any resection or atrophy of these muscles would disrupt these landmarks. Unseen with the arms at the side, the armpit crevasse is seductively deepest when the arm is extended 90° and flattens with the arm fully extended. The L brachioplasty is similar to Pitanguy’s [15] extended brachioplasty except that the anterior incision line is made just behind the AAF. This position allows the greatest effect to raise the descended PAF and the largest angle of divergence, minimizing the chance for constricting contracture. The eventual scar, due to competing skin tensions across the closure, however usually ends up in the midlateral chest. The authors have used a deepithelialized thoracic extension of the Pitanguy operation to contribute to an upper body lift and spiral flap reshaping of the breast. Along with the spiral flap reshaping of the breast, the L brachioplasty restores complex aesthetic curves of the upper torso [16, 17]. Postoperative complications range from delayed healing at the tip of the triangular flap, lymphoceles, and hypertrophic scarring. Lymphoceles and prolonged postoperative edema can be troublesome [18]. The

81 L Brachioplasty Following Massive Weight Loss

authors have accepted Pascal’s [19] rationale of excision site liposuction for sparing of lymphatic structures, with a reduction in the rate of lymphocele formation to near zero. Moreover, skin-only excision after liposuction preserves the underlying vasculature and obviates the need for extensive undermining. The medial and lateral antebrachial cutaneous nerves that travel in conjunction with the basilic and cephalic veins, respectively, should be protected and preserved. The securing of the triangular flap to the deltoid fascia obviates deep stitching into the axillary fascia and injury to the major nerves [3, 13]. Drains have never been used because there is no significant undermining and the vacuum may encourage late lymphoceles.

81.7 Conclusions The L brachioplasty is a safe, innovative, effective, and aesthetically pleasing technique to correct upper arm and lateral chest deformities following massive weight loss. This approach also has utility in selected cases of aging arms. The final scars are inconspicuous and the arm mobility is unrestricted. Integrating the brachioplasty into an upper body lift improves the contours of the arms, axilla, and lateral chest, thus contributing to an improved and harmonious body contour. Integrating excision site liposuction has proven useful in reducing lymphatic and vascular disruption and postoperative morbidity.

References 1. Regnault P. Brachioplasty, axilloplasty, and pre-axilloplasty. Aesthetic Plast Surg. 1983;7(1):31–6. 2. Vogt PA, Baroudi R. Brachioplasty and brachial suctionassisted lipectomy. In: Cohen M, editor. Mastery of plastic

801 and reconstructive surgery. Boston: Little Brown; 1994. p. 2219–36. 3. Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96(4):912–20. 4. Baroudi R. Dermolipectomy of the upper arm. Clin Plast Surg. 1975;2:485–91. 5. Hurwitz DJ, Holland SW. The L brachioplasty: an innovative approach to correct excess tissue of the upper arm, axilla, and lateral chest. Plast Reconstr Surg. 2006;117(2): 403–11. 6. Richards ME. Minimal-incision brachioplasty: a first-choice option in arm reduction surgery. Aesthetic Surg J. 2001; 21:301–10. 7. Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg. 1998;102(2):545–51. 8. Abramson DL. Minibrachioplasty: minimizing scars while maximizing results. Plast Reconstr Surg. 2004;114(6): 1631–4. 9. de Souza Pinto EB, Erazo PJ, Matsuda CA, Regazzini DV, Burgos DS, Acosta HA, do Amaral DG. Rejuvenation technique with the use of molds. Plast Reconst Surg. 2000; 105(5):1854–60. 10. Regnault P. Brachioplasty, axilloplasty, and pre-axilloplasty. Presented at VII International Congress of the Confederation of Plastic and Reconstructive Surgery, Rio de Janiero, May 20–25, 1979. Abstract in Transaction of the Seventh International Congress of Plastic and Reconstructive Surgery. São Paulo: Cartgraft; 1979. p. 639. 11. Guerrerosantos J. Brachioplasty. Aesthetic Plast Surg. 1979; 3:1–9. 12. Chandawarker RY, Lewis JM. “Fish-incision” brachioplast. J Plast Reconstr Aesthetic Surg. 2006;59(5):521–5. 13. Strauch B. A technique of brachioplasty. Plast Reconstr Surg. 2004;113(3):1044–8. 14. Juri J, Juri C, Elias J. Arm dermolipectomy with a quadrangular flap and “T” closure. Plast Reconstr Surg. 1979;64(4): 521–5. 15. Pitanguy I. Correction of lipodystrophy of the lateral thoracic aspect and inner side of the arm and elbow. Clin Plast Surg. 1975;2(3):477–83. 16. Hurwitz DJ. Single stage total body lift after massive weight loss. Ann Plast Surg. 2004;52(5):435–41. 17. Hurwitz DJ, Agha-Mohammadi S. Postbariatric surgery breast reshaping: the spiral flap. Ann Plast Surg. 2006;56(5): 481–6. 18. Knoetgen J III, Moran SL. Long-term outcomes and complications associated with brachioplasty: a retrospective review and cadaveric study. Plast Reconstr Surg. 2006;117(7): 2219–23. 19. Pascal JF. Brachioplasty. Aesthetic Plast Surg. 2005;29(5): 423–9.

Brachioplasty After Bariatric Surgery

82

Franco Migliori

82.1 Introduction The increase of body contouring procedures after massive weight loss following bariatric surgery is astonishing: in the United States in 2004, almost 56,000 out of 140,000 bariatric patients underwent BC surgery, and in 2005, 100,000 out of 250,000 [1]. Even a neologism has been proposed: “bariplasty” [2]. Plastic surgery is a science. Body contouring is a scientific art. This means that, despite any surgical algorithm, there is no “perfect shape” to aim for: there can be, for any body district, some key points to respect; but the main key point remains the patient’s “body image” as a whole. This concept includes subjective and objective evaluations, which differ from patient to patient. In our experience, 67% of postbariatric patients underwent multiple body contouring procedures (from 2 to 4 operations): there is no algorithm that determines the timing and suitability of one procedure rather than another. So the “right time” or the “right place” in which brachioplasty should be performed cannot be stated. Among every consideration, the psychological impact on the patient should be considered, trying to choose more effective one as starting procedure. As usually happens in body contouring procedures, the surgeon’s main aim is to find the right compromise between maximal reduction of excess tissue and maximal reduction of scar length. Moreover, body contouring is quite an aggressive surgery and the risk/ benefit rate is important to be well evaluated and

F. Migliori Plastic Surgery Unit, “San Martino” University Hospital, Genova, Italy e-mail: [email protected]

understood: the same operations could fit a patient, but not another. A personal histological study [3] on postbariatric surgery dermis and fat is running nowadays. Preliminary reports, comparing postbariatric surgery tissues with healthy tissues, demonstrates: 1. In the fat: presence of collapsed adipocytes with thicker membranes, prominent nuclei (usually not visible), and thickened intracellular fibrous septa. 2. In the dermis: thickening of the fibrous net and the hypertrophy of the vascular net. A reduction of elastic fibers is supposed, but results of histochemical and EM study are awaited. The anatomosurgical and histological features of postbariatric surgery patients confer to their tissues an “anergic behavior,” meaning a poor or absent scar retraction. Because of that, the surgical techniques mainly suggested are those removing all exceeding tissue. Thus liposuction, where results depend on scar retraction, cannot be utilized except as an ancillary technique in rare selected cases.

82.2 General Management Brachioplasty (unless extreme cases) is a medium/ minimal invasive surgery with reduced tissue removal. Although one complication of BS (mainly gastric bypass and biliopancreatic diversion) can be vitamin B12 and Fe++ malabsorption, with consequent anemia [4], major blood losses are not expected after brachioplasty: autotransfusion is not taken into consideration. Nevertheless, it is strongly suggested to perform infiltration of all the tissues to be excised with a diluted

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_82, © Springer-Verlag Berlin Heidelberg 2010

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solution of adrenaline (1 mL/500 mL NaCl) of at least 20 mL before cutting: this procedure allows a great amount of circulating mass to be squeezed off, significantly reducing blood losses. A referred major risk in body contouring is deep venous thrombosis [5], with blood clots and pulmonary embolism. So, prophylaxis with antiembolic compressive stockings and low-molecular weight heparin (4,000/6,000 U.I. 12 h before surgery, continued daily for 2 weeks) is suggested. Seromas and liponecrosis can be challenging complications. There are two general rules to reduce their incidence:

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morphological correction. This does not mean passing from a “batwing” effect (Fig. 82.1) to a “sweater sleeve” effect (Fig. 82.2), but to a normal arm profile. A stigma of this “normality” should be represented by a slight concavity in the arm lower profile proximal to the elbow (Fig. 82.3).

• Avoiding any cutting device but blade: no other known instrument is less tissue damaging • Limiting undermining and/or performing it along anatomical planes, minimizing tissue damaging (exp. fat tissue) The extension of scars can be overwhelming in the majority of brachioplasties. Extreme accuracy in suture technique and material choice can make the difference, reducing hypertrophies and keloids occurrence. Only deep, dermal, and intradermal suture should be utilized, with no cutaneous suture. Dedicated threads and needles have been conceived for BC and it is advisable to use them in brachioplasty. In spite of all these, brachioplasty scar quality is often low.

Fig. 82.1 An example of “batwing” defect

82.3 General Surgical Strategies Within postbariatric body contouring procedures, brachioplasty appears to be very exclusive, since the request is definitely lower than for other districts (7% of all procedures in our experience). Reviewing the literature [6–13], modest results are usually found due to modest improvement of the morphological defect, together with remarkable scars and important complication risks. In this particular anatomical area, the best possible result should be pursued, optimizing cost/benefit ratio in terms of maximal correction/less visible scars. If this strategy cannot be applied, brachioplasty should be discouraged. A technique has therefore been developed, based on a linear scar programmed to be hidden in the medial bicipital groove, and aiming to obtain the best possible

Fig. 82.2 “Sweater sleeve” effect, typical unpleasant result of a brachioplasty

Fig. 82.3 Normal arm, with lower profile concavity proximal to the elbow

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Patients are grouped according with Strauch 4-class classification of defects [7]:

82.4 Preoperative Markings

1. Minimum or modest subcutaneous fat with minimum cutaneous laxity. 2. Generalized accumulation of subcutaneous fat with minimum cutaneous laxity. 3. Generalized obesity with extended cutaneous laxity. 4. Minimum subcutaneous fat with extended cutaneous laxity.

Special care is spent in evaluating the amount of tissue to be excided. Only the anterior aspect of the excision is normally drawn, and the actual quantity of skin to be dismissed is determined intraoperatively. This algorithm is operator dependent, and the compulsory rule is that markings must be drawn by the first surgeon. With patient standing in frontal view, arms abducted at shoulder level and forearms proned (“crucifix” position), the incision line is drawn within the medial bicipital groove, while applying with the contralateral hand a slight anteroposterior tension on the medial face of the arm (the same tension will be applied during surgery) (Fig. 82.4). In this way, the incision line lies about 1–2 cm. above the medial bicipital groove (Fig. 82.5). This line continues on the posterior axillary pillar, gently curving at 90° and becoming vertical, just posterior to and extending as axillary hair (4–5 cm) (Fig. 82.6).

Postbariatric surgery patients usually belong to classes 3 and 4. The anatomical regions for treatment by surgery are mainly area 2 (arm) and area 3 (axilla), according to the Strauch et al. [7] anatomical scheme.

82.5 Surgical Technique

Fig. 82.4 Markings performed with tissues under tension

Fig. 82.5 Incision line scheme

After a wide literature review, proposing any kind of incision shape, no acceptable demonstration is found showing that linear incision (from medial epicondyle to axilla along medial bicipital groove) produces worse scar than other ones. So the linear

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Fig. 82.6 Final aspect of the drawing: quite a simple one, because other evaluations will be made intraoperatively

incision is preferred because it is better hidden than other ones. A deep incision is done on that line, directly on the muscular fascia, preserving it. An anteroposterior undermining is gently performed with the tip of a blade, following fascia surface for almost half circumference of the arm Fig. 82.7). Great attention must be paid as undermining passes above bicipital groove because it is easy to deepen the incision and to get behind triceps muscle: in that case, ulnar nerve and brachial artery could be exposed and damaged. All perforating vessels and nerves (i.e., medial antibrachial cutaneous nerve),

Fig. 82.7 Undermining scheme

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Fig. 82.8 Undermining performed on the fascia layer, preserving vessels and nerves

long enough to be let loose, are preserved until exceeding tissue extension is determined (Fig. 82.8). As the undermining is completed, an overcorrective tension is applied to anterior edge of incision and to the undermined flap, similar to that applied while marking. The flap is overlapped to incision edge, whose superficial projection is spot-marked with 3–4 transfixed needles and completed with a straight line joining incision tips. Incision is then performed obtaining, in this way, an excided tissue extension always rather abundant: only perforating vessels and nerves feeding this area are tied and cut (Fig. 82.9).

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1 month postoperatively. Drugs (i.e., Dermatix® and Sifravit®) and devices preventing pathological scars are strongly suggested, because hypertrophies and keloids are frequent in this area. Suggested follow-up time is ranged about 6 months postoperative. A self-administered rating scale test (i.e., BUT) study [14] is recommended as in any other postbariatric surgery body contouring procedures, in order to evidence the percentage of improvement of patient discomfort.

82.7 Complications Fig. 82.9 Redundant tissue excision completed

General complications are represented by scar hypertrophy/keloid (40%), edema (15%), seroma (10%), and wound dehiscence (5%). Specific complications include: 1. Compression of the ulnar nerve with acute pain and hand motor deficiencies; the symptoms must be promptly recognized and solved by partial suture releasing and sequential delayed closure (1 suture/ day within 1 week); 2. Section of cutaneous branches of the anterior medial brachial nerve results in small areas of anesthesia (2–3 cm2.). A long period of time (6 months/2 years) may be required to recover.

Fig. 82.10 Flap rotation on axillary incision angle

82.8 Discussion

Suture is performed under tension, so great care is spent to provide precise and tight edge fitting, through at least two suture layers. The first suture must fix a posterior flap whose medial length is determined by the axillary incision angle (Fig. 82.10). Suction drains are placed and maintained 1–2 days postoperatively.

This technique confers a natural arm shape and profile, reproducing the inferior concavity proximal to the elbow (Figs. 82.11 and 82.12). The results, compared with average ones published in literature, appear better. Linear scar is long, seldom of high quality, but often well hidden within the medial bicipital groove and not visible in the frontal view as well as in the posterior view. Respect of sensitive cutaneous branches innervation allows good preservation of touch within the medial arm aspect. This is not a simple technique, requires a long learning curve, and is strongly operator dependant. Good experience in body contouring plastic surgery is needed. In spite of this, we are strongly convinced that this is the best way to face the “batwing” deformity. Arm profile defects are not primary aesthetic problems in a postbariatric patient, and an optimal result should

82.6 Postoperative Care The mean operating time is 135 min (range 115/155). Mean hospital stay is 3 days (range 2/4) after surgery without main complications. In case of main complications (ulnar nerve compression, major seromas), mean hospital stay increases up to 10 days (range 8/12). Elastic tubular bandages (i.e., Tubigrip®) have to be worn for about

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Fig. 82.11 (a) Preoperative 38-year-old female after gastric by-pass. (b) Postoperative

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Fig. 82.12 (a) Preoperative 46-year-old female. (b) Postoperative

be aimed in order to justify such a quite invasive surgery. In our experience and in the literature, an easyto-use procedure is more safe, but offers much less aesthetic improvement.

References 1. Singh D, Forte A, Loerke C, Bell R, Thomson JG. Prognostication of body contouring after bariatric surgery. Plast Reconstr Surg. 2006;118(4 suppl):144. 2. O’Connell JB. Bariplastic surgery. Plast Reconstr Surg. 2004;113(5):1530. 3. Migliori F, Robello G, Ravetti JL, Marinari GM. Histological alterations following bariatric surgery: pilot study. Obes Surg. 2008;18(10):1305–7. 4. Folope V, Coëffier M, Déchelotte P. Nutritional deficiencies associated with bariatric surgery. Gastroenterol Clin Biol. 2007;31(4):369–77. 5. Shermak MA, Chang DC, Heller J. Factors impacting thromboembolism after bariatric body contouring surgery. Plast Reconstr Surg. 2007;119(5):1590–6.

6. Guerrero-Santos J. Brachioplasty. Aesthetic Plast Surg. 1979;3:1–4. 7. Strauch B, Greenspun D, Levine J, Baum T. A technique of brachioplasty. Plast Reconstr Surg. 2004;113(3): 1044–8. 8. de Souza Pinto BE, Erazo PJ, Matsuda CA, Reggazini DV, Burgos DS, Acosta HA, do Amaral AG. Brachioplasty technique with the use of molds. Plast Reconstr Surg. 2000; 105(5):1854–60. 9. Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96(4):912–20. 10. Goddio AS. A new technique for brachioplasty. Plast Reconstr Surg. 1989;84(1):85–91. 11. Mahjouri F. A technique in brachioplasty. Plast Reconstr Surg. 2005;116(2):678–9. 12. Abramson DL. Minibrachioplasty: minimizing scars while maximizing results. Plast Reconstr Surg. 2004;114(6): 1631–4. 13. Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg. 1998;102(2):545–51. 14. Pecori L, Serra Cervetti GG, Marinari GM, Migliori F, Adami GF. Attitudes of morbidly obese patients to weight loss and body image following bariatric surgery and body contouring. Obes Surg. 2007;17(1) 68–73.

Brachioplasty and Axillary Restoration with Treatment Algorithm for Brachioplasty

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Charles K. Herman and Berish Strauch

83.1 Introduction Surgical planning for upper extremity contouring must consider several important anatomic features. The location and extent of skin excess must be assessed, the quality and tone of the skin must be addressed, the amount of fat present must be determined, and the interface between the arm, axilla, and chest wall must be visualized. Many methods of upper extremity contouring have been described, including resection brachioplasty [1–8], liposuction-based techniques, and combination procedures, but none is completely satisfactory for all deformities. The surgical approach must be tailored to the individual patient based on the surgeon’s analysis of the aforementioned anatomic considerations. The unresolved problems of brachioplasty techniques include postoperative residual contour deformities, hypertrophic scars, widened scars, and patient dissatisfaction with scar location. In order to systematically address the above concerns, we have utilized a treatment algorithm based on four anatomic treatment zones to help the surgeon evaluate the upper extremity contour deformities (Fig. 83.1). Zone I is defined as the forearm, Zone II is defined as the region between the olecranon and the anterior axillary fold, Zone III is defined by the borders of the axilla, and Zone IV is defined as the subaxillary lateral chest wall. By evaluating each of these zones, the surgeon can develop a surgical plan that limits postoperative contour deformities. Patients with limited skin excess in Zone II can be good candidates for a short-scar brachioplasty

C. K. Herman () Plastic and Reconstructive Surgery, Pocono Health Systems, 100 Plaza Court, East Stroudsburg, PA 18301, USA e-mail: [email protected]

Fig. 83.1 Zonal classification of the upper extremity based on anatomy

with an elliptical incision placed in the axillary crease that extends anteriorly and posteriorly (Fig. 83.2). A short distal extension to provide a “T-shaped” closure can be added for more skin excision. In cases of significant fat excess, suction-assisted lipectomy is an effective adjunct. Patients presenting with deformities extending across a combination of Zones II, III, and IV, which includes many massive weight-loss patients, or Zones II and III alone are more amenable to full brachioplasty technique described in this chapter (Fig. 83.3). In the most extreme cases, many of the patients who lose massive amounts of weight from weight-loss surgery or from aggressive dieting and

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Fig. 83.2 Short-scar brachioplasty with liposuction, before and after. Scar is relatively wellconcealed in the axilla

Fig. 83.3 Full brachioplasty with a posteromedial sinusoidal scar and axillary contouring with a Z-plasty

exercise develop a contour deformity similar to a bat’s wing that extends from the olecranon across the axilla to the chest wall (Figs. 83.4 and 83.5). This extensive deformity necessitates a long incision length to adequately resect the ptotic skin of the arm, axilla, and chest wall that predispose to postoperative contour deformities, especially of the axilla and chest wall. In addition to contour deformities, scars are significant concerns for patients. Patients with mild to moderate skin and/or fat excess limited to Zone II are generally less tolerant of scars. In these cases, the concealed axillary scar afforded by a short-scar technique is generally

preferred (Fig. 83.2). For full brachioplasty procedures, a variety of locations have been described for final scar placement, including along the anteromedial arm in the bicipital groove, along the medial arm, and along the posterior arm. The authors believe that scar placement can account for the difference between a satisfied and dissatisfied patient. Patients object to bad scars, but the location of scars may make their presence more or less acceptable. There are many examples of this. An obvious example would be to compare a visible facial scar with a similar scar on the back of the head. The former is more objectionable because the scar is constantly

83 Brachioplasty and Axillary Restoration with Treatment Algorithm for Brachioplasty

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Fig. 83.6 Axillary contouring with a Z-plasty restores the normal concavity to the axilla

Fig. 83.4 Brachioplasty, before and after. Massive weight-loss patient with extensive upper extremity and axillary skin excess

visible to a patient looking into a mirror and to friends and family, who see the face more readily than the back of the head. Keeping this philosophy in mind, the brachioplasty technique described below, as previously published, creates an undulating sinusoidal scar, reducing linear scar contracture, that is placed well posterior to the medial bicipital groove, minimizing the visibility of the final scar from the frontal position [9]. A Z-plasty in the axilla reconstitutes the natural concavity of the axillary dome (Fig. 83.6). The brachioplasty technique described in this chapter uniquely combines modifications of previously described approaches with a novel treatment for restoration of the axillary contour.

83.2 Technique 83.2.1 Short-Scar Brachioplasty

Fig. 83.5 Brachioplasty, before and after. Full brachioplasty and axillary contouring

This procedure is performed under local anesthesia with intravenous sedation or general anesthesia. Markings are made preoperatively. The existing axillary crease is marked proximally. By providing traction on the distal skin and pulling proximally, an elliptical excision with its widest dimension along the medial midaxial line of the arm is drawn. In cases where skin excess extends more distally along Zone II, a medially placed longitudinal ellipse is drawn, resulting in a “T-shaped” closure.

