Body Contouring

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Body Contouring

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Body Contouring McGraw-Hill Plastic Surgery Atlas Michele A. Shermak, MD Associate Professor of Plastic Surgery The Johns Hopkins School of Medicine Part-Time Faculty The Johns Hopkins Division of Plastic Surgery Baltimore, Maryland

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This book is dedicated to my husband Howard Sobkov who provides endless support and constant encouragement in my professional efforts. My inspiration comes from my beautiful children, Samuel and Max: the evolution of their bright, clever minds never ceases to amaze me!

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Contents Preface / ix Acknowledgments / xi

PART I PERIOPERATIVE ISSUES / 1 Section 1 Introduction / 3 1. 2. 3. 4. 5. 6.

Safety in Body-Contouring Surgery / 4 Operative Positioning and Precautions / 6 Managing Expectations and Psychosocial Issues / 10 Nonprescription Medications to Avoid / 18 Massive Weight Loss / 20 Surgical Wound Care and Complication Management / 22

PART II OPERATIVE PROCEDURES / 29 Section 2 Upper Extremity / 31 7. 8. 9. 10. 11. 12.

Presentation for Upper Extremity Contouring / 32 Upper Extremity—Anatomy / 34 Upper Extremity Liposuction / 36 Traditional Brachioplasty / 42 Extended Brachioplasty / 48 Minimal Incision Brachioplasty / 52

Section 3 Female Breast / 57 13. Common Presentation for Breast Contouring / 58 14. Female Breast—Anatomy / 60 15. Liposuction of the Breast / 62 16. Wise Pattern Breast Reduction with Inferior Pedicle / 66 17. Traditional Wise Pattern Mastopexy with Autoaugmentation / 72 18. Vertical Pattern Breast Reduction with Superior Pedicle / 78 19. Vertical Pattern Mastopexy (with Augmentation) / 86 20. Wise Pattern Superior Pedicle Breast Reduction with Nipple Grafting / 94

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Contents

Section 4 Male Chest—Gynecomastia / 101 21. 22. 23. 24. 25. 26. 27. 28.

Gynecomastia Presentation and Its Enormous Variability / 102 Male Chest: Gynecomastia—Anatomy / 104 Gynecomastia Liposuction / 106 Gynecomastia—Excisional Technique / 110 Mastectomy Through a Horizontal Approach / 114 Gynecomastia—Wise Pattern Excision Technique / 120 Gynecomastia—Vertical Excision Technique / 128 Gynecomastia—Extended Technique with J Excision / 134

Section 5 Abdomen / 143 29. Abdominal Presentation for Abdominal Contouring / 144 30. Abdomen—Anatomy / 152 31. Abdominal Liposuction / 154 32. Abdominoplasty with Abdominal Wall Plication / 162 33. Mini-abdominoplasty Combined with Liposuction / 168 34. Reverse Abdominoplasty / 174 35. Panniculectomy / 178 36. Massive Panniculectomy / 182 37. Ventral Hernia Repair and Abdominoplasty / 186 38. Umbilical Hernia Repair at the Time of Abdominoplasty / 192

Section 6 Back / 199 39. 40. 41. 42. 43. 44. 45.

Back Presentation for Contouring / 200 Back—Anatomy / 204 Back Liposuction and Fat Grafting / 206 Upper Back Lift / 214 Upper Body Lift with Autologous Breast Augmentation / 220 Lower Back Lift / 226 Belt Lipectomy with Autologous Gluteal Augmentation / 232

Section 7 Lower Extremity / 239 46. 47. 48. 49. 50.

Presentation for Lower Extremity Contouring / 240 Lower Extremity—Anatomy / 246 Lower Extremity Liposuction / 252 APEX (Proximal) Thigh Lift / 258 Extended Thigh Lift / 264

Index / 269

Preface Breast and body-contouring surgery, discussed in the literature for hundreds of years, has increasingly evolved over time. While new techniques are hardly ever actually new (once an intensive literature search is done), we do see change, whether it be the addition of a new suspension suture or a combination of techniques that were not combined before. This field has applications across a broad swath of the population, from the petite “mommy” looking for a makeover to the male who lost more than 100 lb after gastric bypass surgery. There are many techniques to cover, and we aim to include an excellent representation. This atlas is directed to residents preparing for surgical cases and to seasoned plastic surgeons hoping to innovate or refresh their current surgical repertoire. We cover the scope of breast surgery, including reduction, augmentation, lifting, and gynecomastia; arm and thigh contouring with liposuction and excisional techniques; abdominoplasty, upper and lower, with hernia repair techniques; and back contouring. We have included the traditional, well-hewn techniques, as well as techniques which are increasingly finding a place in contemporary plastic surgery. Every surgeon needs to be equipped with a handful of techniques for each type of surgery, such as breast reduction or gynecomastia or thigh lift, to best serve the broad range of patient presentations we see. Each section includes detailed anatomic illustrations by Bill Winn describing the regions of interest. These illustrations should provide a landscape for surgical planning. The illustrations guide important planes for surgical dissection. They also provide information about neurovascular anatomy to understand supply to the skin and muscle, and importantly, to avoid injury. This atlas opens with discussions regarding perioperative issues. We are performing procedures that involve greater time in the operating room and are combining multiple procedures that complement one another. Positioning resulting in prolonged compression or stretch must be avoided, as sequelae may be permanent and disabling. We have patients with baseline medical issues and medications that need to be considered in designing the safest surgical approach and in advising patients. We need to anticipate and prevent bad outcomes and optimize postoperative care. This atlas provides this perioperative guidance while also describing surgical technique. The endpoint of breast and body-contouring surgery is provision of the best possible contour while respecting important safety issues and continually innovating to improve outcomes. The goal of this atlas is to help in this endeavor and provide a “soup to nuts” approach to plastic surgery of the breast and body.

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Acknowledgments My interest and career in breast and body-contouring surgery were initially sparked by my plastic surgery residency experience with Dr. Bernard Chang in Baltimore, Maryland, and were further stoked by my fellowship experience with Dr. G. Patrick Maxwell in Nashville, Tennessee. Both are modern innovators in breast surgery who shared closest interests in bodycontouring surgery, as well as a Hopkins legacy. Dr. Maxwell strongly encouraged a global approach to the torso, with circumferential techniques and combination treatments utilizing both liposuction and excisional surgery to enhance overall results. This clinical experience laid the groundwork for my extension of primarily cosmetic-based techniques to the more reconstructive field of postbariatric body contouring for massive weight loss. Friendly professional mentoring relationships developed during my career. One standout mentor is Dr. David Hidalgo, an artist and master breast surgeon, who graciously opened his doors and generously offered his thoughts and advice about breast augmentation and reduction surgery. Dr. Hidalgo catalyzed my interest in the vertical approach to breast surgery for men and women, minimizing scar and maximizing contour. Dr. Foad Nahai and Dr. Stanley Klatsky, well known in the field of aesthetic plastic surgery, encouraged my participation in the Aesthetic Surgery Journal, which led to my fortuitous introduction to Bill Winn, a patient, diligent, creative illustrator, who became my invaluable collaborator on this project. Life is a journey, and friends we meet along the way create the highlights. Finally, I thank my colleagues who help me take care of patients everyday. The residents and fellows educate me about as much as I educate them and keep me abreast of new approaches and technologies, which help advance my results that much further. Jessie Mallalieu, my PA, is a tireless, meticulous technician in the operating room and an attentive caretaker for pre- and postoperative patients, whose support promotes patient safety and positively impacts our outcomes.

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PartI Perioperative Issues Section 1 Introduction

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Section 1

Introduction Chapter 1.

Safety in Body-Contouring Surgery

Chapter 2. Operative Positioning and Precautions Chapter 3.

Managing Expectations and Psychosocial Issues

Chapter 4. Nonprescription Medications to Avoid Chapter 5.

Massive Weight Loss

Chapter 6. Surgical Wound Care and Complication Management

Chapter 1.

Safety in BodyContouring Surgery

Safety is of the utmost importance in surgery, unsurpassed by cosmetic result. Although complications including wound healing problems, seromas, venous thromboembolism (VTE), and bleeding occur, a sound surgical plan protecting against predictable pitfalls optimizes surgical outcome. Certain medical conditions have a well-documented, negative impact on surgical recovery. Obesity includes a constellation of medical problems called metabolic syndrome, including hypertension, dyslipidemia, type 2 diabetes, coronary artery disease, stroke, gallbladder disease, osteoarthritis, obstructive sleep apnea, and cancers such as breast and colon. Hypertension places patients at risk for postoperative bleeding and may be associated with coronary artery disease or chronic renal failure. Anemia, particularly in menstruating women, is common in massive weight loss patients and may require preoperative optimization or postoperative blood transfusion. Asthma may be exacerbated by surgery and oxygen requirements may be greater, resulting in the greater need for blood transfusion and pulmonary care. Endocrine disorders such as hypothyroidism may impair wound healing. Patients with autoimmune disease also have impaired wound healing, often due to anti-inflammatory medication they take such as steroids. Tobacco smoke causes vasospasm and decreases vessel caliber, resulting in wound healing problems. Any of these disorders that can negatively impact wound healing must be treated and addressed prior to surgery. Tobacco use must be stopped. Diabetes, endocrine disorders, and hypertension must be addressed and medicated if necessary, normalizing glucose and hormone levels and blood pressure. History of VTE including deep venous thrombosis and pulmonary embolism is the greatest risk factor for future VTE, potentially the most deadly possible outcome after body-contouring surgery. Other risk factors for VTE include obesity, immobility, history of lower extremity trauma, hormonal therapy, history of cancer, and hypercoagulable states. High-risk patients require examination

and clearance by physicians specializing in the treatment of VTE. Previous abdominal and breast scars must be considered in surgical planning. Prior surgical incisions may devascularize regions dependent on the sacrificed blood supply. Scars may indicate diminished circulation in areas impacted by the blood supply originating in the area of the scar. For example, a right subcostal “Kocher” incision scar may result in a nonhealing abdominal wound after abdominoplasty with aggressive undermining. Secondary breast surgery is fraught with a complication rate greater than that which results after primary surgery. Unless undermining can be performed in order to allow all compromised skin to be resected, it is important to avoid undermining under scars that cannot be completely resected, particularly in patients with medical issues that impact wound healing. Prescription and herbal medications must be documented. Medications such as anticoagulants, anti-inflammatories, aspirin, and vitamin E increase bleeding risk after surgery and are best stopped weeks prior to surgery. Many patients will not voluntarily share that they regularly take aspirin or ibuprofen, and patients often do not define herbal supplements as medications. Many herbal medications result in anticoagulation effects, and it is important to elicit a history of herbal medication use in patients. Many body-contouring procedures require complex positioning, including prone and lateral decubitus positions. Improper pressure to neurovascular structures throughout the body may lead to short- or long-term disability. Most reported sequelae associated with prone positioning are due to excessive pressure on the head and neck region, so attention to positioning of the head is extremely important. Inadvertent ocular pressure during surgery may result in visual loss even with the use of a padded headrest. Stabilization of the neck is also important. The neck must be in a neutral, nonextended position to avoid pressure on nerves and vessels. Dissection of the carotid and/or vertebrobasilar arterial systems has been associated with abnormal neck rotation, manipulation, or sudden, accelerated

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Chapter 1 • Safety in Body-Contouring Surgery movement. Peripheral nerve injury in the extremities is also a risk with improper arm positioning. A 1990 analysis of the American Society of Anesthesiologists Closed Claims Project database showed that 15% of the medico-legal claims were for nerve injuries. Superficial nerves that travel long distances across bony surfaces, such as the ulnar nerve, require appropriate angle and padding on the table to avoid compression and stretch. Stretch from positioning secondary to arm abduction greater than 90 degrees may also result in brachial plexopathy. Closed fascial spaces present a risk to nerves when compartment pressure rises from compression. With pressure and improper arm placement, the nerve suffers from stretch with tension and/or compression, leading to ischemia, and the longer the duration of the surgical procedure, the more likely there will be neuropathy over the long-term. Awake patients suffer pain and numbness from nerve compression, whereas the anesthetized patient cannot shift his/her position to improve nerve perfusion. Padding and flexion of the arm and elbow

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less than 90 degrees reduces the risk of nerve compression in the upper extremity. Combination procedures addressing multiple body regions may result in significant blood loss. Massive weight loss patients in particular may be anemic at baseline and require optimization of blood levels prior to surgery. During surgery, it is important to consider a two-team approach to facilitate efficiency of surgery, and reduce blood loss. Longer procedures also present higher risk for postoperative VTE, so conservative measures taken to prevent deep venous thrombosis such as sequential compression devices and prophylactic subcutaneous unfractionated or low-molecular-weight heparin must be instituted. Breast- and body-contouring procedures may present considerable risk to patients. Careful history and physical examination are necessary to prepare, and measures must be taken for surgery to be performed in the safest possible environment.

Chapter 2.

Operative Positioning and Precautions

To optimally perform breast- and body-contouring procedures, the surgeon may employ different positioning modalities to gain the best access and allow most efficient treatment to specific body regions of interest. The most common positions are supine, prone, and lateral decubitus, and all or a combination of these positions may be utilized in a single case. For lower extremity contouring, the thighs may be placed on spreader bars or in lithotomy in stirrups. Proper safety precautions must be followed in order to ensure that complications do not arise secondary to improper positioning. With pressure that may occur with immobile weight on a firm surface, patients may sustain compression of vital structures including the nerves, skin, and eyes. Neuropathies may follow from compression of relatively unpadded nerves close to the skin surface. Tourniquets used on the upper or lower extremity must also be placed on areas where there is more soft tissue present to protect nerves: the most proximal aspect is the safest. The ulnar nerve is a nerve particularly at risk for compression with its location right under the skin and against bone. Pressure can also lead to skin and muscle breakdown from ischemia. In the supine position, the back of the scalp needs to be padded and ideally massaged to avoid pressure ulcerations and alopecia (Figure 2-1). Compartment syndrome and rhabdomyolysis have been reported in the literature as complications of prolonged surgery, extreme lithotomy position, and lateral decubitus position, causing acute renal failure. Diagnosis includes myoglobinuria and elevated levels of serum creatinine kinase. Treatment includes intravenous fluids, forced diuresis, and urine alkalinization, preferably with the help of the nephrology service. The eyes are particularly vulnerable to pressure injury. While in the prone position, pressure must be kept off the eyes with use of protective goggles and prone pillows (Figure 2-2). In other positions, oxygen masks may compress the eyes and these masks need to be assessed for adjustment throughout the surgical procedure. The key to compression avoidance is placement of egg crate foam or pillows underneath pressure-bearing

surfaces such as the head, elbows, and heels in the supine position and the knees in the prone position. Improper positioning may also cause stretch of nerves, leading to neuropathy after surgery. While in the prone position, the brachial plexus must be protected with axillary support and avoidance of extension of the arms (Figure 2-3). Neither the axilla nor the elbows should be extended greater than 90 degrees. In the lateral decubitus position, the brachial plexus may also be stretched requiring protective positioning. Tucking arms or stabilizing legs improperly may lead to sagging of the extremity or having the extremity fall off the bed with stretching and possible compression (Figure 2-4).

Figure 2-1. This illustration demonstrates important measures to take when a patient is laying on the operating room table in the supine position. The head is resting on a padded surface, in this case a foam donut ring, and the extremities are placed on eggcrate foam padding. Padding protects against compression neuropathy and pressure necrosis resulting in wounds. Furthermore, positioning of the arms is at right angles to the body to avoid stretch of the brachial plexus, and the wrist is supinated to avoid carpal tunnel syndrome. The neck is in neutral to avoid kinking of the carotid and vertebrabasilar arterial systems. Sequential compression devices and a pillow placed under the knees protect against thromboembolic event.

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Chapter 2 • Operative Positioning and Precautions

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A B Figure 2-2. The eyes are particularly vulnerable to pressure injury. A, B. While in the prone position, pressure must be kept off the eyes with use of protective goggles and prone pillows.

Figure 2-3. While in the prone position the brachial plexus must be protected with axillary support and avoidance of extension of the arms. Here a soft gel roll is placed transversely across the sternum to support the axillae. The elbows are not extended greater than 90 degrees and are well padded.

A B Figure 2-4. A. In the lateral decubitus position, the arms must remain stabilized and well padded in neutral position, without allowing sagging to avoid stretching of the brachial plexus. The patient is stabilized on a beanbag and taped to maintain position. B. Posteriorly, the axillary roll placed under the dependent axilla is visible.

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Chapter 2 • Operative Positioning and Precautions

Improper positioning of the head and neck or extremities may cause kinking of nerves or blood vessels, leading to long-term difficulties. Optimal positioning of the neck is in neutral: the head should not be turned to either side and placed on a pillow (Figure 2-5). This could lead to kinking of the carotid or vertebral arterial systems, ultimately causing stroke. When placed in stirrups, careful attention must be paid to not overly flexing the hip joint to avoid kinking of the femoral vessels and nerves and common peroneal nerve. When using spreader bars, the legs must be well padded and stabilized so that the legs remain stable on the boards. Imperceptibly, the lower extremity may slide off the bar under drapes leading to potential neuropathy (Figure 2-6). In case a patient complains after surgery of a complication from sequela of positioning, evaluation includes examination of the location of concern, including detailed nerve examination. With the possibility of nerve injury, electromyography (EMG) performed acutely will help determine whether the nerve problem preceded surgery, and EMG delayed 2–3 weeks after surgery is when denervational changes of muscle become apparent.

Figure 2-5. Optimal positioning of the neck is in neutral: the head should not be turned to either side and placed on a pillow. A prone pillow keeps the head well padded and stabilized.

B A Figure 2-6. A. The legs are well padded and stabilized on the spreader bars so that the legs remain stable on the boards. Imperceptibly, the lower extremity may slide off the bar under drapes leading to stretching of lower extremity nerves and potential neuropathy. B. A large lumbar gel roll is placed transversely across the thigh to protect femoral nerves from stretch. Furthermore, foot pumps are in place for thromboembolism prophylaxis.

Chapter 2 • Operative Positioning and Precautions In any extended procedure, the patient should be admitted for overnight observation, including hemodynamic monitoring and laboratory check, as well as intravenous hydration. The patient can be deemed safe for discharge when he or she is ambulating independently and responding appropriately with improvement. Treatment in the acute period of nerve injury includes provision of medication such as gabapentin to treat pain and neuralgia. Motor deficits may be treated with physical therapy. Serial physical examinations and EMG are necessary for documentation of recovery. Surgical intervention takes place if there is no improvement and may include neurolysis, intraoperative evaluation of neuroma-in-continuity, resection, and grafting of nonconducting lesions. Preoperative history and examination is necessary to target the presence of preexisting nerve injury or predisposition to injury. This is important in preventing intraoperative nerve injury by taking extra precautions. Anesthetics and muscle relaxants abolish protective mechanisms rendering patient susceptible to injury. Utmost care must be taken in ensuring proper patient positioning to ensure the best patient outcome and to avoid potential medicolegal action.

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RECOMMENDED LITERATURE Alterman I, Sidi A, Azamfirei L, Copotoiu S, Ezri T. Rhabdomyolysis: another complication after prolonged surgery. J Clin Anesth. 2007;19(1):64-6. Bildsten SA, Dmochowski RR, Spindel MR, Auman JR. Risk of rhabdomyolysis and ARF with the patient in the exaggerated lithotomy position. J Urol. 1994;152(6 pt 1):1970-2. Bocca G, van Moorselar JA, Feitz WF, et al. Compartment syndrome, rhabdomyolysis and risk of ARF as complications of the lithotomy position. J Nephrol. 2002;15(2):183-5. Gabrielli A, Caruso L. Postoperative renal failure secondary to rhabdomyolysis from exaggerated lithotomy position. J Clin Anesth. 1999;11(3):257-63. Kong SS, Ho St, Huang GS, et al. Rhabdomyolysis after a longterm thoracic surgery in right decubitus position. Acta Anaesthesiol Sin. 2000;38(4):223-8. Roth JV. Bilateral sciatic and femoral neuropathies, rhabdomyolysis, and ARF caused by positioning during RRP. Anesth Analg. 2007;105(6):1747-8. Shermak MA, Shoo B, Deune EG. Prone positioning precautions in plastic surgery. Plast Reconstr Surg. 2006;117(5): 1584-8. Winfree CJ, Kline DG. Intraoperative positioning nerve injuries. Surg Neurol. 2005;63:5-18.

Chapter 3.

Managing Expectations and Psychosocial Issues other elective procedures are more economically feasible as hospital costs are covered. While operating on multiple body regions may be reasonable, many patients are not ideal candidates. Particularly in morbidly obese patients with medical comorbidities, operations may result in difficult complications such as wound healing problems, chronic seromas, and venous thromboembolism (VTE). In the case of a patient who appears to be risky, it is best to be conservative and aim for a more focused surgical procedure with minimal undermining (Figure 3-1). Working with multiple regions should push the surgeon to admit the patient to the hospital for supervision after surgery. Monitoring fluid status, protecting against VTE, coaching the patient to ambulate, and assuring that the patient eats and drinks adequately are a number of important reasons to keep a patient in a medically supervised setting. Surgery that involves one body region that is extensive also merits admission, like a large panniculectomy or liposuction procedure.

The physician-patient consultation is critical to the patient understanding the physician and the physician understanding the patient in order to optimize management of patient expectations and psychosocial issues. The initial consultation is the best time for the physician to gather as much data as possible: objective data about the patient and subjective information about the patient’s goals, intelligence, body image, perspectives on surgery, and psychological makeup. Fact gathering includes information about medical and surgical history, family history, medications, allergies, and social concerns such as smoking, drinking, and recreational drug use. The physician also must determine the patient’s reason for presentation: what he/she perceives to be or has been told is problematic. A physical examination is performed, particularly directed to the areas of concern. Height and weight are taken to determine body mass index (BMI). Prior surgical scars should be noted. The physician may then formulate a plan and create a dialogue with the patient to understand what appeals to the patient and what is unacceptable to the patient. The dialogue is the critical piece. It helps the physician and the patient come together and agree on a course of action. The patient may have a desired goal that is impossible to reach safely, and it is the physician’s job to determine what may be safely accomplished and to communicate this so that the patient understands and appreciates the rationale. Limitations may be secondary to objective or subjective issues. Following are some patient scenarios that surgeons come across.

HIGH BMI Patients with high BMI seek breast reduction due to symptomatic macromastia and seek body contouring to reduce lipodystrophy or treat symptomatic skin excess after MWL. Surgeons must tread lightly around patients with high BMI due to their high risk of complications, including VTE, wound healing problems, and seromas (Figure 3-2). Patients with high BMI often require surgery, and one major tenet of surgical planning is to minimize potential complications. Short, focused procedures addressing only the functional issue of concern is critical. Minimal undermining in body lifting is important to maintaining vascular and lymphatic integrity, which protects against wound healing problems and seromas. When patients require ventral hernia repair in combination with panniculectomy, these two sites should be treated separately without communication to decrease risk of complication associated with excessive undermining or communication of problems from one site to another. Foreign material such as mesh should not be routinely utilized either.

“I WANT EVERYTHING DONE” Particularly with body-contouring consultations, patients may describe dissatisfaction with multiple body regions. Massive weight loss (MWL) patients, for example, often present with skin laxity and redundancy from head to toe. Patients who have full-time commitments may desire to get as much done at one time as possible to limit the number of recovery periods. Financial considerations may also come into play: with insurance covering a portion of the surgery, 10

Chapter 3 • Managing Expectations and Psychosocial Issues

A

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B

D

C Figure 3-1. This healthy 50-year-old woman lost 120 lb after laparoscopic gastric bypass surgery. She opted to have almost everything done in one procedure. She had abdominoplasty, back lift, brachioplasty, and thigh lift performed in just less than 5 hours. She stayed in hospital one night and did not require transfusion. A, B, C, D represent preoperative frontal, lateral, and posterior photographs, as well as arms. (continued)

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Chapter 3 • Managing Expectations and Psychosocial Issues

E

F

H

G Figure 3-1.

