• Trunk: Removal of excess skin and subcutaneous tissue, often after massive weight loss ▪ Degree of skin excess, fatty excess, and muscular diastasis assists with selection of appropriate procedure. ○ Suction-assisted lipectomy: Minimal skin excess, moderate subcutaneous adiposity, no diastasis ○ Abdominoplasty: Excess anterior abdominal skin and subcutaneous tissue, with appreciable diastasis. Lower incision placed at least 5 to 7 cm superior to vulvar commissure ◆ Miniabdominoplasty: Short scar, often no transposition of umbilicus, minimal diastasis ◆ Fleur-de-lis: Excess skin in both transverse and vertical dimensions. By adding vertical excision, can improve vertical excess ➔ In general, perform the vertical excision first. ◆ Lipoabdominoplasty: Combination of full abdominoplasty and liposuction ○ Circumferential body lift/lower body lift: Excess skin and subcutaneous tissue circumferentially with ptosis of gluteal soft tissues ◆ Can perform gluteal lift/autoaugmentation with gluteal artery flaps ▪ Complications: Reportedly occur in 15% to 25% of patients (50% for active smokers) ○ Skin necrosis: Most commonly occurs in supraumbilical region ○ Skin dehiscence: Most common complication when combining skin resection procedures ○ Bulge: Most commonly occurs superior to umbilicus because of failure to plicate supraumbilical rectus fascia during diastasis repair ○ Encephalopathy: Most commonly associated with thiamine deficiency (Wernicke-Korsakoff encephalopathy) in the massive-weight-loss patient ○ Pain/numbness (see Figure 29.1) ◆ Lateral femoral cutaneous n.: Numbness/pain along anterolateral thigh (see Figure 29.2) ◆ Iliohypogastric n.: Numbness/pain along the inguinal crease and lateral gluteal region ➔ Danger zone: Lateral lower abdominal transverse incisions near inguinal ligament ◆ Ilioinguinal n.: Numbness along the medial thigh and scrotum/labia ➔ Danger zone: Lateral lower abdominal transverse incisions near inguinal ligament ◆ Intercostal n.: Numbness along abdominal/flank dermatomes T5 to L1 • Upper extremity/brachioplasty: Removal of excess skin and adipose tissue of the upper arm (see Figure 29.3) ○ Re-anchoring the posteromedial upper arm soft tissue to axillary fascia with nonabsorbable suture ▪ Complications: Reportedly occur in 25% to 50% of patients ○ Hypertrophic scarring (occurs in up to 40%): Most frequent complication of brachioplasty; often caused by tension, tissue mismatch, poor nutrition ◆ Treatment: Conservative including compression, silicone sheeting, steroid injection ○ Wound healing complications: Seroma, wound dehiscence ◆ Can be exacerbated by further weight loss ○ Nerve injury (occurs in up to 5%) ◆ Medial antebrachial cutaneous n. ➔ Runs in close proximity to the intramuscular septum and penetrates fascia at 14 cm proximal to the medial epicondyle; especially at risk of injury here ➔ Leads to paresthesia of upper arm and anterior proximal forearm ➔ Treat with hand therapy and local massage, gabapentin; improves with time ◆ Medial brachial cutaneous n. ➔ Runs with basilic vein, sends out branches at 7 cm and 15 cm proximal to the medial epicondyle ➔ Injury leads to numbness and paresthesias of the medial upper arm.
Body Contouring and Suction-Assisted Lipectomy
Therefore, always identify nerve at this level and leave fat on deep fascia in this area.
Body Contouring and Suction-Assisted Lipectomy
Chapter 29