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Areas of planned liposuction are drawn with a marking pen. In the operating room, the skin excision areas are locally infiltrated with xylocaine with epinephrine; dilute liposuction infiltrate is used with a “superwet” technique for the areas of planned liposuction. Tumescence of the liposuction areas is not necessary and can distort the anatomy and interfere with the assessment of skin excess. Liposuction infiltrate is not used in any case except for a short-scar brachioplasty combined with liposuction. Liposuction is generally performed first. A small stab incision just posterior to the olecranon facilitates liposuction. In the axilla, the proximal incision is made first and the skin and fat undermined from the deep fascia from proximal to distal. The dissection is extended just beyond the planned line of distal skin excision to promote improved skin redraping. The skin is pulled proximally and the markings readjusted if necessary to provide minimal tension on the closure. Overresection of the skin is to be avoided and can result in “tenting” of the axillary crease. Drains are generally not used. The incisions are dressed with Xeroform gauze and Telfa and then wrapped with Kling (Johnson and Johnson Medical, Arlington, TX) and a snugly applied Ace bandage (DE Healthcare Products, Denver, PA). A Spandage (Medi-Tech International, Brooklyn, NY) dressing is then applied over the Ace wrap from the right wrist across to the left wrist, with an opening in the center for the head and neck. The patient is placed into an elastic upper extremity compression garment during the postoperative visit at 3–4 days after surgery.

83.2.2 Full Brachioplasty The procedure is performed either under local anesthesia with intravenous sedation or, more commonly, general anesthesia. The patient is marked immediately before surgery in the standing position; however, the final markings are completed and refined with the patient asleep. The patient is positioned supine with the arm abducted 90° and the elbow in approximately 80° of flexion. A line is then visualized along the axis of the arm from point A to the medial end of the excess tissue, either on the chest wall or in the axilla; the latter point is marked point B. This line serves as a reference about which two sinusoidal incisions are planned on either side of the excess skin fold, much as one would plan to separate syndactylous digits. The sinusoidal flaps are planned to interdigitate

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when the excess skin and fat are resected. The incisions are marked so that their proximal convergence is at point A and their distal convergence is at point B. The distance between the two skewed sinusoids is planned to produce a final scar that lies on the posteromedial aspect of the arm, slightly posterior to the medial bicipital groove. Markings are made on the bilateral upper extremities, as described. The olecranon and the medial epicondyle of the humerus are identified; the midpoint between these structures is identified as point A and marked on the skin surface (Fig. 83.3). Next, the skin and superficial subcutaneous tissue are sharply incised along the sinusoidal markings down to the level of the underlying muscular aponeurosis. The subcutaneous tissue between the sinusoidal incisions is elevated off the muscular aponeurosis. Care must be taken to avoid injury to the ulnar nerve and superficial sensory nerves at this stage. There is no need to undermine wider than the margins of the surgical wound, as the laxity of the remaining skin should permit easy closure. An axillary Z-plasty is planned with the final transverse limb lying in the apex of the axilla, extending between the two axillary folds, to restore the appearance of the axillary dome (Fig. 83.6). The upper and lower limbs of the Z are marked at approximately 60° to the central limb on either side of the resection. The central limb of the Z will ultimately lie in the transverse axis of the axillary dome, and the other limbs will run parallel to the anterior and posterior axillary folds. A portion of the sinusoidal incisions extends medial to the Z-plasty in those patients who have their excess extending into Zone IV. The Z-plasty principle creates a longer length in the direction of the major scar, allowing the tissue to settle into the dome, and at the same time, allowing also for an anteroposterior tightening of the skin closure. All incisions are closed using a two-layer Vicryl clip closure for deep and more superficial subcutaneous tissue levels. A 3–0 Monocryl continuous dermal suture followed by Dermabond (Ethicon) and Steri-Strips (3M) complete the closure. Closure of the sinusoidal incisions is begun at both ends. Jackson-Pratt drains are brought out of the chest wall closure site. Wounds are dressed with Xeroform (Sherwood Medical, St. Louis, MO) and saline-moistened gauze. The extremities are then wrapped from the wrist to the axilla with Kling (Johnson and Johnson Medical) and a snugly applied Ace bandage (DE Healthcare Products). A Spandage (MediTech International) dressing is then applied over the Ace wrap from the right wrist across to the left wrist, with an opening in the center for the head and neck.

83 Brachioplasty and Axillary Restoration with Treatment Algorithm for Brachioplasty

83.3 Complications Complications associated with brachioplasty surgeries have been reported to include contour deformities, skin flap necrosis and dehiscence, infection, hematoma formation, seromas, nerve damage, and hypertrophic scarring. In our experience with 264 consecutive cases, no cases of skin flap necrosis or dehiscence, infection, hematoma, or nerve damage occurred. The incidence of contour deformity requiring revision was less than 0.5%, seroma collections in 1, and 15% of patients developed hypertrophic scars that improved with time, steroid injections, and/or compression dressings. A recent review by Knoetgen and Moran [15] of 47 bilateral brachioplasties reported a 12.5% revision rate and 5% incidence of injury to the medial antebrachial cutaneous nerve. Gusenoff et al. [10] prospectively registered massive weight-loss patients in a study examining complication associated with brachioplasty surgery. A higher incidence of complications was found in this subset of patients, and even higher during brachioplasty surgery performed concomitantly with other surgeries, including thighplasty, abdominoplasty, lower body lift, and mastopexy. A seroma rate of 24%, a wound dehiscence rate of 9%, and an infection rate of 3% were reported.

83.4 Discussion During the evolution of brachioplasty surgery, a variety of techniques have been described, including straight-line and sinusoidal pattern closures; anteriorly-, posterior-, and medially-placed scars; adjunctive liposuction; and short-scar techniques to decrease the scar burden. As no single technique has been found to be ideal, a variety of complications associated with brachioplasty continue to be reported, including hypertrophic and noticeable scarring, seromas, hematomas, skin loss, nerve injury, and significant contour deformities. A patient’s individual anatomy must be considered in the light of the abovementioned classification system in order to systematize the approach that provides the optimal result. Short-scar techniques are best reserved for patients with limited skin excess in Zone II. More pronounced fat deposits can be effectively treated by combining the skin excision with liposuction. In our experience, these

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patients are generally older patients with poor skin tone and skin ptosis mainly along the proximal upper arm, or younger patients with a significant amount of fat amenable to liposuction with limited skin excess. The full brachioplasty technique described above has been found to be highly effective for patients with significant skin excess and ptosis extending beyond Zone II, particularly massive weight-loss patients. The sinusoidal type pattern used for the lengthy skin incision reduces the possibility of a straight-line linear contracture, and its more posteromedial placement, in line with the posterior axillary fold, makes the resultant scar less noticeable to the patient when viewed from the front. This is in contrast to the typically described location along the medial bicipital sulcus, where the scar is more visible when viewed from this perspective or when the patient looks at himself/ herself in a mirror. By incorporating the long-axis arm incision into the Z-plasty rather than performing a separate procedure proximal to the arm brachioplasty such as T or V closures as others have previously described [11–13], we are able to restore more natural contour to the axilla. A smaller axillary Z-plasty was first described in a drawing by Guerrero-Santos in his 1979 article [14]. However, the magnitude and extent of our described Z-plasty is intended to restore axillary contour and lengthen the scar. This maneuver reduces axillary ptosis and restores a more natural dome shape to the axilla, thereby correcting deformities that extend through Zones II and III and those in Zones II, III, and IV. Finally, by extending the resection proximally to the subaxillary chest wall, a natural contour to the medial portion of the axilla and the subaxillary chest wall can be reestablished (Zone IV). Further attempts at correcting the centripetal sagging of the back and breasts simultaneously with the brachioplasty [15] appear to create scar directions that are in competition with each other. Deeply placed anchoring sutures are not used or advisable, as vital structures in the axilla may be injured. For the brachioplasty patient, an algorithm can be developed that is dependent on the extent and involvement of each of the four zones. In Zone II alone, the patient’s deformity may be addressed with liposuction and a short-scar or sinusoidal excision, or with liposuction alone, depending on the extent of the deformity present. In those patients with tissue excess involving Zones II and III, treatment consists of sinusoidal resection to the medial limits of the axilla, with a Z-plasty in

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Zone III. In deformities involving Zones II, III, and IV, generally seen in massive weight-loss patients, the sinusoidal incisions continue medial to the Z-plasty into Zone IV. In this manner, the excess skin in this zone is contoured. Deformities of Zone I alone are almost invariably excess volume without excess skin and can be treated with liposuction alone if desired. The surgeon should be cautious in combining brachioplasty surgery with other operations at the same setting, as a higher complication rate may result during the brachioplasty [10]. It is our preference to perform the brachioplasty alone or with corrective breast surgery, avoiding performing the surgery with more extensive operations, such as lower body lift.

83.5 Conclusions Upper extremity contouring surgery requires an understanding of the anatomy of the upper arm and is facilitated by the zonal classification of skin excess described above. Each patient must be considered individually with the operation tailored to the patient’s anatomy. Patients objecting to traditional extremity scars, who demonstrate limited skin excess, may benefit from a short-scar approach; liposuction may be added for the reduction of fatty tissue. The full brachioplasty approach that is described in this chapter combines sinusoidal scars, posteriomedial scar placement, and an axillary Z-plasty to decrease the incidence of many of the complications that have plagued traditional brachioplasty techniques.

C. K. Herman and B. Strauch

References 1. Correa-Iturraspe M, Fernandez JC. Dermolipectomia braquial. Prensa Med Argent. 1954;41(34):2432–6. 2. De Souza Pinto EB, Erazo P, Matsuda CA, Regazzini DV, Burgos DS, Acosta HA, do Amaral AG. Brachioplasty technique with the use of molds. Plast Reconstr Surg. 2000; 105(5):1854–60. 3. Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg. 1998;102(2):545–51. 4. Richards ME. Minimal-incision brachioplasty: a firstchoice option in arm reduction surgery. Aesthetic Surg J. 2001; 21:301. 5. Goddio AS. Brachioplasty: new technique. Ann Chir Plast Esthet. 1990;35(5):201–8. 6. Lockwood T. Contouring of the arms, trunk and thighs. In: Achauer BM, Eriksson E, Guyuron B, Coleman JJ III, Russell RC, Vander Kolk CA, editors. Plastic surgery: indications, operations, and outcomes. St. Louis: Mosby; 2000. 7. Grazer FN. Rejuvenation of the upper arm. Plast Reconstr Surg. 1998;102(2):552. 8. Goddio AS. A new technique for brachioplasty. Plast Reconstr Surg. 1989;84(1):85–91. 9. Strauch B, Greenspun D, Levine J, Baum T. A technique of brachioplasty. Plast Reconstr Surg. 2004;113(3):1044–8. 10. 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(2):595–603. 11. Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96(4):912–20. 12. Juri J, Juri C, Elias JC. Arm dermolipectomy with a quadrangular flap and T closure. Plast Reconstr Surg. 1979;64(4): 521–5. 13. Regnault P. Brachioplasty, axilloplasty, and pre-axilloplasty. Aesthetic Plast Surg. 1983;7(1):31–6. 14. Guerrero-Santos J. Brachioplasty. Aesthetic Plast Surg. 1979;3:1. 15. Hallock GG, Altobelli JA. Simultaneous brachioplasty, thoracoplasty, and mammaplasty. Aesthetic Plast Surg. 1985; 9(3):233–5.

Current Techniques in Medial Thighplasty

84

David W. Mathes

84.1 Introduction The medial thigh area remains a troublesome region for body contouring in patients with generalized liphodystrophy and skin flaccidity. Skin laxity is one of the first signs of aging in the thighs and is often a harbinger of significant ptosis in the body. The use of suction-assisted lipectomy to contour the medial thigh can be used in those patients with lipodystrophy without skin laxity. However, this technique fails, in most circumstances, to remodel and tighten the inner thigh when the skin is thin and inelastic. In addition, aggressive liposuction may also result in conspicuous contour abnormalities. Rejuvenation of the medial thigh, in many patients, requires both removal of fat deposits as well as excision and redraping of the medial thigh skin. This is especially true in the massive weight loss (MWL) patient, where the skin laxity can be quite severe and extend down to, and even below, the knee. The medial thigh lift was first described more than 30 years ago [1], but did not gain widespread acceptance due to the postoperative problems of inferior wound migration and widening of the scars, a lateral traction deformity of the vulva, and early recurrence of ptosis. The morbidity is due, in part, to the thin nature of the skin and dermis and the relative absence of a well-defined superficial facial system in the medial thigh. Lockwood attempted to address these issues when he described a fascial anchoring technique in the medial thigh lift [2, 3]. He recommended anchoring the dermal tissue of the

D. W. Mathes Department of Surgery, Division of Plastic Surgery, University of Washington School of Medicine, Seattle, WA 98195, USA e-mail: [email protected]

distal medial thigh tissue to Colles’s fascia to allow for more stable and long-term result. These changes in the surgical design of the medial thigh lift have improved results and decreased complications, but still have the fundamental problem of poor tissue fixation to rigid tissue. Modifications to this technique have been described in an effort to provide increased support to the medial thigh incisions. In this chapter, we describe our approach to the medial thigh lift in those patients that have undergone a previous weight loss procedure, the MLW patient, and the more traditional non-MLW thigh lift patient [4–7].

84.2 Anatomy In contradistinction to other areas undergoing surgical rejuvenation, such as the abdomen or the lateral thigh, the medial thigh has a relatively thin outer layer of epidermis and dermis. Deep to the dermis, there are two distinct layers of adipose tissue. In between these two layers is a poorly defined superficial facial layer. The deep layer of the superficial perineal fascia as described by Lockwood is a distinct connective tissue layer lying deep to the subcutaneous fat of the perineum. It attaches to the ischopubic rami of the bony pelvis, while anteriorly, it is continuous over the pubis with Scarpa’s fascia of the abdominal wall. Posteriorly, it fuses with the posterior border of the urogenital diaphragm. At the junction of the perineum and medial thigh, a dense area of this strong Colles’ fascia can be identified. Colles’ fascia provides the anatomic shelf that defines the perineal thigh crease. One can identify the Colles’ fascia by, first, dissecting to the origin of the adductor muscles on the ischiopubic ramus and then retracting the skin and superficial

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fat of the vulva medially. The Colles’ fascial roll lies at the deepest and most lateral aspect of the vulvar soft tissue. The femoral triangle should be identified and preserved to reduce the chance of complications, as deep dissection can lead to disruption of the lymphatic channels. Damage to these important structures can result in prolonged edema and even lymphatic collections.

84.3 Patient Selection One of the earliest signs of aging of the lower extremities is the presentation of medial thigh laxity. The skin of the superior medial thigh is quite thin which may allow the development of early ptosis. Women begin to present with these symptoms between the ages 35 and 45. They also commonly complain of fat deposition in the trochanteric and hip areas as well as in the medial thigh. It is important to address the lower torso circumferentially with suction lipectomy at the time of medial thigh lift. Two factors need to be addressed to ensure a longlasting and effective medial thigh lift. On physical exam, the degree of skin laxity and lipodystrophy must be quantified. Once these factors are correctly analyzed, the patient can then be classified and an appropriate treatment plan can be determined. In the MWL patient, medial thighplasty is done after or at the time of the lower body lift. The lower body lift addresses the lateral thigh. The fat is removed through liposuction and direct excision. The skin laxity is improved with a combination of excision and via the process of discontinuous undermining. The medial thigh is addressed with the thighplasty. However, in the MWL patient, the thigh must be evaluated for the degree of skin laxity, the quality of skin, the degree of deflation, and the overall extent of deformity. These different factors are more pronounced in the MWL patient than the classic medial thighplasty patient. Therefore, we have found that the classic approach to thigh lift does not address all of the anatomic problems found in the MWL patient. Over time, we have transitioned from the vertical vector Lockwood (Fig. 84.1) approach to a horizontal vector approach (Fig. 84.2).

Fig. 84.1 Classic Lockwood medial thighplasty. (Adapted from Mathes and Kenkel [11])

Fig. 84.2 Vertical incision thighplasty. The orange indicates resection and arrows indicate vectors of pull. (Adapted from Mathes and Kenkel [11])

84.4 Classification of Medial Thigh Patents There are two separate categories of medial thigh patients. They are divided into those patients that have

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undergone MWL and those that have not. The nonMWL patients are divided into four categories (Fig. 84.3). Patients that present with type I medial thigh deformity (Fig. 84.3) and possess only lipodystrophy with no sign of skin laxity can be treated with liposuction alone. Those patients with type II present with skin laxity confined to the upper one-third of the thigh (Fig. 84.3) and will require liposuction and a horizontally orientated skin excision. The horizontal excision is only for vertical laxity of the proximal medial thigh. In general, as the degree of skin laxity progresses from the upper and medial (type III) (Fig. 84.3) to the entire medial thigh (type IV) (Fig. 84.3) the size of the skin resection increases. In addition, a vertical component is incorporated into the design of the skin excision to produce a contoured thigh. The advent and success of morbid obesity surgery has led to patients with significant medial thigh laxity after MWL. The author places these patients in a separate category. There are two types of patients after MWL (Fig. 84.4). The type 1 MWL (Fig. 84.4) patients are those who demonstrate skin laxity over the entire thigh, but do not demonstrate significant residual lipodystrophy (often denoted as deflated). These patients are treated with horizontal vector thigh lift. The type 2 MWL (Fig. 84.4) patient demonstrates both skin laxity and significant lipodystrophy (denoted as nondeflated). These patients often benefit from a staged procedure. The suction lipectomy can be performed at the first stage combined with a lower body lift. This is followed by a second stage horizontally based, medial thigh lift operation 3–4 months later to achieve an esthetic thigh.

84.5 Surgical Technique 84.5.1 Classic Medial Thigh Lift The patient is marked in the standing anterior position with the knees apart. In this position, retraction of the skin both medially and posteriorly demonstrates the amount of skin to be removed. In addition, the location of fat deposits are delineated and marked for liposuction. The femoral triangles are marked in order to avoid dissection into the lymphatics. The incision is marked from the level of the coccyx along the inner surface of

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the buttocks fold medially and inferiorly to the labia majora. The location of the incisions and the need to add a vertical component is determined by the classification of the thigh laxity. In general, if the skin laxity extends beyond the upper one-third of the thigh, then a vertical component is needed to contour the thigh. The range of excision of redundant tissue is between 4 and 8 cm. The procedure is performed under general anesthesia. The patient should be prone initially which will allow for trochanteric liposuction to be performed first. In addition, the prone position is preferred to reconstruct the buttock crease more accurately and to address the posterior dog-ear when necessary. The procedure is then completed in the frog-leg position. The patient is placed with the hips flexed 30° and stockinettes are placed to the knees so that the thighs can be repositioned during surgery. We also advocate the use of foot pumps for deep vein thrombosis prophylaxis. Liposuction of the medial thigh, deep fat only, is performed, and then the thigh lift is completed. The first step is to infiltrate the flank and inner thigh with wetting solution. The wetting solution is prepared by mixing 30 mL of 1% Xylocaine and 1 mL of 1:100,000 epinephrine. After the injection of the wetting solution, ultrasonic-assisted liposuction is performed and the deep fat is suctioned bilaterally and symmetrically from the lateral and medial thigh area. Subsequently, a posterior portion of the medial thigh is excised in a wedge just below the perineal crease to the lateral gluteal fold. After obtaining meticulous hemostasis with the electrocautery, the wound is irrigated and closed with 2–0 and 4–0 Vicryl and then 4–0 PDS, and the skin is sealed with Dermabond. The patient is then placed supine and the medial thigh lift is then completed. The anterior medial thigh is then excised and the crescent of the skin and fat is resected. Once hemostasis has been achieved, the band of Colles’ fascia is identified. This structure is best identified with traction applied on the lateral aspect of the fascia as not to produce any vulvar distortion. This digital dissection using a dry gauze sponge most readily preserves Colles’ fascia. It is also important to limit the undermining to a superficial level. The surgeon must preserve the soft tissue bundle coursing between the mons pubis and femoral triangle, which appears to reduce the risk of lymphatic complications. Anchoring sutures, 2–0 PDS, are placed to incorporate Colles’ fascia with the subdermal layer of both superior and

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Fig. 84.3 Four types of medial thigh patient classifications. (a) Type 1. (b) Type II. (c) Type III. (d) Type IV

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84 Current Techniques in Medial Thighplasty Fig. 84.3 (continued)

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Fig. 84.4 The two types of MWL medial thigh patients. (a) Type I MWL patient is deflated and can be treated by excision alone. (b) Type II is the nondeflated patient and is best treated in a staged fashion

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inferior skin flap. These sutures can be permanent; however, we favor large absorbable suture. The deep dermal sutures are placed with 3–0 PDS and a subcuticular suture is placed using 4–0 PDS. Finally, we have used Dermabond to seal the skin closure. Small drains (10 French) are usually placed before the closure of the skin. Once final closure is completed and the wound is dressed, depending on surgeon preference, a compression garment is applied. In the postoperative period, the patient is out of bed and ambulating the night of surgery. The drains are placed to wall suction for 24 h and then to bulb suction. All patients receive antibiotics (Ancef) and a morphine PCA pump. The majority of patients are discharged the day following surgery. The drains are removed in the office once the drain output is less than 30 mL.

84.6 Horizontal Vector Medial Thigh Lift The change in design addresses the unique laxity of the medial thigh in the MWL patient. The classic technique described above has its vector of pull upwards toward the groin. Many of the complications and postoperative issues, such as recurrent ptosis and traction deformity of the labia appear to be related to this pull. The horizontal laxity seen in the MWL patient is often quite severe and difficult to completely address with the classic vertical pull. It also cannot address middle distal third of the leg. In our new technique, the vertical portion is used solely to remove the “dog-ear,” but does not contribute to the actual lift of the medial thigh. Thus, we minimize the horizontal incision and the vertical lift. The contour is dependent on the vertical incision and not on the classic horizontal pull. There is no need for tension closure to Colles as the tension is distributed along the cylindrical medial thigh closure from the knee to the groin (Fig. 84.5).