(Continued) E, F, G, H demonstrate the postoperative photographs taken 7 months after surgery.

Chapter 3 • Managing Expectations and Psychosocial Issues

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A B Figure 3-2. This 48-year-old man lost 117 lb after gastric bypass surgery, decreasing his body mass index from 61 to 46.5. He was offered surgery only on his abdomen, including abdominal panniculectomy and hernia repair, because of his high body mass index.

Plastic surgery removal of excess weight is not a rational method for weight loss just as it is not rational to put patients through extensive procedures that in the end may fail. If individuals are not willing to commit to a rigid weight loss program, then they will not have longterm success after massive panniculectomy. Although there have been some studies which seem to demonstrate that large volume liposuction may cure diabetes, this is controversial. The most successful means of achieving long-term weight loss is bariatric surgery. There is a subgroup of weight loss patients who have lost substantial amounts of weight, yet they are still in the morbidly obese category. Despite their degree of weight loss, they need to be considered at their existing weight which still may be high. If patients have not stabilized in their weight loss, they need to plateau before they proceed with surgery. Talking to patients who have BMI greater than 35, it is important to discuss upfront what their goals are, what the surgical plan is, and that “no,” liposuction is not a routine part of any body lifting or breast reduction procedure.

HISTORY OF VTE History of VTE must be elicited in history-taking. Individuals who in the past had either a deep venous thrombosis (DVT) or pulmonary embolism, no matter how

remote, must be treated as a patient with a high risk of VTE. The overall incidence of DVT in the United States is 250,000 per year. The rate of DVT recurrence is 10% in the presence of other risk factors for VTE, such as obesity, immobility, venous stasis disease, smoking, and use of hormones. The rate of pulmonary embolism recurrence is 10%, and mortality is 45% in these cases (Figure 3-3). Conservative prophylactic measures that one may take in any surgical patient include initiation of antiembolism support stockings and sequential compression devices prior to induction of anesthesia and continuing through ambulation, ambulation within 24 hours of surgery and sooner if possible, and fractionated or unfractionated heparin medication starting either before or after surgery on the day of surgery. In obese patients (BMI ⬎35), an extra dose must be provided during the day, that is, 5000 units of heparin given subcutaneously three times a day or 40 mg of enoxaparin twice a day. Adequate pain relief assists in early mobilization supporting the use of intravenous patient-controlled anesthesia and subcutaneous bupivacaine pain pumps. Conservative operative management to get the patient on and off the operating room table in as expeditious a manner as possible is another excellent means of prophylaxing against VTE. In high-risk patients with history of VTE or BMI greater than 40, the surgeon must consider treatment dosing of anticoagulation medication such as heparin intravenously

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Chapter 3 • Managing Expectations and Psychosocial Issues

A

B

Figure 3-3A, B. This 53-year-old woman with history of venous thromboembolism (VTE) and right subcostal scar had a conservative panniculectomy performed to limit wound healing problems and risk of another VTE, while also improving her symptoms of pain and intertrigo.

followed by warfarin orally, titrating to prothrombin time, or enoxaparin 30 mg subcutaneously twice a day, starting within 8 hours of surgery completion. The risk is that the patient will bleed after surgery, but this risk is balanced by the more deadly risk of pulmonary embolus. An option with little associated morbidity available today is the temporary Greenfield filter. The filter may be placed by colleagues in vascular surgery or interventional radiology within a day of surgery and removed within 3 weeks after surgery, requiring baby aspirin only after surgery. Prophylaxis against VTE in patients who are high risk for VTE and particularly those with a history of VTE must be followed to maintain safety for these patients.

MULTIPLE FOLDS With patients who are obese and/or who have sustained MWL, multiple skin folds may be present. The torso may have a fold of skin under the inframammary fold in the epigastric region and one at the lower abdomen. The back may have similar folds continuing from the breast and axillary region into the upper back, and laxity and overhang in the abdomen continuing into the lower back.

Addressing both upper and lower folds is difficult to do in a single-stage surgery without extreme undermining. The safest approach is to address multiple folds on the torso in a staged fashion, that is, performing lower body lift in the first stage and upper body lift with reverse abdominoplasty in a second stage, or vice versa (Figure 3-4). While the patient may desire to have both the upper and lower portions addressed at the same time, the degree of excision and undermining necessary could result in wound healing problems, seromas, and unsatisfactory aesthetic outcome.

ABDOMINAL SCARS In taking a history and performing physical examination, attention must be paid to prior abdominal scars, particularly when working on the abdomen. Abdominal scars located in areas in which the theoretical blood supply lives may serve to threaten circulation to the surgical site, resulting in significant wound healing problems and fat necrosis. The classic example of this is the right subcostal, or Kocher, scar associated with open cholecystectomy. When considering abdominoplasty, the Kocher scar must be considered, and potential worst-case scenarios must be shared with the

Chapter 3 • Managing Expectations and Psychosocial Issues

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A B Figure 3-4. A. This 39-year-old woman, a tobacco user, lost 100 lb after laparoscopic gastric bypass surgery. She had a two-stage procedure, the first was a traditional abdominoplasty. B. She was left with upper epigastric folds, requiring a second-stage reverse abdominoplasty with minimal undermining.

patient. To avoid trouble, conservative elevation of tissue inferior to the area must be performed, unless it looks like it might be possible to remove all the tissue, including the scar, from that side of the abdomen (Figure 3-5). While abdominal scars may threaten circulation, they also might hide hernias, so careful, slow dissection through scar tissue in the abdomen is necessary to avoid potential bowel injury. If there is anticipated complexity to the scarred region, then it is best to involve a general surgeon in the surgical procedure.

ACTIVE SMOKERS There is incontrovertible evidence that smoking causes postoperative complications including wound healing problems, pneumonia, heart attack, and herniation, and bleeding with a Valsalva-like cough. Smoking history must be elicited in discussion with the patient, including exposures to second-hand smoke which may be as dangerous as primary smoking with significant exposure. Nicotine patches, while better than cigarettes, are not ideal since nicotine is problematic in causing vasospasm. Varenicline is a medication specifically targeted to breaking tobacco addiction and can be prescribed, with minimal side effects. One should encourage potential surgical

patients to stop smoking prior to surgery, or else understand that there is a significant likelihood of complications after surgery. In case there is concern that the patient is an unreliable historian and the surgeon will not operate on an actively smoking patient, a urine or blood cotinine test can provide the definitive test result for active smoking.

TOO THIN/MALNUTRITION Many patients interested in plastic surgery to improve their appearance are compulsive, and some who present have areas that concern them seemingly out of proportion to the degree of deformity. A subset of this patient group is the MWL group of patients who overshoot their weight goal and who become too thin. Another subset of eating disordered groups includes those with anorexia or bulimia. Before proceeding with surgical intervention, the patient goals must be fleshed out. If this patient has a psychiatric history, and this must be elicited, then the question of suicide attempts in the past must be investigated and clearance from the patient’s psychiatrist is recommended. Furthermore, the patient must be referred to a nutritionist for full assessment to assure that the individual is meeting all of her nutritional needs. Clearance

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Chapter 3 • Managing Expectations and Psychosocial Issues

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from the nutritionist is mandatory to proceeding with surgery (Figure 3-6).

PSYCHIATRIC DISORDER—BODY DYSMORPHIC DISORDER Dissatisfaction with body image often drives individuals to pursue elective breast- and body-contouring surgery.

B

Figure 3-5. A. This 49-year-old woman with diabetes lost 100 lb after open gastric bypass surgery. She dropped from a body mass index of 43.2 to 27.6. She had a right subcostal scar from prior cholecystectomy. B. In light of her medical issues, a conservative panniculectomy with minimal undermining was performed initially. C. Two years later, she had an upper abdominoplasty with minimal undermining.

Body dysmorphic disorder (BDD) is described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition as comprising (1) preoccupation with an imagined or minor defect in physical appearance; (2) marked distress or impairment in social functioning resulting from the appearance preoccupation; and (3) the preoccupation is not attributable to the presence of another psychiatric disorder. BDD often coexists with

Chapter 3 • Managing Expectations and Psychosocial Issues

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Figure 3-6. A. This 56-year-old woman with body mass index of 19.5 and weight loss of 130 lb after open gastric bypass surgery was initially sent back to her nutritionist and bariatric surgeon for clearance for plastic surgery because of concerns about malnutrition. B. She was optimized and had abdominal panniculectomy performed.

mood and anxiety disorders, obsessive-compulsive spectrum disorder, substance abuse, eating disorders, and personality disorders. Patients affected by BDD typically do not benefit from surgical treatment, and approximately 5–15% of individuals who seek cosmetic surgical treatments suffer from BDD. Those with BDD are less likely to experience improvement in body image after surgery and may even express worsened feelings. This patient group is known to threaten its surgeons with lawsuits. In addition to potential for legal action, these patients are also more likely to become violent against their surgeons. A diagnosis of BDD is a contraindication to elective surgery for enhancement. These patients fare better with pharmacologic therapy and cognitive behavioral therapy. There was a time in plastic surgery when surgeons partnered with psychiatrists to ensure that the patient was making the right decision before performing surgery. Now that plastic surgery is more widely accepted in society and there appears to be a lower rate of psychopathology in plastic surgery patients; it is rare to

have a plastic surgeon refer an individual for psychiatric assessment. Informed consent is ultimately the final opportunity to confirm understanding of what will be done and limitations of the procedure. When patients understand the risks and limitations of surgery, they will understand that complications may occur and secondary surgery may be necessary. An expected outcome is critical to patients being on board with their surgeons and being satisfied that their surgeon has provided the best possible medical care.

RECOMMENDED LITERATURE Pavan C, Simonato P, Marini M, Mazzoleni F, Pavan L, Vindigni V. Psychopathologic aspects of body dysmorphic disorder: a literature review. Aesthetic Plast Surg. 2008(3): 473-84 Sarwer DB, Crerand CE. Body dysmorphic disorder and cosmetic surgery. Plast Reconstr Surg. 2006;118(7):167e-80e. Sarwer DB, Fabricatore AN. Psychiatric considerations of the massive weight loss patient. Clin Plast Surg. 2008;35(1):1-10.

Chapter 4.

Nonprescription Medications to Avoid

While certain prescription medications, such as blood thinners and appetite suppressants, lead to known detrimental issues in surgery, there are a great number of nonprescription supplements patients take that may unknowingly impact patient outcomes. Herbal medications are classified as dietary supplements in Dietary Supplement Health and Education Act of 1994, not as prescription medications, so they are exempt from safety and efficacy regulations applicable to prescription and over-the-counter drugs. The lack of regulation by the Food and Drug Administration leads to lack of consistency in the strength of herbal preparations. Furthermore, lack of classification of herbal medication as prescription medication may impair communication between the surgeon and the patient. Patients may not voluntarily share history of use of herbal medication because they either do not consider it to be a medication or due to their concerns that use of these supplements may be frowned upon by medical caregivers. Herbal medication use increased 380% from 1990 to 1997, with greater prevalence among white, educated and wealthy individuals, comprising a significant population of concern when considering elective breast- and bodycontouring surgery. As reported in a 2006 study by Heller et al, a 55% rate of usage of herbal medications has been observed among cosmetic surgery patients in Southern California. Of these, 100% took at least two different preparations. The top four herbals used in the cosmetic population were chondroitin, ephedra, echinacea, and glucosamine. Despite high prevalence in the population of use of herbal medications, physicians traditionally receive very little formal education about them. In a survey of physicians only one side effect was known by the majority, ephedrine. None of the other herbals except for ephedra was typically recommended to be stopped prior to surgery because of lack of knowledge about potential side effects. Overall, physicians surveyed were unable to identify side effects for 90% of the herbal medications. Certain herbal medications are used more commonly than others. Listed below are common herbal medications individuals use, including their benefits and potential side effects. Many have side effects that can impair surgical outcome, and therefore need to be stopped prior to surgery.

Arnica montana is used topically or orally for its antiinflammatory, analgesic, and antiseptic properties. It has been shown to be beneficial in decreasing postoperative swelling and bruising after liposuction and rhytidectomy. Bromelain also reduces inflammation and swelling after surgery. It acts as a potential immunomodulator of tumor cells and inhibitor of platelet aggregation. It may enhance the antithrombotic effect of aspirin and may increase heart rate. It could decrease wound healing time through immunomodulation effects. Bromelain should be stopped 2 weeks prior to surgery. Chondroitin is often paired with glucosamine to treat osteoarthritis. Chondroitin’s structure closely resembles that of heparin, leading to increased risk of bleeding. It should be stopped 2–3 weeks before surgery. Echinacea is known for its immunostimulatory effects that may impair efficacy of immunosuppressants. If used for more than 8 weeks, Echinacea may conversely cause immunosuppression, leading to wound healing problems and infections. Prolonged use may cause tachyphylaxis. Echinacea is an inhibitor of the cytochrome P450, so it can potentiate toxicity of drugs metabolized by this pathway: there is a risk of hepatotoxicity if used along with other anesthetic or nonanesthetic hepatoxic agents. Echinacea should be stopped 2–3 weeks preoperatively. Ephedra (Ma-huang) promotes weight loss and increases energy. It may increase blood pressure and heart rate. Ephedra is taken to treat respiratory conditions such as asthma and bronchitis. Ephedra may cause vasoconstriction and vasospasm of heart and cerebral vessels, thereby resulting in stroke and myocardial infarction. Halothane anesthesia in combination with Ephedra use may cause intraoperative ventricular arrhythmias. It should be stopped 24 hours prior to surgery. Garlic decreases blood pressure and thrombus formation and lowers serum lipid and cholesterol levels. It inhibits platelet aggregation and may potentiate the effect of 18

Chapter 4 • Nonprescription Medications to Avoid other platelet inhibitors, so it should be stopped 7 days prior to surgery. Ginger is used as a digestive aid, stimulant, diuretic, and antiemetic. It has been shown to inhibit thromboxane synthetase enzyme, leading to prolonged bleeding time. It should be stopped 2–3 weeks preoperatively. Gingko is used for cognitive disorders, peripheral vascular disease, macular degeneration, vertigo, tinnitus, erectile dysfunction, and altitude sickness. It has been shown to alter vasoregulation, act as an antioxidant, modulate neurotransmitter and receptor activity, and inhibit platelet-activating factor, leading to increased bleeding risk. Gingko should be stopped 3 days prior to surgery. Ginseng, labeled “adaptogenic,” is believed to protect the body against stress. Ginseng lowers postprandial glucose levels leading to risk of hypoglycemia, inhibits platelet aggregation, and inhibits the coagulation cascade. Ginseng can cause hypertension. It should be stopped 7 days prior to surgery. Glucosamine is used to treat osteoarthritis. Preparations contain plant insulin, so glucosamine may cause hypoglycemia. Glucosamine should be stopped the day prior to surgery. Chondroitin is often paired with glucosamine. Goldenseal is used as a mild laxative and anti-inflammatory and to treat infection. It may increase blood pressure or cause electrolyte imbalance. Goldenseal inhibits cytochrome P450 metabolism, potentiating drugs metabolized by this system, such as barbiturates and benzodiazepine medications. It causes photosensitivity, so laser is contraindicated. Goldenseal should be stopped prior to surgery. Grape seed is an antioxidant. It reduces inflammation, stabilizes collagen and elastin, acts as a natural antihistamine, protects and heals connective tissue, and has chemopreventive effects in patients with cancer. Kava is used as an anxiolytic and sedative. It has demonstrated effects on the central nervous system including antiepileptic, neuroprotective, and local anesthetic properties. It has been shown to increase barbiturate-induced sleep time in laboratory animals. Kava may lead to dermopathy (reversible, scaly cutaneous eruptions) and fulminant hepatitis. It should be stopped 24 hours prior to surgery. Milk thistle is used for its hepatoprotective, anti-inflammatory, and regenerative properties. It may lead to dehydration from loose stools. It should be stopped 2–3 weeks preoperatively. Saw palmetto is used for benign prostatic hypertrophy. There is a risk of postoperative bleeding. It should be stopped 2–3 weeks preoperatively. St. John’s Wort helps treat mild to moderate depression by inhibiting serotonin, norepinephrine, and dopamine

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reuptake by neurons. It can significantly increase metabolism of drugs, with induction of the cytochrome P450 system, including cyclosporine, midazolam, lidocaine, calcium-channel blockers, warfarin, nonsteroidal antiinflammatory drugs, and digoxin. St. John’s Wort may increase photosensitivity. Long-term use may lead to cardiovascular collapse on induction of anesthesia. It should be stopped 5 days prior to surgery. Valerian is used as a sedative and potentiates sedative effects of anesthetics, such as midazolam. Valerian inhibits cytochrome P450 3A4. There is a risk of benzodiazepine-like withdrawal. It should be tapered off over the weeks prior to surgery. Vitamin A plays a role in vision, immunity, gene transcription, red blood cell production, growth, and embryologic development. It may improve wound healing and help counter the effects of chronic corticosteroid use and irradiation. Excess dosing of vitamin E leads to toxicity resulting in liver damage, hemorrhage, and coma, and also causes increased risk of congenital anomalies. Vitamin B12 complexes with intrinsic factor and is absorbed into the bloodstream. Deficiency is seen in malabsorption associated with gastric bypass surgery, pernicious anemia, and in strict vegetarians who do not consume animal proteins. Vitamin C is required for synthesis of collagen and plays an important role in the synthesis of norepinephrine. It is also an effective antioxidant. Vitamin E is a fat-soluble vitamin with antioxidant properties and a free radical scavenger. Platelet aggregation and adherence are inhibited by vitamin E. High doses of vitamin E (⬎400 IU/day) might increase risk of bleeding due to inhibition of platelet aggregation and antagonism of vitamin K-dependent clotting factors. Vitamin E inhibits collagen synthesis and wound healing. It should be discontinued 2–3 weeks prior to surgery.

RECOMMENDED LITERATURE Ang-Lee MK, Moss J, Yuan CS. Herbal medicines and perioperative care. JAMA 2001;286:20-216. Broughton G, Crosby MA, Coleman J, Rohrich RJ. Use of herbal supplements and vitamins in plastic surgery: a practical review. Plast Reconstr Surg. 2007;119:48e. Heller J, Gabbay JS, Ghadjar K, et al. Top-10 list of herbal and supplemental medicines used by cosmetic patients: what the plastic surgeon needs to know. Plast Reconstr Surg. 2006; 117:436. Kaye AD, Kucera I, Sabar R. Perioperative anesthesia clinical considerations of alternative medicines. Anesthesiol Clin North America 2004;22:125-39. Wittkowsky AK. Dietary supplements, herbs and oral anticoagulants: the nature of the evidence. J Thromb Thrombolysis 2008;25:72-7.

Chapter 5.

Massive Weight Loss metic issues. Functional issues include rashes, skin breakdown, hygiene problems, panniculitis and lymphedema, pain within the skin, and exacerbation of back and joint pain. Some patients are limited in achieving further weight loss because of symptomatic skin redundancy. Aesthetically, the excess skin can negatively impact body image to a point where some patients express that they wished they never lost the weight. Excess skin can affect the face and neck, chest, abdomen, upper and lower back, and thighs. Growth in numbers of plastic surgery procedures performed for MWL patients has followed the growth of gastric bypass procedures in the United States in a parallel fashion. The American Society of Plastic Surgery data from 2008 demonstrate significant growth in body lifting procedures over time (www.surgery.org). Abdominoplasty is one of the top five surgical procedures performed by plastic surgeons, and increased in prevalence 94% from 2000 to 2008. In 2008, 9286 lower body lifts were performed, up 4368% between 2000 and 2008. Thigh lift increased from approximately 1000 procedures in 1992 to 11,500 in 2006, up 1025%. Treatment of skin laxity including abdominoplasty, lower body lift, and thigh lift echoes the growth in MWL patient successes. From the medical, psychological, and cosmetic viewpoint, the MWL population presents a unique and growing challenge to the plastic surgeon. These patients present a profile that differs from those who have not sustained MWL. Their deformities are typically more severe with greater excess skin and a greater degree of laxity. Because of the global weight loss and hence the global laxity of skin, traditional body-contouring techniques are often insufficient to correct these deformities. Multiple procedures and complex intraoperative positioning may be required, surgeries are time-consuming, and blood loss can be substantial. Often, patients require hospitalization. Safety during surgery is a major concern, including prophylaxis against venous thromboembolism. Patients also often have medical comorbidities and previous surgical scars as well as nutritional deficiencies and anemia to consider, so procedures may be “dialed down” to ensure optimal healing and minimize complications. Some MWL patients are still obese which puts them at greater risk for complications after

Obesity has reached epidemic levels in the United States. Obesity presents a major health concern and has significant economic implications for our medical system. A constellation of medical problems known as metabolic syndrome is associated with morbid obesity, including hypertension, dyslipidemia, type 2 diabetes, coronary artery disease, stroke, gallbladder disease, osteoarthritis, obstructive sleep apnea, and cancers such as breast and colon. Obesity is the second leading cause of death in the United States, with 400,000 deaths attributed to obesity in the United States each year. Body mass index (BMI), a ratio of weight to height, is the most common method used for determining a patient’s weight status. The clinical definition of obesity is a BMI of 30 or more. A BMI of 30–35 is classified as obese, of 35–40 defines severe obesity, of 40–50 defines morbid obesity, and of 50 or more defines “superobesity.” BMI is not a direct measure of body “fatness” or health, since it is calculated from an individual’s weight which includes both muscle and fat. In this way, highly trained athletes may have a high BMI but not have a high percentage of body fat. Greater health risks are associated with higher BMI. Health benefits are associated with massive weight loss (MWL). Medical conditions such as hypertension, diabetes, and obstructive sleep apnea may dramatically improve or even reverse with significant weight loss. With increasing knowledge of the health benefits of MWL, more individuals are pursuing medical and surgical treatment to alleviate MWL. Bariatric surgery is the only effective therapy to achieve successful maintenance of weight loss in morbidly obese patients. The two major categories of bariatric surgery include restrictive operations and malabsorptive operations. Restrictive operations include vertical banded gastroplasty, adjustable gastric band, and gastric bypass. Malabsorptive operations include biliopancreatic diversion, duodenal switch, and distal gastric bypass. Currently, gastric bypass is the most common form of bariatric surgery performed in the United States, followed by an adjustable gastric band and duodenal switch procedures. MWL on the order of loss of 50% of excess body weight or 100 lb or more leads to skin redundancy and laxity from head to toe, resulting in functional and cos20

Chapter 5 • Massive Weight Loss surgery. It is most prudent to wait at least for 1 year since bariatric surgery or until weight loss plateaus and stabilizes. The more stable and optimal the weight at the time of body-contouring surgery, the better the surgical outcome with regard to healing and aesthetics. MWL patients left with physical deformity and associated body image issues may benefit from body-contouring surgery. Such surgery can correct problems from head to toe. Safety is of utmost importance, followed by functionality and aesthetics. Surgery is fraught with potential pitfalls, but if performed safely, patients may experience the full benefits of MWL: improvement not only in their medical status but also in their psychiatric outlook.

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This atlas contains many procedures that apply to MWL patients.

RECOMMENDED LITERATURE Aly A, Ed. Body Contouring After Massive Weight Loss. Clinics in Plastic Surgery. Philadelphia, PA: Elsevier; 2008. American Society for Metabolic and Bariatric Surgery. www.asbs. org. Rubin JP, Matarasso A. Aesthetic Surgery After Massive Weight Loss. New York: Elsevier Health Sciences; 2008. The American Society for Aesthetic Plastic Surgery. www. surgery.org. The American Society of Plastic Surgery. www.plasticsurgery.org.

Chapter 6.

