15 Aesthetic Body and Trunk Abstract This chapter will review aesthetic surgery of the trunk and body, including abdominoplasty, liposuction, brachioplasty, and thighplasty. Readers will be able to identify physical examination findings that can be addressed with aesthetic surgery of the body and trunk, draw and describe operative incisions and techniques, formulate postoperative protocols, and manage complications. Keywords: abdominoplasty, brachioplasty, thighplasty Six Key Points • Abdominoplasty is distinct from panniculectomy in that it includes rectus plication. • Whether liposuction can be performed at an ambulatory facility is determined by the amount aspirated. • Postoperative fluid shifts in liposuction must be monitored. • Liposuction and brachioplasty or thighplasty can be staged. • Care for the postliposuction, fluid-overloaded patient is supportive. • Widened scars for brachioplasty and thighplasty are common, and are monitored and revised as needed. A patient presents the following in Fig. 15.1 1. What do you do for this patient? In a patient with infraumbilical lipodystrophy, an abdominoplasty will help with the abdominal contour by removing excess skin and fat, and correcting a rectus diastasis. The evaluation begins with an assessment of the patient’s history, including pregnancy history and any history of abdominal surgery. Social history, including tobacco use, is also assessed. A physical examination includes an assessment of rectus diastasis as well as any evidence of hernias. Assuming the patient is a nonsmoker, otherwise healthy, is not obese, and has no evidence of hernias, an abdominoplasty can be offered as an outpatient procedure. 2. Describe the operative procedure. The patient is marked in the standing position. The midline is marked from the xyphoid process to the pubic bone. Any asymmetries are noted to the patient. The inferior extent of the incision is marked, and the lateral aspect measured to ensure symmetry. The superior aspect of the incision is tentatively marked, and any areas of liposuction are marked. The patient is placed supine on the operating room table, and prepped and draped. The inferior incision is made, and electrocautery is used to dissect through subcutaneous fat to rectus abdominis fascia. Scarpa’s fascia is identified during the dissection. Once the rectus fascia is identified, the dissection proceeds cranially. Over the anterior superior iliac spine, the lateral femoral cutaneous nerve is identified and protected, or a layer of fat is left over the anterior superior iliac spine to protect it. Once the region of the umbilicus is reached, a knife is used to incise the skin around the umbilicus. Either electrocautery or Metzenbaum scissors are used to dissect around the stalk to the abdominal wall. Once the umbilicus has been isolated, the dissection proceeds superiorly in a triangle shape such that wide undermining is not performed laterally. The diastasis is corrected by imbricating the diastasis and sewing it closed with 0 polypropylene suture and then over-sewing it again. The abdominal flap is advanced, the excess skin is removed, and the incision is closed in layers after drain placement. Fig. 15.1 A patient presents for abdominoplasty. 3. Postoperatively, she calls to report that her umbilicus appears dark. What do you do? The umbilicus must be evaluated in person. “Duskiness” indicates venous congestion, and some degree can be expected. If it is dusky on examination, I would recommend conservative management with dressing changes. 4. She is doing dressing changes, and states that it has turned into a scab. What do you do? The umbilicus can still be managed conservatively. If there is loss of some of the umbilicus, it can still be managed conservatively and will granulate. RATIONALE: A 2006 study in the Journal of Plastic, Reconstructive, and Aesthetic Surgery reviewed complication in abdominoplasties1 and noted that 18% of patients had early complications, and skin necrosis represented 1.5% in the early complications category. Overall, early complication rates are 18 to 32%, although not all complications require revision. 1. A patient wants liposuction of her abdomen. What do you do? Liposuction is most appropriate for patients who have localized lipodystrophy and whose skin has good elasticity. In a patient with abdominal, thigh, or flank lipodystrophy, liposuction may be appropriate. 2. The patient states she has read about laser liposuction and would like that done. What do you tell her? There are several different ways to perform liposuction. Suction-assisted lipectomy is traditional liposuction, which uses a cannula attached to a vacuum source. Ultrasound-assisted liposuction uses ultrasound, which first liquefies the fat and tissue, followed by traditional liposuction, and is useful for dense tissue, such as a gynecomastia correction. Laser-assisted liposuction uses varying wavelengths to help produce adipocyte lipolysis, and skin contraction, thought to be mediated by neocollagenesis. Currently 1,064-, 1,320-, and 980-nm diode laser-assistant liposuction machines are available.2 Wither laser-assisted liposuction confers any benefit over other techniques has not been clearly established—some studies have failed to show any advantage other than reduction in pain and lipocrit levels.3 3. How do you counsel the patient about the risks? There are several categories of risks of liposuction. First, there are intraoperative risks of bleeding, infection, lidocaine toxicity, and abdominal viscera perforation. In the immediate postoperative period, there are the risks of fluid shifts and fat embolism. Postoperatively, there are risks of contour irregularity and seroma. 