84.6.1 Preoperative Marking The patient is marked in the standing position with the legs slightly apart. To eliminate lost time in the preoperative holding area, we now mark the patient in the office the day before surgery. This allows for adequate time to mark the patient in a deliberate unhurried manner. It also

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allows for time to further educate the patient as to the location of the incision and placement of drains. Finally, it allows for standardized photography of the marking for complete evaluation of the technique. The first step is to outline the areas of lipodystrophy around the knee and lower one-third of the thigh. This also enables the surgeon to taper the lower thigh with liposuction when necessary. Next, the desired ultimate location of the medial thigh incision is marked from the lower aspect of the knee to the groin crease. The skin is then transposed from the anterior thigh toward the posterior thigh to meet this previously drawn line. This serves to delineate the amount of skin to be resected. The same technique is done from the posterior thigh toward the anterior thigh to determine the extent of resection of the posterior thigh. This should lead to a wedge-like resection. Once these marks are in place, the final incision lines are drawn. The anterior incision is drawn such that a “bottleneck” area of skin is preserved more proximally (Fig. 84.6). Skin that is posterior and proximal is more adherent and less mobile. The bottle neck allows for this and helps prevent anterior migration of the scar and visibility. The bottleneck also helps to keep the incision more hidden in the groin crease. The posterior line, however, follows the line determined during the initial transposition of the skin. The final incision is often determined after the medial thigh resection and should begin in the groin crease and then form a wedge resection of the thigh. This design allows the thigh to be closed as a cylinder without any tension on the groin. There will be no need to anchor the flaps to the Colles fascia. In addition, this technique eliminates the need to operate prone and the incision in the buttock crease as the posterior laxity is rotated forward and excised (Fig. 84.7).

84.6.2 Patient Positioning The patient is positioned on the operating room table in the supine position. We have found that the use of spreader bars (Steris) to hold the legs allows the surgeon to sit in between the legs and this can reduce some of the neck strain noted with this operation (Fig. 84.8). The patient should have sequential compression devices and a Foley catheter placed, and all pressure points should be well padded to protect the patient.

84 Current Techniques in Medial Thighplasty

Fig. 84.5 A patient treated with the vertical incision thighplasty. (a) Patient with excessive thigh skin and thigh ptosis. (b) Preoperative marking for the thigh lift with the bottleneck placed

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to allow for better final scar placement. (c) Final result with good scar placement and thigh contour

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Fig. 84.6 (a) Intraoperative markings. (b) The postoperative, on the table, results. Note that the inguinal incisions are used to hide the dog-ear and are skin only

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Fig. 84.7 Use of the Steris spreader bars that allow easier access to the medial thigh and can reduce the surgeon’s neck strain

84.6.3 Operative Technique As in the classic technique, the thigh is first addressed with ultrasound-assisted liposuction. In those patents that are MWL but are nondeflated, we use a two-stage approach. Aggressive liposuction is done, with resection at a second stage. In those patients that have lost much of the deep subcutaneous layer, the two procedures can be performed at the same operation. However, the use of liposuction is usually limited to the area around the knee.

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The anterior incision is made first and carried down to the level of the deep fascia. Care should be taken to preserve the greater saphenous vein as well as the fat around and deep to it to preserve the lymphatics. At times, it is necessary to divide some of the sidebranches of the vein to the flap. This can be quickly accomplished using an automatic surgical clip applier. If the patient has undergone previous liposuction, as is often performed as a first stage in the nondeflated MLW patient, a scar plane can often be identified and followed. The dissection is then carried to the posterior marks and continued until the flap of skin and fat can be mobilized anteriorly beyond the marked posterior incision line. Careful hemostasis is obtained and a 15 French drain is placed through a separate stab incision. Once the dissection is complete, the flap is transposed to the anterior incision line to determine the amount of tissue to be excised, after which distal to proximal excision of the skin commences. The anterior incision line is mobilized posteriorly to confirm the posterior extent of resection. This proceeds proximally and the tissue is removed, and the two flaps are temporarily closed with staples. The wound is then closed in layers. The first layer is a deep layer closed with a running 0 PDS closing the SFS. The running sutures allow for the even distribution of tension and minimize the problem of suture extrusion of the knots. The deep dermal layer is then closed with a running 2–0 PDS and the

Fig. 84.8 (a) Preoperative markings for the patient. (b) Preoperative photograph. (c) Final result at 6 months

84 Current Techniques in Medial Thighplasty

epidermis is closed with a running 3–0 Monocryl. The specimens are weighed before disposal. The postoperative care is similar to the classic medial thigh lift as described above. However, the use of Dermabond to seal the wound minimizes the need for any complex surgical dressing. We have also abandoned any use of Ace wraps or other constricting garments around the medial thigh.

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This technique allows for the restoration of the medial thigh contour (Fig. 84.8). While the Lockwood medial thigh lift can be employed when treating some nonMWL patients, we have found that this technique does

not address many of the anatomic issues encountered in the MWL patient or the entire aging thigh. The author’s new technique minimizes the horizontal incision and the need for vertical lift [11] and relies on a vertical incision and horizontal pull. The groin incision is limited to remove the “dog-ear” and there is no need for tension closure to Colles fascia. This technique also avoids the “T” incision. The more recent addition of the “bucket handle” to the anterior incision has further refined the closure of the medial thigh. This has lead to a more concealed incision and less undermining of the anterior aspect of the groin. The author has also begun to explore the use of a modification of the technique with the addition of a suprapatellar incision on those patients with significant excess skin located over the knee (Fig. 84.9). After the elevation of the standard anterior and posterior medial

Fig. 84.9 Treatment plan for the patient after MWL with significant excess skin over the knees. (a) Demonstrates the normal thigh lift with an extension over the suprapatellar region. (b) The degree of resection of the skin needed above the knee. (c) Note

the excess skin before resection, but after elevation of the flaps. (d) Preoperative patient with excess skin in the medial thigh that extends over the knees. (e) Postoperative result demonstrating a much improved thigh contour

84.6.4 Results

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thigh flaps, the incision can then be extended over the suprapatellar region (Fig. 84.9). Once the dissection is completed, the excess skin is excised and the incision closed. This modification can help to address those patients that have excess skin over the medial thigh as seen in the MWL patient (Fig. 84.9).

84.7 Alternate Techniques There are a variety of techniques described for medial thigh lifts. Early attempts to provide more support to the lift included skin suspension techniques that anchored the medial thigh soft tissue to the mons pubis. Lewis in 1966 described an inverted L or boomerangshaped excision that attempted to combine the advantages of both the horizontal and vertical excisions. Pitanguy described the excision of a fusiform strip along the inguinocrural fold with limited undermining of the area [8]. He stated that adequate rotation and posterior anchorage of the lower mobile flap to the upper fixed flap should allow suturing of the inner thighs without tension. In 1975, Planas advocated the “Crural Melopasty” for the lifting of the medial thigh. Planas changed the direction of the traction on the skin to a vertical one [9]. The skin excision was extensive and the technique required rotation of the thigh in a posterior direction with the incision across the entire buttock crease. These and other techniques, however, did not provide long-term support to the lift. In 1988, Lockwood suggested that the deep fascia (Colles) be used in the lift to provide stability. The inferior skin flap is suspended from the Colles’ fascia of the perineum without the need for undermining or creation of flaps. Lockwood reported on 18 patients that underwent medial thigh lifts in combination with trochanteric liposuction and were followed for 6–4 months. The average patient follow-up in his study was for 12 months. There were very few complications and only one patient presented with recurrent ptosis. This patient had very heavy thighs as a complicating factor. He concluded that this technique is very successful except in those patients with extremely heavy thighs who are at a high risk for recurrent ptosis. This article demonstrates the importance of preoperative evaluation and tailoring the resection of skin to the type of medial thigh preoperatively. It also provided evidence

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for the fascial suspension of the medial thigh flap for long-term correction of thigh ptosis. A modification of Lockwood’s technique was recently proposed by Candiani et al. in which they employed a fascio-fascial suspension technique. Their technique is based on the overlap of the adductor longus and gracilis fascia. The skin and fat are undermined in this technique from the gracilis and adductor longus fascia equal to the area of required tissue resection. The fascia is then incised parallelly, but 6–7 cm below the inguinal crease, and the inferior fasciocutaneous thigh flap is advanced upward and outward. This fascial overlap is sutured into place and provides support to the lift and removes the tension from the skin closure. The authors also believe that muscle laxity contributes to the ptosis seen in the medial thigh. In their report, they followed 18 patients who underwent this modification of the medial thigh lift. Three patients presented with seromas that were drained. Long-term follow up at 12 months demonstrated normotrophic scarring without widening or downward migration. No vulvar distortion or recurrence of thigh ptosis is reported, but two patients did complain of incomplete correction of their initial defect. The authors concluded that this modification may provide even more support than the classic lift described by Lockwood. However, the more extensive dissection may increase problems in lymphedema and seroma formation and outweigh the benefits provided by the facial advancement. The problem of hypertrophic scars is addressed in a modification of the technique as described by Spirito. In this modification perivulvar tissue is resected. This technique is called a DECLIVE lift and consists of liposuction, resection of a triangular portion of the perivulvar skin, and the creation of a perivulvar vertical scar. This modification has been performed on 50 patients with purported excellent results. It cannot be used in those patients that are significantly overweight or present with a type III thigh. The authors report a 4% incidence of dehiscence of the scar with some moderate displacement of the pubic hair with this technique. The authors claim that an accurate reconstruction of the inguinocrural fold can stabilize and contour the inner thigh, thereby leading to improved healing of the scars. The procedure appears to change the contour of the mons pubis, producing a pinched appearance and does not eliminate the problems such as widening of the scars.

84 Current Techniques in Medial Thighplasty

In another technique described by Le Louarn et al., the standard skin excision is modified to change the direction of the lift to the horizontal direction [9]. Their new incision is located along the labia majora in the perineal crease and remains at the same height as it tracks back toward the buttocks. The incision does not, however, descend into the buttock crease. They also subscribe to the importance of minimal undermining and use liposuction for the removal of fat. The anchor sutures, through Colles’ fascia, are thought to pull on this nonundermined skin, and thereby, avoid necrosis and problems with dead space. They report that they have used this technique in 25 patients and have noted improvement in “the quality of the result.” They have, however, noted some postoperative complications. Two cases had delayed wound healing that resulted in scar widening. One case demonstrated mild scar migration and one patient did not obtain enough lift from the procedure and required a subsequent surgery. Ersek advocates a saddle lift for the medial thigh that allows for the removal of a large area of tissue (25 × 10 cm). This excision is marked from the level of the coccyx along the inner surface of the buttock’s fold medially and inferiorly to the labia majora. These incisions take tissue from the central buttock and medial thigh but remain hidden within the innermost creases. There is also no undermining of skin flaps in this operation. It would appear that such an approach is appropriate only for type II and possibly type III medial thighs. The result of this technique is reported only for a single case. All of the recent techniques of medial thigh lift are now based on Lockwood’s concept of supporting the thigh lift with sutures to create a superficial fascial-like suspension. They all attempt to anchor the lift on some portion of Colles’ fascia. This technique of closure appears to address many of the problems associated with the original techniques of the medial thigh lift. All the recent modifications attempt to increase the facial support and decrease the tension on the healing scars. Obviously, there have not been any studies that examine the superiority of one technique over another. However, there is clearly merit in limiting the size of the tissue flaps and the degree of undermining. More aggressive techniques to support the flap do not appear to reduce the complications and may actually lead to other complications such as seroma or contour deformity of the mons pubis.

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84.8 Complications Serious complications are uncommon after medial thigh lift. However, patients should undergo preoperative counseling in regard to the more common problems seen after this operation. The most common complication seen is persistent drainage from the medial thigh drain and a high incidence of seroma. This is especially true with the MWL patients as they can require significant undermining of the skin flaps to produce good contour. Some authors advocate the use of postoperative compression; however, this does not significantly reduce the incidence of seromas. Lymphedema is quite a rare complication of this procedure and can be the result of unnecessary dissection in the femoral triangle with the disruption of the lymphatics. The second issue is the degree of scarring; much like in brachioplasty, the skin in the medial thigh is thin with poor dermal support and this can lead to more pronounced scars. The greater the tension on the scar, the more likely the production of hypertrophic scars. Our modification removes the need for upward tension and may produce less tension on the scar. In addition, if too much tension is placed on the vaginal sidewalls, it can result in vulvar distortion and should be avoided by either anchoring to Colles fascia or using a more vertical approach to the thigh lift. Finally, the poor dermal support in the tissues can result in early recurrence of the thigh ptosis. The patient should expect 10–15% recurrence of thigh ptosis over the first year. This is especially true in the MWL patients whose skin has poor elasticity.

84.9 Conclusions The critical determinant of success in this procedure is in the preoperative assessment and surgical planning. The operation can then be tailored to the patient’s individual needs based on the preoperative assessment of the amount of skin laxity as well as the location of the lipodystrophy. The use of the thigh classification system simplifies this process and allows the surgeon to compare patient results based on a standardized classification. A thigh lift design based on the correct medial thigh classification should lead to an operation that best suits the patient’s anatomic needs and results in a cosmetically acceptable thighplasty.

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References 1. Lewis JR Jr. Correction of ptosis of the thighs: the thigh lift. Plast Reconstr Surg. 1966;37(6):494–8. 2. Lockwood TE. Fascial anchoring technique in medial thigh lifts. Plast Reconstr Surg. 1988;82(2):299–304. 3. Lockwood T. Lower body lift with superficial fascial system suspension. Plast Reconstr Surg. 1993;92(6):1112–22; discussion 1123–5. 4. Candiani P, Campiglio GL, Signorini M. Fascio-fascial suspension technique in medial thigh lifts. Aesthetic Plast Surg. 1995;19(2):137–40. 5. Spirito D. Medial thigh lift and DE.C.LI.VE. Aesthetic Plast Surg. 1998;22(4):298–300.

D. W. Mathes 6. Ersek RA, Salisbury AV. The saddle lift for tight thighs. Aesthetic Plast Surg. 1995;19(4):341–3. 7. Pitanguy IP. Surgical reduction of the abdomen, thighs and buttocks. Surg Clin N Am. 1971;51(2) 479–89. 8. Planas J. The “Crural Meloplasty” for lifting of the thighs. Clin Plast Surg. 1975;2(3):495–503. 9. Le Louarn C, Pascal JF. The concentric medial thigh lift. Aesthetic Plast Surg. 2004;28(1):20–3. 10. Vilain R, Dardour JC. Aesthetic surgery of the medial thigh. Ann Plast Surg. 1986;17(3):176–83. 11. Mathes DW, Kenkel JM. Current concepts in medial thighplasty. Clin Plast Surg. 2008;35(1):151–63.

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Thighplasty Cristina Hachul Moreno, Aline Rodrigues Bragatto, Américo Helene Jr, Carlos Alberto Malheiros, and Henrique Jorge Guedes Neto

85.1 Introduction Obesity is a metabolic disease that has become a serious public health problem, reaching epidemic rates in industrialized countries as well as in developing countries. Morbid obesity is a chronic condition, which is extremely difficult to treat and is related to unhealthy diet choices, sedentary lifestyle, genetic factors, and complex associated diseases [1–5]. Surgical treatment for morbid obesity has wellestablished indications which consist of resistance to clinical treatment, patients with a body mass index (BMI) over 40 kg/m2, or those with a BMI between 35 and 40 with associated diseases, acceptable surgical risk, capacity to comprehend the surgical implications, and multidisciplinary follow-up [6–9]. Gastroplasty with reconstruction in “Y de Roux” yields objective results of weight loss with low rates of complications, reaching a loss of 40% of the initial weight and a loss of 77% of the excess weight after a year, on average [10]. With this weight loss following the surgical procedure, the disease associated with obesity in these patients is decreased or even eliminated, presenting a clinical improvement. From the physiological, psychological, and esthetic standpoint, patients submitted to bariatric surgery present a new challenge to a multidisciplinary team and especially to plastic surgeons. It is a known fact that one of the consequences of rapid weight loss is the appearance of excess skin and subcutaneous cellular tissue located in various parts of the

C. H. Moreno (*) Rua Vergueiro, 1353, cj 407, Paraiso CEP 04101-000, São Paulo, SP, Brazil e-mail: [email protected]

body, making plastic surgeries imperative in order to improve the corporal contours [5, 7, 11]. In many cases, this excess skin and subcutaneous cellular tissue can alter the patient’s physical health, as the redundant tissue – be it on the trunk, mammillae, thighs, or arms – may increase the musculoskeletal work due to its weight, as well as induce cutaneous lesions due to intertrigo, limit physical exercise, hinder personal hygiene, and alter sexual activity, among others [2, 11]. In some cases, the psychological, emotional, and social health suffers detriment, as the patient presents a preoccupation with the esthetic and corporal image which must be treated effectively, definitively, and healthily, keeping in sight the fact that for many, even with weight loss, this excess skin can be a negative influence, leading the patient to forget or to overlook all the benefits of bariatric surgery [5, 11, 12]. One important consideration to be made is related to the ideal period for the patient to be directed to the plastic surgeon, the stabilization of weight loss being the fundamental point. It is known that the average time interval between bariatric surgery and plastic surgery is approximately 12–18 months, with the patient having presented weight loss stabilization for at least 3 months, the ideal stabilization period being in fact 6 months. If we consider the BMI, noting that the average is around 32–34 kg/m2, in the case that the patient presents a higher index, he or she will be directed to a nutrition regimen and encouraged to do physical exercise so as to anticipate the positive corporal image, leading to an additional weight loss before the esthetic surgery [5]. The planning can be simple, with the performance of only one surgery, even a complex one, with the execution of various procedures, isolated or in conjunction, possibly taking 12 months or more, until a better

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body contour is acquired. The presentation of these points with an adequate spreadsheet reduces anxiety and improves personal satisfaction, once there is neither as yet, nor will there likely ever be, any precise algorithm, as the complaints are individual [5]. Cutaneous flaccidity is frequent in these patients; however, it is not always present, the genetic factor being determinant in the skin quality and consequent determination of flaccidity due to the abrupt decrease in the BMI. We should observe that in these patients, the parts of the body are not only defined by their individual anatomies, but with their anatomies in relation to adjacent areas; for example, the lower trunk affecting the lower abdomen, flanks, and lower limbs, the upper trunk, involving mammillae, back, and upper limbs [5, 13]. The plastic surgeries performed are basically on the abdomen, flanks, breasts, thighs, upper limbs, and the face, there being one variation which is when the socalled circumferential dermolipectomy is done all at once, treating the abdomen and flanks in a single procedure [14]. The surgeries are usually done in sequence, depending on the complaints of each patient. These procedures, following the excessive loss of weight, present advances and innovations of Lockwood [13, 15, 16], through his studies on the superficial fascial system in support of a younger corporal image. His studies furthered, in particular, the procedures performed in the lower limb lifting, decreasing the complications and improving the results by means of fixating the cutaneous flap in the deep layer of the superficial fascia of the perineum, known as Colles fascia [13–18].

85.2 History Thighplasties or lower limb dermolipectomies were introduced by Lewis in 1956 [19], with skin and subcutaneous cellular tissue resections in the vertical and inguinal sense on the internal facet of the thigh, as such procedures were performed on older patients who had a recent history of weight loss, but almost all of the group showed discontent with the resulting scar. Abandoning the vertical resection component, Schultz and Feinberg [20] described a technique of ellipsoid skin resection, with an incision from the inguinal ligament to the gluteus groove, performed in

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the lithotomy position, with sutures in two planes, without associated procedures such as abdominoplasty, due to the possibility of venous or lymphatic commitment. The long-term results demonstrated inferior migration of the scar and the pubic hairs, the latter not remaining covered by swimming attire. Agris [21] utilized the dermal suspension, fixing the upper elements of the internal facet of the thigh to the fascia, in an attempt to diminish both the inferior migration of the scar and the distortion of the female genitalia. In 1982, Teimourian and Adham [22] described the periosteal fixation of the medial component of the thigh, demonstrating in this way, the advances in surgical technique so as to minimize the complaints with reference to the scar. Regnault and Daniel [23] reinforced conservative resection associated with suturing on two planes, without making use of the lithotomy position. They showed their discontent with this procedure due to the migration and functional limitation of the scar, corrected by Z-plasty, once again leading to the presence of a vertical scar. In 1984, Candiani et al. [17] described another technique, attaining the fasciocutaneous patch suspension of the gracile and long adductor muscles, suturing them on three planes with minimal skin tension and cutaneous dislocation, which diminishes the chance for venous and lymphatic lesion because of the anatomical position. In 1988, van der Stricht [24] reported a technique in which the surgical incision must be made behind the anatomical projection of the vessels, with a reduced dislocation of the cutaneous flap, leaving a fine layer of subcutaneous cellular tissue covering the aponeurosis, so as to minimize the lesion of lymphatic vessels, once the resection of all of this tissue, as well as the incision next to the great vessels of the internal facet of the thigh, would increase the risk of edema in the lower limbs, with the destruction of a significant number of lymphatic vessels due to the anatomical position of the same. In 1989, Hodgkinson [25] described a technique that, in order to prevent scar migration, combined a vertical incision only in the lata fascia, fixating it to the inguinal ligament and periosteum, followed by solely horizontal suturing of the resection without tension, with satisfactory results. Grazer [26] described an incision slightly above the inguinal ligament and more medial to the gluteus

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groove, being a conservative resection done with flexed thighs and abducted knees, associating other procedures, such as abdominoplasty, with good results, yet maintaining the inferior migration of the scar. In 1993, Lockwood [13] described crucial technical elements in the inferior corporal suspension which affect the thighs and lower abdomen, among which was the importance of the detachment of the more superficial cutaneous flap, thus avoiding lymphatic damage. Even with the various techniques described, the thighplasty, due to its innumerable complications, was not a surgical procedure that was performed very often. Among its most common complications, one can cite migration of the scar, vulvar deformity, depressions, asymmetries, hematomas, repetition infections, vascular, and lymphatic lesions, among others, inducing the doctor to perform the said surgery on patients with poor quality skin and excess fat in the internal facet of the thigh [16–18, 23]. Due to the increase in the frequency of bariatric surgeries, there has been a consequent increase in the number of thighplasties performed, and with this, the appearance of complications at a greater rate. Among the rarest local complications are the lymphatic lesions, with cases, described in the literature, of the appearance of lymphoceles, lymphorrhagia with serious local infections, initially having clinical treatment, followed by a surgical procedure for its solution, thereby increasing the morbidity. In 1983, Leitner and Sherwood [27] described the formation of lymphoceles following lower limbs dermolipectomy, which progressed into local infection, necessitating hospitalization for clinical treatment with intravenous antibiotic therapy, followed by surgical intervention for the resection of the same as a definitive treatment. In 2002, Staldemann [28], presented a case of elective thighplasty, which progressed into an increasing lymphorrhagia along the surgical incision, with local infection, making it necessary for the patient to have a surgical procedure with intraoperative mapping with patent blue as a means of identifying the damaged lymphatic vessel and affecting their repair, thus increasing the hospitalization time. Such clinical cases reflect the existence of lymphatic lesion during this surgical procedure, albeit in very small numbers when compared with other complications; however, with elevated morbidity, such lesions can progress

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into infection with more serious consequences on a systemic level.