Surgical Wound Care and Complication Management

Complications may occur after breast- and body-contouring procedures. It is important to understand how to best avoid these complications, and when they do occur, how to provide the best form of management. The most common and compelling complications seen after surgery include wound healing problems, seromas and lymphoceles, infections, venous thromboembolism (VTE), lymphedema, hematomas, and nerve injury. It is particularly important to discuss the possibility of complications occurring when discussing procedures with patients in consultation and in the informed consent process. Patients are more accepting of complications if they are prepared for the possibility: they may doubt their surgeon’s skills if they have not been told. When complications do occur, it is important for the surgeon to remain engaged and see the patient frequently in the acute perioperative period to optimize wound healing and reassure the patient that he or she will be fine.

sis of subcutaneous fat. All wounds should be cleansed daily and dressed until epithelialization takes place. Uninfected partial thickness wounds may be treated with petrolatum ointments using nonadherent gauze to minimize trauma to the healing wound. With cellulitis, antibacterial ointments such as mupirocin or gentamicin should be utilized. Wounds involving full thickness loss of skin and fat may be treated initially with wet-to-dry dressings with saline twice a day, and debridements performed at least once a week. Once adequate granulation tissue develops with flattening of the wound, ointment can be substituted for wet-to-dry dressings. Large tunneling wounds may be treated initially with wet-to-dry dressings, and once the wounds are clean, vacuumassisted closure (VAC) may be applied to optimize healing by decreasing edema and bacteria counts and drawing the wound edges together through application of negative pressure. Silver VAC is very good for antibacterial treatment. Patients may develop thinned-out scars or conversely, hypertrophic scarring, after secondary healing, which may result in the need for scar revision after surgery. Wounds should be allowed to heal preferably for a year before proceeding with formal scar revision surgery. Steroid injections may be considered for thin hypertrophic scars, starting with triamcinolone 10 and graduating up to triamcinolone 40, as needed. Silicone gel sheeting may be considered.

WOUND HEALING COMPLICATION Wound healing problems are a relatively frequent complication after breast- and body-contouring surgery. This complication is more likely in patients with obesity, diabetes, endocrine disorders, Ehlers-Danlos syndrome and autoimmune disease, advanced age, and peripheral vascular and coronary artery disease. Patients with medical comorbidities such as these either should not undergo surgery at all or should be offered only limited procedures. Wound healing problems may also occur secondary to prior surgical procedures performed, resulting in undermining or scarring that impairs circulation to the surgical site. (Figure 6-1) In the case of dehiscence or skin necrosis with eschar development, dead tissue should be debrided to optimize healing and reduce risk of infection. While superficial wounds may involve only partial skin loss, deeper wounds may result in full thickness skin loss with necro-

SEROMAS Seromas are fluid collections that develop under the skin in actual or potential dead space after surgery (Figure 6-2). With undermining and/or significant skin removal, closed drains need to be placed at the time of surgery to drain fluid that may develop after surgery. After drains are removed, seromas may develop. Seroma formation is exacerbated by shear forces postoperatively, preventing 22

Chapter 6 • Surgical Wound Care and Complication Management

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Figure 6-1. A. This 38-year-old woman with a smoking history and very large incisional hernia sustained after open gastric bypass surgery and massive weight loss of 260 lb underwent panniculectomy and hernia repair surgery. The umbilicus was connected to the lower portion of the hernia. B. Within 36 hours of surgery, her umbilicus necrosed. C. The patient was immediately taken back to the operating room for removal of the necrotic umbilicus which was resected. The midline incision was closed without umbilical reconstruction. These photographs were taken 5 months after surgery.

closure of the dead space. They are more common in obese patients, patients who have had significant tissue removal, patients with low albumin such as in malnutrition, and patients with conditions that put them at risk for wound healing problems.

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While silent seromas need not be investigated or treated, seroma fluid collections may become clinically evident with ballotable fluid apparent under the skin or with abdominal discomfort. They may also manifest themselves when they become infected, causing redness,

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Chapter 6 • Surgical Wound Care and Complication Management

Figure 6-2. This is an abdominal seroma that developed after abdominal panniculectomy and hernia repair.

pain, and fever. Patients with clinically evident seromas require further procedures to treat them. If ballotable fluid is present, transcutaneous needle aspiration may be performed and compression therapy with the use of foam and binder may be used as an adjunct to prevent recurrence. Sometimes, needle aspiration may be performed several times on a weekly basis. If fluid continues to recur, a transcutaneous drain may be placed, either by the surgeon in the clinic if it is easily accessible or by an interventional radiologist with ultrasound or computed tomography (CT) guidance. If this drain then continues to drain, or if drains placed during surgery continue to have high outputs impairing their removal, sclerosis through the drainage tube may be initiated. Popular sclerosants include doxycycline (500 mg in 50 cc of saline with 10 cc or 1% lidocaine plain) or bleomycin (60 units mixed with 1 amp D5W in a 60-cc luer lock syringe). These solutions are infused in the drain, and the drain is then clamped for 45 minutes to an hour, with the patient turning in various positions to ensure that the sclerosant contacts the full extent of the seroma cavity. If serial sclerosant treatments with different medications are unsuccessful, surgery may be performed. It is rare to get to this stage, and it is most common in the morbidly obese patient. Surgery may include removal of the seroma wall, quilting sutures, or open treatment with a VAC dressing to allow secondary closure. It is preferable to treat seromas in a closed fashion to avoid committing the patient to open wound management; however, if there is clear infection, the surgeon may be compelled to open the area to drain it. Infected seromas in the breast particularly require surgery to completely treat infection, which may perforate

through the breast tissue. If the seroma is thin-walled as revealed by CT examination, closed treatment may be attempted with intravenous antibiotic administration and closed drainage. It is best to check cultures to specifically treat the bacteria involved. Broad-spectrum antibiotics should first be initiated and then tapered once culture data are available. If the infection does not subside with appropriate antibiotic treatment, surgical treatment followed by open wound care may be necessary. It is sometimes unclear whether the subcutaneous fluid collection is a seroma or an actual lymphocele, particularly if the fluid collection occurs in a region where lymphatics are dense, such as the knee, groin, elbow, or axilla. If repeated aspirations and compression do not adequately treat these regions, surgery may be considered, including lymphazurin dye injection in the hand or foot to help identify leaking lymphatics. If blue dye leakage is found in the fluid collection, the leaking lymphatic vessel should be identified and ligated (Figure 6-3).

INFECTION Infection may occur after breast- and body-contouring surgery, less frequently than wound healing problems and seroma. Although prophylactic antibiotic treatment with a first-generation cephalosporin or clindamycin is typically given for a 24-hour period, with the first dose preceding incision, or in a single dose for patients not admitted to the hospital after surgery, there is no standard of care with regard to antibiotic treatment after the first day. Many surgeons do not prescribe antibiotics for patients after discharge, whereas others argue that large dead spaces and closed drainage tubes put patients at risk for infection, and therefore treat these patients for a week or more after surgery. There are no good outcome studies investigating the risk of infection after plastic surgery and creation of large dead spaces. When infections occur, inciting bacteria are often those that reside on the skin such as Staphylococcus aureus, Streptococcus, and Corynebacterium. With its increasing prevalence in the hospital and general population, methicillin-resistant S. aureus may be the infecting bacterium, often requiring intravenous vancomycin therapy or oral linezolid. Infection is particularly prone to occur if a drain becomes unsutured, leading to motion of the drain, with the risk of bacteria traveling from the skin into the subcutaneous space. Seromas, hematomas, and foreign material such as mesh used in hernia repair are other catalysts that promote postoperative infection (Figure 6-4). Treatment of infection may require evacuation of fluid or blood and possibly removal of artificial material.

Chapter 6 • Surgical Wound Care and Complication Management

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Figure 6-3. This patient had a thigh pannus which was directly excised. The transverse incision cut across lymphatics as revealed by recurrent seroma which became infected. Lymphazurin dye injection in the foot helped identify leaking lymphatics in the thigh which were ligated, effectively treating this seroma.

Figure 6-4. This patient has chronic wounds almost 1 year after her abdominal panniculectomy. These wounds are related to #1 braided permanent suture used to plicate the abdominal wall that became infected and required removal.

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Chapter 6 • Surgical Wound Care and Complication Management

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Figure 6-5. A temporary caval filter was placed by a colleague in vascular surgery just prior to abdominal panniculectomy in a morbidly obese patient with prior history or pulmonary embolism. Low dose of aspirin is taken each day it is in place until removal within 2–3 weeks of surgery.

VENOUS THROMBOEMBOLISM Previous history of VTE including deep venous thrombosis (DVT) and pulmonary embolism is the greatest risk factor for future VTE, potentially the most deadly outcome possible after body-contouring surgery. Other risk factors include obesity, immobility, history of lower-extremity trauma, venous stasis disease, hormonal therapy, history of cancer, and hypercoagulable states. VTE most often occurs in the lower extremity, but the upper extremity is also at risk with surgery around the axilla and elbow, and if there are indwelling central venous catheters. Conservative measures should always be taken in patients undergoing a surgical procedure requiring anesthesia and lasting for more than 30 minutes. Such measures include antiembolism support stockings, sequential compression devices, and postoperative prophylactic dosing with subcutaneous low-molecular-weight or unfractionated heparin. Placing a pillow under the knees also improves venous outflow and stasis. More aggressive measures need to be taken in highrisk patients, particularly those with a history of VTE because no matter how remote the history, patients are at greater risk for a second event. These patients may get treatment dosing of low-molecular-weight or unfractionated heparin; however, this will increase their risk of postoperative bleed. Temporary caval filters are available and

can be placed by colleagues in vascular surgery or interventional radiology within a day of surgery, to be removed 2–3 weeks after surgery (Figure 6-5). The filter also must be paired with low dose of aspirin each day while in place. The possibility of VTE must always be considered postoperatively. If a patient has a swollen, painful extremity, venous duplex study should be performed, and if results are positive for DVT, then anticoagulation treatment must be instituted with observation in the hospital. If the patient complains of dyspnea or shortness of breath, then a pulmonary embolism must be considered and spiral CT scan ordered for diagnosis (Figure 6-6). VTE can kill a patient, so even if low on the differential diagnosis, the possibility must be pursued.

LYMPHEDEMA Lymphedema occurs because of obstruction of lymphatic outflow from surgical scars. This may occur after brachioplasty, with swelling in the forearm, or after thigh lift and/or abdominoplasty, with swelling in the lower extremities (Figure 6-7). Compression therapy, massage, and physical therapy are beneficial in treating lymphedema, and usually successful outcome will occur. DVT must be ruled out in the patient with lymphedema, which may require duplex ultrasound study of the leg or arm.

Chapter 6 • Surgical Wound Care and Complication Management

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Figure 6-6. A. This thin patient who had abdominoplasty and hysterectomy performed in stirrups presented within a week of surgery complaining of a minimally swollen, painful left extremity with dyspnea and shortness of breath. B. Venous duplex confirmed a left lower-extremity thrombosis involving the common femoral vein and extending distally. C. Spiral computed tomography scan confirmed diagnosis of a pulmonary embolism on the right side. The patient was immediately admitted to the hospital and started on intravenous heparin and oral warfarin (Coumadin).

HEMATOMA Postoperative bleeding may occur resulting in hematoma formation. This bleeding may be active, occurring within several days of surgery, because of an actively bleeding blood vessel in the surgical wound from failure to coagulate during surgery or postoperative hypertensive episode. Patients with hypertension or who use medications that thin the blood, including herbal preparations, are most likely to suffer from hematoma. Active bleeding often occurs within 24 hours of surgery when the patient

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is still in the hospital and may manifest itself through dizziness, syncope, high-drain output with gross blood, no drain output from the drain clogging with blood, or may become apparent after routine postoperative blood levels are checked. In general, the diagnosis is clinically obvious and requires immediate return to the operating room to coagulate the bleeding vessel (Figure 6-8). Pervasive bleeding may occur because of medical causes unknown prior to surgery, and in this case, medical treatment and a hematology consult may be in order. If there is concern about possible hematoma after the

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Chapter 6 • Surgical Wound Care and Complication Management with closed drainage because of the thick nature of the collection: they most often require surgery. If the patient is stable and clinical diagnosis is not obvious, CT scan is recommended.

NEUROPATHY AND NEUROMAS

Figure 6-7. This patient had extended thigh lift with resulting lymphedema which was asymmetrical. A venous duplex was negative for deep venous thrombosis.

patient has left the hospital, it is best that the patient be immediately examined, and this may require going to an emergency department close to his or her home if he or she is a distance away. Planning for the worst-case scenario is always safest. Hematomas do not clear well

Figure 6-8. This patient with a history of hypertension had panniculectomy and hernia repair and the morning after surgery was noted to have frank blood in his drain and swelling at the inferior portion of his incision indicating an acute hematoma. He was taken to the operating room immediately for hematoma evacuation and hemostasis.

Nerve injury may occur from surgery, either due to direct injury with the knife or cautery, or through positioning, which caused compression or stretch of the involved nerve. The best treatment of compression neuropathy is prevention through safe positioning. When neuropathy does occur, supportive care with massage, physical therapy, and prescription medications often results in improvement over time. If improvement does not occur, electromyogram and nerve conduction studies should be checked and neurology consult ordered. In some cases, nerve injury may require surgery to release scar tissue around the nerve. Sometimes injury to nerves is difficult to avoid in certain procedures, and an example is injury of the intercostobrachial or medial antebrachial cutaneous nerves in brachioplasty, causing numbness of the upper arm or forearm which should recover over time (Figure 6-9). Patients often experience numbness around surgical incisions due to injury to sensory nerves, but this often improves over time. If there is extreme tenderness after surgery around incision sites or hernia repairs, the possibility of neuroma should be considered. Initially, steroid injection combined with local anesthesia may help treat this condition; however, in some cases, surgical treatment of neuroma and possible nerve grafting may be necessary.

Figure 6-9. This is the intercostobrachial nerve in the axilla, visualized in a minimal incision brachioplasty. Surgery around this nerve even if uninjured can result in temporary numbness of the upper arm.

PartII Operative Procedures Section 2 Upper Extremity Section 3 Female Breast Section 4 Male Chest—Gynecomastia Section 5 Abdomen Section 6 Back Section 7 Lower Extremity

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Section 2 Upper Extremity Chapter 7.

Presentation for Upper Extremity Contouring

Chapter 8. Upper Extremity—Anatomy Chapter 9. Upper Extremity Liposuction Chapter 10. Traditional Brachioplasty Chapter 11. Extended Brachioplasty Chapter 12. Minimal Incision Brachioplasty

Chapter 7.

Presentation for Upper Extremity Contouring LAX ARM SKIN

Arm contouring is most often pursued for skin laxity sustained after massive weight loss, and this group can present with a great deal of variability. Other patients who have not sustained massive weight loss but have issues with lipodystrophy or skin laxity also pursue surgery on the arm. The challenge is that there is room for error in arm liposuction with overresection, and that scars are visible in brachioplasty. The patient must be aware that contour must be exchanged for scar. These are some common scenarios:

Women of more advanced age with loose arm skin may come for tightening of the skin which may be amenable to minimal incision brachioplasty or traditional brachioplasty. This also may be presentation secondary to liposuction with residual skin laxity.

MASSIVE WEIGHT LOSS Weight loss leads to variable degrees of skin redundancy. Some patients benefit from minimal incision brachioplasty, whereas others benefit from traditional brachioplasty, and others have so much laxity that the brachioplasty needs to be extended beyond the axilla along the lateral chest wall.

DISPROPORTIONATE ARMS WITH LIPODYSTROPHY Women interested in contouring of the arm who would like to get improvement along the deltoid region and over the triceps are good candidates for liposuction of the arm. The degree of fat removal must be tempered by the risk of skin laxity and relative inability of the skin to contract with liposuction, unlike the back or the thigh. In some cases, massive weight loss patients have remaining lipodystrophy of the arm requiring liposuction possibly followed by a formal brachioplasty.

LYMPHEDEMA AND LIPOMATOSIS SYNDROMES Patients with congenital or acquired lymphedema or lipomatosis syndromes of unknown etiology may benefit from liposuction along the forearm and upper arm, understanding that there is a risk of recurrence.

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Figure 7-1. Disproportionate arms with lipodystrophy—This woman complains of a thick arm with poor contour. She would benefit from liposuction of the triceps region below the deltoid and along the lower border of the arm.

Figure 7-2. Lax arm skin—This woman of advanced age has lax upper arm skin of minimal to moderate degree. She does not desire a long, visible incision, opting for a minimal incision brachioplasty.

Figure 7-3. Massive weight loss—There is a good deal of excess, ptotic skin on the arm that deflates body image after significant weight loss. These patients require formal brachioplasty with removal of the skin from axilla to elbow.

Figure 7-4. Lymphedema and lipodystrophy syndromes— This patient with Madelung’s deformity has significant fatty deposition in the upper arm and forearm. Although she is a good candidate for liposuction, there is a high-probability risk that the deformity will recur spontaneously.

Chapter 8.

Upper Extremity— Anatomy

A Biceps brachii m.

N Brachioradialis m.

B Brachial a.

O Radial n.

C Median n.

P

D Basilic v.

Q Articular cartilage

Radius

E

Medial antibrachial cutaneous n.

R Humerus

F

Longhead triceps m.

S

Triceps tendon & m.

G Axillary a.

T

Subcutaneous layer

H Medial brachial cutaneous n.

U Ulnar n. Medial antebrachial cutaneous nerve branches

I

Subclavian vein

V

J

Latissimus dorsi muscle

W Basilic v.

K Biceps brachii m.

X

Median n.

Brachial fascia

Y

Brachial a. and v.

L

M Brachialis m.

34

35

A B

C

D

E

F G

H I J

Y X W

K L M N

V

O P

U Q T S

R

Chapter 9.

Upper Extremity Liposuction

INTRODUCTION

attached to the operating room bed or double-arm boards are placed on either side of the bed. Padding is placed on these extensions and covered with a sheet to provide a smooth, padded surface. A half screen should be placed by the anesthesiologist over the patient’s head, stabilized under the patient’s head, for potential suspension of the arms off the arm table to get better access along the inferior portion of the arm and improve the circumferential approach. Pulse oximeter should be placed on the ear or nose, not the finger, and blood pressure cuff should be placed on the calf, removing one of the sequential compression devices on the calf. A lower body forced warming blanket should be placed on the patient throughout surgery to avoid hypothermia. The arms are circumferentially prepared and draped in sterile fashion, placing the wrists and hands in sterile towels. The intravenous catheter must be sterilely prepared in the surgical field or placed into the foot. Single, stab incisions are made in the elbow and axilla to address the areas of concern (Figure 9-2). Tumescent solution including 30 cc of 1% lidocaine with 1 cc of epinephrine 1:1,000 in a liter of Lactated Ringers solution is infused into the arm until it is turgid. After adequate time is given for hemostatic effect of the epinephrine, a 3.0-mm cannula is used to perform liposuction (Figures 9-3 and 9-4). Powerassisted and ultrasound-assisted lipectomy may be used over traditional liposuction techniques to improve skin contracture. When the desired contour is achieved, liposuction is complete. Aspirate volume should approximate the volume of tumescent solution infused. Access incisions are closed with a single #4-0 monofilament, permanent suture (Figure 9-5). The arms are dressed with foam with a silicone layer against the skin, and wrapped in elastic bandages.

Liposuction in the arm is challenging, finding the balance between removal of subcutaneous fat to uncover a more muscular physique without removing so much that there is resulting skin redundancy.

INDICATIONS Upper extremity liposuction is appropriate for younger patients with thick subcutaneous fat and good skin quality. This procedure is more often requested by women than by men. Patients with lipodystrophy syndromes such as Madelung’s disease are also good candidates, with the understanding that there may be recurrence. Skin is relatively thin in the arm, so skin retraction is less likely in the standard patient than in the abdomen or back. Skin laxity is possible after liposuction, and if this is anticipated, it is best to discuss the possible need for second-stage skin removal. Arm liposuction is also used to treat lymphedema in the arm that does not respond to nonsurgical measures. Liposuction treatment is often weighed against brachioplasty with the possibility of a hypertrophic, visible scar. While liposuction reduces bulk and improves the contour of the arm, it cannot adequately treat skin redundancy.

MARKINGS Patients are asked to point out their areas of concern. The deltoid region is a great area to address, as well as the area below the biceps muscle. The forearm may be addressed in lymphedema (Figure 9-1).

DETAILS OF PROCEDURE The patient is brought into the operating room and anesthesia is induced. Either an arm table that can be

36

37

Figure 9-1

Figure 9-2

Figure 9-3

Figure 9-4

Figure 9-5

38

Chapter 9 • Upper Extremity Liposuction

POSTOPERATIVE CARE This procedure is safe to perform as an outpatient. The patient may shower within days of the operation. After he/she showers, the foam and elastic bandage may be replaced. The first postoperative visit occurs a week after surgery, at which time the sutures are removed. The patient is instructed not to perform any lifting or upper extremity exercise for 1 week. The second postoperative visit occurs 6 weeks after the first, and then patients are followed as needed.

PITFALLS The main risk in this surgery is choosing the wrong patient, the patient with poor skin quality or more of a skin

issue than adipose tissue. Overresection is also a risk. Both of these problems may be corrected with brachioplasty, yet that would often demand a visible scar which might not be well accepted. When used for lymphedema treatment, liposuction may result in recurrence, requiring further treatment. This is also standard for lipomatosis syndromes including Madelung’s deformity and Dercum’s disease.

TIPS Compression is a great way to decrease edema and bruising after liposuction. Gentle foam with silicone sheeting is recommended. Arnica montana herbal medication, oral and topical, may also help in resolving edema and bruising. Some support the use of magnets for this purpose.

39

A

B

C

Figure 9-6A–C. This 42-year-old woman has Madelung’s deformity of unknown etiology involving her head, neck, arms, and torso. She had liposuction performed on her arms, shoulders, and torso, in addition to a neck lifting procedure. Approximately 2500 cc was removed from each arm and shoulder region through ultrasound-assisted liposuction followed by power-assisted liposuction. (continued)

40

Chapter 9 • Upper Extremity Liposuction

D

E

F

Figure 9-6D–F. (Continued) The postoperative photographs were taken 13 months after surgery.

41

A

B

Figure 9-7 A. This 41-year-old woman was interested in improving her arm definition and did not desire brachioplasty due to her concerns about the scars. B. She underwent ultrasound-assisted liposuction resulting in improved contour and some skin retraction.

Chapter 10.

Traditional Brachioplasty

INTRODUCTION

one needs to adjust the mark down for less removal along the back of the arm. Another ellipse along the axillary axis is marked. This creates the classic fishmouth, or “T,” incision of the traditional brachioplasty.

Brachioplasty is a great way to achieve improved contour in the arm. Prior to the explosion of the massive weight loss population, brachioplasty was less commonly performed, primarily due to wound healing difficulties and the potential for visible, prominent scars.

DETAILS OF PROCEDURE The patient is brought into the operating room and anesthesia is induced. Either an arm table that can be attached to the operating room bed or double arm boards are placed on either side of the bed. Padding is placed on these extensions and covered with a sheet to provide a smooth, padded surface (Figure 10-2). A half screen should be placed by the anesthesiologist over the patient’s head, stabilized under the pad under the patient’s head, for potential suspension of the arms off the arm table to get better access posteriorly in the dependent portion of the axilla. A bump is placed under the scapula on each side and if breasts are large, they are taped together in the midline. Pulse oximeter should be placed on the ear or nose, not the finger, and blood pressure cuff should be placed on the calf, removing one of the sequential compression devices on the calf. A forced warming blanket should be placed on the patient throughout the surgery to avoid hypothermia. The arms are prepared and draped circumferentially, placing sterile towels over the wrists and hands. The intravenous catheter must be sterilely prepared in the surgical field or placed in the foot. Incision is made in the bicipital groove and in the axillary ellipse. Dissection is taken through subcutaneous tissue straight down to the fascia overlying muscle and neurovascular structures and continued in that plane postero-inferiorly, undermining skin anticipated to be excised (Figure 10-3). It is critical to stay in the proper plane, understanding the tubular nature of the arm.

