Body Contouring

TRUNCAL CONTOURING

Outline the blood supply zones of the abdomen.

1. Zone I is the midabdomen, supplied by deep superior and deep inferior epigastric arcades.

2. Zone II is the lower abdomen, supplied by the superficial and deep circumflex arteries.

3. Zone III is the lateral abdomen/flanks, supplied by intercostal, subcostal, and lumbar arteries.

What zone is responsible for blood supply to abdominoplasty flap?

Before surgery, the major blood supply is from zone I. After abdominoplasty, zone I is lost. Blood now enters the flap primarily from the lateral aspect via zone III segmental perforators, with some minor collateral flow from zone II.

What is the major blood supply to the abdominoplasty flap?

The lateral intercostal arteries.

What nerve is responsible for numbness of the anterolateral thigh after abdominoplasty?

The lateral femoral cutaneous nerve of the thigh. In several studies of complications of abdominoplasty, the most common nerve injury was to the lateral femoral cutaneous nerve.

Name the nerves that are at increased risk for entrapment or injury during abdominoplasty.

Iliohypogastric, ilioinguinal, and intercostal nerves are at an increased risk of injury.

What kind of previous abdominal scar can cause postoperative healing problems in an abdominoplasty patient?

A right upper quadrant subcostal scar may disrupt blood supply from the lateral intercostal vessels. Avoid undermining above the scar to avoid wound-healing problems.

What is the difference between mini-abdominoplasty versus full abdominoplasty?

Mini-abdominoplasty removes a small amount of lower abdominal skin and fat. The position of umbilicus remains unchanged and the length of the scar is limited. Full abdominoplasty involves removal of excess skin and fat from the lower abdomen, plication of the rectus diastasis from xiphoid to pubis, and transposition of the umbilicus.

What is an umbilical float procedure?

Abdominoplasty with umbilical fascial transection with subsequent resuturing of the umbilicus to the abdominal wall fascia. There is no skin scar around the umbilicus. The umbilicus typically ends up slightly lower than the original position. This technique is typically utilized with mini-abdominoplasty.

What is the optimal treatment for an obese male with a massive pannus?

The best treatment is simple, transverse, elliptical wedge resection without undermining: panniculectomy.

In a postabdominoplasty patient, what area has the most tenuous blood supply?

The suprapubic and lower midline regions are at greatest risk for ischemia and necrosis (Zone 1).

Does combining liposuction with abdominoplasty increase the risk of complications?

Yes. There is an increased risk of delayed healing (Zone 1), thrombotic emboli, fat emboli, skin necrosis, and fat necrosis. Increased complication rates are reported in patients with risk factors such as obesity, smoking, and diabetes mellitus. Care should be taken to avoid wide undermining or use discontinuous undermining if necessary.

What is the most common complication of combined abdominoplasty and liposuction?

Seroma formation is the most common complication in this situation. The risk is higher in those who smoke and those having diabetes.

What are the main determinants that help to select the optimal procedure for body contouring?

The optimal procedure is based on the patient’s skin tone and amount of skin excess, abdominal wall musculature/rectus diastasis, fat distribution, and patient preference.

How are seromas managed following abdominoplasty?

Aspiration followed by placement of closed suction drains. If persistent, sclerosing agents may be used. If this fails, the cavity may be marsupialized or excised.

Why is smoking a relative contraindication to abdominoplasty?

Smokers are at much higher risk of abdominal flap necrosis and wound-healing problems.

What mechanism is most likely to cause wound-healing complications in abdominoplasty patients who are recent smokers?

Increased microvascular vasoconstriction with resultant decreased tissue oxygenation. Smoking also increases carboxyhemoglobin, increases platelet aggregation, increases blood viscosity, decreases collagen deposition, and decreases prostacyclin formation, which all negatively affect wound healing.

What is a Fleur-de-lis abdominoplasty?

The typical horizontal excision and scar is combined with excision of a vertical ellipse, which results in an inverted T-shaped scar. Wound-healing problems are lessened by performing minimal undermining of the flaps (see Fig. 15-1).

Figure 15-1 Fleur-de-lis abdominoplasty.

What is the truncal procedure of choice for a patient who has lost 150 lb (massive weight loss) and when should the procedure be performed?

Lower body lift or belt lipectomy. This procedure removes the circumferential excess present following massive weight loss combining an abdominoplasty with a lateral thigh lift and buttock lift. The procedure should be delayed until the patient is at least a year out from a bariatric procedure and weight stable for 3 to 6 months.

What are the safety considerations in a patient who requests a total body lift following massive weight loss?

Consideration should be given to mechanical or chemical deep venous thrombosis (DVT) prophylaxis, keeping the patient warm, padding pressure points, and staging procedures.

What is the initial step in management of a massive weight-loss patient who has become increasingly disoriented and obtunded 1 day after belt lipectomy?

Thiamine therapy. Many massive weight-loss patients suffer from malnutrition, including thiamine deficiency, or B12, which can lead to Wernicke–Korsakoff encephalopathy. Treatment is intravenous administration of 100 mg/d of thiamine, continuing with 100 mg every 8 hours until resolution of symptoms. Administration of thiamine is low risk and may reverse symptoms.

Patients who have undergone Roux-en-Y gastric bypass surgery commonly have what underlying deficiencies?

Iron deficiency anemia (most common), vitamin B12 (cobalamin) deficiency, folate, calcium and fat soluble vitamin deficiency (vitamin D is fat soluble).

What is the recommended amount of daily protein consumption in patients seeking body contouring?

70 to 100 g per day.

What is the most common complication in patients undergoing combined procedures in a single stage?

Wound-healing issues (approximately 15%). Seroma is the next most common complication (approximately 10%). Infection, hematoma, and pulmonary embolism occur at rates of less than 5%.

What procedure is associated most frequently with postoperative mortality in an ambulatory surgery center?

Abdominoplasty (secondary to pulmonary embolism).

What areas do the lower body lift and belt lipectomy address differentially?

The lower body lift (LBL) allows a lower scar placement and better control over gluteal ptosis and deflation (auto-augmentation) as well as more aggressive treatment of the lateral thigh. The belt lipectomy will address the gluteal and lateral thigh in a less aggressive manner but allows more treatment of the upper area of the low back (higher scar placement). Belt lipectomy also addresses the abdomen by definition, whereas Lockwood variations do not necessitate addressing the abdomen in LBL.

What are the most common complications in lower body lift versus belt lipectomy?