85.3 Thighplasty Technique The patients to be submitted to thighplasty should be hospitalized on the eve of the surgery date for preanesthetic evaluation, having fasted for 8 h and having taken antibiotic prophylaxis with cephazolin at a dose of one gram in the anesthetic induction (Fig. 85.1). The recommended surgery for the resection of excess skin and subcutaneous cellular tissue in the internal facet of the thigh was described by Lewis [19], with cutaneous resections in the vertical and horizontal senses, as a means of removing a greater quantity of skin and subcutaneous cellular tissue. The incisions should be mapped out at first with the patient in a supine position, with flexed thighs and abducted knees and confirmed with the patient in horizontal dorsal decubitus (Fig. 85.2). The horizontal line is marked from the inguinal crease in the direction of the gluteus groove and the final vertical line is marked in the median portion of the internal face of the thigh from the inguinal region to the internal facet of the knee. The resection limits of the spindles are determined by the pinching test, estimating the most distal point which can be advanced without detriment to the final suture, be it in a supine position or in horizontal dorsal decubitus. Following the demarcation, the patient is then submitted to a continuous peridural anesthetic procedure and positioned in horizontal dorsal decubitus on the surgical table, followed by delayed vesical probing. For the performance of the surgical procedure, the lower limbs are placed in a flexed thigh and abducted knee position, with approximately 500 mL of physiological serum with adrenalin (solution at a dilution of 1:500,000) being infiltrated into each lower limb. Then the operation is initiated with the detachment of the cutaneous flap in the sense from the root of the thigh to the knee, starting from the previously marked horizontal incision. The vertical median incision must be performed next with the detachment of the anterior and posterior portion, leaving a fine layer of subcutaneous cellular tissue covering the musculature of the thigh in an attempt to preserve the lymphatic vessels, a technique recommended by Van der Stricht (Fig. 85.3) [24].

830 Fig. 85.1 Preoperative views (a1) Anterior, (a2) Lateral right, (a3) Lateral left, (a4) Posterior

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a1

a3

Rigorous hemostasis must be performed with electrocautery and careful dissection of the saphenous vein, with a ligature of the same in case there is a necessity due to its anatomical position. Resection of the skin and subcutaneous cellular tissue, previously determined by markings, is performed with a scalpel comparing the resections of each member. The surgical time can be facilitated by the previous demarcation, but if there is any doubt as to the quantity of skin to be resected, stitches can be made

a2

a4

with the Mononylon 2–0 at the marked sites and one can verify whether the resection is sufficient or not, with simple sutures on the skin, invaginating the patches and then marking the sutures once again to perform the resection (Fig. 85.4). The suturing of the patches is performed on three planes, the first being the subcutaneous cellular tissue with nonabsorbable thread (Mononylon® 2–0) in separate stitches, the second being the subdermal plane with absorbable thread (Monocryl® 4–0) with separate

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stitches, and the third being the intradermal continuous plane with nonabsorbable thread (Mononylon® 3–0), the most important factor of this procedure being the absence of tension in the suturing so as to avoid dehiscence and/or vulvar distortion (Fig. 85.5). The bandage is local and simple with just the placing of Micropore over the scar. This bandage should be changed every day and a compressive girdle in the form of Bermuda shorts should be worn over it. The patient must remain in complete repose after the surgery.

Fig. 85.2 Preoperative demarcation with the patient in horizontal dorsal decubitus with ﬂexed thighs and abducted knees

85.4 Postoperative Following the termination of the surgery, the patient should remain in postanesthetic recuperation for approximately 4 h, after which he or she will be transferred to the infirmary. Once the delayed vesical probe is removed 24 h after surgery, ambulation is initiated.

Fig. 85.3 Detachment of the cutaneous flap from the left lower limb and the patch from the previously sutured right thigh. Note the fine layer of subcutaneous cellular tissue on the left lower limb demonstrating the preservation of the superficial lymphatic vessels located in this region

a

Fig. 85.5 Thighplasty of the lower limbs after suturing in three planes, immediately postoperative

b

Fig. 85.4 Patch from the right lower limb sutured after resection of the skin and subcutaneous cellular tissue. Such sutures (Mononylon 2–0) should be previously marked with the pinch-

ing test or redone intraoperatively in the skin and invaginating the cutaneous patches. The final suture should not present tension in order to avoid dehiscence

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Simple bandages are applied utilizing physiological serum and the placing of Micropore® along the whole of the incision, so as to decrease the tension in the local suturing. Orientation for the performance of personal hygiene to exhaustion is given, advising local cleansing following each urination and defecation and 24-h use of the compressive girdle for a period of 3 months postoperatively. Antibiotic therapy with first-generation cephalosporin is prescribed for 7 days, as well as anti-inflammatories and analgesics, if necessary.

85.5 Outpatient Follow-Up The first outpatient return is scheduled on the sixth day postoperatively, with the objective of verifying the surgical incision, local hygiene, and presence of hematomas or dehiscence, as well as the use of the compressive girdle. The postoperative clinical exam should be performed so as to also evaluate edema of the lower limbs and the presence of lymphoceles along the scar. After 15 days, the sutures are removed and the wound checked. In the case that there is formation of lymphocele, a draining puncture with Jelco® number 16 is performed, the quantity in millimeters is recorded and weekly returns should be scheduled for new punctures until the lymphocele has been eradicated. The compressive girdle is maintained for 3 months postoperatively and the patients return after one year for follow-up and the performance of the remaining plastic surgeries.

85.6 Discussion The understanding of obesity in the last few years as a grave chronic disease, and a more aggressive form of dealing with it, such as surgery, solved one problem, but entailed the sequelae of accentuated weight loss. Among them, dermochalasis in various body segments stands out, bringing in the plastic surgeon for relevant participation in the complex multiprofessional treatment of the morbidly obese patients [11].

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There is a great quantity of skin and subcutaneous cellular tissue to be resected, and the cutaneous contraction following excessive weight loss is very deficient, different from the habitual population following gestation or light weight loss among other groups, once there is the endeavor to return to the body contour preceding the weight gain [7]. The majority of this group is female, in the active age bracket, which presents a greater concern not only with weight, but also with the body image [28]. This group perceives the attempt to achieve less absenteeism from the work activities with improvements in surgical techniques. There are various surgical procedures performed on this group of patients that can be single or multiple, depending on the location of the remaining excess skin. As for dermochalasis of the lower limbs, it is known that there is an accumulation of skin and subcutaneous cellular tissue both in the internal and the external facets of the thigh, the principal complaint of these patients, after massive weight loss, being the excess skin in the internal facet of the thigh. The said accumulation results in contact dermatitis and difficulties in doing physical exercise due to local friction, as well as complaints of a sexual nature and personal hygiene [11, 16, 17, 29]. In studies done by Lockwood [13, 16], the classic procedures for single lower limb dermolipectomies on the internal aspect of the thigh presented a greater morbidity when compared to those of suspension of both the internal and external facets of the thigh. These results were described following analysis, making use of a better knowledge of the anatomy of the superficial fascial system, improving results and decreasing complications, such as those of the lymphatic system, for example. The habitual population treated by the plastic surgeon also complains of lower limb lipodystrophy, albeit with little surplus skin, for which the elective treatment is liposuction. The said surgical method has come to substitute for thighplasty, once the esthetic sequelae of the latter procedure include great scars and their migrations, as well as the distortion of the small labia, among others, with possible lesion to the lymphatic vessels due to the anatomical position of the detachment of the cutaneous flap [16, 17, 29]. In the process of developing and improving the techniques for dermolipectomy of the lower limbs, the authors attempted to develop methods to decrease the surgical incisions; but many patients with a small

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accumulation of skin and local fat were still resistant to the presence of scars. With the advent of liposuction as the standard method in the last two decades, this procedure of associated cutaneous resection became restricted to a few cases [14, 16, 17]. The recommendation for liposuction is relatively frequent, being acceptable for patients with slightly reduced skin tonus, moderate obesity, and a BMI up to 35 kg/m2, among others, but with limited esthetic results. Dillerud [30] reports on the elevated dissatisfaction of the patients in view of the resultant cutaneous irregularities, especially in the regions of the internal and external facets of the thigh, iliac crest, and knees, in his study of complications related to liposuction. If planned and executed correctly, with knowledge of the technical principals, anatomy of the subcutaneous cellular tissue, and precise recommendation, liposuction provides satisfactory results. There are other complications, such as intra- and postoperative bleeding, related to the aspiration of massive volumes, as well as persistent edema. Studies on this edema for a prolonged period reveal lymphatic drainage alterations following liposuction, confirmed by macroscopic exams performed on cadavers, which had been injected with patent blue [31]. In this group of patients submitted to reductive gastroplasty, there is a limitation as to the quantity of fat that may be aspirated, the principal factor to be considered being the quantity of excess skin to be resected, making it imperative that the surgeon always recur to the traditional surgical procedure of dermolipectomy [2, 16, 32]. In some cases, successive liposuctions may be executed, as long as there is a satisfactory quality of cutaneous retraction, achieving surprising results, but in the majority of cases, dermolipectomy with rotation techniques and advancement of patches provides a better result in the long term [2]. With the resurgence of this group with accumulation of skin and subcutaneous cellular tissue, this procedure has once again been taken up and recommended with good results for this group of ex-obese, for whom it is believed that the exchange of deformity for a great vertical scar in the inguinal region brings more benefits to the same in view of their complaints about difficulties in ambulation, hygiene, and others. Much care must be taken in the surgical moment, bearing in mind that the region to be resected presents certain peculiarities. The skin in this region is fragile, taking into consideration the local humidity

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and thickness. In this way, the healing process is slower and susceptible to complications such as tissue necrosis, this being an important factor in the resection moment [18]. In this procedure, the detachment of the cutaneous flap is performed in the anatomical region of the lymphatic vessels. Some patients may present with edema and the formation of secondary lymphoceles with alterations in the lymphatic system in the postoperative period [18]. This edema, of lymphatic origin or not, presents a difficult differential diagnosis, and many times, the patients are submitted to innumerable inconclusive diagnostic methods which are expensive and many times unnecessary [33]. During dermolipectomy, resection of the hypodermis in the internal facet of the thigh leads to a high risk of edema due to the destruction of the local collector lymphatic vessels. This complication can be avoided by positioning the vertical incisions posterior to the anatomical location of the vessels and by limiting the detachment of the cutaneous flap, leaving a fine layer of subcutaneous cellular tissue anterior to the aponeurosis of the lower limb muscles [24, 27]. Haaverstad et al. [34] prospectively studied the effect of the type of incision made in popliteal femoral anastomoses in 1995. According to the lymphoscintigraphic analysis, the conclusion was reached that a reduction in the damage to the lymphatic system was nonexistent, when comparing the groups with an incision on the femoral triangle and an incision lateral to this anatomical structure. The surgical procedure described by the authors is that of the inguinal incision on the projection of the inguinal ligament in the femoral triangle and a vertical incision positioned posterior to the anatomical location of the larger vessels. Such incisions associated with the limited cutaneous flap detachment, leave a layer of subcutaneous cellular tissue anterior to the aponeurosis of the muscles of the interior facet of the thigh that guarantees less damage to the lymphatic system during thighplasty. The alteration observed in the authors’ patients was the formation of lymphoceles in the distal part of the vertical incision, and by means of statistical analysis of the lymphoscintigraphic results, both preand postoperatively, no statistically relevant relation was observed. A lymphocele is a space filled by lymph without precise epithelial lining and although it has been described following some surgical procedures of greater complexity, seldom has it been described following the dermolipectomy of the lower limbs [27].

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An immediate cause of the formation of lymphoceles is a lesion of the afferent lymphatic vessels and subsequent collection of the lymph in the operated area. This lymphatic fluid contains a low concentration of coagulation factors and platelets; thus, the lymphatic ducts continue eliminating the lymph for hours or days following the surgical procedure. The diagnosis of lymphocele is based on clinical, laboratorial, and imaging examinations. Clinically speaking, it is represented by a painless, floating, noninflammatory, and palpable mass of nonspecific dimensions. The aspiration of this tumor yields a clear, yellow fluid, that upon analysis shows few cells, has a low total rate of protein, and presents the lymphoscintigraphic image of increased capture in saccular form along the surgical incision [27, 35]. One of the causes for the formation of lymphoceles at this point in the incisions in the authors’ patients may be related to the use of compressive girdles, whose distal part coincides with the final part of the scar, making for inadequate local compression, leading in this way to the formation of the same. Another hypothesis is that, at this distal point of the incision, there is the possibility of a greater incidence due to the effect of gravity and that in this point of lesser detachment, as this is the final part of the incision, the first plane of the closing of the operative wound may be incomplete, thus accumulating the local lymph, promptly treated upon each return of the patients with a local puncture for drainage. Treatment for lymphoceles depends on the size, location, and secondary infections. They can be cured spontaneously, taking months, with repose and compressive measures and with the use of analgesics and antiinflammatories. The aspirate puncture may be the definitive treatment, performed in weekly consultations and in repetitive form, and in some cases, a sclerosal agent may be used. In case of failure of the above measures, the surgical resection of this mass as well as the identification and crimping of the afferent lymphatic vessels are performed [27, 35].

85.7 Conclusions Thighplasty is a surgical procedure that yields excellent results in body contour improvement in ex-morbidly obese patients, with reference to the possibility of resections of

C. H. Moreno et al.

excess skin and subcutaneous cellular tissue on the internal facet of the thigh. This surgical procedure presents complications such as the inferior migration of the scar, distortion of the small labia, presence of widened scars, and alteration of the lymphatic drainage. When executed in the manner described by the authors, following Lockwood’s techniques, with decreased detachment and preserving a fine layer of subcutaneous cellular tissue over the muscular fascia, there is a decrease in postoperative complications. Such a surgical procedure performed on these exmorbidly obese patients yields an important improvement in the body contour with a decrease in morbidity.

References 1. Seidell JC, Flegal KM. Assessing obesity: classification and epidemiology. Br Med Bull. 1997;53(2):238–52. 2. Pitanguy I, Amorim NFG, Radwanski HN. Contour surgery in the patient with great weight loss. Aesthetic Plast Surg. 2000;24(6):406–11. 3. Mancini M. Guia pratico de obesidade. Associação Brasileira para o Estudo da Obesidade, São Paulo; 2002. 4. Mancini MC. Noções fundamentais: diagnostico e classificação da obesidade. In: Garrido AB Jr, editor. Cirurgia da obesidade. São Paulo: Atheneu; 2002. p. 1–6. 5. Kenkel JM. Body contouring surgery after massive weight loss. Plast Reconstr Surg 2006;117(suppl.1):1–86S. 6. Sagar PM. Surgical treatment of morbid obesity. Br J Surg. 1995;82(6):732–9. 7. Sanger C, David LR. Impact of significant weight loss on outcome of body-contouring surgery. Ann Plast Surg. 2006; 56(1):9–13. 8. Kolanowski J. Surgical treatment for morbid obesity. Br Med Bull. 1997;53(2):433–44. 9. Nasser D, Elias AA. Indicação de tratamento cirúrgico da obesidade grave. In: Garrido AB, Jr. Cirurgia da obesidade. São Paulo: Atheneu 2002. p. 45–6. 10. Garrido AB Jr, Oliveira MR, Berti LV, Elias AA, Pareja JC, Matsuda M, et al. Derivações gastrojejunais. In: Garrido AB Jr, editor. Cirurgia da Obesidade. São Paulo: Atheneu; 2002. p. 155–61. 11. Chandawarkar RY. Body contouring following massive weight loss resulting from bariatric surgery. Adv Psychosom Med. 2006;27:61–72. 12. Shons AR. Plastic reconstruction after bypass surgery and massive weight loss. Surg Clin North Am. 1979;59(6): 1139–52. 13. Lockwood TE. Lower body lifts with superficial fascial system suspension. Plast Reconstr Surg 1993;92(6):1112–22; discussion 1123–5. 14. Ersek RA, Salisbury AV. The saddle lifts for tight thighs. Aesthetic Plast Surg. 1995;19(4):341–3. 15. Lockwood TE. Fascial anchoring technique in medial thigh lifts. Plast Reconstr Surg. 1988;82(2):299–304.

85 Thighplasty 16. Lockwood TE. Transverse flank-thigh-buttock lifts with superficial fascial suspension. Plast Reconstr Surg. 1991; 87(6):1019–27. 17. Candiani P, Campiglio GL, Signorini M. Fascio-fascial suspension technique in medial thigh lifts. Aesthetic Plast Surg. 1995;19(2):137–40. 18. Le Louarn C, Pascal JF. The concentric medial thigh lift. Aesthetic Plast Surg. 2004;28(1):20–3. 19. Lewis JR Jr. The thigh lift. J Int Coll Surg. 1956;27(3): 330–4. 20. Schultz RC, Feinberg LA. Medial thigh lift. Ann Plast Surg. 1979;2(5):404–10. 21. Agris J. Use of dermal-fat suspension flaps for thigh and buttock lifts. Plast Reconstr Surg. 1977;59(6):817–22. 22. Teimourian B, Adham MN. Anterior periosteal dermal suspension with suction curettage for lateral thigh lipectomy. Aesthetic Plast Surg. 1982;6(4):207–9. 23. Regnault P, Daniel R. Secondary thigh-buttock deformities after classical techniques. Prevention and treatment. Clin Plast Surg. 1984;11(3):505–16. 24. Van der Stricht J. Surgery of lipodystrophy. Phebologie. 1988;41(3):589–91. 25. Hodgkinson DJ. Medial thighplasty, prevention of scar migration, and labial flattening. Aesthetic Plast Surg. 1989; 13(2):111–4. 26. Grazer FM. Abdominoplasty. In: McCarthy JG, editor. Plastic surgery. the trunk and lower extremity. Philadelphia: W.B. Saunders; 1990. p. 3929–63. 27. Leitner DW, Sherwood RC. Inguinal lymphocele as a complication of thighplasty. Plast Reconstr Surg. 1983;72(6): 878–81.

835 28. Ellabban MG, Hart NB. Body contouring by combined abdominoplasty and medial vertical thigh reduction: experience of 14 cases. Br J Plast Surg 2004;57(3): 222–7. 29. Vilain R, Dardour JC. Aesthetic surgery of medial thigh. Ann Plast Surg 1986;17(3):176–83. 30. Dillerud E. Suction lipoplasty: a report on complications, undesired results, and patient satisfaction based on 3511 procedures. Plast Reconstr Surg 1991;88(2):239–46; discussion 247–9. 31. Frick A, Hoffmann JN, Baumeister RG, Putz R. Liposuction technique and lymphatic lesions in lower legs: anatomic study to reduce risks. Plast Reconstr Surg. 1999;103(7): 1868–73; discussion 1874–5. 32. Chang KN. Surgical correction of postliposuction contour irregularities. Plast Reconstr Surg 1994;94(1):126–36; discussion 137–8. 33. Khan O, Maharaj P, Rampaul R, Archibald A, Naipaul R, Loutan N. Lymphoscintigraphic evaluation of chronic lower limb oedema. West Indian Med J. 2003;52(2):136–9. 34. Haaverstad R, Johnsen H, Saether OD, Myhre HO. Lymph drainage and the development of post-reconstructive leg oedema is not influenced by the type of inguinal incision. A prospective randomized study in patients undergoing femoropopliteal bypass surgery. Eur J Vasc Endovasc Surg 1995;10(3):316–22. 35. Stadelmann WK. Intraoperative lymphatic mapping to treat groin lymphorrhea complicating an elective thigh lift. Ann Plast Surg 2002;48(2):205–8.

Combined Thigh and Buttock Lift After Massive Weight Loss

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Claudio Cannistrà

86.1 Introduction Surgical correction of the thigh and gluteal region has been previously described. The first publication regarding esthetic surgery on the lower limb is attributed to Posse [1]. Lewis proposed [2] a procedure that produced longitudinal, unsightly scars extending down the thigh. Pitanguy [3, 4] described a procedure for the correction of both crural and gluteal deformities using a single incision passing through the inguinal and gluteal fold and contouring the buttocks up to the anterosuperior iliac spine. Many techniques have been proposed for the correction of gluteal and thigh deformities based on excising the skin and subcutaneous tissue along the inguinal and gluteal folds. Vertical incisions were performed if necessary on the medial and lateral aspects of the thigh [5–7]. The use of dermal flaps was introduced in 1974 by Delerm and Cirotteau [8], who described the “ buried dermal flap technique.” Guerrero Santos [9] utilized an inferiorly-based dermafat flap with “waist coated” skin closure. Shaer [10] proposed a primary superiorlybased dermafat flap with fascia lata fixation, overlap of the inferior thigh, and associated preplanned local fat excision. The posterior sutures were not placed through the gluteal fascia and thus no inadvertent inclusion of the gluteal musculature. In 1990, Lockwood [11] described the superficial fascial system and its role as an anchor for surgical

C. Cannistrà Department of Surgery, Plastic Surgery Unit, Bichat C.B. University Hospital, 71 Rue de Rome, 75008 Paris, France e-mail: [email protected]

skin tightening that renewed interest in excisional body contour surgery. Procedures for skin and fat excess treatment of the thigh may cause unfavorable results as well as the potential for serious and sometimes catastrophic complications. Skin resection and lipectomy done in these regions are sometimes responsible for lymphorrea and delayed scarring [12]. When the posterior scars are placed in the buttock fold, the patients have pain for a long period of time [2–5]. For this reason, other authors placed the scars in the gluteal region [10]. But the body lift [12–13] is a veritable large intervention with significant undermining over the underlying musculature and interruption of the lymphatic vessels. For patients, following excessive loss of weight, it is better to treat the gluteal and inguinal regions with two procedures: first, abdominal lipectomy and lipoaspiration of the internal and external face of the thigh, and second, after 6 months, buttock and thigh lift by a heart-shaped incision traced previously anteriorly from the perianal region in the inguinal fold and spread on the iliac crest until the intergluteal fold posteriorly.