INDICATIONS Brachioplasty is most often performed for massive weight loss patients but may also be applied to individuals who desire to address skin laxity and excess on the arms. These are patients who have primarily skin redundancy contributing to poor shape, as those with excessive subcutaneous fat are best treated with liposuction. Traditional brachioplasty may also be performed secondary to arm liposuction leading to undesirable skin laxity and minimal incision brachioplasty which does not reach the desired contour results.

MARKINGS Patients are marked upright with the arms elevated at 90 degrees. Ideally, they can rest their hand on the side of the bed or a chair (Figure 10-1A, B). An ellipse is formed to define excision along the long axis of the arm from axilla to elbow, or as far distally as the skin laxity extends. The upper aspect of the ellipse is marked along the bicipital groove anteriorly up to the axilla. The posterior portion of the ellipse is marked along the inferior portion of the posterior arm. The amount of tissue one predicts can be excised is not the amount of tissue excess that can be pinched along the lower arm: this amount of excision is an overestimate. Accounting for skin closure over the structures deep to and including the subcutaneous fat,

42

43

A

B Figure 10-1

Superior mark in antebrachial groove

Bump under scapula Figure 10-2

Brachial fascia Brachial a. and v. Median n. Medial antebrachial cutaneous n. B

A Figure 10-3

Skin elevated off brachial fascia

44

Chapter 10 • Traditional Brachioplasty

Gentle blunt dissection with fingers or a clamp can help reveal the proper plane of dissection. The arm skin is then excised from distal to proximal in a stepwise fashion to ensure that there is no over- or underresection, stapling the incision closed (Figure 10-4). Once the proximal-most portion is reached, dog-ear is worked out in the axillary crease posteriorly. The towel around the forearm and hand may be clamped with a nonpenetrating towel clamp to the half screen to elevate the arm off the table and allow access to the posterior axilla. In planning the axillary closure, the goal is to keep this incision within the axillary fold.

A drain is placed in the subcutaneous space exiting out the distal incision and traveling up to the axilla. The wounds are then closed. The deep fascia is approximated with interrupted #2-0 braided absorbable suture, and a deep bite of the subcutaneous tissue in the axilla is important to secure the wound closure. The dermis is approximated with buried #3-0 absorbable monofilament suture, followed by a running #4-0 monofilament absorbable intracuticular suture (Figures 10-5 and 10-6). Barbed suture may be considered for the deep and/or superficial closure. The arms are dressed with petrolatum gauze and absorbent pads and then gently wrapped with 4- to 6-inch elastic bandages.

45 Brachial fascia Brachial a. and v. Median n. Medial antibrachial cutaneous n. B

Excess tissue elevated marked and excised A Figure 10-4

Layered closure: Basilic v. Median n.

Scarpa’s fascia closed with #2-0 absorbable suture

Brachial v.

Dermis closed with #3-0 absorbable monofilament

Brachial a.

Superficial layer closed with #4-0 running absorbable monofilament B

Drain

A Figure 10-5

Scar

Figure 10-6

46

Chapter 10 • Traditional Brachioplasty

POSTOPERATIVE CARE These patients might be kept for overnight observation if the brachioplasty is paired with other surgical procedures, but brachioplasty is safe to perform outpatient as a solo procedure. The drain is maintained for 1 week to avoid fluid collection and axillary dehiscence. The patients may shower within days of the operation. After they shower, they do not replace the dressing or the elastic bandage. The first postoperative visit occurs a week after surgery, at which time the drain is removed. The patient is instructed not to perform any lifting or upper extremity exercise for 4–6 weeks to avoid dehiscence. Deodorants must also be avoided for this period of time as well. The second postoperative visit occurs 6 weeks after the first, and then patients are followed every 3 months. The big postoperative issues addressed are wound healing and scar management. If there is wound breakdown, it is recommended that the patients wash the wounded area twice a day and apply petroleum ointment, unless there is cellulitis, and then mupirocin or gentamicin ointment is recommended. Guidance for optimal scar outcome includes massage, cocoa butter/shea butter/vitamin E creams, or silicone bandages or sheets. Steroid injection may be considered but should be diluted to avoid telangiectasias and overaggressive skin thinning or blanching. If scar is tight or limited across the axilla, physical therapy may be consulted to work on range of motion exercises and advanced scar management including compression and massage. They are also helpful if lymphedema is prolonged.

PITFALLS It is very important to clearly state complications that may occur after brachioplasty, so patients understand the requisite exchange of scar for contour. The scar location must not be promised due to lack of a stable fixation point. Patients may experience numbness down to their hand and forearm for a period of time and may experience forearm lymphedema. Wounds may also complicate healing, particularly in the axilla. Finally, it is important that patients understand that skin laxity may rebound

after surgery. Complications are compounded in patients with body mass index greater than 35, so it is best to either turn these patients away or offer a first-stage liposuction procedure which may then need to be followed with brachioplasty. Excision of the arm skin is most safely performed in a stepwise fashion, not committing to marks. There have been many cases in which the surgeon commits to the excision marked, resulting in a wound closure that is too tight or impossible. The wounds should not be left open for long as edema may set in, making the wound difficult to close. Temporary, staged closure with skin staples or definitive closure should be performed to protect against difficulty in closure. Large caliber, absorbable barbed suture may result in aggravating and compounding wound healing problems if the suture becomes exposed in the wound. It is important to remove any suture that is visible within a wound to accelerate wound healing. Postoperatively, it is dangerous to have patients wrap their arms with elastic bandages on their own: they may wrap the arm so tight that forearm lymphedema results or they may create a tourniquet that results in ischemia and skin necrosis. If arm compression is necessary, the patient must be properly educated about wrapping from the hand up to the axilla in a firm but not tight fashion, possibly using foam padding to protect the skin from ridging with elastic bandages. Some patients present with a contracture band across the axilla after surgery, particularly, patients who heal with hypertrophic scar. While physical therapy alone may improve this, it is possible a Z-plasty scar revision may be necessary about a year after surgery.

TIPS Some surgeons advocate for liposuction of the arm at the time of brachioplasty, but doing this may result in seromas, poor assessment of necessary skin removal, and added edema after surgery. Rather than complicate brachioplasty with liposuction, it is most prudent to perform these procedures in a staged fashion, liposuction first followed by brachioplasty several months later.

47

A

B

Figure 10-7. A. This 35-year-old woman lost 175 lb through diet and exercise: her body mass index decreased from 46 to 21.3. She had breast augmentation and traditional brachioplasty performed. B. The postoperative photographs were taken 27 months after surgery.

Chapter 11.

Extended Brachioplasty

INTRODUCTION

placed on either side of the bed. Padding is placed on these extensions and covered with a sheet to provide a smooth, padded surface. A half screen should be placed by the anesthesiologist over the patient’s head, stabilized under the pad under the patient’s head, for potential suspension of the arms off the arm table to get better access posteriorly in the dependent portion of the axilla and along the midaxillary line of the lateral chest wall. A bump is placed under the scapula on each side and if breasts are large, they are taped together in the midline. Pulse oximeter should be placed on the ear or nose, not the finger, and blood pressure cuff should be placed on the calf, removing one of the sequential compression devices on the calf. A lower body forced warming blanket should be placed on the patient throughout the surgery to avoid hypothermia. The arms and breasts are prepared and draped in sterile fashion, placing the hands and wrists in a sterile towel. The intravenous catheter must be sterilely prepared in the surgical field or in the foot. Incision is made in the markings from distal to proximal, from the elbow to the axilla, and then down the lateral chest wall. Dissection is taken through subcutaneous tissue down to the fascia overlying muscle and neurovascular structures, and in that plane proximally (Figure 11-2). Stepwise incision, dissection, and deep fascial closure from distal to proximal with interrupted #2-0 braided absorbable suture are performed to continually calibrate the degree of excision (Figure 11-3). A drain is placed along the lateral chest wall up into the axilla and sutured into place. A Z-plasty is designed in the axilla with 2–3 cm limbs to prevent scar contracture across the axilla (Figure 11-4). The towel around the forearm and hand may be clamped with a nonpenetrating towel clamp to the half screen to elevate the arm off the table and allow improved access to the axilla. The superficial wounds are then closed. The dermis is approximated with buried, interrupted #3-0 absorbable monofilament suture, followed by a running #4-0 monofilament absorbable intracuticular running suture (Figure 11-5). Tissue glue is then placed on the skin closure. The arms are dressed with petrolatum gauze and absorbent pads and then gently wrapped with 4- to 6-inch elastic bandages up to the axilla.

In patients with skin redundancy extending from the arm down the side of the chest wall, extended brachioplasty is optimal. The procedure best addresses the “bat wing deformity.”

INDICATIONS Extended brachioplasty is most often performed for massive weight loss patients who would not get adequate treatment with a traditional brachioplasty. For women, it is important to weigh the benefit of maintaining axillary tissue for future autoaugmentation of the breast against extending the brachioplasty scar inferior to the axilla. This is not an ideal procedure for patients with significant subcutaneous lipodystrophy due to increased complication risk and diminished aesthetic outcome.

MARKINGS Patients are marked upright with the arms elevated at 90 degrees, and they may hold the side of the bed for support. An ellipse is formed to define excision along the long axis of the arm from elbow to axilla and continuing down the lateral chest wall. The superior mark of the ellipse travels along the bicipital groove between the biceps and triceps muscles (Figure 11-1). The amount of tissue one predicts can be excised on the arm is not the amount of tissue excess that can be pinched along the long axis of the arm: this amount of excision is an overestimate. Accounting for skin closure over the structures deep to and including the subcutaneous fat, one needs to lessen the marking of excision, with plans to adjust the excision intraoperatively. A Z-plasty will be marked in the axilla during the procedure to ensure that scar contracture banding does not develop across the axilla.

DETAILS OF PROCEDURE The patient is brought into the operating room and anesthesia is induced. Either an arm table that can be attached to the operating room bed or double arm boards are

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49

Figure 11-1

Figure 11-3 and 4

Figure 11-2

Figure 11-5

50

Chapter 11 • Extended Brachioplasty

POSTOPERATIVE CARE These patients may be kept for overnight observation if the brachioplasty is paired with other surgical procedures, but extended brachioplasty is safe to perform outpatient as a solo procedure. The drain is maintained for 1 week to avoid fluid collection and axillary dehiscence. The patients may shower within days of the operation. After they shower, they do not replace the dressing or the elastic bandage. The first postoperative visit occurs a week after surgery, at which time the drain is removed. The patient is instructed not to perform any lifting or upper extremity exercise for 4–6 weeks to avoid dehiscence. The patient should avoid deodorants for this period of time as well. The second postoperative visit occurs 6 weeks after the first, and then patients are followed every 3 months. The big postoperative issues addressed are wound healing and scar management. If there is wound breakdown, it is recommended that the patients wash the wounded area twice a day and apply petroleum ointment, unless there is cellulitis, and then mupirocin or gentamicin ointment is recommended, in addition to obtaining a culture and prescription of oral antibiotic. Guidance for optimal scar outcome includes massage, cocoa butter/shea butter/ vitamin E creams, or silicone bandages or sheets. Steroid injection may be considered but should be diluted to avoid telangiectasias and overaggressive skin thinning or blanching. If scar is tight or limited across the axilla, physical therapy may be consulted to work on range of motion exercises and advanced scar management including compression and massage. They are also helpful if lymphedema is prolonged.

PITFALLS It is very important to clearly state complications that may occur after brachioplasty so that patients understand the requisite exchange of scar for contour. The scar location must not be promised due to lack of a stable fixation point. Patients may experience numbness down to their hand and forearm for a period of time and may

experience forearm lymphedema. Wounds may also complicate healing, particularly in the axilla. It is possible that patients will be left with continued skin laxity inferior to the lateral chest wall into the abdomen, which might need later surgical treatment. Finally, it is important that patients understand that skin laxity may rebound after surgery. Excision of the arm skin is most safely performed in a stepwise fashion, not committing to marks. There have been many cases in which the surgeon commits to the excision marked, resulting in a wound closure that is too tight or impossible to close, requiring skin grafting. The wounds should not be left open for long as edema may set in making the wound difficult to close. Temporary, staged closure with skin staples or definitive closure should be performed to protect against difficulty in closure. Axillary wounds are not infrequent after brachioplasty. Large caliber, absorbable barbed suture placed in the deeper subcutaneous layers in particular may aggravate and compound wound healing problems if the suture becomes exposed in the wound. It is important to remove any suture that is visible within a wound to accelerate wound healing. Postoperatively, it is dangerous to have patients wrap their arms with elastic bandages on their own: they may wrap the arm so tight that forearm lymphedema results or they may create a tourniquet that creates ischemia and skin necrosis. If arm compression is necessary, the patient must be properly educated about wrapping from the hand up to the axilla in a firm but not tight fashion.

TIPS Some surgeons advocate for liposuction of the arm at the time of brachioplasty, but doing this may result in seromas, poor assessment of necessary skin removal, and added edema after surgery. Rather than complicate brachioplasty with liposuction, it is most prudent to perform these procedures in a staged fashion, liposuction first followed by brachioplasty months later.

51

A

B

C

Figure 11-6. A. This 49-year-old woman lost 150 lb after open gastric bypass surgery: her body mass index decreased from 59.2 to 28.9. She had back lift, thigh lift, and extended brachioplasty performed. B,C. The postoperative photographs were taken 8 months after surgery.

Chapter 12.

Minimal Incision Brachioplasty potential suspension of the arms off the table to get better access posteriorly in the dependent portion of the axilla. If the breasts are large, they are taped together in the midline. Pulse oximeter should be placed on the ear or nose, not the finger, and blood pressure cuff should be placed on the calf, removing one of the sequential compression devices on the calf. A lower body warming blanket should be placed on the patient throughout the surgery to avoid hypothermia. The arms are prepared and draped in sterile fashion and the hands and wrists are placed in sterile towels. The intravenous catheter must be sterilely prepared in the surgical field or placed in the foot. The more proximal of the axillary ellipse incisions is made through subcutaneous fat to the fascia overlying neurovascular structures. Undermining is then performed distally and the amount of tissue that may be safely excised is determined (Figures 12-2 and 12-3). The towel around the forearm and hand may be clamped with a nonpenetrating towel clamp to the half screen to elevate the arm off the table and allow access to the posterior axilla. Temporary closure is performed with skin staples and then the wound is closed in a layered fashion with the deep fascia approximated with interrupted #2-0 braided absorbable suture: deep bites of the subcutaneous tissue in the axilla are important to secure the wound closure. The wound is closed from the outside in order to avoid dog-ear scarring. The dermis is approximated with buried #3-0 absorbable monofilament suture, followed by a running #4-0 monofilament absorbable intracuticular suture (Figure 12-4). Closure may have a pleated appearance as the outer elliptical incision is longer than the proximal incision length, but this will settle after surgery. No drain is necessary. Local anesthesia may be placed into the skin closure for postoperative comfort. Skin glue may be placed on the incision to avoid the need for dressings. Dressings include absorbent pads taped into position.

INTRODUCTION Minimal incision brachioplasty is a procedure that satisfactorily addresses only minimal skin laxity. The procedure allows a relatively hidden scar, but in this case, “less is less,” and the contour result is compromised by a shorter scar.

INDICATIONS Minimal incision brachioplasty may be performed for massive weight loss patients but is best applied to individuals who are fit and desire improved skin tautness. Patients must understand the limitation of this limited scar technique.

MARKINGS The patient is marked upright with the arms elevated at 90 degrees. Ideally, she can rest her hand on the side of the bed or a chair. An ellipse is formed to define excision along the axis of the axilla (Figure 12-1). The amount of tissue predicted to be excised guides the ellipse marking. The ellipse cannot be placed deep within the axilla because the power of the pull over skin laxity as far as the midarm will be lost.

DETAILS OF PROCEDURE The patient is brought into the operating room and anesthesia is induced. Either an arm table that can be attached to the operating room bed or double arm boards are placed on either side of the bed. Padding is placed on these extensions and covered with a sheet to provide a smooth, padded surface. Folded sheets are also placed under each scapula and upper arm. A half screen should be placed by the anesthesiologist over the patient’s head, stabilized under the padding under the patient’s head, for

52

53

Figure 12-1

Figure 12-2

Figure 12-3

Figure 12-4

54

Chapter 12 • Minimal Incision Brachioplasty

POSTOPERATIVE CARE It is safe to perform minimal incision brachioplasty as an outpatient procedure and local anesthesia should be used to improve postoperative comfort. The patient may shower within days of the operation. Skin glue is very helpful in avoiding the need for dressings and in sealing the wound closure. The first postoperative visit occurs a week after surgery. The patient is instructed to not perform any heavy lifting or upper extremity exercise for 4–6 weeks to avoid dehiscence. Avoidance of deodorants for this period of time is recommended as well. Concerns about the pleated appearance of the closure should be alleviated as time will allow resolution of this. After a week or two, massage of the scar and scar management should be encouraged: optimal scar outcome includes massage,

cocoa butter/shea butter/vitamin E creams, or silicone bandages or sheets.

PITFALLS It is very important to clearly state the limitations of this procedure in that minimal laxity is all that is adequately addressed and that scar may be visible because hiding the scar deep in the axilla loses the effect this procedure has on the upper arm.

TIPS In patients seeking minimal incision brachioplasty, the effect of the excision may be lost with liposuction which can exacerbate skin laxity. In a patient with significant skin laxity extending to the elbow, traditional brachioplasty is the proper procedure to offer.

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A

B

Figure 12-5. A. This 32-year-old woman lost 130 lb through diet and exercise to a body mass index of 24.9. She had brachioplasty with minimal incision performed. B. The postoperative photographs were taken 24 months after surgery.

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Section 3

Female Breast Chapter 13. Common Presentation for Breast Contouring Chapter 14. Female Breast—Anatomy Chapter 15. Liposuction of the Breast Chapter 16. Wise Pattern Breast Reduction with Inferior Pedicle Chapter 17. Traditional Wise Pattern Mastopexy with Autoaugmentation Chapter 18. Vertical Pattern Breast Reduction with Superior Pedicle Chapter 19. Vertical Pattern Mastopexy (with Augmentation) Chapter 20. Wise Pattern Superior Pedicle Breast Reduction with Nipple Grafting

Chapter 13.

Common Presentation for Breast Contouring

Women of variable ages and backgrounds pursue breastcontouring surgery. These are some common scenarios:

shoulder grooving, and upper extremity neuropathy from bra straps. Some get chest pain or have difficulty breathing when lying supine. There is also difficulty with exercise. These patients are candidates to consider for breast reduction, and the technique chosen may depend on breast size and degree of ptosis, medical comorbidities, and acceptable scars. Teenagers presenting early with significant macromastia are at risk for recurrence after breast reduction.

THE POSTPARTUM WOMAN Deflation and ptosis are present in many women after childbirth, affecting appearance and body image. These patients may benefit from breast lift, augmentation, or a combination of both to achieve better volume and lift and overall rejuvenation. The mastopexy technique chosen depends upon the degree of ptosis, with lesser degrees of ptosis creating a great opportunity for vertical lifting and larger degrees of ptosis more amenable to Wise pattern techniques to shorten the breast.

CONGENITAL BREAST ASYMMETRY AND BREAST DEFORMITY Adolescents, teenagers, and mature women present with significant breast asymmetry that became particularly noticeable at puberty. In many situations, one breast has overdeveloped while the other has not developed at all. Poland syndrome includes an underdeveloped breast and pectoralis muscle, and may be associated with craniofacial or upper extremity developmental deformities. Tubular breast deformity is another common congenital deformity with a tight, constricted base width and pseudoherniation of breast tissue through an enlarged nipple areolar complex. Reconstruction of any of these congenital anomalies often involves staged procedures with bilateral treatment and possible use of implants to compensate for discrepant breast volumes.

MASSIVE WEIGHT LOSS Weight loss may be achieved through diet and exercise or through surgical means. Many women losing greater than 50% of their excess weight sustain significant loss of volume in the breast, with ptosis. Complicating this situation, a large group of these patients had breast reduction surgery prior to their weight loss. The breast-lifting technique chosen depends on the degree of ptosis. Some patients desire breast augmentation, and while many patients have skin excess that de-epithelialized provides opportunities for autogenous augmentation, many still require augmentation with implants.

SYMPTOMATIC MACROMASTIA Women with large breasts may suffer from disabling symptoms such as rashes, neck pain, backache, headaches,

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Figure 13-1. The postpartum woman—This 39-year-old female is postpartum, complaining of deflation and ptosis of her breasts. She is a candidate for mastopexy, vertical or Wise pattern, with possible breast augmentation if she desires increased volume. This could also be performed at a second stage. Figure 13-3. Symptomatic macromastia—This 45-year-old woman presented with symptomatic macromastia including back pain, rashes, and bra grooving, desiring breast reduction operation. She is a very good candidate for Wise pattern breast reduction due to her degree of ptosis.

Figure 13-2. Massive weight loss—This woman lost 100 lb after laparoscopic gastric bypass surgery. She has a teenaged child. She desired lifting of her breast as well as augmentation of volume. Figure 13-4. Congenital breast asymmetry and breast deformity—This 28-year- old woman with congenital breast asymmetry presented for augmentation of the left breast and improved symmetry.

Chapter 14.

Female Breast—Anatomy

A Sternum

H Anterior cutaneous branches of T1–T7

B Internal thoracic artery with breast perforators

I

Latissimus dorsi muscle

C Pectoralis fascia

J

Serratus anterior muscle

D Breast gland

K Lateral mammary branches of posterior intercostal arteries

E

Perforators to internal thoracic vein

F

Inframammary fold

L

Pectoralis major muscle

M Clavicle G Rectus fascia

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M

L

A B C

K

D

J

E F

I H G

Chapter 15.

Liposuction of the Breast

INTRODUCTION

DETAILS OF PROCEDURE

Liposuction of the breast is not often performed, as most women desire formal breast reduction to treat skin excess and the weight of the breast. This technique is reserved for patients who are too risky for breast reduction or for those who want conservative change. Liposuction is typically performed with standard liposuction or powerassisted liposuction. Past literature has reported theoretical risk of cancer with ultrasound-assisted liposuction, so this should not be performed in the breast to avoid the risk of blaming this technique on ultimate cancer occurrence which might otherwise occur.

The patient is brought into the operating room and anesthesia is induced. Positioning includes arms at no greater than 90 degrees from the body and laid on egg crate to avoid compression. The knees are placed on a pillow to encourage flexion, and antiembolism support stockings and sequential compression devices are initiated prior to anesthesia. The breasts are prepared and draped in sterile fashion, placing a lower body forced warming blanket. Stab incisions are made and tumescent solution is infiltrated (Figure 15-2). Tumescent solution is infiltrated for hemostasis and anesthetic benefit. This solution includes 30 cc of 1% lidocaine and 1 cc of 1:1,000 epinephrine per liter of lactated ringers at room temperature. If liposuction volume will be less than 2 liters, 50 cc of lidocaine may be placed in the tumescent solution. The solution must be allowed to permeate within the tissues for at least 10 minutes or so for the full epinephrine effect to help reduce blood loss. For volume of tumescent solution, a ratio of 1–2 times the amount of anticipated aspirate should be infused. Standard liposuction or power-assisted liposuction is then performed to reduce breast volume (Figure 15-3). The access incision sites are closed with single #4-0 monofilament permanent suture to allow drainage of remaining fluid out (Figure 15-4). The patient is placed into a postoperative mammary support garment prior to moving to the recovery room.

INDICATIONS Liposuction is a safe way to reduce symptoms associated with macromastia in patients with high risk for complication. Such patients including those with prior breast reduction or breast scars, those older than 50 years, and patients with heart disease.

MARKINGS The patient is marked in the upright position. Marks should be made for incision sites and areas to be suctioned (Figure 15-1).