4. Where do you perform the operation? The operation can safely be performed in an outpatient setting; however, indications to perform surgery in an inpatient facility include large-volume liposuction and patient-specific factors such as obstructive sleep apnea. Rationale: While there are no randomized controlled trials addressing this topic, there are currently restrictions at the state level regarding the circumstances under which liposuction can be safely performed at an outpatient facility. Some states restrict the amount of aspirate to 1,000 mL. The American Society of Plastic Surgeons (ASPS) consensus statement is that in the absence of more restrictive state guidelines, liposuction with aspirate greater than 5,000 mL should be performed in an acute-care hospital. 5. What technique to do you use for tumescence? The tumescent technique, in which 3 mL of infiltrate is infused to 1 mL of aspirate, is appropriate for non–large volume liposuction. For large-volume liposuction, a superwet technique in which 1 mL of infiltrate is infused for each milliliter of aspirate is appropriate to reduce the risk of fluid overload. 6. How do you do the procedure? Under general anesthesia, the patient is given perioperative antibiotics and has deep vein thrombosis (DVT) prophylaxis with sequential compression devices placed. 7. In the postanesthesia care unit, the nurse calls you to tell you that the patient has a higher-than-usual blood pressure. What do you do? The first step is to evaluate the patient at the bedside and confirm the vital signs. A higher-than-usual blood pressure can indicate pain, which would need to be assessed, and can also indicate fluid overload. Other signs of fluid overload are pulmonary symptoms such as a cough, dyspnea, and crackles on auscultation. 8. If the patient is fluid overloaded, what do you do? Care is supportive. The patient would need to be admitted for observation, and a Foley catheter placed. Diuretics can be given as needed, although this can be controversial and potassium levels must be monitored during treatment. 9. The patient returns 2 months postoperatively and complains that there is contour irregularity. What do you do? Contour irregularities are the most common complication of suction lipectomy. This can be prevented by the following: not using suction until the cannula has been inserted, cross-tunneling from separate sites, fanning, and using small-diameter cannulas near the surface. Immediately postoperatively, it is appropriate to continue to monitor it, as there can still be swelling. If it persists after 1 year, fat grafting can be performed to the irregularities. A patients presents the following in Fig. 15.2 1. What do you offer the patient? A traditional brachioplasty can be offered to the patient and can reduce the circumference of the arms. 2. How do you decide which type of brachioplasty to perform? The decision of which type of brachioplasty to perform is based on the presence of excess fat and the amount and location of skin laxity. In patients with excess fat but no skin laxity, liposuction may be appropriate. In patients with excess skin in the proximal third of the arm, a limited medial brachioplasty can be performed. If the excess skin extends to the chest wall, an extended brachioplasty is performed. If the excess skin includes the entire upper arm but does not extend to the chest wall, a traditional brachioplasty is performed. RATIONALE: The algorithmic approach to brachioplasty takes into account fat as well as excess skin. 3. Where do you design your incisions? The incisions can be designed in the bicipital groove. 4. Describe the procedure. The patient is marked in the standing position and placed supine on the operating room table with the arms abducted. Antibiotic and DVT prophylaxis is instituted. The upper extremities, axillae, and shoulder are prepped into the field. After the patient is prepped and draped, local anesthetic is infiltrated into the incision sites. The superior incision is made and dissection is in the subcutaneous plane, deep to Scarpa’s fascia but leaving 1 cm of fat on the muscle fascia. As the dissection proceeds distally, fat is left on the muscle fascia to protect the medial antebrachial cutaneous nerve. Once the flaps have been created, the final resection is not performed until closure is confirmed. Closure is performed by anchoring the superficial fascial system with interrupted sutures. Drains are placed, and the skin is closed in layers.
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