86.2 Surgical Technique Outlines on the patient are marked with a felt pen in the hospital room before surgery. Four vertical orientation lines are drawn on the torso along the right and left midaxillary lines (Fig. 86.1) and along the midline between the posterior axillary line and the middle dorsal line (Fig. 86.2). On the anterior face of the thigh, one line is drawn perpendicular to the inguinal ligament, and on the internal face of the thigh, one line is drawn parallel to the adductor muscles insertion (Fig. 86.3). A line is marked in the inguinal groove that

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Fig. 86.2 A line is marked along the midline between the posterior scapular (axillary) line and the middle dorsal line. This line is then carried posteriorly around the superior buttock border to the dorsal midline over the sacrum

Fig. 86.1 Four vertical orientation lines are drawn on the torso along the right and left midaxillary lines

starts from the perianal level and extends over the iliac crest. This line is then carried posteriorly around the superior buttock border to the dorsal midline over the sacrum (Fig. 86.2). The skin is pinched on the internal face of the thigh and pulled upward toward the inguinal line to estimate the skin resection (Fig. 86.4). The inferior line (B) of incision is marked in the internal and anterior faces of the thigh (Fig. 86.5). The superior line (A) passes 1–2 cm above the inguinal groove in the pubic hair. In the iliac and dorsal regions, the skin is pinched to obtain the elevation of the trochanteric region of the buttock to obtain traction of the dorsal region (Fig. 86.6).

At the level of the inferior pinch, one line (B) is drawn that defines the resection surface of the skin (Fig. 86.7). The patient is placed in the supine position for induction and intubation and then placed in prone position on the surgical table. The same solution as that for tumescent liposuction is injected in the marked area and at five cm from the border. The skin incision is made from the dorsal region to the middle-axillary line, and the resection of the skin and fat is carried out in one block at the level of the superficial fascial system (Fig. 86.8). It is very important to preserve the continuity of the aponeurosis and to keep hemostasis (Fig. 86.9). It is possible to interrupt the superficial fascial system at the level of the lower incision to elevate a small buttock flap (4–5 cm). There is no dissection on the dorsal region at the level of the upper incision in order to preserve the fibrotic

86 Combined Thigh and Buttock Lift After Massive Weight Loss

Fig. 86.3 On the anterior face of the thigh, one line is drawn perpendicular to the inguinal ligament, and on the internal face of the thigh, one line is drawn parallel to the adductor muscles insertion

musculocutaneous ligaments that are needed to support the pulled up the buttock and the trochanteric area. After hemostasis, French J-Vac drains are inserted and two layers of sutures performed (Fig. 86.10). A dressing is fixed with an Opsite transparent film. Then the patient is placed in the supine position. The same tumescent solution is injected again superficially throughout the tissues to be operated on. The skin incision is made into the superficial fat layer. After the skin and fat have been removed in one block, strong traction is applied from the cephalic extremity of the cutaneous flap which is in the perianal region. It is very important not to use any scalpel to dissect the skin and fat in the inguinal region in order to stay on the superficial fascial system and not to damage the lymphatic system. Two or three permanent sutures with nonabsorbable suture are anchored on one edge of the pubic periosteum near the inguinal ligament and the adductor

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Fig. 86.4 The skin is pinched on the internal face of the thigh and pulled upward toward the inguinal line to estimate the skin resection

muscles insertion (Fig. 86.11), and on the other edge, at 2–3 cm from the cutaneous thigh flap in the dermal layer (Fig. 86.12). These sutures form a new inguinal groove and reduce the scars. Two or three drains are placed. The skin intradermal suture is performed with absorbable suture. Opsite film (Fig. 86.13) is placed over the edges of the suture to check the viability of the skin edges. The dressing is removed 48 h after the operation. In the inguinal region, it is preferable to clean the scars with a Dakin solution for 2 weeks rather than placing any dressing. In the dorsal and iliac regions, a traditional dressing is used for 2 weeks. The author prefers to keep the patients in the hospital for 3 days until the drainage bottles are removed. The operative time generally lasts for 3½ h. The patients do not require any blood transfusion and are on sick leave for 3–4 weeks.

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Fig. 86.5 The inferior line (B) of incision is marked in the internal and anterior faces of the thigh. The superior line (A) passes 1–2 cm above the inguinal groove in the pubic hair

86.3 Complications This technique has not had any inguinal lymphorrhea or infections. When the patient smokes, it is possible to observe a poor and unesthetic scar.

86.4 Discussion Morbid obesity patients treated by a surgical technique to reduce weight have significant excess of skin after they have lost 30–90 kg. At the level of the anterior and internal face of the thigh, there is a large excess of skin showing an unattractive fat area. To correct this situation, it is preferable first to regularize the subcutaneous fat layer by lipoaspiration 4–5 months preoperatively. Subdermal lipoaspiration [14] in the internal face of the thigh makes the second intervention of a groin lift easier, because the subcutaneous fat layer is

Fig. 86.6 In the iliac and dorsal regions, the skin is pinched to obtain the elevation of the trochanteric region of the buttock to obtain traction on the dorsal region

reduced and it is not necessary to dissect the subdermal lipectomy region. To preserve the superficial lymphatic vessels in the groin area, dissection is performed to Scarpa’s fascia where the superficial aponeurosis and the lymphatic vessels under located [15]. In the dissection of the skin, it is preferable to use a nonelegant but very efficient procedure that consists of an incision of the skin and fat without touching the superficial aponeurosis, and after the skin flap is torn off with force, the skin flap is anatomically isolated from the superficial Scarpa’s fascia (Fig. 86.9). The lymphatic vessels are then not much damaged. These procedures decrease

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Fig. 86.9 The continuity of the aponeurosis is preserved and hemostasis maintained

Fig. 86.7 At the level of the inferior pinch, one line (B) is drawn that defines the resection surface of the skin Fig. 86.10 After hemostasis, French J-Vac drains are inserted and two layers of sutures performed

Fig. 86.8 The skin incision is made from the dorsal region to the middle-axillary line, and the resection of the skin and fat is carried out in one block at the level of the superficial fascial system

the risk of infectious complications and lymphorrea in this intervention. The choice of the heart-shaped incision is linked to the observation that the traditional drawing of the groin and the thigh lift allows a lifting of the anterior and medial face of the thigh, but does not modify the buttock aspect. The obese patient after losing weight always has significant ptosis of the buttock. The traditional techniques [1–10] make a scar in the posterior face of the thigh to correct the ptosis of the buttock but does not lift its superior aspect and the scar can be very painful for a long time when the patient sits down. The Lockwood technique [11–13] can present important complications and very long rehabilitation period caused by the association of lipoaspiration and body lift, at the same time with significant

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Fig. 86.13 Opsite film is placed over the edges of the suture to check the viability of the skin edges

Fig. 86.11 Two or three permanent sutures with nonabsorbable suture are anchored on one edge of the pubic periosteum near the inguinal ligament insertion and near the adductor muscles insertion

Fig. 86.12 Sutures are placed on the other edge, at 2–3 cm from the cutaneous thigh flap in the dermal layer

undermining, sometimes needing blood transfusion that is preferable to avoid. The Avelar technique proposes a less invasive procedure, a combination of liposuction and skin resection without panniculus undermining that decrease the risk of seroma or skin necrosis [15]. But this procedure is optimal for the patients with a small excess of weight because their silhouette is less modified by further weight loss. Patients after a severe weight loss (30–90 kg) need two procedures. The first lipoaspiration represents a psychological help for the patients during weight loss and removes the localization of thick, fibrotic, and poorly vascularized fat. Superficial liposuction, similar to the Gasparotti technique [14] helps skin retraction during the waiting period (3–6 months) until the patient completes the weight loss and the result is more definitive. With the heart-shaped technique [16], skin resection is performed in the dorsal region of the buttock that is anchored on the dorsal aponeurosis and is pulled upwards. The fold located under the buttock is then visible and the shape of the buttock is higher. Unlike the other procedures, this technique is not so painful for the patient especially when sitting. In the anterior and internal face of the thigh, the cephalic traction of the skin lifts the region and then reduces the ptosis of the skin of the knee. In certain cases (20%) with circumferential excess of skin, it is necessary to resect the skin of the thigh with a vertical scar on the internal face [17]. The esthetic result depends on the scar quality (Fig. 86.14–86.16).

86 Combined Thigh and Buttock Lift After Massive Weight Loss

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b1

a2

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a3

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Fig. 86.14 (a1–3) Preoperative 26-year-old woman with a weight loss of 68 kg after surgical treatment of obesity. Lipectomy 9 months ago and flank, trochanteric, and internal

b3

face of the thigh lipoaspiration 6 months ago. (b1–3) Two years postoperative. Good improvement of the body contour and the internal face of the thighs

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a1

a2

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Fig. 86.15 (a1–3) Preoperative 38-year-old woman with a weight loss of 54 kg after surgical treatment of obesity. Lipectomy 10 months ago, internal face of the thigh lipoaspiration 6 months

a3

b3

ago. (b1–3) One year postoperative. Good improvement of the body contour on the flank and the internal face of the thighs. Lipoaspiration of the trocanteric region is still necessary

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a

b

Fig. 86.16 (a) Preoperative 52-year-old woman with a weight loss of 38 kg after surgical treatment of obesity. Lipectomy 1 year ago. (b) One year after flank, trochanteric, and internal face of the thigh lipoaspiration

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Reduction of infection and lymphorrea is due to three separate procedures, lipoaspiration, abdominal lipectomy, and thigh and buttock lift as well as the anatomical aspect of the superficial fascial system and Scarpa’s aponeurosis. This different timing is important for the patients who are going to lose a lot of weight. Indeed, the results after important and precocious interventions are compromised if the patient continues to lose weight. These different interventions during the period of weight loss allows the patient to be conscious of the new silhouette and new scar. It is preferable to model the external skin after shaping what is under the skin. For obese patients, the surgical work is similar to the tailor, having weight loss before getting a new suit.

86.5 Conclusions The surgical treatment of the thigh and buttock after weight loss are very complicated interventions. The advantages of this procedure are the reduction of the operative time to reduce the thromboembolic risks, reduction of the postoperative pain, discomfort, blood loss, and lymphatic disruption, prevention of the labial splay, and scar migration. The superficial treatment of the skin to improve the skin elasticity is done by superficial chemical or physical treatment. The final result, however, is related to the natural elasticity of the skin.

C. Cannistrà

References 1. Posse P. Cirugia Estetica. Buenos Aires; 1946. 2. Lewis JR. The thigh lift. J Int Coll Surg. 1957;27(3):330–4. 3. Pitanguy I. Trochanteric lipodystrophy. Plast Reconst Surg. 1964;34:280–6. 4. Pitanguy I. Aesthetic plastic surgery of head and body. Berlin: Springer; 1981. p. 129–53. 5. Gilles H, Millard RD Jr. The principles and art of plastic surgery. Boston: Little Brown; 1957. p. 404. 6. Farina R, Baroudi R, Coleman B. Riding-trousers like type of pelvicrural lipodystrophy (trochanteric and lipomatosis). Br J Plast Surg. 1961;13:174. 7. Aronson RB, Epstein RA. The miracle of cosmetic plastic surgery. Los Angeles: Sherbourne; 1972. p. 294–306. 8. Delerm A, Cirotteau Y. Plastie cruro-femoro-fessière ou circumfessière. Ann Chir Plast. 1973;18(1):31–6. 9. Guerrero Santos J. Lipectomies and body sculpture. Presented at the Annual General Meeting of the American Society of Plastic and Reconstructive Surgery, Boston; 1976. 10. Shaer W. Gluteal and thigh reduction: reclassification, critical review, and improved technique for primary correction. Aesthetic Plast Surg. 1984;8(3):165–72. 11. Lockwood T. Transverse flank-thigh-buttock lift with superficial fascial suspension. Plast Reconstr Surg. 1991;87(6): 1019–27. 12. Lockwood T. Lower body lift with superficial fascial system suspension. Plast Reconstr Surg. 1993;92(6):1112–22. 13. Lockwood T. Lower body lift. Aesthetic Surg J. 2001;21(4):355. 14. Gasparotti M. Superficial liposuction for flaccid skin patients. Symposium Annals of the II International Symposium, Recent Advances in Plastic Surgery-Raps/90”Sao Paulo, Marques-Savarva, 28–30 March; 1990. p. 441. 15. Avelar J, Toledo L. The new abdominoplasty and derived techniques (instructional course) presented at the Annual Meeting of the American Society for Aesthetic Plastic Surgery, New York, NY; 2001. 16. Cannistrà C, Valero R, Benelli C, Marmuse JP. Thigh and buttock lift after massive weight loss. Aesthetic Plast Surg. 2007;30(3):233–7. 17. Toledo L. Sculpting the buttocks after major weight loss. Aesthetic Surg J. 2003;23:125–7.

Venous Thromboembolism in Bariatric Body Contouring Surgery

87

Maura Reinblatt and Michele A. Shermak

87.1 Introduction Over the past decade, the number of bariatric surgeries has significantly increased. As a result of this trend, more patients are expected to present for body contouring procedures after massive weight loss [1]. The American Society of Plastic Surgeons (ASPS) estimated that over 350,000 body contouring procedures were performed in the United States in 2006, which is a 95% increase when compared to 2000 [2]. As a result, the plastic surgeons must be prepared to manage massive weight loss patients, to ensure patient safety and optimize surgical outcome in elective body contouring procedures. Venous thromboembolism (VTE) is the most common cause of death in body contouring procedures and is associated with significant morbidity [3, 4]. Body contouring procedures in the massive weight loss patient have been reported to have an even greater VTE risk. This elevated risk may be a result of intraoperative positioning, length of surgery, elevated body mass index, use of general anesthesia, patients with multiple medical problems, and limited postoperative mobility [5]. Nonetheless, despite increasing numbers of massive weight loss patients, there is a paucity of research relating to VTE prophylaxis in those patients undergoing body contouring surgery [2]. VTE includes the spectrum of disease ranging from deep venous thrombosis (DVT) to pulmonary embolism (PE) [1]. Both DVT and PE result in an estimated

M. A. Shermak (*) Division of Plastic Surgery, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Suite A-518, Baltimore, MD 21224, USA e-mail: [email protected]

600,000 hospitalizations in the United States each year [6, 7]. The incidence of a first episode of symptomatic VTE is approximately 1:1000 (71–117 per 100,000), with two thirds having DVT and one third PE [8]. The American Heart Association estimates that there are more than 200,000 new VTE cases each year, with an associated 30% mortality within the first month of diagnosis [5]. The majority of VTE patients may not be recognized by physicians, since only a third of patients develop the classic signs and symptoms. The development of DVT is associated with major morbidity, which includes life-threatening PE, increased risk of recurrent thrombosis, venous incompetence, and postthrombophlebitic syndrome. These can result in significant long-term pain and disability. DVTs are anticipated to recur in approximately 10% of patients within 1 year [5]. Between 40 and 80% of DVT patients develop postthrombophlebitic syndrome within 5–10 years. Symptoms include chronic leg fatigue, swelling, and venous ulceration in severe cases [5, 9]. PE results in 150,000 deaths each year and is the third most common direct cause of death in the United States, with an associated 5% perioperative death rate [3, 10–12]. An initial PE event has a mortality rate of 2–8% when diagnosed and treated early. Despite treatment, 10% of PE patients will develop recurrent PEs. Mortality rate for recurrent PE rises significantly compared to the initial episode, with estimates approaching 45% [10, 13]. Although most DVTs are believed to originate in the distal calf veins, approximately one quarter to one third of untreated, symptomatic distal DVT extend to involve the proximal veins as well. Most cases of symptomatic proximal DVT will progress to PE, including both symptomatic and asymptomatic PE cases. Preventing DVT formation in distal calf veins, will therefore decrease the risk of a potentially fatal PE [5, 14].

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VTE results in a substantial economic burden. This includes the initial hospitalization, as well as the resulting readmission due to the high recurrence rate. A report of 25 million patients in the United States estimated the annual health care cost per patient for primary DVT and PE to be $10,804 and $16,644 respectively. Most hospital readmissions occurred within 90 days of the initial episode, with a significant number recurring within 30 days (27.1% for DVT and 44.3% for PE). These results underscore the importance of VTE prophylaxis. Preventing a first episode will reduce the associated medical costs, while also decreasing the high costs of recurrence and resultant readmission [15].

87.2 Venous Thromboembolism in Surgery VTE is a dreaded complication of surgery, resulting in significant morbidity and possibly death. With an increasing recognition of patient safety by both the public and the medical community, surgeons must address VTE and balance the need for prevention with the risk of postoperative bleeding. VTE is one of the most preventable causes of morbidity and mortality after surgery. Without prophylaxis, DVT risk is substantial in the surgical patient. The incidence of DVT in hospitalized patients following surgical procedures, who did not receive prophylaxis, differs based on the type of surgery performed: general surgery 15–40%, gynecologic surgery 15–40%, neurosurgery 15–40%, orthopedic surgery 40–60%, and major trauma and spinal cord injury 40–80% [5, 16]. Despite VTE prophylactic measures, orthopedic surgery has one of the highest rates of postoperative PE. Elective hip replacement is associated with a 2–3% PE rate and hip fracture fixation with 4–7% [17]. This incidence is lower in general and oncologic surgery patients receiving prophylaxis, with an estimated PE rate of 0.1–0.8% [10]. Obese patients who undergo surgery are at a significant risk for developing VTE. Gastric bypass surgery has been associated with a 2.4% incidence of PE, with 0.21% resulting in death. A survey conducted by the American Society for Bariatric Surgery reported that 48% of the surgeons had at least one fatal PE in their practice, with 95% of surgeons routinely utilizing VTE

M. Reinblatt and M. A. Shermak

prophylaxis [5, 18]. A series of autopsies performed on 10 patients who died after gastric bypass surgery revealed that 3 patients died from PE, with 8 patients having unsuspected microscopic PE. Furthermore, these patients received perioperative VTE prophylaxis with subcutaneous heparin and pneumatic stockings [5, 10, 19].

87.3 Venous Thromboembolism in Plastic Surgery When compared to the general or orthopedic surgery literature, there are far fewer reports evaluating VTE incidence in plastic surgery. Nonetheless, plastic surgery patients are also at risk for VTE. An ASPS survey estimated that 18,000 cases of DVT occur in plastic surgery patients each year and that more than half of the plastic surgeons do not routinely use DVT prophylaxis [20]. Most studies report the rate of VTE in plastic surgery patients to be between 1 and 2% [5, 10, 21–23].

87.4 Abdominoplasty Abdominal surgery has been associated with higher rates of VTE, due to a disruption of the lower extremity venous return and injury to the pelvic veins during surgery [5, 16]. Similarly, among plastic surgery procedures, abdominoplasty carries the highest VTE risk (1.2–2%) [5, 22, 24]. A survey of more than 10,000 abdominoplasties, reported an incidence of 1.2% for DVT and 0.8% for PE [22]. Utilizing plastic surgery statistics from 2001, these percentages have been translated into 644 cases of DVT and 468 cases of PE [1]. Combining abdominoplasty with other procedures has been reported to carry an even greater risk of VTE when compared to abdominoplasty alone. Combining abdominoplasty with gynecologic procedures, such as hysterectomy, has a reported 6.6% PE risk [25]. Likewise, Aly et al. [26] reported a 9.4% PE rate with belt lipectomy. However, Hester revealed a composite PE risk of 1.1% when combined with other aesthetic procedures, with obesity being a more significant predictor of PE than the combination of procedures [24]. The addition of liposuction to abdominoplasty

87 Venous Thromboembolism in Bariatric Body Contouring Surgery

procedures has not been shown to increase the incidence of VTE [21]. A recent national survey of ASPS members evaluated the incidence of complications after abdominoplasty and abdominal contouring surgery. A total of 20,029 procedures were reported: 7,010 cases of abdominal liposuction (35%), 2003 cases of limited abdominoplasty (10%), and 11,016 cases of full abdominoplasty (55%). No cases of DVT or PE were reported with either abdominal liposuction or limited abdominoplasty. The full abdominoplasty group had an associated DVT and PE rate of 0.04% and 0.02%, respectively [27].

87.5 Rhytidectomy A study assessing the VTE risk in face lift patients surveyed 273 plastic surgeons and reported on 9,937 face lifts [23]. This report revealed a 0.35% risk of DVT and 0.14% risk of PE in rhytidectomy patients. Using statistics from 2001, these percentages have been translated into 485 and 199 cases of DVT and PE, respectively [1]. Those rhytidectomies performed under general anesthesia were associated with a greater VTE risk. This may be a result of complete patient immobility under general anesthesia. This study revealed that plastic surgeons utilize a broad array of VTE prophylactic measures, ranging from elastic stockings to pneumatic compression devices. However, most surgeons (60.7%), used no VTE prophylaxis when performing face lifts [23].

87.6 Suction-Assisted Lipectomy Fatality after liposuction has been extensively studied [28]. A survey of 917 board-certified plastic surgeons and members of the American Society of Aesthetic Plastic Surgery (ASAPS) reported more than 496,000 liposuction procedures performed between 1994 and 1998. This study demonstrated a 0.191% mortality rate, which represents 1 in 5,224 liposuction cases. PE was the main cause of death after liposuction, accounting for 30 of the 130 fatalities (23%). More recently, a follow-up survey of 1,432 boardcertified ASAPS members was performed between

849

1998 and 2000, to assess whether ASAPS members modified their liposuction practice as a result of recommendations set forth by the Lipoplasty Task Force. Over 94,000 lipoplasty procedures were reported, with an associated mortality rate of 1 in 47,415 cases (0.0021%). This mortality rate increased to 1 in 7,314 cases (0.0137%) when liposuction was combined with other procedures (excluding abdominoplasty), and to 1 in 3281 cases (0.0305%) when liposuction and abdominoplasty were performed concomitantly. Nonfatal complications included a DVT rate of 1 in 3,040 patients (0.0329%) and a PE rate of 1 in 3,759 cases (0.0266%). It was determined that almost one third of the responders modified their practice according to the Task Force recommendations, specifically with respect to: performing liposuction as a single procedure, stricter patient selection, limiting the length of surgery, and removing smaller volumes of fat [21]. Large volume liposuction has been associated with an increased VTE rate, estimated to be between 0 and 1.1% [5].