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Stab wounds Ted hose Sequential compression devices

Midsternal mark IMF Stab wounds at medial and lateral inframammary fold

A

B

Tumescent solution injected

Figure 15-2

Figure 15-1

Cannulas moved throughout breast tissue

Wounds closed with a single suture

Figure 15-3

Figure 15-4

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Chapter 15 • Liposuction of the Breast

POSTOPERATIVE CARE Breast liposuction may be performed as an outpatient. Prior to leaving the recovery room, the patient must be able to ambulate and take adequate oral fluids. The patient returns 1 week after surgery for the first postoperative visit. Sutures are removed. Physical limitations within the upper body last for a week. Patients may shower several days after the procedure, and a soft support bra is recommended for a month.

PITFALLS While breast liposuction creates an effortless recovery period and reduction of breast weight, there is minimal

effect on the breast skin and ptosis. Patients may continue to experience macromastia symptoms from significant ptosis like massive weight loss patients do. This possibility must be discussed with the patient.

TIPS The balance of safety and outcome here weigh more heavily toward safety than toward a remarkable change after surgery. Risks of breast reduction surgery including wound healing problems requiring prolonged wound care, fat necrosis, and seromas are high in women older than 50 years and in those with significant coronary artery disease. The patient must weigh these risks in choosing the right surgical procedure, in concert with her physician.

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A

B

C D Figure 15-5. A, B. This is a 52-year-old woman with a history of coronary artery stenting and cardiac disease who desired relief from symptomatic macromastia. Because of her risk of healing problems, liposuction was strongly advocated for weight reduction with minimal scar and no dead space. C, D. Her postoperative photographs were taken 2 months after surgery.

Chapter 16.

Wise Pattern Breast Reduction with Inferior Pedicle 7 cm in width (Figure 16-1). The new nipple areolar position is measured again as well as the existing NAC position to determine preoperative asymmetry. This should be confirmed with the patient. Once the patient is asleep on the operating room table, the symmetry of markings may be further checked, ensuring that the distance from midline to the central breast axis is the same, as well as the distance of the pedicle from midline and the width of the pedicle.

INTRODUCTION Wise pattern breast reduction through a keyhole incision and inferior pedicle is the most versatile breast reduction technique, applicable to the broadest range of patients.

INDICATIONS Wise pattern inferior pedicle breast reduction is very good for the majority of women seeking breast reduction. Whereas classical literature claims a limit of nipple elevation of 16 cm, we have found success in up to 20 cm of elevation. Wise pattern breast reduction addresses axillary fullness well.

DETAILS OF PROCEDURE The patient is brought into the operating room and anesthesia is induced. A Foley catheter may be placed to monitor urine output, particularly if the case will last longer than 3 hours. Arms are positioned at 90 degrees from the body, and egg crate is placed on the arm boards to prevent nerve compression. The knees are placed on a pillow to encourage flexion, and antiembolism support stockings and sequential compression devices are initiated prior to anesthesia. Markings on the breast are determined to be symmetric with regard to midpoint marked on the IMF on each breast and the width and position of the inferior pedicle centered on the central IMF marking. The breasts are prepared and draped in sterile fashion, placing a lower body forced warming blanket to avoid hypothermia. The drapes on the chest should be stapled into position, stapling superiorly on the clavicles and stapling the central axis of each breast above the proposed NAC complex and below the IMF. A 42- to 45-mm nipple areolar cookie cutter is used to designate the new nipple areolar diameter, and this mark is incised with the NAC on moderate stretch (Figure 16-2). The central pedicle is then de-epithelialized with a knife or with large mayo scissors, preserving the NAC (Figure 16-3).

MARKINGS The patient is marked in the upright position. The central axis of the breast is marked bilaterally and transposed below the level of the inframammary fold (IMF). The new nipple position is marked on this axis at the level of the IMF, often 22–23 cm from the sternal notch. Limbs of 8 cm in length are designed from the nipple to define the new nipple-inframammary distance, and the distance between these two limbs varies depending upon the width of the nipple areolar complex and the degree of breast narrowing the surgeon aims to achieve, usually on the order of 7–8 cm. Symmetry can be checked by comparing distances between each distal limb to the sternal notch with a tape measure. A wire nipple marker can be used to mark the ultimate 4-cm nipple areolar complex (NAC) centered around the apex of the limbs drawn. The IMF is marked. Markings then connect the distal portion of the limbs medially and laterally to the IMF. An inferior pedicle is marked symmetrically on the two breasts, at least

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Midsternal mark Breast meridian marked IMF Hatch mark—new NAC location at approximately 22–23 cm from the sternal notch

A

8 cm vertical limbs

Wise procedure markings

Marking mid-inframammary fold continuous with central breast axis and bilaterally symmetrical

B Figure 16-1

Areola incised along mark made by 42–45 mm cookie cutter, reducing size of NAC Figure 16-2

Top of inferior pedicle

All markings incised through dermis Inferior pedicle de-epithelialized, protecting the NAC

Medial & lateral triangles of breast tissue to be excised Figure 16-3

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Chapter 16 • Wise Pattern Breast Reduction with Inferior Pedicle

After this, the cautery is used to resect breast and skin of the medial and lateral triangles (Figure 16-4A, B). Skin flaps are developed superiorly as these triangles are excised, at least 2 cm in thickness, making the resection specimens’ shape resemble tetrahedrons. The medial and lateral triangles of tissue are excised from the central pedicle laterally, ensuring that excellent blood supply is maintained on the pedicle. The new NAC and vertical limbs are then incised, connecting into the medial and lateral resection areas. The superior breast skin flaps are elevated as far as necessary to comfortably accommodate the breast tissue, up to the clavicles and above the pectoralis fascia. Breast tissue may then be resected superiorly from the inferior pedicle with the cautery or a dermatome blade, and further removal laterally and medially from the pedicle is performed (Figure 16-5). Careful hemostasis is achieved and the wound is irrigated. Intercostal blocks may be placed with lidocaine, bupivacaine, or a mixture of the two for postoperative comfort below the ribs. Dermal sutures (#3-0 monofilament absorbable) are then placed to approximate the skin

flaps centrally under the NAC and at the fold. Staples may then be used to approximate the inframammary closure. A 10-mm flat Jackson-Pratt drain is placed, exiting out the lateral position and sutured into position with a #3-0 permanent monofilament suture. The patient is flexed on the operating room bed to elevate the back and assess symmetry, and any necessary revisions are performed. The weight of tissue removed from each side is compared and should be similar unless there was remarkable preoperative asymmetry. The skin flaps vertically and horizontally are approximated with buried dermal interrupted #3-0 monofilament absorbable sutures, as is the NAC. A #4-0 monofilament absorbable running intracuticular suture is placed (Figure 16-6). Interrupted #4-0 monofilament permanent sutures may be used to reinforce closure. The wounds are then washed and dressed with petrolatum gauze and absorbent pads. The patient is placed into a bra which is soft, supportive, and snug but not tight. The patient should then be extubated and the urine catheter removed if one was placed at the beginning of the case.

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Medial and lateral resections

B A

Location of new NAC Medial and lateral skin flaps undermined with breast resection. Breast parenchyma removed medial and laterally

Figure 16-4

Superior breast parenchyma resected

Figure 16-5

Drain

Figure 16-6

Skin closure with: #3-0 dermal absorbable monofilament suture and #4-0 subcuticular running monofilament absorbable

Skin flaps elevated to clavicle, or as far as needed to comfortably accommodate the breast tissue

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Chapter 16 • Wise Pattern Breast Reduction with Inferior Pedicle

POSTOPERATIVE CARE Breast reduction as a solo procedure may be performed as an outpatient. Before leaving the recovery room, the patient must be able to urinate, ambulate, and take adequate oral fluids. The patient may stay in the hospital overnight for monitoring, intravenous antibiotics, and pain management. If the patient stays in hospital, the drains are often removed the following morning. If output overnight is more than 50 cc, the drains may be left in for a week until the first postoperative visit. Oral antibiotics should be considered until drain removal. The patient returns 1 week after surgery for the first postoperative visit. Sutures are removed, and drains are removed if still in place. Physical limitations within the upper body last for a month. Patients may shower several days after the procedure, and a soft support bra is recommended for 2 months. Scar management with massage and cocoa butter or scar cream should be instituted 2 weeks after surgery as long as there are no open wounds. If small open wounds occur, most often under the NAC or at the IMF, they are treated locally with antibiotic ointment, cleansing, and bandaging.

PITFALLS This technique has been most criticized for its scars and flattened breast contour. The scars that are most problematic lie along the IMF medially and laterally and around the NAC. Scars may be particularly problematic when central inferior scars are connected across the lower sternum when symmastia is treated. Scars may be thicker if there is secondary wound healing. The scars require aggressive postoperative management. The contour associated with this technique is flatter than that associated with vertical techniques, but the benefit in this technique is the vertical reduction in breast length that can be achieved and the symmetry that is easily attained. Careful attention must be paid to not making the NAC too high. A high NAC may be hard to hide in a bra or swimsuit top and is not easy to correct. The patient must understand how far lateral the incisions will go as they may be visible in revealing clothing. If this is a secondary breast reduction it is very important to ensure that the prior pedicle is not disconnected,

no matter how much time has passed since the first procedure. As much information about the initial procedure should be gained to protect against complications, including if there were complications associated with the initial procedure, such as large seromas or hematomas. Secondary breast reduction has much higher risk for complication than primary breast reduction. The most common complication of Wise pattern breast reduction is wound healing problems with skin necrosis centrally where the skin flaps are approximated and tension is the greatest. Adequate thickness on skin flaps and minimizing risk of overresection of skin must be ensured to allow optimal healing.

TIPS Careful patient selection is important in ensuring success in this case. The skin flaps are elevated and undermined, leading to significant compromise of vascularity and potential skin loss along the medial inferior skin flaps. Patients who smoke, have coronary artery disease, have autoimmune disease requiring steroids, are diabetic with poor glucose control, have psychiatric problems, or are older than 50 years are at elevated risk for healing problems. Patients who are morbidly obese, particularly teenagers, should be referred for weight loss prior to breast reduction. With congestion of nipples or a seemingly tight closure, leaving incisions open either around the NAC or throughout the breast allows for swelling, and closure may take place at a later time. Nipples may be converted to grafts if there is an obvious problem with circulation. This possibility should be anticipated in larger breasted patients with medical comorbidities, and the patient should be prepared for the possibility of nipple grafting. Always underresect rather than overresect in creation of incisions, the inferior pedicle and skin flaps. One can always go back and remove more, but once the tissue is gone, it is gone. In teenagers presenting for breast reduction, scars must be reviewed with the family and potential patient so that they understand what is involved. Teenagers may not be accepting of the scars. Teenagers with macromastia may be prone to recurrent macromastia, so this possibility needs to be discussed as well.

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A

B

C D Figure 16-7A–D. A, B. This 20-year-old woman had symptomatic macromastia including back pain, bra grooving, and posture problems. She had Wise pattern, inferior pedicle breast reduction with removal of approximately 400 g of tissue from each breast. C, D. Photographs were taken 13 months after surgery.

Chapter 17.

Traditional Wise Pattern Mastopexy with Autoaugmentation areolar complex (NAC) centered around the apex of the limbs drawn. The IMF is marked. Marks are then drawn connecting the distal portion of the limbs medially and laterally to the IMF mark. The degree of axillary reduction laterally is judged on the basis of a pinch test. An inferior pedicle centered around the central axis of each breast and no less than 7 cm is marked which will include the tissue in the new nipple areolar position (Figure 17-1). The new nipple areolar position is measured again as well as the existing NAC position to determine preoperative asymmetry. This should be confirmed with the patient.

INTRODUCTION Wise pattern mastopexy with a keyhole incision is necessary for patients with significant ptosis and volume loss requiring shortening of the vertical dimension of the breast. The autoaugmentation recycles the tissue that would otherwise be excised from the medial and lateral breast, allowing optimization of breast volume.

INDICATIONS This procedure is very good for patients who have never had breast reduction and who have significant ptosis. This procedure lends itself well to women who have excess axillary fullness that can be remedied by rotating the tissue out of the axilla into the chest. This procedure may be combined with submuscular breast augmentation with implants if it is anticipated that volume achieved will be insufficient with autoaugmentation alone.

DETAILS OF PROCEDURE The patient is brought into the operating room and anesthesia is induced. Arms are positioned at 90 degrees from the body, and egg crate is placed on the arm boards to prevent nerve compression. The knees are placed on a pillow to encourage flexion, and antiembolism support stockings and sequential compression devices are initiated prior to anesthesia. Markings on the breast are determined to be symmetric with regard to midpoint marked on the IMF on each breast and the width and position of the inferior pedicle. The breasts are prepared and draped in sterile fashion, placing a lower body forced warming blanket to avoid hypothermia. A 42–45 mm nipple areolar cookie cutter is used to designate the new nipple areolar diameter on the existing NAC, and this mark is incised (Figure 17-2). The inferior pedicle is then de-epithelialized up to the new NAC position with a knife or with large mayo scissors, preserving the NAC (Figure 17-3). After this, the cautery may be used to remove skin from the medial and lateral triangles (Figure 17-4).

MARKINGS The patient is marked in the upright position. The central axis of the breast is marked bilaterally and transposed below the inframammary fold (IMF). The new nipple position is marked on this central axis at the level of the IMF, 23 cm from the sternal notch. Limbs of 8–9 cm in length are designed from the nipple to define the new nipple-inframammary distance, and the distance between these two limbs varies depending upon the degree of breast narrowing the surgeon aims to achieve, usually on the order of 6–8 cm. Symmetry can be checked by comparing each side against the sternal notch. A wire nipple marker can be used to plan on the ultimate 4-cm nipple

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Midsternal mark Breast meridian marked New NAC marked at IMF A

Vertical limbs— 7–9 cm

Extension laterally into axillary roll

Mid IMF mark bilaterally symmetrical B

Figure 17-1

New NAC diameter incised and excess pigmented skin de-epithelialized along with surrounding skin

Areola reduced in diameter by incising along mark left by 45-mm cookie cutter Figure 17-3

Figure 17-2

New NAC location de-epithelialized in continuity with inferior pedicle

Medial triangle Skin removed only from both medial and lateral triangles with cautery

Figure 17-4

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Chapter 17 • Traditional Wise Pattern Mastopexy with Autoaugmentation

Skin flaps are developed superiorly, at least 2 cm in thickness. Skin flaps are elevated up to the clavicle. The medial and lateral triangles of tissue are then elevated off the pectoralis major fascia from lateral toward the central pedicle, maintaining good supply and chest wall attachment of the central pedicle (Figure 17-5). The medial and lateral tissue is then sutured to the central pedicle with running #2-0 braided absorbable suture, being careful to avoid suturing this tissue to the dermis of the central pedicle so that the NAC is not deformed or tethered (Figure 17-6). Careful hemostasis is achieved and the wound is irrigated. Intercostal blocks inferior to the ribs may be performed with lidocaine, bupivacaine, or a mixture of the two for postoperative comfort. The augmented central pedicle may be sutured to the chest wall superiorly just below the clavicle and medially and laterally to the pectoralis major fascia to centralize it and stabilize position. Sutures (#3-0 monofilament absorbable) are then placed to approximate the skin flaps centrally under the NAC and at the fold.

Staples may then be used to approximate the inframammary closure. A 10-mm flat Jackson-Pratt drain is placed in the space, exiting out the lateral position and sutured into position with a #3-0 nylon suture. The patient is flexed on the operating room bed to elevate the back and assess symmetry. Superior tissue may need to be removed from the central pedicle to achieve symmetry, or the medial or lateral augmenting tissue may need to be reduced or discarded altogether. The skin flaps vertically and horizontally are approximated with buried dermal interrupted #3-0 monofilament absorbable sutures, as is the NAC. A #4-0 monofilament absorbable running intracuticular suture is placed (Figure 17-7). Interrupted #4-0 monofilament permanent sutures may be used to reinforce closure. The wounds are then washed and dressed with petrolatum gauze and absorbent pads. The patient is placed into a bra which is soft, supportive, and snug but not tight. The patient should then be extubated and the urine catheter removed if one was placed at the beginning of the case.

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Superior flaps undermined to clavicle

Medial and lateral triangles (skin removed) to be elevated off chest wall to central pedicle Figure 17-5

Inferior pedicle elevated and stabilized with #2-0 braided absorbable sutures superiorily, medially, and laterally Medial and lateral triangles of breast tissue rotated superiorily and sutured to central pedicle with #2-0 running braided absorbable suture Figure 17-6

Skin flaps closed over elevated breast tissue

Figure 17-7

Medial and lateral triangles sutured to central breast tissue Wise pattern closed in usual fashion Drains

IMF

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Chapter 17 • Traditional Wise Pattern Mastopexy with Autoaugmentation

POSTOPERATIVE CARE Mastopexy with autologous augmentation as a solo procedure may be performed as an outpatient. Before leaving the recovery room, the patient must be able to urinate, ambulate, and take adequate oral fluids. The patient may stay in the hospital overnight for monitoring and pain management. If the patient stays in hospital, the drains are often removed the following morning. If output overnight is more than 50 cc, the drains may be left in for a week until the first postoperative visit. Oral antibiotic is continued until drain removal. The patient returns 1 week after surgery for the first postoperative visit. Sutures are removed. Physical limitations within the upper body last for a month. Patients may shower several days after the procedure, and a soft support bra is recommended for 2 months. Scar management with massage and cocoa butter or scar cream should be instituted 2 weeks after surgery as long as there are no open wounds. If small open wounds occur, most often under the NAC or at the IMF, they are treated locally with antibiotic ointment, cleansing, and bandaging.

PITFALLS Many women pursuing breast lift after massive weight loss have previously had breast reduction. In these cases, the medial and lateral breast tissue may be vascularly compromised, so it should be discarded to avoid possible fat necrosis. Judicious elevation of this tissue must also be performed in women who smoke, are diabetic, or who are older than 50 years. Vascular compromise may also be present in women who have had extended brachioplasty down the chest wall performed. Despite attempts to reduce axillary fullness, women may be left with a torso that is still too wide that may benefit from vertical excision in the axilla in the future, particularly in conjunction with future brachioplasty.

Breast shaping sutures may actually cause more harm than good. In suturing tissue for autoaugmentation, sutures to the de-epithelialized dermis of the central pedicle should be avoided as they may unfavorably pull on the NAC. Similarly, sutures to the chest wall should be placed carefully to avoid a distorted appearance and may require modification after the skin flaps are approximated and the patient is elevated on the operating room table.

TIPS Preoperative discussion may touch on the merits of lifting versus augmentation to improve fullness and ptosis. Some patients may require both to achieve their goals. It is always safe to isolate the breast lift and the breast augmentation to improve healing and predictability of result. When augmenting at the time of breast lift, augmentation is most safely performed in the submuscular position to avoid devascularizing the breast tissue, as it preserves thoracoacromial attachments to the breast and nipple. Implant augmentation may result in a tense closure. If there are concerns about closure being too tight, augmentation should be aborted and planned for a later time. This possibility is best discussed preemptively with the patient prior to surgery. For augmentation-mastopexy, which procedure should be performed first: the augmentation or the mastopexy? The primary, most important procedure for the patient should be performed first. In a massive weight loss patient with significant ptosis and involutional change, the mastopexy design should be created first. The chest wall is longer and may be more barrel-shaped in the weight loss patient making the pectoralis major muscle more difficult to place. Augmentation through the lateral pectoralis after the skin flaps are elevated eases implant placement in this patient population. In a patient interested in augmentation who has ptosis, the augmentation should be performed first, followed by a tailored mastopexy for tightening.

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A

B

C D Figure 17-8A–D. A, B. This 42-year-old woman lost 122 lb after laparascopic gastric bypass surgery, going from a body mass index of 44.5 to 24.9. She was interested in breast lift and did not desire breast augmentation. She had Wise pattern mastopexy with autoaugmentation utilizing tissue from the axilla. She also had abdominoplasty. C, D. Postoperative photographs were taken 4 months after surgery.

Chapter 18.

Vertical Pattern Breast Reduction with Superior Pedicle notch because of anticipated elevation of the nipple areolar complex (NAC) with the vertical closure. The inframammary fold is marked (Figure 18-1A). The breast is shifted laterally and medially to mark the area that will be resected, creating an ellipse in which the apex will become the superior aspect of the new nipple position (Figure 18-1B, C). The inferior portion of the ellipse is drawn several centimeters above the inframammary fold. The superior pedicle is marked transversely below the NAC within the ellipse for de-epithelialization. Any asymmetries in nipple position or breast size should be checked and confirmed with the patient.

INTRODUCTION The benefit of vertical breast reduction compared with other techniques of breast reduction is the minimal scar and the full appearance of the breast with a more conical shape.

INDICATIONS This procedure is best for patients with minimal to moderate ptosis, pseudoptosis, or minimal descent of the nipple below the inframammary fold. This procedure narrows the chest and improves the conical shape of the breast. This is a great procedure for the younger patient who presents with symptomatic macromastia to preserve shape and minimize scar.

DETAILS OF PROCEDURE The patient is brought into the operating room and anesthesia is induced. Arms are positioned at 90 degrees from the body, and egg crate is placed on the arm boards to prevent nerve compression. The knees are placed on a pillow to encourage flexion, and antiembolism support stockings and sequential compression devices are initiated prior to anesthesia. The head is placed on a soft pillow or donut ring and stabilized to the table in preparation for raising the back of the table (Figure 18-2). Markings on the breast are checked for symmetry. The

MARKINGS Markings and the procedure are performed guided by the vertical breast reduction technique popularized by Dr. David Hidalgo, depending on a superior pedicle. The patient is marked in the upright position. The central axis of the breast is marked bilaterally and transposed onto the inframammary fold. The new nipple position is tentatively marked on this axis at the level of the inframammary fold and lowered to 24 cm from the sternal

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Breast meridian 24 cm

Breast meridian

Medial limb of vertical ellipse marked in line with mid IMF moving the breast laterally

IMF Hatch mark (new NAC position) below IMF Mid IMF line marked continuous with breast meridian & symmetric to contralateral mark

A Figure 18-1A

Mid IMF B Figure 18-1B

With breast retracted medially, lateral mark is made continuous with mid IMF marking C Figure 18-1C

Ted hose and SCDs

Pillow under knees encourages flexion

Figure 18-2

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Chapter 18 • Vertical Pattern Breast Reduction with Superior Pedicle

breasts are prepared and draped in sterile fashion, placing a lower body forced warming blanket to avoid hypothermia. A 42- to 45-mm nipple areolar cookie cutter is centered on the NAC to designate the new nipple areolar diameter, and this mark is incised (Figure 18-3A, B). The skin within the superior pedicle marked is then deepithelialized, protecting the NAC (Figure 18-3C). Breast tissue below the de-epithelialized superior pedicle is centrally removed within the ellipse marked, leaving soft tissue on the pectoralis major fascia (Figure 18-4A). Breast resection follows medially, avoiding resection of breast tissue superomedially above the axis of the NAC, maintaining a 2-cm wide pillar of breast tissue lateral to

the central resection (Figure 18-4B). Resection then takes place laterally up to the axilla, maintaining an adequately vascularized pillar lateral to the central breast resection, 2 cm in width. Lateral and medial breast skin where tissue is resected should not be thicker than 2 cm. Careful hemostasis is achieved, and a 10-mm flat Jackson-Pratt drain is placed in the space and sutured into position. The dermis is incised along the margins of the ellipse around the superior pedicle. The back of the operating room table is elevated 90 degrees. A fine double hook is placed at the apex of the ellipse and retracted superiorly, and temporary closure of the skin with staples is performed (Figure 18-5). The drains are placed on suction to apply negative pressure

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42- to 45-mm nipple areolar cookie cutter used to designate new diameter of NAC Bottom of superior pedicle marked

Tissue to be resected

Superior pedicle de-epithelialized

A

Mark incised

A B

C

Midline block of tissue removed

Figure 18-3A–C

Pillars

Dissection above pillars to resect medial and lateral breast tissue

B Superior pedicle (under skin) Top of resection in line with NAC De-epithelialized tissue Resected breast tissue Lateral pillar

Figure 18-4A, B

Central breast meridian Vertical limb temporarily approximated with staples retracting superiorly with skin hook

Drain passes through lateral and medial dead space from tissue resection Figure 18-5

2-cm thickness maintained under skin Medial pillar

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Chapter 18 • Vertical Pattern Breast Reduction with Superior Pedicle

to the dead space to provide a better idea of the appearance of the treated breast. Any asymmetries are addressed at this time with removal of more breast tissue. After temporary closure of the vertical incision, tailor tack suturing is performed vertically and obliquely/laterally at the inferior portion of the breast to achieve the desired shape. The plicated skin is marked and de-epithelialized. The new nipple areolar position is marked using a cookie cutter, and typically the top of the new NAC is the top of the vertical incision approximated (Figure 18-6A). The pillars on either side of the central ellipse are approximated in layers with #2-0 braided absorbable suture to support the superior pedicle, retracting the superior pedicle up with an army/navy retractor (Figure 18-6B, C, D). The vertical inci-

sion should not extend above the new NAC position. The staples are then removed from the region inside the gentle cookie cutter mark, and the cookie cutter is applied again to definitively designate the new NAC. This is then deepithelialized, and the NAC is expressed through the breast wound into the new position. The skin is approximated with buried interrupted #3-0 monofilament absorbable suture in the dermis, followed by a running #4-0 monofilament absorbable suture subcuticular stitch in the skin (Figure 18-7). The wounds are then washed. Half-inch sterile-skin closures are placed around the NAC, and the vertical limb may be dressed with petrolatum gauze or sterile-skin closures and absorbent pads. The patient is placed into a bra which is soft, supportive, and snug but not tight.