87.7 Other Body Contouring Procedures Several plastic surgery reports have retrospectively reviewed various body contouring procedures and examined VTE incidence (Table 87.1). To date, there is no prospective, multicenter, randomized, controlled trial evaluating VTE rates and different VTE therapies in body contouring patients [2]. The duration of body contouring procedures and difficult postoperative ambulation may place the patients undergoing body contouring surgery at higher risk for VTE [5]. A series by Shermak et al. [3] reported a 2.9% VTE risk in 138 body contouring cases preformed on massive weight loss patients. Contouring procedures were most often combined, with contouring of the abdomen 92%, thighs 34%, arms 29%, and back 26%, the most commonly reported. Patients routinely received graduated elastic stockings and intermittent pneumatic compression devices during and after surgery, subcutaneous heparin within hours of surgery, and were encouraged to ambulate the day of surgery. Three patients (2%) developed DVT and 1 patient (0.7%) suffered from a fatal PE. DVT occurred within 2 weeks of the surgery and was most often diagnosed by the patient’s primary care physician. Although the overall risk of VTE was 2.9%, this risk rose significantly to 8.9% in those

Modified vertical abdominoplasty

Lower body lift and superior gluteal 18 artery perforator flap

Combined, mostly abdominal

Abdominoplasty Limited abdominoplasty Liposuction of the abdomen

Lower body lift

Central body lift

Borud and Warren [29]

Coldwell and Borud [30]

Shermak et al. [3]

Matarasso et al. [27]

Nemerofsky et al. [31]

Rohrich et al. [32]

151

200

11,016 2003 7010

138

64

65 103 159

Circumferential Abdominoplasty Breast/upper body contouring Abdominoplasty ± other procedure

Hatef et al. [2]

Patient number

Surgery location

Reference

Table 87.1 Risk of venous thromboembolism in body contouring procedures

1.3

2

0.04 0 0

2

0

0

7.7 0.97 1.89

Deep venous thrombosis %

0.6

1

0.02 0 0

0.7

0

0

0 1.9 3.14

Pulmonary embolism %

Early ambulation Enoxaparin (pre and postoperatively)

IPC

IPC Elastic stockings Early ambulation

–

IPC Elastic stockings Early ambulation Subcutaneous heparin (postoperatively)

IPC Early ambulation

IPC Early ambulation

IPC Early ambulation Enoxaparin

VTE prophylaxis

850 M. Reinblatt and M. A. Shermak

–

230 216

Abdominoplasty alone

Abdominoplasty + intabdominal or pelvic procedure Abdominoplaty + other aesthetic procedure

Hester et al. [24]

70 76 76

Abdominoplasty alone Gynecologic procedure alone

Abdominoplasty and gynecologic procedure

94,159

IPC intermittent pneumatic compression; LMWH low-molecular weight heparin

Voss et al. [25]

–

117

Lipoplasty ± other procedure ± abdominoplasty

–

– –

–

0.0329

0

Hughes [21]

32

Belt lipectomy

0

Aly et al. [34]

75

Mid-body lift

Strauch et al. [33]

6.6

0 0

0.93

1.7

0

0.0266

9.3

0

–

–

IPC (one arm) Early ambulation LMWH (4 h postoperatively until discharge) IPC Early ambulation –

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patients with a body mass index of 35 or greater (45 of 138 patients) compared to 0% for patients with a body mass index less than 35. The mean body mass index for patients with VTE was 48.5 vs. 31.8 kg/m2 in those patients who did not develop VTE. VTE incidence was not associated with the type of procedure performed, number of procedures at a single surgery, or blood transfusion. A retrospective study from the University of Texas Southwestern Medical Center, examined 360 patients who underwent various body contouring procedures [2]. Like the study by Shermak et al. they reported an increased risk of VTE in patients with a body mass index greater than 30. Patients were stratified into groups according to the Davison-Caprini risk assessment model (see Sect. 87.9). The highest risk patients had a significantly increased VTE rate compared to the lower risk group. Abdominoplasty was associated with a 5.03% VTE rate (DVT 1.89% and PE 3.14%). Half of these events occurred in patients who underwent abdominoplasty alone (4.65%) and the other half in patients undergoing abdominoplasty with other contouring procedures (5.48%). Circumferential abdominoplasty was associated with an increased DVT rate compared to other procedures at 7.7%, with no associated PE reported. Body mass index greater than 30 and hormone therapy were associated with an increased VTE rate. Use of low-molecular weight heparin (LMWH) was associated with significantly increased bleeding rates (7.3% with enoxaparin vs. 0.5% without), as well as significantly decreased VTE rates in patients undergoing circumferential abdominoplasty (0% with enoxaparin vs. 20% without). Another review of 32 circumferential abdominoplasty cases reported a 9.4% rate of PE [26]. This is similar to the 7.7% VTE rate reported by the Texas group [2]. This increased risk in circumferential abdominoplasty may be associated with more dissection, longer surgical times, more difficult postoperative ambulation, and circumferential disruption of superficial veins [2].

M. Reinblatt and M. A. Shermak

Today, this can be thought of in the context of bed rest causing stasis, surgery resulting in injury, and thrombophilic states (such as Factor V Leiden) promoting hypercoagulability. Not all the components of the triad, and likely only one or two, are needed for thrombus formation [5]. Surgery promotes venous stasis through anesthesia and immobilization. Furthermore, venous stasis can be worsened by position on the operating room table. Maximum blood flow through the popliteal vein is achieved by flexing the knee 5° [1, 17]. About half of the DVTs which develop from surgery begin intraoperatively, while the patient is lying on the operating room table [5]. Patients undergoing body contouring procedures experience venous stasis as a result of both the length of the surgery and difficulties with postoperative mobility. These factors may contribute to an increased VTE risk. Hypercoagulation disorders are often not identified preoperatively unless the patient has a personal or family history of VTE. Factor V Leiden is the most common genetic prothombotic abnormality, occurring in 5% of the Caucasian population. Protein C, protein S, and antithrombin III deficiencies are other commonly inherited disorders. Surgeons should consider consultation with a hematology specialist when encountering these genetic, prothrombotic disorders [5]. DVTs related to surgery most commonly occur in the deep calf veins. If left untreated, approximately 15–35% of these may extend to the proximal veins with the potential for embolization [5, 14, 16]. The majority of symptomatic proximal DVT progress to PE. Moreover, 70% of the patients with symptomatic PE have DVT involving the proximal veins. Approximately, 10% of symptomatic PEs are fatal within 1 h of symptom development, with most fatal PEs occurring between 3 and 7 days after surgery [5, 14]. Surgeons must therefore be prepared to diagnose and treat PE in the early postoperative period.

87.9 Risk Factor Assessment 87.8 Pathophysiology More than a century ago, Rudolph Virchow identified the risk factors for VTE, comprising the well-known triad of venous stasis, vascular injury, and hypercoagulability.

Risks factors for VTE may be temporary or persistent. Transient factors include major surgery, trauma, immobilization, prolonged airline travel for more than 8 h, and elevated estrogens. Increased levels of estrogen may be related to pregnancy and exogenous estrogens, from

87 Venous Thromboembolism in Bariatric Body Contouring Surgery Table 87.2 Risk factors for VTE Transient

Chronic

Surgery Immobilization Prolonged air travel (>8 h) Estrogen increase (pregnancy, hormone replacement therapy, oral contraceptives, tamoxifen, prostate cancer treatment) Chemotherapy Obesity (body mass index >30) Central venous catheter Acute medical illness Trauma

Age (>40 years) Prior history of venous thromboembolism Cancer Inherited disorders Antiphospholipid antibodies

either oral contraceptives or postmenopausal hormone replacement therapy. Chronic factors include cancer, history of VTE, inherited disorders, and antiphospholipid antibodies (Table 87.2) [10, 13, 29, 30]. As the number of predisposing risk factors increases, so does the risk of VTE [5, 29]. Patients older than 40 years have a greater risk of VTE, and this risk continues to increase with advancing age. The corollary being that VTE is very rare in children [29]. There is conflicting data regarding obesity alone as a significant risk factor for VTE. When combined with surgery however, the risk of obesity is clearly significant. This may be related to decreased mobility and decreased venous return [5]. Reports show that obesity is associated with a relative risk factor of 2.5 for DVT and 2.1 for PE [5, 29, 31]. Estrogen has been associated with an increased risk of VTE as it disrupts the balance of clotting factors, favoring thrombosis. This is related to the amount of estrogen in the compound taken. A fivefold VTE risk is associated with pregnancy, a 3–4fold risk with oral contraceptives, and a 2–4-fold risk with hormone replacement therapy. This risk decreases after the first year of hormonal treatment; however, the risk remains above the baseline thereafter. This estrogen effect is rapidly reversible and supplemental estrogens should be discontinued at least 1 week before surgery [2, 13, 29]. The American College of Chest Physicians (ACCP) releases consensus guidelines regarding the prevention of VTE every few years, with the most recent guidelines published in 2008 [30]. These evidence-based

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guidelines are regarded as the standard of medical care, and take the most recently published VTE literature into account. The ACCP currently recommends group-specific thromboprophylaxis, as these are the basis of randomized trials of thromboprophylaxis. The ACCP guidelines address various groups, including: general, vascular, gynecologic, urologic, laparoscopic, bariatric, thoracic, cardiac, orthopedic, neurologic, and burn surgery patients [30]. According to these clinical standards, the majority of plastic surgery patients require VTE prophylaxis; however, this patient population is not specifically addressed in these practice guidelines. The closest plastic surgical guidelines might be those intended for general surgery patients [5]. Previous ACCP guidelines published in 2004 stratified patients into four risk categories based on the type of operation (minor or major), patient age (older or younger than 40 years), and additional risk factors (including, previous VTE and cancer). Although patients could be easily classified into the various groups, a paucity of recent literature supporting these recommendations, ambiguity of the relative importance of each individual risk factor, uncertainty of how the risk factors interact, and vague definitions regarding “major” and “minor” surgeries have prompted the release of more current guidelines [16, 30]. These broader guidelines are less individualized, allowing the clinician to more freely identify a general risk group and provide more general thromboprophylactic recommendations [30]. Currently, the ACCP stratifies hospital patients into three risk groups: low, moderate, and high-risk groups. Each group has an estimated DVT risk without prophylaxis, a general definition of risk, and suggested thromboprophylactic options. The low-risk group includes minor surgery in mobile patients, with less than 10% DVT risk without prophylaxis. No specific thromboprophylaxis is needed in this lower risk group, although early and “aggressive” ambulation is recommended [30]. The moderate risk group includes the most general, open gynecologic, and urologic surgery patients. These patients have a reported 10–40% DVT risk without thromboprophylaxis. Suggested prophylactic measures included low molecular weight heparin (LMWH), low dose unfractionated heparin (LDUH) twice or three times daily, or the newer drug fondaparinux. For those patients in the moderate risk group at high risk of bleeding, mechanical

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prophylaxis is suggested instead. This includes intermittent pneumatic compression devices, graduated compression stockings, and venous foot pumps [30]. The high-risk group includes orthopedic, trauma, and neurosurgical patients. This includes those patients undergoing hip or knee arthroplasty, hip fracture surgery, major trauma patients, or those sustaining spinal cord injuries. These patients have a significant DVT risk of 40–80% without prophylaxis. Preventive therapies in this group include LMWH, fondaparinux, and oral vitamin K antagonists (Warfarin). For those patients at high VTE risk, with a high bleeding risk, mechanical thromboprophylaxis is recommended instead [30]. Based on these AACP risk criteria, massive weight loss patients may be classified as moderate risk group. Nevertheless, there are no plastic surgery-specific recommendations. Plastic surgery patients, particularly massive weight loss patients undergoing body contouring procedures, comprise a unique group not represented by other surgical specialties. These patients may be obese, with multiple medical problems, and will be undergoing lengthy procedures that may limit postoperative mobility. Furthermore, body contouring procedures may result in a high bleeding risk when anticoagulant thromboprophylaxis is used. Other key ACCP guidelines include never using aspirin alone for thromboprophylaxis for any patient group, utilizing mechanical methods of prophylaxis for patients at high bleeding risk, and utilizing mechanical prophylaxis as an adjunct to other prophylactic measures. They also recommend that every general hospital develop their own formal strategy to address VTE prevention [30]. Due to the lack of plastic surgery-specific thromboprophylactic guidelines and risk stratification, several risk assessment models have been developed for this patient population. In 2004, Davison et al. reviewed the Caprini risk assessment model and made modifications specific to plastic surgery patients. The risk assessment model comprises three steps (Table 87.3). The first step “exposes” the patient’s risk factors. The second step assesses the “predisposing” risk factors. The scores from the first and second steps are added to assign a patient to one of the four risk groups (low, moderate, high, and highest risks) [1]. Each risk group in the Davison-Caprini risk assessment model has associated recommendations for VTE prophylaxis (Table 87.3). Low-risk groups require proper surgical positioning and early ambulation. It is recommended that the moderate risk group receive proper

M. Reinblatt and M. A. Shermak

positioning, early postoperative ambulation, as well as elastic stockings and intermittent pneumatic compression devices. The high-risk group receives similar prophylaxis as that of the moderate risk group, with consideration of LMWH administration based on bleeding risk. The highest risk group should have proper operating room positioning, early ambulation, mechanical devices such as intermittent pneumatic compression or venous foot pumps, anticoagulant therapy with LMWH, and consideration of Warfarin therapy postoperatively [1]. A recent retrospective study consisting of 360 body contouring patients evaluated the Davison-Caprini risk-assessment tool [2]. Their data showed that this risk-assessment model is useful in assigning thromboembolic risk to plastic surgery patients. Of the 19 VTE events identified in their patients, 89.5% (17 out of 19) were placed in the highest risk group and the remainder (2 out of 19) were stratified to the high-risk group. They suggest further revision to the DavisonCaprini risk-assessment model to include circumferential abdominoplasty, body mass index greater than 30, and hormone replacement therapy as important VTE risk factors. These factors may be used to more specifically stratify plastic surgery patients into VTE risk categories. Clearly, further randomized-controlled plastic surgical studies are needed.

87.10 Prevention of Venous Thromboembolism Each surgeon must weigh the risk of VTE against the risk of bleeding. Body contouring patients pose a particular challenge, since there might be a reluctance to provide anticoagulant thromboprophylaxis due to an increased bleeding risk despite the patient having various comorbidities putting them at higher risk for VTE. Furthermore, hormonal therapy with estrogens should be discontinued at least 1 week before the planned surgical procedure.

87.11 Mechanical Prophylaxis Various devices are available for mechanical prophylaxis, which include graduated elastic stockings, intermittent pneumatic compression, and venous foot pumps. These devices have each been shown to reduce

87 Venous Thromboembolism in Bariatric Body Contouring Surgery

855

Table 87.3 Steps in exposing risk factors, predisposing risk factors, and risk assignment (adapted from [1]) Step 1 Exposing risk factors 1 Factor 2 Factors 3 Factors 5 Factors Minor surgery

Major surgery

Previous myocardial infarction

Hip, pelvis or leg fracture

Immobilizing plaster cast

Congestive heart failure

Stroke

Confined to bed >72 h

Severe sepsis

Multiple trauma

Central venous access

Free flap

Acute spinal cord injury

Step 2 Predisposing risk factors Clinical setting Age 40–60 years (1 factor)

Inherited

Acquired

Any genetic hypercoagulable state (3 factors)

Lupus anticoagulant (3 factors)

Age >60 years (2 factors)

Antiphospholipid antibodies (3 factors)

History of VTE (3 factors)

Myeloproliferative disorders (3 factors)

Pregnancy of <1 month postpartum (1 factor)

HIT (3 factors)

Malignancy (2 factors)

Hyperviscosity (3 factors)

Obesity >20% ideal wt (1 factor)

Homocystinemia (3 factors)

Oral contraceptive/HRT (1 factor) Step 3 Total step 1 and step 2 Step 4 Risk assignment 1 Factor

2 Factors

3–4 Factors

>4 Factors

Low risk

Moderate risk

High risk

Highest risk

DVT risk. These methods are not as effective as chemoprophylaxis; however, the ACCP recommend mechanical methods as well as additional prophylactic methods, for those patients who have a high bleeding risk [30]. Graduated elastic stockings decrease the cross-sectional area of the leg. These have been shown to decrease venous distension, improve venous flow, reduce venous stasis, lower edema, and improve venous valvular function. These must be properly fitted and should be applied preoperatively. Reports reveal a DVT reduction of approximately 50%. Ace bandages do not provide graduated compression and should not be used [5, 16]. Intermittent pneumatic compression and venous foot pumps have been reported to decrease the risk of DVT by 60%. These are more effective than graduated

elastic stockings; however, both methods can be used simultaneously. These devices are believed to decrease the venous stasis by driving the blood from the leg, as well as stimulating fibrinolysis by promoting the release of tissue plasminogen activator [5, 23]. Graduated elastic stockings, intermittent pneumatic compression, and venous foot pumps offer simple prophylactic measures that should be used in all surgeries performed under general anesthesia which last longer than 1 h [5]. To be most effective, mechanical methods should be placed on the patient and the machine turned on 30–60 min before anesthesia is induced [4]. These items should remain in place until the patient is fully ambulatory in the postoperative period. Nevertheless, they should not prevent or impede ambulation in any way. The devices should be removed when the patient is mobile and replaced when the patient returns to bed.

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M. Reinblatt and M. A. Shermak

prophylaxis and have found aspirin to be inferior to other anticoagulants. Therefore aspirin is not an appropriate method to protect against VTE [30].

87.13 Heparins

Fig. 87.1 Intermittent pneumatic compression and venous foot pumps are placed on the patient prior to the induction of anesthesia. A pillow also may be placed under the knees to improve venous outflow during surgery

It is therefore highly recommended that these methods be used in the perioperative period until the patient is fully ambulatory [5, 30]. Since there is no bleeding risk, these mechanical methods are beneficial in VTE prevention and remain as the prophylactic method of choice in patients at high risk for bleeding. (Fig. 87.1). Nevertheless, there has been no study large enough to accurately assess whether these mechanical methods reduce the risk of PE or death. Studies suggest that combining mechanical devices with anticoagulant thromboprophylaxis has additive preventative efficacy [30]. Proper surgical positioning and early postoperative ambulation are of utmost importance. Flexing the patient’s knees to 5° on the surgical table has been demonstrated to maximize the venous return through the popliteal vein. Repositioning a patient’s lower extremities during surgery may be similarly useful [5, 17]. The patient should also be encouraged to ambulate within the first postoperative day. Adequate pain control and physical therapy may be helpful aids for ambulation.

87.12 Chemoprophylaxis Several studies support chemoprophylaxis in body contouring procedures [3, 4, 30]. Since few studies are available to evaluate the use of anticoagulants in plastic surgery, guidelines are generally adopted from the orthopedic literature. The ACCP guidelines recommend against the use of aspirin alone as thromboprophylaxis against VTE [36]. A number of studies have reported no significant benefit from aspirin for VTE

Two of the most widely used therapies in VTE prophylaxis include LMWH and low-dose unfractionated heparin (LDUH). Each of these agents inactivates the clotting factors Xa and Thrombin (which is factor IIa). LDUH binds to the circulating plasma proteins and therefore requires larger doses. As a result of protein binding, the bioavailability of LDUH is less predictable. LMWH, including enoxaparin, dalteparin, and tinzaparin, have become therapies of choice. These agents have less protein binding, greater bioavailability, a longer half-life with once daily administrations via subcutaneous injection, no required blood monitoring, and less platelet binding with a resultant decreased risk of heparin-induced thrombocytopenia [32]. However, they are still associated with a small risk of heparin-induced thrombocytopenia, and nonheparin agents must be used to completely abolish this risk. LMWH has been shown to be more effective than LDUH in decreasing the rates of asymptomatic DVT, although both the drugs greatly decrease symptomatic VTE rates [5, 16]. Reports vary in the literature and are conflicting as to whether LMWH or LDUH causes increased or decreased bleeding risks compared to the other agent. The dose of LMWH seems to play an important role in this, with doses less than 3,400 U/day having less bleeding risk than higher doses. Dose adjustment recommendations based on weight remain vague and should also be considered in the obese patient [5, 16, 30].

87.14 Other Agents In 2004, fondaparinux was approved by the United States Food and Drug Administration for VTE prophylaxis in orthopedic surgery. The following year, this approval was broadened for wider use in VTE prophylaxis. Fondaparinux is a synthetic pentasaccharide that specifically inhibits factor Xa. Like LMWH, it is administered by subcutaneous injection

87 Venous Thromboembolism in Bariatric Body Contouring Surgery

with a prefilled syringe. Fondaparinux is not metabolized and is cleared by the kidneys. Thus it is not recommended for use in patients with renal insufficiency [5, 10, 30]. Published trials show that fondaparinux is significantly more effective than LMWH in reducing postoperative DVT in orthopedic joint replacement and hip fracture repair. Although studies have shown an increased bleeding with fondaparinux when compared to LMWH, the dose and perioperative timing may play a role in this (refer to Timing and Duration of Chemoprophylaxis). A double-blinded randomized controlled trial of more than 2,000 patients undergoing abdominal surgery demonstrated that more cancer patients developed VTE while on LMWH (7.7%) vs. fondaparinux (4.7%), although the results showed no statistical difference in noncancer patients [5, 33]. The usual prophylactic dose of fondaparinux is 2.5 mg, which is lower than the general therapeutic dose of 7.5 mg. Other agents are being developed and are undergoing testing, including direct factor Xa inhibitors, which may be taken orally, and direct thrombin inhibitors administered parenterally. These newer therapies do not have reversal agents, and bleeding may be difficult to reverse if it occurs. In contrast, heparin can be reversed with protamine sulfate, which diminishes heparin’s effect on Factor IIa [5, 10].

87.15 Warfarin Warfarin, a vitamin K antagonist, is an oral anticoagulant that requires blood level monitoring. Very high-risk patients may be placed on long-term Warfarin prophylaxis. Doses may be difficult to monitor and levels are often affected by diet. Since Warfarin takes approximately 5 days to reach therapeutic levels, concurrent treatment with LMWH, fondaparinux, or LDUH is recommended. Furthermore, Warfarin is initially prothrombotic, inhibiting the anticoagulants protein C and S prior to the other clotting factors. Because of this, Warfarin is often started 1–3 days after other methods have been instituted. Warfarin levels are monitored by measuring the international normalized ratio (INR), with a target level between 2.0 and 3.0. Depending on the patient’s risk factor assessment, Warfarin may be administered for several months [5, 10].

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87.16 Timing and Duration of Chemoprophylaxis The development of safe protocols for chemoprophylaxis administration comes predominately from the orthopedic literature. Surgeons must balance the risks of postoperative bleeding with the benefits of VTE prevention. Anticoagulants must be administered at particular times in the perioperative period to reduce bleeding risk. LMWH or LDUH may be administered 2 h prior to anesthesia induction. However, if given postoperatively, administration of LMWH or LDUH should be delayed for 12 h after surgery, with the subsequent dose given 24 h later. If prophylaxis is needed prior to this, it is recommended to use half the prophylactic dose before 12 h postoperatively [4, 34]. Fondaparinux (2.5 mg prophylactic dose) may be given 6–8 h after surgery, with an increased bleeding risk demonstrated with administration less than 6 h postoperatively [34]. A recent review of the literature regarding the optimal timing of chemoprophylaxis comparing preoperative vs. postoperative administration, failed to demonstrate improved efficacy with preoperative administration. Furthermore, there is an increased risk of major bleeding when chemoprophylaxis is begun within 2 h preoperatively. Administration of the various anticoagulants 12–24 h postoperatively may be less effective than at 6 h; however, further studies comparing the same anticoagulant administered at different times are required [5, 34]. A study comparing fondaparinux to LMWH (enoxaparin) revealed that treatment with fondaparinux (2.5 mg) administered 6 h postoperatively is more effective and as safe as enoxaparin administration at 12 or 24 h after surgery. Fondaparinux administered less than 6 h postoperatively resulted in major bleeding with no change in efficacy [34]. Chemoprophylaxis is most commonly maintained, with either LMWH or fondaparinux, for 5–10 days after surgery. Patients with more VTE risk factors should receive a longer course than those with fewer risks. Massive weight loss patients undergoing body contouring procedures likely require some form of anticoagulation through discharge, and those higher risk patients may require several days of therapy at home. Patient ambulation and mobility also play a role in assessing the duration of therapy [5]. There are

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no plastic surgery studies to date to help guide therapy. Chemoprophylaxis may be a concern for those plastic surgeons that utilize epidural anesthesia. The American Society of Regional Anesthesia and Pain Management (ASRA) issued guidelines for patients with neuraxial anesthesia who are receiving prophylaxis with LMWH. These guidelines differ depending on the type of LMWH used: once daily or twice daily preparations. For dalteparin (a once daily administration of 2,500 mg), the first dose should be given 6–8 h after surgery with the next dose given 24 h later. Epidural catheters may be safely left in place while prophylaxis is administered. Catheters can be safely removed in a minimum of 10–12 h after the previous dose, with subsequent doses delayed for at least 2 h after the device removal. For enoxaparin (twice-daily administration of 30 mg), the first dose should be administered more than 24 h postoperatively and indwelling neuraxial catheters should be removed before LMWH treatment is started. For either regimen, ASRA recommends the first dose of LMWH to be delayed by 24 h, if there is blood during catheter placement [34].

87.17 Inferior Vena Cava Filters Inferior vena cava (IVC) filter placement is another form of VTE prophylaxis reported in the bariatric surgical literature [35, 36]. In patients undergoing bariatric surgery for morbid obesity, preoperative IVC filter placement has been recommended for those with a history of PE, prior DVT, known hypercoagulable state, and venous stasis [35]. These filters were inserted via a percutaneous, jugular approach on the day before surgery (Fig. 87.2). Out of fourteen patients studied, there were no postoperative PEs or reported complications from IVC filter placement. With the development of newer, retrievable IVC filters, preoperative IVC filter placement for VTE prophylaxis may be more frequently used [35]. This prophylactic method may also be useful in the massive weight loss patient undergoing body contouring surgery, particularly those at a high risk for both bleeding and VTE development. Further studies addressing this patient population are needed.

M. Reinblatt and M. A. Shermak

Fig. 87.2 Temporary inferior vena caval filter in place as visualized by intraoperative fluoroscopy

87.18 Diagnosis of Venous Thromboembolism Most thromboembolic complications occur after discharge from the hospital and within the first month after surgery [3, 30, 37]. Discussions with patients prior to discharge, encouraging ambulation and close postoperative follow-up are therefore essential for prevention. The risk of postoperative DVT is greatest within 2 weeks of surgery; however, VTE can develop in high-risk patients up to 7 weeks postoperatively [5, 30]. The diagnosis of VTE is especially difficult since the symptoms and signs of DVT or PE can be nonspecific. Moreover, the signs and symptoms do not always correlate with the disease severity [5, 10, 38]. Risk factors for VTE are not only helpful in guiding prophylaxis, but also aid in highlighting those patients most prone to developing DVT or PE. A patient’s risk factors help raise suspicion for VTE in those patients with vague signs or symptoms. Understandably, those patients with 1 or more risk factors are more likely to develop VTE than those without risk factors. Chronic risk factors may also increase the risk of VTE recurrence in a patient who has suffered one episode already [38]. In a study evaluating 1,231 consecutive patients treated for acute DVT or PE, 88.5% were over 40 years of age, 37.8% were obese, 26% had a history of VTE, 22.3% had cancer, and 12% had 5 or more days of bed rest [29, 38]. These statistics clearly mimic those previously outlined risk factors for VTE.

87 Venous Thromboembolism in Bariatric Body Contouring Surgery

87.19 Signs and Symptoms of Acute DVT and PE Symptoms of DVT may be acute, progressive, or highly variable. Patients may present with lower extremity muscle cramping, warmth, pain, swelling, and erythema (Fig. 87.3) [38]. Additional signs of DVT development include lower extremity tenderness in the absence of infection, skin discoloration, skin ulceration, calf pain on ankle dorsiflexion (Homan’s sign), and “palpable leg cords” -which represent thrombosed veins. Only 25% of the patients with DVT present with these classic symptoms [10]. Symptoms of PE may develop over hours or days. The most frequent signs include dyspnea 73%, pleuritic pain 66%, cough 37%, and leg swelling 28%. PE is often associated with signs including, tachypnea (greater than 20 breaths/min) 70%, rales or crackles on chest auscultation 51%, and tachycardia (greater than 100 beats/min) 30%. Surgeons must have a differential diagnosis of PE in mind in any patient with unexplained rapid heart or respiratory rate. Physicians have been reported to be correct only 30% of the time when diagnosing PE clinically. PE may also be confused with cardiac angina, another life-threatening process.

a

Fig. 87.3 (a) This patient presented within 2 weeks after abdominoplasty and hysterectomy. She had subtle swelling of her left calf and thigh with complaints of pain in the lower extremity. (b) On closer look, there was associated erythema of the distal medial thigh. The concern of DVT was confirmed by a venous duplex ultrasound study

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Pleuritic chest pain is commonly associated with embolism and pulmonary infarction [10, 38].

87.20 Initial Work Up of Deep Venous Thrombosis If DVT is suspected, after a thorough physical exam, Doppler ultrasound of the lower extremities should be performed. Ultrasound is the most frequently used imaging study to diagnose DVT since it is noninvasive, readily available, and accurately detects proximal thrombus [38]. However, Doppler is more sensitive and specific in patients with leg symptoms, including pain and swelling (Fig. 87.4). In symptomatic DVT, Doppler ultrasound is 95% sensitive and 96% specific. In patients without leg symptoms, sensitivity and specificity decrease to 62% and 75% respectively. However, studies show that ultrasound is still accurate in diagnosing asymptomatic DVT, especially those involving the proximal veins [10, 39]. Doppler ultrasound should not be used in the setting of suspected PE. Less than half of the patients with PE will have leg symptoms or signs, and less than

b

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M. Reinblatt and M. A. Shermak

Fig. 87.4 This Duplex ultrasound study demonstrates acute thrombus in the popliteal veins

a third of the patients will have an abnormal ultrasound. Serial Doppler ultrasounds may be required to assess the migration of a thrombosis from below to above the knee. This propagation usually occurs within 1 week; therefore, in those patients with a high index of suspicion of DVT, ultrasound should be repeated after 7 days [10, 39]. Serologic studies, measuring fibrin D-dimer, may be useful in the work up of DVT. This is a marker of thrombosis and has a reported sensitivity of 90% and specificity of 75% in VTE. The best reason to measure D-dimer is when the surgeon has low clinical suspicion, but would like to rule out DVT in a patient. Antithombin III blood levels have been shown to be decreased in patients with VTE; however, this test is not readily available and further studies are underway [10, 40, 41]. Magnetic resonance imaging (MRI) is another diagnostic modality than can be used to diagnose DVT. However, this method is costlier and less readily available. MRI has been shown to have a good sensitivity for both acute and chronic DVT. This modality is useful in patients with severe leg trauma, superficial wounds, splints or casts that cannot be removed, and significant swelling [38]. Venography is the historical gold standard study in the diagnosis of DVT, but this is rarely performed in the United States since it is invasive and has associated risks [38].

The surgeon must also consider an upper extremity source of VTE when no lower leg cause is identified. Although these are less common than lower extremity DVT, they should be considered in patients with a history of arm DVT, as well as upper extremity swelling, trauma, or indwelling catheter placement [10].

87.21 Initial Work Up of Pulmonary Embolism Every patient with suspected PE should receive a chest X-ray to rule out other causes of shortness of breath and chest pain, which may mimic PE. Chest X-ray can quickly rule out congestive heart failure or pneumonia. Findings of PE on chest X-ray are nonspecific and include, effusion, atelectasis, elevated hemidiaphragm, and lung opacification. Approximately 86% of the patients with PE will have nonspecific and subtle radiographic abnormalities [10, 38]. Serologic studies for PE include a room air arterial blood gas sample. This evaluates for hypoxia and measures the alveolar–arterial oxygen pressure gradient (A-a gradient). This test is most valuable in the hypoxemic patient who may require supplemental oxygen. However, 20% of the patients with documented PE

87 Venous Thromboembolism in Bariatric Body Contouring Surgery

Fig. 87.5 Spiral CT scan demonstrates a large clot in the base of the right lung

had a normal alveolar–arterial oxygen gradient, and it has been shown that a large PE may be associated with a normal gradient as well [10, 40]. With the widespread availability of CT (computed tomography) imaging, particularly newer spiral CT, it is being more commonly used to diagnose PE. CT scanning is rapid, available, and can rule out other sources of disease if no clot is seen (Fig. 87.5). Nevertheless, the patient must be stable to be transported to the radiology suite. Disadvantages of CT include the use of contrast dye in patients with renal insufficiency, lack of portability, and cost. A normal CT is less sensitive than a normal Ventilation-Perfusion (V/Q) scan, although specificity is good. CT sensitivity for acute PE has a wide variation in the literature, ranging from 53 to 100%. CT specificity for PE has been reported to be between 81 and 100%. CT identifies lung infarcts as triangular pleural-based densities and may reveal emboli within the pulmonary vasculature [38]. Ventilation-Perfusion (V/Q) scanning used to be the mainstay method of diagnosing PE. Currently, this modality has generally fallen out of favor, since the common “indeterminate” diagnosis is of limited value. Patients with underlying lung disease should not undergo V/Q scanning, as pulmonary processes decrease test specificity. Furthermore, unlike CT

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imaging, a V/Q scan cannot identify other causes of hypoxia or pulmonary diseases that may be mimicking PE. A normal scan, which is relatively infrequent, can reliably rule out PE. A high-probability scan is specific for the diagnosis of PE. However, an indeterminate scan has often been associated with PE when there is high clinical suspicion for PE. In these situations, further PE imaging with CT or angiography is needed. Advantages of the V/Q scan include availability, speed, and noninvasiveness. Exposure to radiation in pregnancy and frequent indeterminate results are among the disadvantages with this modality [10, 38]. Pulmonary angiography is the gold-standard for diagnosing acute PE, but like venography in the diagnosis of DVT, it is invasive, requires large contrast loads, and is rarely used. MRI may be a valuable tool for diagnosing PE. MRI can examine the legs, chest, and heart function. However, MRI is costly, not readily available, and time-consuming in a potentially hypoxic patient. Since VTE is a disease spectrum including DVT and PE, a patient diagnosed with DVT by ultrasound who is suffering from chest symptoms can be assumed to have PE. In this instance, no further imaging is needed [10, 38].

87.22 Treatment of Venous Thromboembolism Half of all the DVT originating intraoperatively will spontaneously resolve. However, the remainder can lead to further complications, including PE and postthrombophlebitic syndrome. Approximately 10% of the patients with acute PE die within 30–120 min of embolization [42]. Aggressive early treatment is required for the therapy to be effective. Intravenous heparin should be administered immediately when there is a high clinical suspicion. In the acute PE setting in an unstable patient, immediate hemodynamic support in addition to heparin or thrombolytic therapies have been shown to decrease mortality [10]. Stable patients with PE can be treated with either LMWH or unfractionated heparin (UFH); each of these augment antithrombin III and prevent fibrinogen conversion to fibrin. LMWH has several advantages over UFH, including easier subcutaneous administration,

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lower rates of heparin-induced thrombocytopenia (HIT), a more predictable dose response, and longer plasma half-life. As a result, LMWH does not requite blood monitoring with partial thromboplastin time (PTT). Comparatively, UFH is much harder to manage. PTT levels must be monitored and there is a less reliable dose-response. With UFH, approximately 50% of the patients do not reach their target PTT within the recommended 24 h. LMWH has been shown to be as effective and safe as UFH in the initial treatment of patients with VTE. Furthermore, considering that LMWH can be administered subcutaneously and routine lab studies are not needed, the stable patient with VTE can be treated as an outpatient [10, 32, 43]. Because the full effect of Warfarin, a vitamin K antagonist, is not observed for the first 5–7 days, concurrent treatment with LMWH or UFH is recommended until the international normalized ratio (INR) is stable and over 2.0. Warfarin is initially prothrombotic, inhibiting the anticoagulants protein C and S (which inhibit clotting factors V and VII) before affecting the remaining clotting factors. Warfarin is therefore frequently started 1–3 days after heparin is initiated. The target INR is generally 2.0–3.0, with a 3–6 month course prescribed based on the patient’s clinical history. However, Warfarin has been associated with a risk of bleeding in patients with a history of gastrointestinal ulcer, stroke, and hypertension. Furthermore, it has been shown to be teratogenic in the fetus, resulting in fetal chondromalacia. In pregnant patients, LMWH is used instead [32]. In those patients who develop HIT, direct thrombin inhibitors are available. Hirudin, a leech-produced anticoagulant, is an alternative therapy. Drugs such as lepirudin, danaparoid, and Argatroban (GlaxoSmithKline, Brentford, Middlesex, United Kingdom) may be used instead of heparin. Although these alternative anticoagulants are useful when heparin is not tolerated, they are given parentally, have an unpredictable dose response, are difficult to monitor, are costly, and have no reliable means of reversal. Lepirudin and danaparoid require hemodialysis for clearance, whereas Argatroban clears rapidly and has a short half-life [10, 44, 45]. Thrombolysis should be considered in the acute PE setting when there is associated hemodynamic instability, syncope, hypoxia, and heart failure. Thrombolytics, such as tissue plasminogen activator (tPA), are most effective when administered early and

M. Reinblatt and M. A. Shermak

in the emergency room. Catheter-directed thrombolysis by an interventional radiologist has also been performed. Timely administration has been shown to significantly reduce the acute and chronic sequelae of PE. These agents have been shown to restore lung perfusion and decrease pulmonary hypertension. Nevertheless, absolute contraindications to thrombolysis include trauma, recent surgery, gastrointestinal bleeding, and hemorrhagic stroke [10, 46]. Patients in whom anticoagulation is contraindicated may be considered for inferior vena cava (IVC) filter placement. IVC filters are especially useful in patients with another active bleeding source and severe thrombocytopenia. These may also be used in patients with recurrent PE despite being placed on chronic anticoagulation. Although IVC filters can prevent recurrent pulmonary embolism, they may increase the shortterm DVT risk and require anticoagulation. However, retrievable temporary filters only require short-term blood thinning compared to older, permanent filters [10, 47, 48]. Endovascular techniques such as catheter-directed thrombolysis or embolectomy have been used for PE. Similarly, severe DVT has been treated with endovascular stenting and catheter-directed thrombolytics. These less invasive techniques have largely supplanted the open surgical procedures. Nevertheless, as a last resort, pulmonary embolectomy may be required in an unstable patient after failed thrombolysis [10, 49, 50].

87.23 Conclusions With the rise in bariatric surgeries, plastic surgeons will manage greater numbers of body contouring patients after massive weight loss. The surgeon must be familiar with this patient population in order to perform surgery safely. VTE prophylaxis is of prime importance in this patient population. Although the risk of VTE in plastic surgery patients is relatively low compared to other specialities such as orthopedic or neurosurgery, proper preventative methods should be provided. The massive weight loss patient may be at an increased risk for DVT and PE as result of increased weight, surgical trauma, decreased ambulation, duration of the surgery, and operative positioning. VTE prophylaxis should be provided to massive weight loss patients undergoing body contouring

87 Venous Thromboembolism in Bariatric Body Contouring Surgery

procedures. Prevention may decrease patient morbidity, possible mortality from PE, as well as significantly lower health care costs by reducing the need for costly testing and therapies. At the very least, each body contouring patient should receive proper surgical positioning, mechanical prophylaxis with graduated elastic stockings and intermittent pneumatic compression, as well as early postoperative ambulation. The surgeon must then evaluate each case individually and consider the need for chemoprophylaxis with LDUH, LMWH, or fondaparinux by weighing the risk of VTE with that of surgical bleeding. The plastic surgical patient is not specifically addressed in the ACCP guidelines for VTE prophylaxis; however, several VTE risk assessment models exist, including the Davison-Caprini model. A recent report evaluating this model on body contouring patients, suggests including body mass index greater than 30, hormone therapy, and circumferential abdominoplasty as additional VTE risk factors in the massive weight loss patient. Although there are several retrospective reviews guiding VTE prophylaxis in body contouring surgery, further randomized and controlled trials are needed to ensure safe surgery with minimal morbidity.

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7. Kahn SR. The clinical diagnosis of deep venous thrombosis: integrating incidence, risk factors, and symptoms and signs. Arch Intl Med. 1998;158(21):2315–23. 8. White RH. The epidemiology of venous thromboembolism. Circulation 2003;107(23 Suppl 1):14–8. 9. Kahn SR. The post-thrombotic syndrome: the forgotten morbidity of deep venous thrombosis. J Thromb Thrombolysis. 2006;21(1):41–8. 10. Most D, Kozlow J, Heller J, Shermak MA Thromboembolism in plastic surgery. Plast Reconstr Surg. 2005;115(2): 20e–30. 11. Dalen JE, Alpert JS Natural history of pulmonary embolism. Progr Cardiovasc Dis. 1975;17(4):259–70. 12. Anderson FA Jr, Wheeler HB Venous thromboembolism. risk factors and prophylaxis. Clin Chest Med. 1995;16(2): 235–51. 13. Young VL, Blinder M American Society of Plastic Surgeons Online Patient Safety Course: Risk assessment and prevention of venous thromboembolism. www.plasticsurgery.org 2008. 14. Kearon C. Natural history of venous thromboembolism. Circulation 2003;107(23 Suppl 1):I22–30. 15. Spyropoulos AC, Lin J Direct medical costs of venous thromboembolism and subsequent hospital readmission rates: an administrative claims analysis from 30 managed care organizations. J Managed Care Pharm. 2007;13(6): 475–86. 16. Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, Ray JG Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126(3 suppl):338S–400. 17. McDevitt NB. Deep vein thrombosis prophylaxis. American Society of Plastic and Reconstructive Surgeons. Plast Reconstr Surg. 1999;104(6):1923–8. 18. Wu EC, Barba CA Current practices in the prophylaxis of venous thromboembolism in bariatric surgery. Obes Surg. 2000;10(1):7–13; discussion 14. 19. Melinek J, Livingston E, Cortina G, Fishbein MC Autopsy findings following gastric bypass surgery for morbid obesity. Arch Pathol Lab Med. 2002;126(9):1091–5. 20. Rohrich RJ, Rios JL Venous thromboembolism in cosmetic plastic surgery: maximizing patient safety. Plast Reconstr Surg. 2003;112(3):871–2. 21. Hughes CE. Reduction of lipoplasty risks and mortality: an ASAPS survey. Aesthetic Surg J. 2001;21(2):120–7. 22. Grazer FM, Goldwyn RM Abdominoplasty assessed by survey, with emphasis on complications. Plast Reconstr Surg. 1977;59(4):513–7. 23. Reinisch JF, Bresnick SD, Walker JW, Rosso RF Deep venous thrombosis and pulmonary embolus after face lift: a study of incidence and prophylaxis. Plast Reconstr Surg. 2001;107(6):1570–5; discussion 1576–7. 24. Hester TR Jr, Baird W, Bostwick J III, Nahai F, Cukic J Abdominoplasty combined with other major surgical procedures: safe or sorry? Plast Reconstr Surg. 1989;83(6): 997–1004. 25. Voss SC, Sharp HC, Scott JR Abdominoplasty combined with gynecologic surgical procedures. Obstet Gynecol. 1986;67(2):181–5. 26. Aly AS, Cram AE, Chao M, Pang J, McKeon M Belt lipectomy for circumferential truncal excess: the University of

864 Iowa experience. Plast Reconstr Surg. 2003;111(1): 398–413. 27. Matarasso A, Swift RW, Rankin M Abdominoplasty and abdominal contour surgery: a national plastic surgery survey. Plast Reconstr Surg. 2006;117(6):1797–808. 28. Grazer FM, de Jong RH Fatal outcomes from liposuction: census survey of cosmetic surgeons. Plast Reconstr Surg. 2000;105(1):436–46; discussion 447–8. 29. Anderson FA Jr, Spencer FA Risk factors for venous thromboembolism. Circulation 2003;107(23 suppl 1):19–6. 30. Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW American College of Chest Physicians: Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008;133 (6 suppl):381S–453. 31. Stein PD, Beemath A, Olson RE Obesity as a risk factor in venous thromboembolism. Am J Med. 2005;118(9) :978–80. 32. Goldhaber SZ. Outpatient treatment of deep vein thrombosis or pulmonary embolism: feasible and safe, but who qualifies? In: Tapson VF, editor. Treatment of venous thromboembolism (monograph). St. Louis: Elsevier; 2006. p. 11–20. 33. Agnelli G, Bergqvist D, Cohen AT, Gallus AS, Gent M; PEGASUS investigators. Randomized clinical trial of postoperative fondaparinux versus perioperative dalteparin for prevention of venous thromboembolism in high-risk abdominal surgery. Brit J Surg. 2005;92(10):1212–20. 34. Raskob GE, Hirsh J Controversies in timing of the first dose of anticoagulant prophylaxis against venous thromboembolism after major orthopedic surgery. Chest 2003;124 (6 suppl):379S–385 35. Keeling WB, Haines K, Stone PA, Armstrong PA, Murr MM, Shames ML Current indications for preoperative inferior vena cava filter insertion in patients undergoing surgery for morbid obesity. Obes Surg. 2005;15(7):1009–12. 36. Ferrell A, Byrne TK, Robison JG Placement of inferior vena cava filters in bariatric surgical patients-possible indications and technical considerations. Obes Surg. 2004;14(6): 738–43. 37. Sapala JA, Wood MH, Schuhknecht MP, Sapala MA Fatal pulmonary embolism after bariatric operations for morbid obesity: a 24-year retrospective analysis. Obes Surg. 2003;13(6):819–25. 38. Tapson VF. Identifying patients with deep vein thrombosis or pulmonary embolism: current standards and future directions. In: Tapson VF, editor. Treatment of venous thromboembolism (monograph). St. Louis: Elsevier; 2006. p. 2–10. 39. Cogo A, Lensing AW, Prandoni P, Hirsh J Distribution of thrombosis in patients with symptomatic deep vein