83 A

Staples removed from skin covering elevated NAC Hatch marks across vertical limb to aid in later approximation

42- to 45-mm cookie cutter marks skin

Drain placed on suction when assessing size & symmetry C

Figure 18-6A

B Staples removed and breast parenchyma/ pillars approximated with #3-0 absorbable sutures, guided by hatch marks

Drain between pillars and pedicle D

Drain through deep “dead spaces”

Pillar Superior pedicle supported by I beam created by pillars

Figure 18-6B–D

Figure 18-7

NAC delivered through wound

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Chapter 18 • Vertical Pattern Breast Reduction with Superior Pedicle

POSTOPERATIVE CARE Vertical breast reduction may be performed as an outpatient. Prior to leaving the recovery room, the patient must be able to urinate, ambulate, and take adequate oral fluids. The patient may stay in the hospital overnight for monitoring and pain management. The patient returns 1 week after surgery for the first postoperative visit. Drains are removed no sooner than 1 week after surgery as seroma may develop if drains are removed prior to this. Sutures are removed. Physical limitations within the upper body last for a month. Patients may shower several days after the procedure, and a soft support bra is recommended for 2 months. Scar management with massage and cocoa butter or scar cream should be instituted 2 weeks after surgery as long as there are no open wounds. If small open wounds occur, most often under the NAC or at the inframammary fold, they are treated locally with antibiotic ointment, cleansing, and bandaging.

PITFALLS Vertical breast reduction is not as effective in shortening the vertical dimension of the breast as the Wise pattern is. The surgeon should start using the vertical technique in patients with minimal to moderate macromastia and pseudoptosis to Grade I ptosis. Vertical breast reduction is also more challenging in the patient with breast asymmetry. Because width and height of the breast is fully predictable in the Wise pattern patient, one may want to utilize the Wise pattern for asymmetric and/or ptotic patients. Vertical breast reductions result in a lesser degree of reduction than Wise pattern as the medial and lateral triangles of tissue typically excised in the Wise pattern reduction remain. In patients with insurance, this may present a problem for reimbursement due to inadequate tissue resection.

In the lateral resection up toward the axilla, it is important to maintain adequate skin flap thickness and to not buttonhole the skin which might occur with retraction up into this area.

TIPS Early in the surgeon’s experience, vertical breast reduction should be applied only to patients in whom breast resection will be no greater than 400 g of tissue, and who are symmetric. Skin flaps in areas of resection should be no thicker than 2 cm to allow adequate mobility and shaping of the skin and sufficient resection. After approximating the limbs of the ellipse and prior to tailor tacking to improve contour, it is critical to have drains in place and on suction. The result seen with suction may indicate a need to remove more tissue to achieve better reduction or symmetry between the two breasts. Approximation of the central pillars requires a layered closure completely up to the superior pedicle to allow ample and predictable support for the breast tissue, like an “I beam.” Contour irregularities along the central breast may also be avoided in this way. Removing the staples in the proposed NAC position within the vertical limb before committing to creation of the new NAC opening helps prevent irregular NAC shape with release of tension. Despite low drain outputs, drains must remain in place for at least a week to allow potential dead space to close adequately.

RECOMMENDED LITERATURE Hidalgo DA. Vertical mammaplasty. Plast Reconstr Surg. 2005; 115(4):1179-97; discussion 1198-9.

85

A

B

C

D

Figure 18-8A–D. A, B. This 20-year-old woman desired relief from symptomatic macromastia, primarily back pain. Because of her minimal degree of ptosis she was felt to be a good candidate for vertical reduction, and 400 g of tissue was removed from each breast. C, D. The postoperative photographs were taken 7 months after surgery.

Chapter 19.

Vertical Pattern Mastopexy (with Augmentation) and medially about the marked midpoint on the fold to mark the skin region that will be de-epithelialized, using the new nipple position marked as the apex of the deepithelialization. The de-epithelialized region marked should stop several centimeters above the inframammary fold (Figure 19-1). If breast implant augmentation is planned, the pocket for the implant should be marked on the skin as well. Any asymmetries in nipple position or breast size should be checked and confirmed with the patient.

INTRODUCTION Vertical mastopexy is an excellent way to achieve lift through tightening of the skin envelope of the breast, allowing improvement in nipple position and a fuller breast appearance, with an imperceptible scar once healed.

INDICATIONS This procedure is best for patients with minimal to moderate ptosis or pseudoptosis. This procedure narrows the chest and improves the conical shape of the breast. The mastopexy may be combined with breast augmentation in the subglandular or submuscular space to treat volume deficiency.

DETAILS OF PROCEDURE The patient is brought into the operating room and anesthesia is induced. Arms are positioned at 90 degrees from the body, and egg crate is placed on the arm boards to prevent nerve compression. The knees are placed on a pillow to encourage flexion, and antiembolism support stockings and sequential compression devices are initiated prior to anesthesia. The head is placed on a soft pillow or donut ring and stabilized to the table (Figure 19-2). Markings on the breast are checked for symmetry and planned width of de-epithelialization. The breasts are prepared and draped in sterile fashion, placing a lower body forced warming blanket to avoid hypothermia. A 42- to 45-mm nipple areolar cookie cutter is used to designate the new nipple areolar diameter, and this mark is incised (Figure 19-3A, B). The skin within the region marked is then de-epithelialized (Figure 19-3C).

MARKINGS The patient is marked in the upright position. The central axis of the breast is marked bilaterally and transposed onto the inframammary fold. The new nipple position is tentatively marked on this axis at the level of the inframammary fold and lowered to 24 cm from the sternal notch, lower than one would mark for a Wise pattern breast reduction due to ultimate elevation of the nipple areolar complex (NAC) with closure of the vertical incision. With pseudoptosis or Grade I ptosis, it is possible that the NAC will elevate adequately with a vertical ellipse below or at the inferior portion of the NAC. The inframammary fold is marked. The breast is shifted laterally

86

87 A

Breast meridian marked IMF level New nipple mark below IMF

Ellipitical markings stop B short of IMF Figure 19-1 Ellipse to be de-epithelialized

Figure 19-2

Cookie cutter marking size of new NAC Area to be de-epithelialized Areola

A Ellipse de-epithelialized Indention from cookie cutter B Areola incised at marking Figure 19-3A–C

C

88

Chapter 19 • Vertical Pattern Mastopexy (with Augmentation)

The dermis of the vertical ellipse edges is incised. If augmentation is planned, an incision is made through the breast tissue at the lateral edge of the de-epithelialized central breast with the cautery (Figure 19-4A). A plane may be developed under the breast tissue or under the pectoralis major muscle to allow placement of the breast implant (Figure 19-4B, C). The breast tissue is reapproximated after augmentation is complete (Figure 19-5A). The back of the operating room table is elevated 90 degrees

at the waist. The apex of de-epithelialized tissue is then retracted superiorly with a narrow skin hook, and the skin is temporarily stapled centrally (Figure 19-5B). Tailor tacking sutures may be placed to tighten the width as needed or to shorten the vertical limb or extend the vertical limb laterally as needed to shorten vertical dimension of the breast. The new NAC is lightly marked with the 42-cm cookie cutter, and the staples are removed superiorly up to the bottom of the marking.

89 A

Dermis incised and pocket created Implant placed either under gland or under pectoralis major m. with release of muscle inferiorily and inferiomedially

B

Figure 19-4A, B

Pectoralis major muscle with inferior release Implant positioned in submuscular plane

Nipple ptosis

C Figure 19-4C Implant Dermis of ellipse incised De-epithelialized ellipse

Breast tissue approximated over implant A

Retract superiorly with skin hook when approximate vertical closure

B Figure 19-5A, B

90

Chapter 19 • Vertical Pattern Mastopexy (with Augmentation)

The area is then more definitively marked again with the 42-mm cookie cutter. Symmetry is assessed, and if satisfactory, the newly proposed NAC position is incised bilaterally, and the NAC is brought out for approximation (Figure 19-6A, B). Any further need for skin adjustments is then made. Dermal sutures (#3-0 monofilament absorbable) are then placed to approximate the NAC and the skin flaps centrally between the NAC and the fold. A

#4-0 monofilament absorbable running intracuticular suture is placed (Figure 19-7). Interrupted #4-0 monofilament permanent sutures may be used to reinforce closure. The wounds are then washed. Half-inch sterile-skin closures are placed around the NAC, and the vertical limb may be dressed with petrolatum gauze or sterile-skin sutures and absorbent pads. The patient is placed into a bra which is soft, supportive, and snug but not tight.

91

Staples

45-mm cookie cutter marks new NAC location at top of vertical closure

A

After de-epithelialization, NAC is delivered through incision B Figure 19-6A, B

Dermis approximated with #3-0 monofilament absorbable suture and running #4-0 monofilament absorbable subcuticular stitch

Figure 19-7

92

Chapter 19 • Vertical Pattern Mastopexy (with Augmentation)

POSTOPERATIVE CARE Vertical mastopexy with or without augmentation as a solo procedure may be performed as an outpatient. Prior to leaving the recovery room, the patient must be able to urinate, ambulate, and take adequate oral fluids. The patient returns 1 week after surgery for the first postoperative visit. Sutures are removed. Physical limitations within the upper body last for a month. Patients may shower several days after the procedure, and a soft support bra is recommended for 2 months. Scar management with massage and cocoa butter or scar cream should be instituted 2 weeks after surgery as long as there are no open wounds. If implants were placed they require massage twice a day for a year to keep the pockets soft.

PITFALLS Vertical mastopexy is not as effective in shortening the vertical dimension of the breast as the Wise pattern mastopexy is. In a patient with significant stretch marks and evidence of poor collagen and elastin quality, ptosis may recur, particularly if a breast implant was placed. Ver-

tical mastopexy is also more challenging in the patient with breast asymmetry. Because width and height of the breast is fully predictable in the Wise pattern patient, one may want to utilize the Wise pattern for asymmetric patients.

TIPS Preoperative discussion may touch on the merits of lifting versus augmentation to improve fullness and ptosis. Some patients may require both to achieve their goals. It is always safe to stage the breast lift and the breast augmentation to improve healing and predictability of result. Lifting may be performed in a Y pattern with an incision around the NAC from 3 o’clock to 9 o’clock if there is pseudoptosis and the NAC does not require significant lift, avoiding a full circumareolar incision. If there are any concerns about recurrent skin laxity or vascular compromise, it is safest to place the implant under the pectoralis major muscle, not above it.

RECOMMENDED LITERATURE Hidalgo DA. Y-scar vertical mammaplasty. Plast Reconstr Surg. 2007;120(7):1749-54.

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A

B

C D Figure 19-8A–D. A, B. This 35-year-old woman lost 135 lb after laparascopic gastric bypass surgery, going from a body mass index of 46.4 to 25.6. In addition to surgery on her abdomen, back, arm, and thigh, she had vertical mastopexy with submuscular breast augmentation with saline implants. C, D. Photographs were taken 4 months after surgery.

Chapter 20.

Wise Pattern Superior Pedicle Breast Reduction with Nipple Grafting

Superior pedicle breast reduction with nipple grafting is the technique reserved for patients with gigantomastia who require nipple elevation greater than 20 cm and breast resection greater than 1 kg for each side.

tion is measured again as well as the existing NAC position to determine preoperative asymmetry. This should be confirmed with the patient. Once the patient is lying on the operating room table, symmetry of the markings may be further checked, ensuring that the distance from midline to the central breast axis is the same.

INDICATIONS

DETAILS OF PROCEDURE

This breast reduction is safe for women with very large breasts. These patients require nipple areolar complex (NAC) elevation from actual position to new position of 20 cm or more. Nipple grafting is necessary to ensure postoperative viability and must be discussed with the patients.

The patient is brought into the operating room and anesthesia is induced. A Foley catheter may be placed to monitor urine output. Arms are positioned at 90 degrees from the body, and egg crate is placed on the arm boards to prevent nerve compression. The knees are placed on a pillow to encourage flexion, and antiembolism support stockings and sequential compression devices are initiated prior to anesthesia (Figure 20-2). Markings on the breast are determined to be symmetric with regard to midpoint marked on the IMF on each breast. The breasts are prepared and draped in sterile fashion, placing a lower body forced warming blanket to avoid hypothermia. The drapes on the chest should be stapled into position, stapling superiorly on the clavicles and stapling the central axis of each breast above the proposed NAC complex and below the IMF to provide a stable guide. A 42- to 45-mm nipple areolar cookie cutter is used to designate the new NAC diameter within the existing NAC, and this mark is incised with the NAC on moderate stretch. The NAC is then harvested as a graft on each side with thickness into superficial dermis (Figure 20-3). The NAC is stored in saline-moistened gauze and marked according to the side from which it came. The superior pedicle is then de-epithelialized with a knife or with large mayo scissors (Figure 20-4). After this,

INTRODUCTION

MARKINGS The patient is marked in the upright position. The central axis of the breast is marked bilaterally and transposed onto the inframammary fold (IMF). The new nipple position is marked on this axis just below the level of the IMF, 23 cm from the sternal notch. Limbs of 9 cm in length are designed from the nipple to define the new nipple–IMF distance, and the distance between these two limbs varies depending upon the degree of breast narrowing the surgeon aims to achieve, typically on the order of 8 cm. Symmetry can be checked by comparing each limb against the sternal notch. A wire nipple marker can be used to plan on the ultimate 4-cm NAC centered about the apex of the vertical limbs. The IMF is marked. A mark then connects the distal portion of the limbs to the IMF medially and laterally. A superior pedicle is marked to just above the actual NAC position (Figure 20-1). The new NAC posi-

94

95

Midsternal mark Breast meridian mark

23 cm

IMF New NAC position Mark connects inferior end of vertical limb to IMF both laterally and medially

Vertical limbs–9 cm Superior pedicle marked

Continuation of breast meridian mark Figure 20-1

Ted hose

Figure 20-2

NAC to be harvested for future repositioning

Saline moistured gauze

Superior pedicle de-epithelialized Nipple harvested to superficial dermis Figure 20-3

Figure 20-4

96

Chapter 20 • Wise Pattern Superior Pedicle Breast Reduction with Nipple Grafting

the cautery is used to resect breast tissue from medial to lateral, leaving adequate tissue under the superior pedicle to maintain vascularity through chest wall attachments (Figure 20-5A, B, C). The superior pedicle is further reduced with cautery or dermatome blade as needed. Skin flaps of approximately 3-cm thickness are developed on either side of the pedicle. Careful hemostasis is achieved and wounds are irrigated. The superior pedicle is sutured into position to the chest wall inferiorly, centrally, medially, and laterally with #2-0 braided absorbable sutures (Figure 20-6). The pedicle is centered around the central axis of the breast at the fold which was marked with a staple prior to surgery. In a very broad chest, the lateral skin flap may be sutured down to the chest wall lateral to the pectoralis major muscle to close down the axilla and improve breast shape. Buried sutures (#2-0 braided absorbable) are then placed to approximate the skin flaps centrally under the NAC and at the fold. The closure of the IMF is approximated with skin staples. A 10-mm closed drain is placed subcutaneously along the IMF, exiting out the lateral position and sutured into position with a #3-0 permanent monofilament suture. The patient is

flexed on the operating room bed to elevate the back and assess symmetry. The skin flaps vertically and horizontally are approximated with #2-0 braided absorbable suture in Scarpa’s fascia layer and buried interrupted #3-0 monofilament absorbable sutures in the dermis. A #4-0 monofilament absorbable running intracuticular suture is placed. The new NAC location marked preoperatively is de-epithelialized (Figure 20-7). The NAC is sutured into position circumferentially with interrupted #4-0 silk sutures after it is definitively thinned with tenotomy scissors to uniform superficial dermis thickness. A tie-over bolster is designed: a petrolatum gauze sheet is placed on the nipple, a generous amount of mineral oil-soaked cotton is placed on the petrolatum gauze over the NAC, and the petrolatum gauze is folded over the cotton and sutured down under the #4-0 silk sutures which are tied together. The wounds are then washed and dressed with petrolatum gauze and absorbent pads. The patient is placed into a bra which is soft, supportive, and snug but not tight. The patient should then be extubated and the urine catheter removed if one was placed at the beginning of the case.

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A

Edges of pedicle & skin flaps incised Superior pedicle

Towel clamps extend inferior margin of central pedicle and then are clamped to drape

Excess breast tissue removed from central pedicle

Tissue removed from superior pedicle outwards

Bottom of pedicle at skin surface

IMF incised C

B Figure 20-5C

Figure 20-5A, B

Flaps undermined medially and laterally Vascularized central pedicle attached to chest wall IMF (distal flap resected) Central pedical sutured to chest wall with #2-0 braided absorbable suture inferiorily, medially, and laterally at Scarpa’s fascia layer of pedicle, not dermis Figure 20-6

NAC thinned to superficial dermis and sutured with interrupted #4-0 silk sutures to design bolster New NAC site de-epithelialized

Drain across base of superior flap under skin Figure 20-7

Staples aid in approximating closure at inframammary fold

98

Chapter 20 • Wise Pattern Superior Pedicle Breast Reduction with Nipple Grafting

POSTOPERATIVE CARE This type of breast reduction is typically performed in older patients, morbidly obese patients, and/or patients with significant medical problems, and they should be observed in the hospital overnight. The drains are left in for a week until the first postoperative visit, as these patients are at higher risk for seroma with medical comorbidities and degree of tissue removal. The bolster dressings must remain dry until removed. Patients are placed on oral antibiotics. The patient returns 7–10 days after surgery for the first postoperative visit. Sutures are removed. Physical limitations within the upper body last for a month. Patients may shower. A soft support bra is recommended for 2 months. Petroleum ointment should be applied to the nipples and incision twice a day for 1–2 weeks. Scar management with massage and cocoa butter or scar cream should be instituted 2 weeks after surgery as long as there are no open wounds. If small open wounds occur, most often under the NAC or at the IMF, they are treated locally with antibiotic ointment, cleansing, and bandaging. If larger wounds develop along the IMF closure, vacuum-assisted closure dressing may be considered to ease care and facilitate healing.

PITFALLS This technique is more often associated with some tension in closure, on pulling the skin flaps down to meet the central IMF over top of the superior pedicle. In attempting to achieve optimal fullness in this patient population, the length of the superior pedicle should be maintained to allow a folding of the tissue above the IMF to improve projection. In many patients with this approach, folding of the superior pedicle coupled with a marginally tight closure will cause the inferior tissue of the superior pedicle to harden. When this occurs and the firmness does not

resolve over the first year, the tissue must be excised to allow proper breast screening for cancer. To optimize wound healing in patients at risk, the superior pedicle should be reduced in length, with the inferior portion not folded but directly sutured to the central chest wall at the IMF. In general, it should be shared with patients prior to surgery that breast projection may be limited in this technique to allow optimal healing. They may have difficulty finding bras after surgery with their smaller size but still large chest circumference. This technique has been avoided because of the disconnection and grafting of the NAC. Erectile sensitivity will be lost with grafting; however, sensitivity to pressure will be gained over time. Many women with significant ptosis and macromastia have lost this sexual sensitivity anyway due to significant tension on the nerve to the nipple. With the bolster technique, aesthetic results of nipple grafting are quite pleasing and difficult to distinguish from a NAC which has not been grafted.

TIPS Maintain the drains in position for a week, even if outputs are low the first 24 hours after surgery. The medical comorbidities of this patient population coupled with the degree of tissue removal create a situation fraught with risk for seroma. In marking patients, one should opt to be conservative in skin removal. Once the tissue is removed, it is gone. Skin may be tailored on the table to avoid overresection and undue tension in closure, which may result in hardening of the breast tissue and wound healing problems. Dyschromia may develop in the grafted NAC, with incomplete pigmentation possible, particularly within the nipple, the thickest part of the graft. Cocoa butter emollience should be encouraged several times a day for a year. If color still does not completely return, the area of depigmentation may either be excised or tattooed.

99

A

B

C

D

Figure 20-8A–D. A, B. This 45-year-old woman had symptomatic macromastia which includes back pain, rashes underneath the breast, and bra grooving. She also had difficulty breathing when supine. She had superior pedicle breast reduction with nipple grafting, with removal of approximately 1350 g of tissue from each breast. C, D. Photographs were taken 12 months after surgery.

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Section 4 Male Chest— Gynecomastia Chapter 21. Gynecomastia Presentation and Its Enormous Variability Chapter 22. Male Chest: Gynecomastia—Anatomy Chapter 23. Gynecomastia Liposuction Chapter 24. Gynecomastia—Excisional Technique Chapter 25. Mastectomy Through a Horizontal Approach Chapter 26. Gynecomastia—Wise Pattern Excision Technique Chapter 27. Gynecomastia—Vertical Excision Technique Chapter 28. Gynecomastia—Extended Technique with J Excision

Chapter 21.

Gynecomastia Presentation and Its Enormous Variability

Males from adolescence to adulthood present with gynecomastia. Thought to be due to imbalance of the estrogen: testosterone ratio, gynecomastia may also develop secondary to use of specific inciting medications. Many patients have no defined etiology. Gynecomastia describes the development of true breast tissue; whereas pseudogynecomastia describes the condition of a breast-like appearance in which the “breast” comprises excess skin and/or fat. Nonsurgical, hormonal therapies have been reported, but surgery remains the mainstay for treatment.

a breast-like appearance, not associated with true breast tissue. Techniques in treatment may spare the nipple through transposition combined with skin removal; however, these patients may require nipple grafting to provide adequate flattening to the chest. Treatment of the chest in the male massive weight loss patient may be combined with upper back lift.

CONGENITAL BREAST DEFORMITY Younger males may present with the appearance of congenital breast deformity with enlarged nipple areolar complexes, ptosis, and/or tubular breast deformity and asymmetry which is particularly psychologically harrowing. These are difficult cases that may be treated with vertical excision, horizontal excision, and possibly nipple grafting and liposuction.

TRUE GYNECOMASTIA WITHOUT SKIN EXCESS These patients tend to be teenagers and young adults who are unhappy about fullness in the chest and palpable breast tissue. Treatments include liposuction or direct excision, possibly with liposuction.

MASSIVE WEIGHT LOSS GYNECOMASTIA This gynecomastia is often a form of pseudogynecomastia, with excess fat and redundant, ptotic skin resulting in

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Figure 21-1. True gynecomastia without skin excess—This 17-year-old male has true gynecomastia with firm breast tissue, right greater than left. Ultrasound-assisted liposuction alone or in combination with removal of remaining breast tissue under the nipple areolar complex treats the firm breast tissue and surrounding fullness.