M. Reinblatt and M. A. Shermak thrombosis. Implications for simplifying the diagnostic process with compression ultrasound. Arch Int Med. 1993;153(24): 2777–80. 40. Robin ED, McCauley RF The diagnosis of pulmonary embolism. When will we ever learn? Chest 1995;107(1):3–4. 41. Lee AY, Ginsberg JS Laboratory diagnosis of venous thromboembolism. Bailliere’s Clin Haematol. 1998;11(3): 587–604. 42. Lee AY, Levine MN, Baker RI, Bowden C, Kakkar AK, Prins M, Rickles FR, Julian JA, Haley S, Kovacs MJ, Gent M Randomized Comparison of Low-Molecular-Weight Heparin versus Oral Anticoagulant Therapy for the Prevention of Recurrent Venous Thromboembolism in Patients with Cancer (CLOT) Investigators Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. New Engl J Med. 2003;349(2):146–53. 43. Levine M, Gent M, Hirsh J, Leclerc J, Anderson D, Weitz J, Ginsberg J, Turpie AG, Demers C, Kovacs M A comparison of low-molecular-weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep-vein thrombosis. New Engl J Med. 1996;334(11):677–81. 44. Farner B, Eichler P, Kroll H, Greinacher A A comparison of danaparoid and lepirudin in heparin-induced thrombocytopenia. Thromb Haemost. 2001;85(6):950–7. 45. Lewis BE, Wallis DE, Berkowitz SD, Matthai WH, Fareed J, Walenga JM, Bartholomew J, Sham R, Lerner RG, Zeigler ZR, Rustagi PK, Jang IK, Rifkin SD, Moran J, Hursting MJ, Kelton JG; ARG-911 Study Investigators. Argatroban anticoagulant therapy in patients with heparin-induced thrombocytopenia. Circulation 2001;103(14):1838–43. 46. Goldhaber SZ, Hennekens CH Time trends in hospital mortality and diagnosis of pulmonary embolism. Am Heart J. 1982;104(2 Pt 1):305–6. 47. Decousus H, Leizorovicz A, Parent F, Page Y, Tardy B, Girard P, Laporte S, Faivre R, Charbonnier B, Barral FG, Huet Y, Simonneau G A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prevention du Risque d’Embolie Pulmonaire par Interruption Cave Study Group. New Engl J Med. 1998;338(7):409–15. 48. White RH, Zhou H, Kim J, Romano PS A population-based study of the effectiveness of inferior vena cava filter use among patients with venous thromboembolism. Arch Int Med. 2000;160(13):2033–41. 49. Haage P, Krings T, Schmitz-Rode T Nontraumatic vascular emergencies: imaging and intervention in acute venous occlusion. Eur Radiol. 2002;12(11):2627–43. 50. Timsit JF, Reynaud P, Meyer G, Sors H Pulmonary embolectomy by catheter device in massive pulmonary embolism. Chest 1991;100(3):655–8.

Index

A Abboud, M., 179, 193, 194 Abdomen, aesthetic units, 28 Abdominolipoplasty classification, 218 Abscess, 146, 333, 366, 478, 608, 776 Acarturk, T.O., 777 Accolate. See Zafirlukast Accreditation Association of Ambulatory Healthcare (AAAHC), 221 Agris, J., 583, 828 Ahmadzadeh, R., 16 AlloDerm, 382 Aly, A.S., 691, 848 American Society for Aesthetic Plastic Surgery (ASAPS), 59, 62, 190, 400 American Society of Anesthesiologists (ASA), 745, 777–779 American Society of Plastic Surgeons (ASPS), 59, 62, 293, 331, 400 Anaphylaxis, 557 Appelt, 331 Arié, G., 150, 169, 723 Arié–Pitanguy procedure, 171 Arion, H., 74 Asaadi, M., 583 Ashley, F.L., 74 Ashwell, M., 33 Asken, S., 577, 581 Asymmetry, 136, 145, 261, 267, 338, 410, 519, 553, 621, 780 Aszmann, O.C., 18 Atrophy, 800 Aubert, V., 149 Aufricht, G.L., 149 B Baker, J.L. Jr., 95 Bames, H.O., 73, 149 Banana roll, 14 Baroudi, R., 262, 294, 348, 355, 358, 778 Barraya, L., 239 Barsky, A.J., 207 Beck, C., 207 Becker, H., 74, 100 Benelli, L., 179 Benvenuti, D., 274 Berdeguer, P., 578, 583 Berson, M., 73

Bibbia, 351 Biesenberger, H., 149, 169 Bircoll, M., 595 Bissacia, E., 623 Blindness, 619 Bobkova, V.I., 59 Body Dysmorphic Disorder (BDD), 82, 644 Body lift, 10, 11, 23, 355 Body mass index (BMI), 34, 223, 224, 496, 633, 641, 687, 769, 776–780, 827, 828, 833 Borges, A.F., 789 Bottoming out, 145 Bowel perforation, 269 Brandow, K., 583 Breast, necrosis, 73 Brodie, B.C., 505 Brown, F.E., 197 Burns, 395, 410, 747 Buschke’s syndrome, 513 Buttock lift, 12, 16, 23, 257, 265, 358, 363, 671 C Calcifications, 94, 179, 194, 197, 198, 478, 578, 620 Caldwell–Moloy pelvis classification, 604 Callia, W., 207 Calman, K.C., 784 Campbell, G.L., 577 Camper’s fascia, 28 Candiani, P., 824, 828 Capsule contracture, 78, 81, 94–98, 100, 716, 739 Carpaneda, C.A., 607 Castañares, S., 239 Castello, J.R., 619 Cavitation, 392, 476, 486 Cellulite, 251, 263, 474 Centers for Disease Control (CDC), 104, 105, 200, 201 Centrifugation, 374, 377 Chahraoui, K., 785 Chajchir, A., 581 Chalekson, C., 743 Christ, J.E., 74 Cimino, W.W., 401, 410 Claoué, C., 161 Clarkson, P., 789 Cohesive gel, 74 Coleman, S.R., 595, 619

865

866 Colles, A., 348 Colle’s fascia, 347, 349, 350, 358, 703, 815–817, 820, 823–825, 828 Compartment syndrome, 66 Conway, H., 73, 150 Cooper’s ligaments, 4, 149 Correa-Iturraspe, M., 293, 307, 321, 789 Courtiss, E.H., 131, 133, 195 Cronin, T., 74, 77, 327 Cuenca-Guerra, R., 14, 602, 604 Cysts, 619 Czerny, V., 73

Index Frey, M., 124 Fulton, J.E., 583, 623

E Edema, 268, 333, 366, 379, 396, 410, 542, 554, 703, 793, 800, 807, 828, 832, 833 Ehlers–Danlos syndrome, 779 Eklund, G., 179 Elam, M.V., 583 El Khatib, H.A., 297 Endermologie, 429 Ersek, R.A., 579, 825 Exsanguination, 267

G Galtier, M., 239 Garcia, O., 565 Gasparotti, M., 842 Gaudet, F., 207 Gerow, F., 74, 77, 327 Gersuny, I., 73 Gigantomastia, 156, 157 Gillies, H., 150 Gilliland, M.D., 297, 303, 789, 792 Gill, T.M., 784 Giovanoli, P., 124 Glanz, S., 293 Gloviczki, P., 342 Goddio, A.S., 295, 789 Goes, J.C., 179 Goethel, J.A., 239 Gonzalez, F., 201 Gonzalez, M., 211 Gonzalez, R., 12 Gonzalez-Ulloa, M., 207, 262, 293 Gore-Tex, 74 Goulian, D. Jr., 73 Graf, R., 282 Granstrom, L., 630 Grassegger, A., 509 Grazer, F.M., 33, 207, 744, 776, 828 Greco, J.A., 776, 777, 779 Grossman, A.R., 74 Grothaus, M.C., 18 Guedes Neto, H.J., 341 Guerrero-Santos, J., 211, 294, 295, 595, 607, 789, 813, 837 Guinard, A., 149 Gusenoff, J.A., 33, 781, 813 Gutstein, R.A., 381 Gynecomastia, 135–137, 139, 141–143, 182, 547, 664

F Fat, necrosis, 66, 191, 198 Fat embolism, 555, 558, 618 Fat embolism syndrome, 274 Fat hypertrophy, 622, 623 Fat necrosis, 613, 620, 702, 739, 775, 804 Fayman, M.S., 109 Fernandez, J.C., 293, 307, 321 Fibrosis, 185, 366, 410, 555, 758, 759 Fischer, A., 219 Fischer, G., 419, 743 Fischer, P.D., 193 Fistula, 478, 776 Fitzpatrick type, 405, 460 Flankplasty, 355, 751 Fodor, P.B., 400, 743 Food and Drug Administration (FDA), 65, 66, 78, 96, 97, 580, 856 Forlini, W., 215 Fournier, P., 219 Franco, T., 789

H Haaverstad, R., 833 Hakme, F., 211 Hall Finlay, E.J., 739 Hammond, D.C., 139 Harper, A.D., 337 Har-Shai, Y., 619 Hematoma, 98, 99, 106, 141, 145, 155, 191, 193, 198, 204, 246, 267, 268, 365, 463, 488, 542, 553, 554 Hematomas, 621, 699, 716, 746, 750, 751, 765, 775, 776, 813 Hernia, 764–766 Hess, D.S., 630 Hetter, G.P., 743 Heywang-Kobrunner, S.H., 197 Hinderer, U.T., 150 Hiragun, A., 581 Hodgkinson, D.J., 828 Hollander, E., 149 Hoopes, J.E., 150 Huger’s zones, 242, 244 Huger, W.E. Jr., 28, 242

D Daniel, M.J.B., 282 Dehiscence, 260, 264, 268, 746, 751, 776, 779, 807, 813 Delerm, A., 837 Demars, M.M., 207 De Souza Pinto, E.B., 420, 743, 789 Dezeuze, J., 239 Dieffenbach, J.F., 149 Dillerud, E., 833 Double-bubble, 713 Dufourmentel, C., 150, 239 Duggleby, S.L., 34 Dujarrier, C., 219, 743 Durston, W., 149

Index Hurwitz, D.J., 281 Hydrodissection, 91 Hyperpigmentation, 66, 556, 624 Hypertension, 766, 778–780 Hypesthesia, 542 Hypotension, 268, 273, 560 Hypothermia, 494, 750 I Iconoclast, 88, 89 Illouz, Y.G., 219, 419, 517, 520, 539, 577, 743 Implant deflation, 100, 716 rupture, 716 Infection, 73, 102, 141, 146, 199, 230, 268, 269, 323, 333, 365, 542, 556–558, 578, 617, 712, 716, 746, 750, 751, 765, 770, 813, 829, 834, 840, 841, 846 Infragluteal fold, 13 Inframammary crease, 102 Inframammary fold, 80, 83, 120–122, 126, 133, 180, 186, 199, 235, 663–665, 667, 705, 736–738 Inframammary scar, 129 Insulin, 577 Intercostal nerve, entrapment, 98 Ivalon, 74 J Jabaley, M.E., 150 Jewell, M.L., 401 Johnson, G.W., 74, 578 Juri, J., 294, 789 K Kelly, H.A., 207, 744 Kelman, C., 399 Kesselring, U., 743 Kim, J., 246 Klein, J.A., 180, 219 Klein’s solution, 184 Klingbeil, J.R., 33 Knoetgen, J., 292, 468, 813 Knoetgen, J. III, 332 Kraske, II, 149 Kremen, A.J., 629 Kuzmak, L.I., 630 L Lassus, C.A., 723 Launois–Bensaude syndrome, 513 Laws, H.L., 630 Leitner, D.W., 366, 829 Lejour, M., 125, 179, 193, 194, 739 Le Louarn, C., 825 Lewis, 351 Lewis, J.R. Jr., 824, 828, 829, 837 Lexer, E., 169, 327 Lidocaine toxicity, 225, 230, 557 Linner, J.H., 629 Lipodystrophy, 817 Lipohypertrophy, 550 Liposculpture with VASER, 229

867 Lipostabil, 59, 65 Lockwood, T., 211, 291, 296, 303, 468 Lockwood, T.E., 262, 347, 348, 351, 358, 700, 703, 789, 815, 816, 823–825, 828, 829, 832, 834, 837, 841 Longacre, J.J., 73 Lordosis, 15 Lugo-Beltran, I., 14 Lykissa, E.D., 98 Lymphedema, 543, 751, 825 Lymphoceles, 323, 333, 338, 350, 365–371, 703, 704, 799, 800, 829, 832–834 Lymphorrea, 840, 841, 846 Lymphoscintigraphy, 337, 338, 340, 344, 704 Lyos, A.T., 297 Lysonix, 220, 400 M Madelung, O.W., 505 Madelung’s disease, 506, 507, 509, 513 Madelung’s neck, 513, 514 Maharaj, S.V., 98 Maillard, G.F., 193 Malabsorption, 653, 656–658 Malekzadeh, S., 297 Maliniac, J.W., 73, 149, 150 Malnutrition, 653 Mammatech, 74 Manjarrez, A., 215 Marc, H., 155 Marchac, D., 723 Marfan’s syndrome, 5 Marino, H., 73, 150 Marx, M., 207 Mason, E.E., 629, 630 Matarasso, A., 211, 217, 274, 779 Mathes, D.W., 816 Maximovich, S.P., 93 May, H., 150 May, J.W. Jr., 583 McCraw, J., 185 McCraw, L.H. Jr., 751 McCurdy, J.A. Jr., 577 McDivitt, R.W., 73 McKissock, P.K., 125, 159 Medsculpt, 68 Meme, 74 Mendelson, E.B., 197 Mendieta, C.G., 12, 499, 502, 503, 602 Mentz, H.A. III, 419 Mesh, 766 Mesotherapy, 59, 65 Metabolic syndrome, 239 Methicillin-resistant Staphylococcus aureus (MRSA), 95, 102–105, 199–201 Meyer, R., 743 MicroAire, 220 Millard, G.F, 619 Miller, C.L., 197 Mirrafati, S., 108 Misty Gold, 74 Mitchell, J.E., 636

868 Mitnick, J.S., 197 Mitz, V., 351 Mohammad, J.A., 267 Mondor’s disease, 93, 105 Montaigne, 157 Montanana Vizcaino, J., 619 Montelukast, 97 Moran, G.J., 103 Moran, S.L., 332 Morbid obesity, 277, 722, 760, 761, 775, 778, 783, 827, 832, 840 Morel Lavallé syndrome, 763 Morestin, H., 149, 207 Morselli, P.G., 139 Mouly, R., 150 Myospasm, 106 N Nagy, M., 185 Natural Y, 74 Nava, M., 352 Necrosis, 106, 114, 141, 146, 155, 156, 165, 191, 193, 200, 201, 204, 217, 218, 241, 246, 268, 269, 273, 274, 407, 410, 556, 557, 560, 620, 621, 736, 750, 766, 776, 779, 796, 813, 833, 842 Necrotizing fasciitis, 218, 269 Neichajev, I., 583 Nemerofsky, R.B., 779 Neuber, F., 692 Neuman, J., 583 Neuromas, 247, 558 Nguyen, A., 583 Nipples, supernumerary, 3 Nodules, subcutaneous, 68 Novagold, 74 Nydick, M., 131 O O’Connor, C.M., 73 Osteopenia, 15 P Pace, W.G., 630 Pain, 106, 201, 202, 230, 366, 373, 463, 542, 558, 560, 715 Palmieri, B., 193 Pascal, J.F., 801 Passot, R., 186, 188 Payne, J.H., 629 Peckitt, N., 60 Pectoral pexy, 663, 668 Perez, M.C.J., 342 Perforation, 558, 750 Perone, M., 351 Pick, J.F., 207 Pierard, 473 Pinch test, 253, 296, 355 Pitanguy flap, 42 Pitanguy, I., 150, 159, 169, 174–176, 207, 278, 293, 334, 743, 744, 789, 837 Pitanguy’s point, 173

Index Pittsburgh rating scale, 675–677, 683–686 Planas, J., 824 PlasmaJetÔ, 778 Pneumothorax, 109, 712 Poland's syndrome, 5 Pollock, H., 778 Posse, P., 789, 837 Pousson, 149 Printon, J.J., 629 Pseudocyst, 267, 554 Psillakis, J.M., 211 Ptosis, 81, 119, 131, 137, 147, 156, 171, 250, 277, 282, 355, 464, 664, 725, 727, 736, 739–741, 796, 800, 810, 815, 824, 825, 841 Pulgam, S.R., 620 Pulmonary edema, 559 Pulmonary embolism, 560, 776, 777, 779, 848, 849, 852, 853, 858 Pulmonary embolus, 111, 112, 230, 247, 271, 618, 706, 859–863 R Raynaud’s syndrome, 543 Rees, T.D., 74 Regnault, P., 119, 123, 207, 239, 295, 296, 744, 751, 769, 789, 828 Reiger, U.M., 751 Replicon, 74 Ribeiro, L., 282 Richards, M.E., 789 Rippling, 716 Ritz, M., 741 Robertson, D.C., 150 Roberts, T.L. III, 10, 602 Rohrich, R.J., 495 Rosenberg G.J., 131, 134 Rosen, H.M., 67, 98 Rothkopf, D.M., 98 Rotunda, A., 60, 61 Rudolph, R., 133 Rutledge, R., 631 S Sacks grading system, 290 Saddle-bags, 14 Sakari formula, 73 Saldanha, O.R., 211 Sanger, C., 776, 779 Sattler, G., 351 Scar, 102, 108, 131, 141, 170, 202, 203, 230, 240, 247, 255, 261, 263, 264, 288–291, 298, 302, 304, 317, 318, 321, 350, 358, 366, 412, 475, 479, 559, 578, 706, 717, 722, 750, 757, 760, 771, 775, 780, 785, 789–792, 794, 795, 799–801, 804, 805, 810–815, 822, 824, 825, 828, 829, 831, 833, 834, 837, 842 hypertrophic, 97, 109, 128, 147, 202–204, 270, 280, 291, 301, 304, 320, 323, 333, 334, 463, 464, 739, 793, 796, 800, 809, 825 hypertrophy, 106, 807 keloids, 109, 202, 203, 270, 334, 750, 807 Scarpa’s fascia, 349, 350, 667, 763, 815, 846

Index

869

Schorr, M.V., 194 Schultz, R.C., 828 Schwartzmann, E., 149, 150 Schwartzman’s maneuver, 173, 278 Scopinaro, N., 630 Scuderi, N., 400, 425, 743 Sepsis, 111, 268 Seromas, 134, 141, 191, 230, 245, 246, 260, 261, 270, 291, 333, 410, 463, 542, 559, 560, 608, 621, 699, 747, 750, 751, 763, 765, 770, 775, 778, 779, 804, 807, 813, 825, 842 Shaer, W.D., 33, 36, 837 Shermak, M.A., 849, 852 Sherman, A.I., 337 Sherwood, R.C., 366 Sidman, R.L., 581 Skin, necrosis, 65 Skoog, T.A., 150, 159, 351 Skouge, J.W., 577 Smith, J., 73, 150 Smoking, 274, 758, 763, 766, 769, 777, 780 Somalo, M., 207 Spear, S.L., 124 Spirito, D., 351, 824 Staldemann, W.K., 829 Steroid fat atrophy, 203, 204 Sterzi, G. II, 350 Strauch, B., 789, 805 Strömbeck, J.O., 150, 155–159, 163–165, 167 Stuerz, K., 785 Superficial musculoaponeurotic system (SMAS), 623 Submammary fold, 161 Superficial fascial system, 15 Superficial musculoaponeurotic system (SMAS), 407–409 Swelling, 578, 747, 771 Synmastia (symmastia), 110

Thrombophlebitis, 112, 247, 271, 272 Tobin, 580 Toledo, L., 581 Topaz, M., 400, 401 Torres, J.C., 630 Toxic shock syndrome, 113, 269, 273, 556, 560 Trilucent, 74

T Tebbetts, J.B., 80 Teimourian, B., 297, 459, 578, 789, 790, 828 Ter-Pergossian, M., 337 Thigh lift, 23, 257, 265, 355, 358, 363, 671, 729, 825 Thighplasty, 700, 834 Thorek, M., 149, 156, 157, 207 Thromboembolism, 243, 271–273, 558, 559, 618, 706, 769, 847–849, 852–863

Y Yalin, C.T., 197 Young, V.L., 194

U Uebel, C.O., 581 Ultrashape, 220 Ultrasound, focused, 476, 478, 487, 488 Umbilical stenosis, 273 V Vague, 33, 34 Van der Stricht, J., 828, 829 Vaser, 131–135, 137, 181–185, 187–189, 193, 220–222, 231, 233, 234, 236, 237, 313, 315, 316, 320, 389, 401, 402, 411–413, 416, 417, 419–421, 423, 426, 493, 495, 499, 502, 520–522, 525, 453, 565, 567–569, 572, 589, 588, 596, 747, 798 Vein thrombosis, 111 W Walden, J.L., 139 Wallach, S.G., 217 Wallerian nerve degeneration, 22 Watson, J., 73 Weinhold, S., 239 Whiteside, J.L., 17 Wise pattern, 150, 159, 281, 705, 706, 710–712, 714 Wise, R.J., 150 Wittgrove, A.C., 631

Z Zafirlukast (accolate), 97 Zhang, X., 505 Zocchi, M.L., 179, 743, 400 Zones of adherence, 520 Zook, E.G., 751