A

A

B

Figure 21-2. Massive weight loss gynecomastia—This 53-year-old man lost 180 lb after open gastric bypass surgery, bringing him to a body mass index of 36.9. He has significant ptosis, lipodystrophy, and axillary redundancy extending into the upper back, requiring a J-incision and nipple grafting. He also had a hernia repair performed concomitantly.

B

Figure 21-3. Congenital breast deformity—These are two males in their teens with significant deformity who seek treatment at a relatively young age due to extreme psychological discomfort with the deformity. Both had normal endocrine testing and were nonsyndromic. These cases require a mastectomy through either a horizontal or vertical approach with nipple grafting to achieve a more normal-looking appearance.

Chapter 22.

Male Chest: Gynecomastia—Anatomy

A Internal thoracic a. (with breast perforators)

H Latissimus dorsi m.

B Pectoralis major m.

I

Anterior cutaneous branches of T1–T7

C Pectoralis fascia

J

Serratus anterior m.

D Perforating arteries from internal thoracic a.

K Lateral cutaneous branches of T2–T6

E

Male breast tissue

F

Inframammary fold

L

Lateral mammary branches of lateral cutaneous branch of posterior intercostal a.

M Pectoralis major m. G Rectus fascia

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A M B L

C D E

K

J I H G

F

Chapter 23.

Gynecomastia Liposuction

INTRODUCTION

than 90 degrees from the body and egg crate to avoid compression (Figure 23-2). The knees are then placed on a pillow to encourage flexion, and compression hose and sequential compression devices are initiated prior to anesthesia. The chest is prepared and draped in sterile fashion, placing a forced lower body warmer to avoid hypothermia throughout the surgery. Two incisions are placed along the inframammary fold, one medial and one lateral in the axilla. Tumescent solution is infiltrated for hemostasis and anesthetic benefit (Figure 23-3). This solution includes 30 cc of 1% lidocaine and 1 cc of 1:1000 epinephrine per liter of lactated ringers, at room temperature. The solution must be allowed to stay within the tissues for at least 8 minutes for the full epinephrine effect to reduce blood loss. For volume of tumescent solution, a ratio of 1–2 times the amount of anticipated aspirate should be infused, often falling within the range of 500–800 cc of tumescent solution for each side. After adequate time has been allowed for hemostatic effect, liposuction begins. Cannulas of varying lengths and calibers are chosen to address areas of concern. Ultrasound-assisted liposuction is an excellent method for primary liposuction of gynecomastia as it is a more powerful technique in attacking denser breast tissue and causing skin retraction. Liposuction is performed with constant motion, sweeping the region and working from deep to superficial (Figure 23-4). More concentrated liposuction is performed under the nipple areolar complex where the dense breast bud is located. Attention must also be paid to the inframammary fold to obliterate it. The endpoint of liposuction is a visibly pleasing result, without any regions of overresection. Incisions are closed with a single #4-0 permanent monofilament suture to allow approximation and further drainage of tumescent solution (Figure 23-5). Gauze or absorbent pads may be placed flat against the incisions, to be covered by foam pads with a silicone layer placed against the skin of the chest. The patient is then placed into a binder around the chest.

Liposuction of the chest is a great way to treat minimal to moderate cases of gynecomastia, either as a primary treatment or an adjunct to excision. The benefit of this procedure is minimal scarring allowing patients to go bare-chested without calling attention to scars. The goal is not only to flatten the chest but also to obliterate the inframammary fold.

INDICATIONS As a primary procedure, liposuction effectively treats gynecomastia with minimal element of ptosis or skin excess. Liposuction may also be used with pseudoptosis or skin laxity such as that found in massive weight loss, as it allows for skin retraction, particularly with ultrasoundassisted liposuction and power-assisted liposuction. It is important to discuss the possibility of the need for excisional procedures after healing from liposuction, as skin retraction is not predictable. Liposuction may be used as an adjunctive procedure to excisional techniques in the periphery of the chest to smooth the outer contour. Combining aggressive liposuction of breast tissue with excisional technique may threaten nipple viability.

MARKINGS The patient is marked in the upright position, and a contour map is drawn with concentric circles, the centralmost circle indicating the thickest breast tissue under the nipple areolar complex, and the larger, outer circles on the chest periphery for feathering (Figure 23-1). Preoperative markings are critical. They are confirmatory to the patient who understands exactly the areas to be addressed. Furthermore, there is distortion when the patient lies supine.

DETAILS OF PROCEDURE The patient is brought into the operating room and anesthesia is induced. Positioning includes arms at no greater

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107

Concentric circle are drawn with the central-most circle representing the fullest, densest prominence under the NAC Figure 23-2

Figure 23-1

A

Tumescent solution injected B Figure 23-3

Aspiration is performed from deep to superficial, with the perimeter guided by the preoperative markings

Stab wounds closed

Extra attention is paid to the region of the NAC and IMF

A B Figure 23-4

Figure 23-5

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Chapter 23 • Gynecomastia Liposuction

POSTOPERATIVE CARE Chest liposuction may be performed as an outpatient. In the recovery room, fluid status must be monitored and the patient needs to ambulate well. Hydration is encouraged for the first week after liposuction. Arnica Montana herbal pills may be taken immediately preoperatively and then postoperatively to reduce edema and bruising. After initial recovery, topical ointment or gel may be massaged into the skin while also taking the oral medication. Physical limitations last for about a week. Patients may shower immediately and foam pads and binder are recommended for the first week, but not required. Using compression does help optimize reduction of bruising and swelling.

PITFALLS Consultation with the patient is important in discussing limitations and possible need for further surgery. Lipo-

suction techniques may help tighten skin but the outcome is unpredictable. Furthermore, palpable residual tissue under the nipple areolar complex after surgery is normal and may be acceptable as a satisfactory outcome. It is important to match the thickness of the chest with the patient’s overall thickness and not oversculpt the chest. Anecdotal reports recommend that Reston foam be avoided after liposuction because of skin injury. Siliconebacked foam is well tolerated by the skin.

TIPS Compression, while not required, helps optimize alleviation of bruising and swelling. Foam and binder compression may be substituted by girdle apparel starting a week after surgery.

109

A

B

C

D

Figure 23-6A–D. A, B. This is a 27-year-old man who lost 114 lb after open gastric bypass surgery. He underwent abdominoplasty, lower back lift, and thigh lift, with removal of 13.5 lb of skin. He also had gynecomastia correction with liposuction to avoid the extra scar, understanding that there may be some residual laxity. C, D. Photographs were taken 12 months after surgery.

A

B

Figure 23-7A–B. A. Patient 2 is a 27-year-old man with gynecomastia since adolescence, a familial condition that occurred in his older brother and father. He had palpable tissue and lipodystrophy, amenable to power-assisted liposuction. Approximately 600 cc of aspirate was obtained from each side. B. Postoperative photographs were taken 16 months after surgery.

Chapter 24.

Gynecomastia— Excisional Technique

INTRODUCTION

greater than 90 degrees from the body and laid on egg crate to avoid compression. The knees are placed on a pillow to encourage flexion and antiembolism support stockings and sequential compression devices, as well as a lower body-warming blanket to avoid hypothermia. If liposuction is planned, tumescent solution including 30 cc of 1% lidocaine and 1 cc of epinephrine 1:1000 in 1 liter lactated ringers solution should is infused. Liposuction may be performed either before or after the breast tissue is removed, preferring that liposuction be done first (Figure 24-2). Incision is then made around the NAC from 3 o’clock to 9 o’clock. The cautery is then used to develop a plane under the subcutaneous fat and over the breast tissue down to the pectoralis major fascia. A button of breast tissue is maintained under the NAC to allow normal nipple projection. The breast tissue is then elevated off of the pectoralis muscle, retracting the breast tissue on small Kocher or Allis clamps. Ultimately, the breast tissue is delivered through the incision (Figure 24-3). After the breast tissue is removed, careful hemostasis is achieved and 1⁄4% bupivacainemay be injected into the intercostal spaces and throughout the surgical field. A #10 flat Jackson-Pratt drain is placed in the subcutaneous space. The dermis is approximated with interrupted, buried, absorbable #3-0 monofilament suture, followed by a running intracuticular #4-0 absorbable monofilament suture (Figure 24-4). Tissue glue may be placed on the incision. Compression foam is placed on the chest, and elastic bandages are wrapped around the chest. Compression should be firm, but not tight.

Nonobese, young males presenting with gynecomastia may present with firm breast tissue primarily located under the nipple areolar complex (NAC). This may be unilateral or bilateral in nature. While this may be treated with ultrasound-assisted liposuction, the breast tissue may be too dense for complete removal without excision. Further, insurance companies tend to offer payment for excisional techniques, which may steer patients in this direction.

INDICATIONS Focal gynecomastia with fibrous breast tissue under the NAC without skin excess or ptosis is most easily treated with local excision. Liposuction may be used as an adjunct to smooth the junction between the excised region of the NAC and the periphery.

MARKINGS The patient is marked in the upright position. A mark is made around the palpable breast tissue and a mark is made at the boundary of the NAC from 3 o’clock to 9 o’clock. If adjunctive liposuction is needed, this should also be marked outside of the breast tissue markings (Figure 24-1).

DETAILS OF PROCEDURE The patient is brought into the operating room and anesthesia is induced. Positioning includes arms at no

110

111

Liposuction (stage 1) Area of fibro-fatty/ breast tissue (stage 2)

Figure 24-2

Figure 24-1

B

Breast tissue dissected

180° incision A

Area dissected Incisions closed

Pectoralis fascia D

Drains placed

C Incision close with running intracuticular suture Figure 24-3

Figure 24-4

112

Chapter 24 • Gynecomastia—Excisional Technique

POSTOPERATIVE CARE This procedure may be performed as an outpatient. Prior to leaving the recovery room, the patient must be able to urinate, ambulate, and take adequate oral fluids. The patient returns 1 week after surgery for the first postoperative visit. When drains are 40 cc or less per day, they are ready for removal. Physical limitations within the upper body last for a month. Patients may shower several days after the procedure, and binder and compression foam is recommended for 1 week after the drain is removed. Scar management is important after surgery. For the first 2 weeks, a gentle moisturizer such as petrolatum is recommended. After that scars should be managed with cocoa butter, shea butter, and/or vitamin E at least twice a

day. Silicone sheeting may be used. If hypertrophic scar develops, dilute steroid injection may be tried.

PITFALLS It is dangerous to consider NAC transposition superiorly for ptosis when removing breast tissue under the NAC. It would be more safe to have two stages of this procedure.

TIPS The goal for chest contour is that the chest thickness should match the rest of the torso proportion. If liposuction is performed, overresection must be avoided.

113

A

C

B

D Figure 24-5A–D. A 29-year-old man presents for examination of chest. He is concerned about large areolas and fullness in the chest that has not improved with working out. The patient underwent liposuction of the chest with direct excision gynecomastia and periareolar mastopexy. (Courtesy of Michael Chiaramonte, MD.)

Chapter 25.

Mastectomy Through a Horizontal Approach from the sternal midline and 21–22 cm from the sternal notch (Figure 25-1). Adjustments can be modified in the marking to what practically appears to be the proper position. A line is marked along the IMF and across the chest that overlies the IMF to determine the tissue to be excised or de-epithelialized. If this tissue is thin and moderately ptotic, the nipple may be transported superiorly on the pedicle. If there is a greater degree of ptosis and significant lipodystrophy, the tissue should be excised and the nipples harvested in preparation for later grafting.

INTRODUCTION Males presenting with gynecomastia and pseudogynecomastia may have ptosis that would respond well to a horizontal approach, with scar lying in the inframammary fold (IMF). Nipple grafting is easily performed with this technique unless the nipple areolar complex (NAC) can be maintained on a pedicle that does not project much.

INDICATIONS Males with massive weight loss with significant ptosis are the ideal candidates for this procedure. Children with developmental abnormality in chest development may also be considered. This technique shortens the chest and does not narrow it. The scar, while potentially visible, falls into the space between the chest and the abdomen, demarcating a virtual anatomic boundary.

DETAILS OF PROCEDURE The patient is brought into the operating room and anesthesia is induced. Arms are positioned at no greater than 90 degrees from the body and are laid on egg crate to avoid compression (Figure 25-2). The knees are placed on a pillow to encourage flexion, and antiembolism support stockings and sequential compression devices are initiated on the legs. A lower body-warming blanket with forced air helps prevent hypothermia. If there is significant projection of the NAC on the underlying breast tissue, the NAC should be harvested as a full thickness skin graft. The NAC graft, about 30 mm in size, is wrapped in a saline-moistened gauze, and the side from which it was harvested should be identified (Figure 25-3).

MARKINGS The patient is marked in the upright position. The midline of each side of the chest is marked. The proper nipple position is marked on this line. A tentative mark may be designed at the level of the IMF and adjusted as needed. As a guideline, the nipple should lie approximately 11 cm

114

Midclavicular line

20

–2

2c m

115

11 cm Position of new NAC

IMF

Figure 25-1

Figure 25-2

NAC Superficial dermis

Figure 25-3

Saline-soaked gauze

116

Chapter 25 • Mastectomy Through a Horizontal Approach

The superior and inferior marks are incised, and breast tissue is removed from underneath the subcutaneous fat on the superior breast skin flap, ensuring that flap thickness is appropriate for the patient’s size (Figure 25-4). The breast tissue is then elevated off of the pectoralis major muscle fascia, leaving some tissue on the fascia to help prevent future seroma formation (Figure 25-5). After the breast tissue is removed, careful hemostasis is achieved and 1⁄4% of bupivacaine may be injected into the intercostal spaces and throughout the surgical field. Temporary approximation should be performed with staples. A #10 flat Jackson-Pratt drain is placed in the subcutaneous space. The Scarpa’s fascia layer is approximately with #2-0 or #3-0 braided absorbable suture.

The dermis is approximated with interrupted, buried, absorbable #3-0 monofilament suture, followed by a running intracuticular #4-0 absorbable monofilament suture (Figure 25-6). A new NAC should be marked, aiming to make it no greater than 30 mm in diameter. This area is de-epithelialized (Figure 25-7). The graft is thinned of most of the dermal thickness and sutured into its recipient site with interrupted #4-0 silk sutures circumferentially. These sutures are used to design a tie-over bolster dressing with petrolatum gauze and mineral oil-soaked cotton (Figure 25-8). Petrolatum gauze and absorbent pads are placed on the rest of the incisions and an abdominal binder may be placed around the upper torso to hold the dressings in place and provide some compression.

117

Upper incision

New NAC IMF marked

Breast dissected from superior flap

Superior incision created below level of IMF Original NAC site

A

B Figure 25-4B

Figure 25-4A

Upper incision

Definitive NAC marking created in midaxial line after sitting patient up on operating room table

Lower incision

Excess breast tissue amputated Figure 25-5

Thin layer of soft tissue remains over pectoralis fascia

Drain placed in subcutaneous space

Temporary approximation performed with staples

Figure 25-6

Bolster

New NAC site de-epithelialized

#4-0 interrupted silk sutures tack NAC graft onto prepared donor site

Silk sutures tied over bolster dressing

Layered closure of IMF performed

Figure 25-7

Uniform thickness of subcutaneous tissue maintained on superior flap

Figure 25-8

118

Chapter 25 • Mastectomy Through a Horizontal Approach

POSTOPERATIVE CARE This procedure may be performed as an outpatient. Prior to leaving the recovery room, the patient must be able to urinate, ambulate, and take adequate oral fluids. If performed in conjunction with surgery on other body regions, overnight stay in a hospital should be considered. The bolster dressings must remain dry while intact. The patient returns 1 week after surgery for the first postoperative visit. When drains are 40 cc or less per day, they are ready for removal. The bolster dressings are removed. Physical limitations within the upper body last for a month. Patients may shower several days after the procedure, and binder and compression foam is recommended for 1 week after the drain is removed. Scar management is important after surgery. For the first 2 weeks, a gentle moisturizer such as Vaseline or Aquaphor is recommended. After that scars should be managed with cocoa butter, shea butter, and/or vitamin E

at least twice a day. Silicone sheeting may be used. If hypertrophic scar develops, dilute steroid injection may be tried.

PITFALLS It is dangerous to consider NAC transposition superiorly for ptosis when removing breast tissue under the NAC. It would be more safe to have two stages of this procedure.

TIPS The chest contour should match the rest of the torso proportion. Skin flaps must be designed to match the abdominal thickness. This procedure does not address chest width, so a vertical excision may be performed in the midaxillary line to reduce fullness.

119

A

B

C D Figure 25-9A–D. A, B. This is a 30-year-old male who lost 114 lb through diet and exercise to a body mass index of 29.6. He underwent abdominoplasty, lower back lift and thigh lift, with removal of 16.7 lb of skin. He also had gynecomastia correction through a horizontal excision of tissue with nipple grafting. C, D. Photographs were taken 7 months after surgery.

Chapter 26.

Gynecomastia—Wise Pattern Excision Technique

INTRODUCTION

mary fold onto the chest and a midline estimate may be used for initial marking of the new nipple position. This estimate should then be checked with measurements. The nipple should be 20–21 cm from the sternal notch and 10–11 cm from the midline. Adjustments can then be made in the marking of the new nipple position. As in the standard Wise pattern marking, 7–8 cm limbs are marked from the new nipple position, 5–8 cm apart, depending on the degree of horizontal excess the patient has. The inframammary fold is marked, and the lines are connected medially and laterally. The midline on the inframammary fold is marked (Figure 26-1).

Males who have sustained massive weight loss may have a great deal of skin excess and ptosis requiring removal of skin and repositioning of the nipple areolar complex (NAC). These patients may have true breast tissue, but most of the pathology is pseudogynecomastia. These patients need shortening/amputation of the breast and narrowing of the chest, which make the Wise pattern excision a great way to address these issues. While the vertical portion of the Wise pattern leads to a visible vertical scar within an aesthetic unit/region, this scar is faint and barely visible after completely healed, particularly if the man has a hairy chest. Nipple grafting leads to a visibly satisfactory nipple without the projection afforded by leaving the nipple attached to its underlying tissue.

DETAILS OF PROCEDURE The patient is brought into the operating room and anesthesia is induced. Positioning includes arms at no greater than 90 degrees from the body and laid on egg crate to avoid compression (Figure 26-2). The knees are placed on a pillow to encourage flexion and antiembolism support stockings and sequential compression devices as well as a lower body-warming blanket to avoid hypothermia. The NAC is harvested as a full thickness skin graft, approximately 25–30 mm in diameter. The NAC grafts are wrapped in saline-moistened gauze, and the sidedness should be identified (Figure 26-3).

INDICATIONS Males with massive weight loss leading to significant skin excess and ptosis are the best candidates for this procedure. The horizontal aspect of the Wise pattern may be extended into the upper back for upper body lift.

MARKINGS The patient is marked in the upright position. The proper nipple position is marked. Transposition of the inframam-

120

121

Midclavicular markings

New nipple position 21 cm from sternal notch and clavicle 10–11 cm

Tissue to be resected

Figure 26-1

Wise pattern marked on chest

Antiembolism support stockings SCDs

Pillow to aid in leg flexion

Figure 26-2

Saline-soaked gauze

NAC Superficial dermis

25–30 mm Figure 26-3

122

Chapter 26 • Gynecomastia—Wise Pattern Excision Technique

The Wise pattern is then incised, and the breast tissue is removed from underneath the subcutaneous fat on the breast skin flaps (Figure 26-4A). The breast tissue is then elevated off of the pectoralis major muscle fascia (Figure 26-4B). After the breast tissue is removed, careful hemostasis is achieved and 1⁄4% bupivacaine may be injected into the intercostal spaces and throughout the surgical field. Temporary approximation should be performed with staples. A #10 flat Jackson-Pratt drain is placed in the subcutaneous space. The Scarpa’s fascia layer is approximated with #2-0 or #3-0 braided absorbable suture. The dermis is approximated with interrupted, buried, absorbable #3-0 monofilament suture, followed by a running intracuticular #4-0

absorbable monofilament suture (Figure 26-5). A new NAC should be marked, aiming to make it no greater than 25 mm in diameter. This area is de-epithelialized (Figure 26-6). The graft is thinned of most of the dermal thickness and sutured into its recipient site with interrupted #4-0 silk sutures circumferentially. These sutures are used to design a tie-over bolster dressing: petrolatum gauze is placed onto the nipple, mineral oil soaked cotton is placed on the petrolatum gauze, and the petrolatum gauze is tied over the mineral oil–soaked cotton with the #4-0 silk sutures. Petrolatum gauze and absorbent pads are then placed on the incisions, and a three-panel abdominal binder is used to hold the dressings in place.

123

Markings for new NAC Incised Wise pattern Excess breast tissue removed from underside of flaps Incision at IMF

IMF Excess breast tissue dissected off the pectoralis fascia and excised at IMF

Excess breast tissue retracted A

B Figure 26-4B

Figure 26-4A

Skin closed with #4-0 continuous intracuticular absorbable monofilament suture Dermis closed with #3-0 interrupted, absorbable monofilament suture #10 flat Jackson-Pratt drain Figure 26-5

Scarpa’s fascia closed with #2-0 or #3-0 interrupted, braided absorbable suture

Previously marked location for new nipple position de-epithelialized

Chest closed at IMF

Figure 26-6

124

Chapter 26 • Gynecomastia—Wise Pattern Excision Technique

POSTOPERATIVE CARE While this procedure may be performed as an outpatient, it is often combined with upper back lift, abdominoplasty, and/or other body contouring procedures, making it better to admit the patient for overnight observation. The patient returns 1 week after surgery for the first postoperative visit. When drains are 40 cc or less per day, they are ready for removal, and compression may be utilized for 1 week further. The bolsters on the nipples need to remain completely dry until follow-up, and they are removed 7–10 days after surgery. After surgery, moisturizing of the incisions and nipples is necessary, and Aquaphor ointment or Vaseline is recommended. Physical limitations within the upper body last for a month.

Scar management is important after surgery. After the first 2 weeks, scars should be managed with cocoa butter, shea butter, and/or vitamin E at least twice a day. Silicone sheeting may be used. If hypertrophic scar develops, dilute steroid injection may be tried.

PITFALLS The nipple needs to be adequately thinned to ensure good healing to the recipient bed.

TIPS Chest contour needs to match the rest of the torso proportion. When excising breast tissue, be sure not to remove subcutaneous fat to maintain proportionality.

125

A

B

C

D

Figure 26-7A–D. A, B. This 22-year-old man presented after losing 200 lb from open gastric bypass surgery to a body mass index of 37. He had Wise pattern gynecomastia correction with nipple grafting, in addition to lower body lift and brachioplasty, with total tissue excision of 33 lb. C, D. The postoperative photographs were taken 30 months after surgery.

126

Chapter 26 • Gynecomastia—Wise Pattern Excision Technique

A

B

Figure 26-8A–B. This 29-year-old man presented after losing 120 lb from diet and exercise from a body mass index of 59 to 41. He had Wise pattern gynecomastia correction with nipple grafting, in addition to lower body lift. (continued)

127

C Figure 26-8C–D. The postoperative photographs were taken 2 months after surgery. (Continued)

D

Chapter 27.

Gynecomastia—Vertical Excision Technique

INTRODUCTION

mammary fold onto the chest and a midline estimate may be used for initial marking of the new nipple position (Figure 27-1A). This estimate should then be checked with measurements. The nipple should be 20–21 cm from the sternal notch and 10–11 cm from the midline. Adjustments can then be made in the marking. The midline on the inframammary fold is marked, extending inferiorly, and the width of excision is checked, retracting breast laterally and medially (Figures 27-1B, C, D).

Young males presenting with gynecomastia may present with significant chest deformity, with widened nipple areolar complex (NAC), skin excess, and/or possible tubular breast. This is often bilateral in nature and associated with obesity, which may result secondary to poor body image. Although vertical excision leads to a visible vertical scar, this scar is barely visible after completely healed. The other benefit of the vertical approach is narrowing of the chest width, which may be desirable. Despite potential visible scarring from surgery, males with this condition comprise some of the most satisfied patients in a plastic surgery practice. Visible changes become apparent in their body image and self-esteem throughout the postoperative follow-up period.

DETAILS OF PROCEDURE The patient is brought into the operating room and anesthesia is induced. Positioning includes arms at no greater than 90 degrees from the body and laid on egg crate to avoid compression (Figure 27-2). The knees are placed on a pillow to encourage flexion and antiembolism support stockings and sequential compression devices as well as a lower body-warming blanket to avoid hypothermia. If there is significant projection of the NAC on the underlying breast tissue, the NAC should be harvested as a full thickness skin graft. The NAC graft, about 25 mm in size, is wrapped in a saline-moistened gauze, and the side from which it was harvested should be identified (Figure 27-3).

INDICATIONS Males with congenital breast deformity, most often bilateral in nature, with ptosis and true breast tissue requiring excision of the breast and skin redundancy and narrowing of the chest diameter are the ideal candidates for this procedure. Axillary redundancy would demand that excision be performed in the “J” shape and not a straight vertical.

MARKINGS The patient is marked in the upright position. The proper nipple position is marked. Transposition of the infra-

128

129

IMF marked by index finger pressure A

Figure 27-1A

Breast pushed laterally to mark medial arm of ellipse using midclavicular line as a reference B Figure 27-1B

20–21 cm

Midline IMF mark

Breast is then pushed medially to mark lateral arm of ellipse

C Figure 27-1C

10–11 cm

New NAC location IMF Midline mark Meridian of breast

D Figure 27-1D

Skin and breast tissue to be removed

A

NAC harvested for later repositioning B Figure 27-2

Figure 27-3

130

Chapter 27 • Gynecomastia—Vertical Excision Technique

The medial and lateral marks are incised, and breast tissue is removed from underneath the subcutaneous fat on the breast skin flaps. The breast tissue is then elevated off of the pectoralis major muscle fascia (Figure 27-4). After the breast tissue is removed, careful hemostasis is achieved and 1⁄4% bupivacaine may be injected into the intercostal spaces and throughout the surgical field. Temporary approximation should be performed with staples. A #10 flat Jackson-Pratt drain is placed in the subcutaneous space. The Scarpa’s fascia layer is approximated with #2-0 or #3-0 braided absorbable suture.

The dermis is approximated with interrupted, buried, absorbable #3-0 monofilament suture, followed by a running intracuticular #4-0 absorbable monofilament suture. A new NAC should be marked, aiming to make it no greater than 25 mm in diameter (Figure 27-5). This area is de-epithelialized. The graft is thinned of most of the dermal thickness and sutured into its recipient site with interrupted #4-0 silk sutures circumferentially (Figure 27-6). These sutures are used to design a tie-over bolster dressing. Foam is placed on the chest, and an elastic bandage or binder is wrapped around the chest.

131

Medial arm of ellipse incised

Undermined Pectoralis fascia

Figure 27-4

Scarpa’s fascia closed with #2-0 or 3-0 braided absorbable suture New nipple position marked and incised at top of vertical closure

#4-0 running intracuticular absorbable monofilament closed skin

Temporary closure with staples Site of new NAC Drains placed in IMF

Dermis closed with #3-0 buried interrupted absorbable suture A B

Figure 27-5

Bolster De-epithelialized recipient site (25 mm) #4-0 silk sutures are tied over bolster dressing

A B Figure 27-6

132

Chapter 27 • Gynecomastia—Vertical Excision Technique

POSTOPERATIVE CARE This procedure may be performed as an outpatient. Before leaving the recovery room, the patient must be able to urinate, ambulate, and take adequate oral fluids. The patient returns 1 week after surgery for the first postoperative visit. When drains are 40 cc or less per day, they are ready for removal. Physical limitations within the upper body last for a month. Patients may shower several days after the procedure, and binder and compression foam is recommended for 1 week after the drain is removed. Scar management is important after surgery. For the first 2 weeks, a gentle moisturizer such as Vaseline or Aquaphor is recommended. After that scars should be managed with cocoa butter, shea butter, and/or vitamin E

at least twice a day. Silicone sheeting may be used. If hypertrophic scar develops, dilute steroid injection may be tried.

PITFALLS It is dangerous to consider NAC transposition superiorly for ptosis when removing breast tissue under the NAC, either directly or through liposuction. It would be more safe to have two stages of this procedure and prepare the patient for that possibility.

TIPS The goal for chest contour needs to match the rest of the torso proportion. Liposuction is not necessary as subcutaneous fat may be directly excised.

133

A

B

C

Figure 27-7. A. This is a 16-year-old male who presented in his teens with congenital gynecomastia resembling tubular breast deformity with true breast tissue pseudoherniating through a widened nipple areolar complex. B, C. He was treated using a vertical mastopexy pattern with removal of the narrow protruding breast and nipple grafting.

Chapter 28.

Gynecomastia—Extended Technique with J Excision line estimate may be used for initial marking of the new nipple position. This estimate should then be checked with measurements. The nipple should be 22 cm from the sternal notch and 10–11 cm from the midline. Adjustments can then be made in the marking, depending on aesthetic appropriateness. The midline on the inframammary fold is marked, extending inferiorly. The width of vertical excision is marked and determined with a pinch test or by retracting breast laterally and medially. The vertical limbs are measured from the nipple to 8 cm and a crosshatch is made: this is where the limbs will be approximated to each other and the inframammary fold. The vertical limb markings are then connected into an elliptical excision of the axilla and/or back, with degree of excision determined through pinch test. Crosshatches can also be made across this excision to better guide wound closure (Figure 28-1A, B, C).

INTRODUCTION This approach provides an excellent means to raising and decreasing the nipple areola complex (NAC) while also narrowing chest width and addressing fullness of skin and/or fat in the axilla and upper back region. Nipple grafting is easily performed with this technique unless the NAC can be maintained on a pedicle that does not project much.

INDICATIONS Males presenting with congenital gynecomastia or gynecomastia after massive weight loss may require treatment of the fullness or skin redundancy in the axilla and back as well as the chest. This is a bilateral condition. Axillary and upper back redundancy requires that excision be performed in the “J” shape and not a straight vertical.

MARKINGS The patient is marked in the upright position. Transposition of the inframammary fold onto the chest and a mid-

134

135

Midclavicular line Midline marked New NAC 8-cm limbs Extension on to back

A

Markings to aid in reapproximation

B Figure 28-1A, B

Angle between vertical limbs determined by medial/lateral breast displacement about midline mark at IMF

Midaxial markings 10–11 cm Vertical limbs 8 cm Crosshatch serves as guide for approximation of skin of vertical limbs to inframammary midclavicular point

C Figure 28-1C

New nipple position (22–23 cm from sternal notch just below midhumeral line)

136

Chapter 28 • Gynecomastia—Extended Technique with J Excision

DETAILS OF PROCEDURE The patient is brought into the operating room and anesthesia is induced. The patient is carefully rotated into the prone position, placing a small gel roll across the chest and supporting the axillary region with a larger lumbar gel roll. Egg crate is placed under all pressure-bearing regions, and axilla and elbows are positioned no greater than 90 degrees (Figure 28-2A). The back is prepared and draped in sterile fashion. Posterior, upper back incisions are made through subcutaneous fat to the latissimus fascia, and the tissue is excised bilaterally, from midline to the midaxillary line (Figure 28-2B). Careful hemostasis is achieved, and closure is performed in a layered fashion, using #2-0 braided absorbable interrupted suture in Scarpa’s fascia, #3-0

monofilament absorbable buried interrupted dermal suture, and #4-0 monofilament absorbable running intracuticular suture (Figure 28-2C). A #10 flat Jackson-Pratt drain is placed from either side of the back into the deep space prior to closure. The patient is then carefully turned into the supine position. Arms are positioned at no greater than 90 degrees from the body and egg crate is placed on arm boards under the arms to avoid compression. The knees are placed on a pillow to encourage flexion and antiembolism support stockings and sequential compression devices as well as a lower body forced warming blanket to avoid hypothermia (Figure 28-3A). The chest is prepared and draped in sterile fashion. If there is significant projection of the NAC on the underlying breast tissue, the NAC should be harvested as a full thickness skin graft (Figure 28-3B).

137 Back markings

Latissimus fascia Midaxillary line A

Gel rolls

Tissue from back elevated laterally B

Figure 28-2A, B

Skin closed superficially with #4-0, absorbable, intracuticular, monofilament suture followed by Dermabond glue Back tissue amputated C Figure 28-2C

Antiembolism support stockings SCDs Pillow to aid in leg flexion A Figure 28-3A

B Figure 28-3B

138

Chapter 28 • Gynecomastia—Extended Technique with J Excision

The NAC graft, about 25–30 mm in size, is wrapped in saline-moistened gauze, and the side from which it was harvested should be identified. The medial and lateral marks are incised extending into the axilla, and breast tissue is removed from underneath the subcutaneous fat on the breast skin flaps leaving appropriate thickness on the skin flaps to be proportionate with the rest of the body. The breast tissue is then elevated off of the pectoralis major and serratus muscle fascia, leaving some tissue on the chest wall to protect against seroma formation (Figure 28-4A, B). After the breast and axillary tissue is removed, careful hemostasis is achieved and 1⁄4% bupivacaine may be injected into the intercostal spaces and throughout the surgical field for postoperative comfort. A #10 flat Jackson-Pratt drain is placed in the subcutaneous space. The skin may be temporarily approximated

with staples, particularly bringing together the inferior vertical limbs to the fold. The Scarpa’s fascia layer is approximated with #2-0 or #3-0 braided absorbable suture. The dermis is approximated with interrupted, buried, absorbable #3-0 monofilament suture, followed by a running intracuticular #4-0 absorbable monofilament suture. A new NAC should be marked, aiming to make it no greater than 30 mm in diameter. This area is de-epithelialized (Figure 28-5). The graft is thinned to superficial dermis and sutured into its recipient site with interrupted #4-0 silk sutures circumferentially. These sutures are used to design a tie-over bolster dressing with petrolatum gauze and mineral oil–soaked cotton. Petrolatum gauze and absorbent pads are placed on the chest, and elastic bandages are wrapped around the chest (Figure 28-6).

139

A Midclavicular line

Back excision closed

Pectoralis fascia Breast resected with skin flaps undermined B

Figure 28-4A, B

New nipple position de-epithelialized Dermis approximated with #3-0 absorbable, buried, interrupted monofilament sutures

Scarpa’s fascia closed with #2-0 or #3-0 braided absorbable suture

Previously closed back wound Figure 28-5

Nipple graft placed under bolster dressing Figure 28-6

140

Chapter 28 • Gynecomastia—Extended Technique with J Excision

POSTOPERATIVE CARE This procedure may be performed as an outpatient. Before leaving the recovery room, the patient must be able to urinate, ambulate, and take adequate oral fluids. When performed in conjunction with reduction of other body regions, an overnight stay should be considered. The bolster dressings must stay dry until sutures are removed about a week after surgery. The patient returns 1 week after surgery for the first postoperative visit. When drains are 40 cc or less per day, they are ready for removal, typically at the first postoperative visit. The bolster dressing is removed from the nipples. Physical limitations within the upper body last for a month. Binder compression is recommended for 1 week after the drains are removed. Scar management is important after surgery. For the first 2 weeks, a gentle moisturizer such as petrolatum is recommended. After that scars should be managed with cocoa butter, shea butter, and/or vitamin E at least twice a day. Silicone sheeting may be used. If hypertrophic scar develops, dilute steroid injection may be tried.

PITFALLS It is dangerous to consider NAC transposition on breast tissue superiorly for ptosis when removing breast tissue

under the NAC through liposuction. It would be more safe for nipple vascularity to have two stages of this procedure or perform nipple grafting. The most difficult part of this procedure is getting the NAC position right. Not only should measured markings be followed, but these must also be tempered with what aesthetically looks correct to the eye. Patients present with variable chest width and subcutaneous thickness which may impact NAC placement and what looks right.

TIPS The goal for chest contour needs to match the rest of the torso proportion, so skin flap thickness must approximate the rest of the patient’s thickness. This procedure complements upper back lift well. The upper back lift should be performed first in the prone position. The patient is then turned supine to complete the upper body lift. When performing this procedure in conjunction with abdominoplasty, the abdominoplasty should be performed first, as the inframammary fold may be inferiorly displaced by abdominoplasty. Markings may require superior adjustment in the chest.

141

A

B,C

D

E,F

Figure 28-7. A–C. This is a 41-year-old man who lost 163 lb after open gastric bypass surgery. He underwent gynecomastia correction through a J excision extending into his upper back, combined with abdominoplasty, hernia repair, and lower back lift, with removal of 9.3 lb of skin. D–F. The photographs were taken 13 months after surgery.

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Section 5 Abdomen Chapter 29. Abdominal Presentation for Abdominal Contouring Chapter 30. Abdomen—Anatomy Chapter 31. Abdominal Liposuction Chapter 32. Abdominoplasty with Abdominal Wall Plication Chapter 33. Mini-abdominoplasty Combined with Liposuction Chapter 34. Reverse Abdominoplasty Chapter 35. Panniculectomy Chapter 36. Massive Panniculectomy Chapter 37. Ventral Hernia Repair and Abdominoplasty Chapter 38. Umbilical Hernia Repair at the Time of Abdominoplasty

Chapter 29.

Abdominal Presentation for Abdominal Contouring

Women and men of variable ages and backgrounds pursue abdominal contouring surgery. These are some common scenarios:

inal laxity. With the Pfannenstiel scar, there may also be contour deformity in the lower abdomen and superior pubis. Postpartum women may require treatment of skin redundancy and stretch marks, which are best treated with skin removal. Women within this age group also present for pelvic floor surgery, which is complemented by the personal boost they can achieve with abdominoplasty. Traditional abdominoplasty is typically the best procedure to address issues of abdominal laxity, contour deformity, and unsatisfactory skin. Umbilical hernias are often present in the postpartum woman, so repair at the time of abdominoplasty also may need to be considered.

LIPODYSTROPHY Particularly in nonobese young women and men, fullness in the abdomen is typically related to subcutaneous lipodystrophy more than abdominal laxity. In these patients, abdominal liposuction is the treatment of choice, but the patient needs to understand that abdominal skin laxity may result after fat removal.

THE POSTPARTUM WOMAN Women after childbirth and particularly after caesarian section or hysterectomy suffer diastasis rectus and abdom-

144

145

A

B

Figure 29-1. Lipodystrophy—This 55-year-old woman who is otherwise fit had disproportionate subcutaneous fat in her abdomen. She is an excellent candidate for liposuction of any modality.

A

B

Figure 29-2. The Postpartum Woman—This 57-year-old postpartum woman was due to have hysterectomy and bladder suspension surgery by her gynecologist and decided to pursue abdominoplasty to tighten the abdomen and remove the extra skin.

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Chapter 29 • Abdominal Presentation for Abdominal Contouring

MASSIVE WEIGHT LOSS

MALE BODY CONTOURING

Weight loss may be achieved through diet and exercise or through surgical means. Many individuals are losing greater than 100 lb, and the benefits include resolution of medical issues such as diabetes, hypertension, coronary artery disease, and arthritis. The abdomen is the most common body region addressed in patients sustaining massive weight loss. Such patients demonstrate functional issues from abdominal wall laxity and abdominal skin excess including rashes, back pain, and exacerbation of arthritis symptoms. Patients who had open Roux-en-Y gastric bypass may have incisional hernias. Many massive weight loss patients pursue abdominoplasty primarily to improve their self-esteem.

Men are pursuing body-contouring surgery in greater numbers. Men tend to distribute fat in the peritoneal cavity more than women, who tend to store their fat in the subcutaneous space. Men also tend to carry their lipodystrophy within the torso, and less so in the extremities. Although there are men who therefore benefit from liposuction of the abdomen, often in combination with liposuction of the flanks and back, many men might not be good candidates for liposuction as their fat may be deep to the abdominal musculature. Men may require abdominoplasty and abdominal wall plication, particularly in the setting of massive weight loss.

147

A

B

Figure 29-3. Massive Weight Loss—This 36-year-old woman lost 130 lb to a body mass index of 21 interested in abdominal wall tightening and skin removal.

A

B

Figure 29-4. Male Body Contouring—This 46-year-old man lost 70 lb through diet and exercise. He carried abdominal fullness within his peritoneal cavity, with minimal subcutaneous fat. He did carry fullness into the back and hip area, as well as the chest. The plan was to perform abdominoplasty with abdominal wall plication and liposuction of the chest and back.

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Chapter 29 • Abdominal Presentation for Abdominal Contouring

ABDOMINAL SCARRING WITH DEFORMITY Many patients have had complex surgical histories with significant scarring throughout the abdomen. Such scars include the right and left subcostal, upper and lower midline, left and right lower quadrants, and the suprapubic scar. Some patients had poor healing or improper closure from their surgical procedures resulting in irregular contour and thinning of the skin. Some patients have scar contracture with tightness, pulling, and pain to touch. These patients often benefit from either direct scar excision or abdominoplasty to remove the involved lower abdominal skin and provide release of other scars that may be causing pain.

ABDOMINAL HERNIAS Patients with prior surgical history or pregnancy may present with hernias. The most common of these are the upper midline incisional, ventral hernias, and umbilical hernias. Patients may have incisional hernias in the lower abdomen as well. These hernia repairs are nicely performed in conjunction with abdominoplasty, either through the same incision or through a distinct, direct incision to avoid creating a large dead space. Some patients have had prior hernia repair, sometimes with mesh, and the mesh may be plicated to gain improved contour at the time of abdominoplasty.

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A

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Figure 29-5. Abdominal Scarring with Deformity—This 42-year-old woman had multiple abdominal surgeries, the most recent complicated by postoperative hematoma. She was interested in improvement of abdominal contour and alleviation of discomfort from the abdominal scar contracture.

A

B

Figure 29-6. Abdominal Hernias—This 54-year-old woman who had open gastric bypass surgery had a large incisional hernia. The plan was to combine panniculectomy with incisional hernia repair.

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Chapter 29 • Abdominal Presentation for Abdominal Contouring

MASSIVE PANNUS Morbidly obese patients may present with abdominal pannus overlying not only the pubis but also the knees. This large quantity of skin is symptomatic with pain, rashes, cellulitis, lymphedema, and/or osteoarthritis aggravation. This procedure should be reserved for individuals who have

demonstrated efforts toward weight loss and fitness, but who are hindered by the symptomatic pannus. These patients are challenging surgical patients at risk for venous thromboembolism, blood loss, hypothermia, and wound healing problems.

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Figure 29-7. Massive Pannus—This 54-year-old woman was working with a personal trainer and was on a strict diet plan to improve her health. Her overhanging pannus was limiting her physical activity in her quest to lose weight.

Chapter 30.

Abdomen—Anatomy

A External layer, rectus sheath

I

Superficial epigastric vein

B Linea alba

J

Great saphenous v.

C Anterior cutaneous branches of intercostal nerves

K Inguinal lymph nodes

D Comper’s fascia

L

Femoral vein

E

Scarpa’s fascia (membranous layer)

M Lateral cutaneous branch of intercostal nerve T-12

F

Thoraco-epigastric vessels

N Internal cutaneous branches intercostal nerves T2–T-11

G Anterior cutaneous branch of iliohypogastric nerve

O Latissimus dorsi m.

H Ilioinguinal n.

P

Serratus anterior muscles.

Section inferior to arcuate line 1

Aponeurosis of external oblique m.

4

Medial umbilical ligament and fold

2

Aponeurosis of internal oblique m.

5

Uracus in median umbilical fold

3

Aponeurosis of trasversalis muscle

6

Transversalis fascia

Section superior to arcuate line 1

Anterior layer of rectus sheath

5

Falciform lig.

2

Rectus abdominus m.

6

Transversalis m.

3

Transversalis fascia

7

Internal Oblique m.

4

Internal layer of rectus sheath

8

External Oblique m.

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153

A P B O

C D E

N

F

M

G H I L K J

Section superior to arcuate line 1 2 3 8 7 6

5

4 Section inferior to arcuate line

6 5

1 2 3 4

Chapter 31.

Abdominal Liposuction most circle indicating the thickest subcutaneous fat layer. The larger, outer circles define the geographic region in the abdomen, such as the left and right upper abdomen and the left and right lower abdomen, with lateral areas marked as well (Figure 31-1). The upper midline is marked in preparation for suctioning and defining the linea alba. Preoperative markings are critical. They are confirmatory to the patient who should understand the exact areas to be addressed. Furthermore, there is distortion when the patient lies supine.

INTRODUCTION Liposuction of the abdomen is a commonly performed procedure. It reduces subcutaneous fat and can result in conservative skin retraction, so it is a procedure that is not applicable to patients with marked overhanging skin or a large proportion of intra-abdominal, visceral fat. Some have reported use of high-volume liposuction to help reduce subcutaneous fat and potentially treat type II diabetes, but this is controversial and not universally advocated. Liposuction can be performed through traditional tumescent technique by manual syringe liposculpture or with a formal vacuum source. Augmented technologies such as power-assisted liposuction and ultrasound-assisted liposuction are useful to promote fat removal while allowing focus on contouring.

DETAILS OF PROCEDURE The patient is brought into the operating room and anesthesia is induced. Positioning includes arms at no greater than 90 degrees from the body and egg crate to avoid compression. Arms should be supinated. A urine catheter is placed for anticipated liposuction volume greater than 4 liters. The knees are placed on a pillow to encourage flexion, and antiembolism support stockings and sequential compression devices are initiated prior to anesthesia (Figure 31-2). The abdomen is prepared and draped in sterile fashion, placing an upper or lower bodywarming blanket to protect against hypothermia. Incision is made in the upper umbilicus and at either inguinal crease. It is preferable that if the patient has prior scar from an abdominoplasty, incisions are made within the old scar. Suctioning areas that may be hiding a hernia is dangerous, so if there are abdominal scars and/or history of radiation and hernia is of concern, liposuction should not be performed. Tumescent solution is infiltrated for hemostasis and anesthetic benefit (Figure 31-3).

INDICATIONS This procedure often applies to young people and athletically fit individuals who have localized fatty deposit in the abdomen resistant to diet and exercise. Abdominal liposuction is useful as a secondary procedure after prior abdominoplasty to help further contour the abdomen, as liposuction would have been unsafe to perform at the initial abdominoplasty. Abdominal etching is a form of superficial liposuction performed to simulate the appearance of muscle definition. The abdomen is an excellent donor source for fat grafts, and for this, fat is best harvested through traditional syringe aspiration techniques to minimize trauma and disruption to the adipocytes.

MARKINGS The patient is marked in the standing position, and a contour map is drawn with concentric circles, the central-

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Upper midline mark Contour map of thickest subcutaneous layer

Inner circles-thicker fat

Lower midline mark

Incision sites Tumescent solution infiltrated into marked areas Figure 31-1

Ted hose and scd’s

Knees placed on pillows encouraging flexion Hands supinated to prevent carpal tunnel compression Figure 31-2

Tumescent solution infiltrated into marked area

Figure 31-3

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Chapter 31 • Abdominal Liposuction

This solution includes 30 cc of 1% lidocaine and 1 cc of 1:1000 epinephrine per liter of Lactated Ringers. If liposuction volume will be less than 2 liters, 50 cc of lidocaine may be placed in the tumescent solution. The solution must be allowed to permeate within the tissues for at least 8 minutes for the full epinephrine effect to help reduce blood loss. If liposuction is part of a combined procedure, tumescent solution should be infiltrated first, another surgical procedure performed, and then return to the abdomen to perform liposuction. For recommended volume of tumescent solution, a ratio of 1 to 2 times the amount of anticipated aspirate should be infused. After adequate time has been allowed for hemostatic effect, liposuction begins. Cannulas of varying lengths and calibers are chosen to address areas of concern. The 3.7 mm Mercedes-style cannula is one of the more versatile cannulas for the abdomen. Liposuction is performed with constant motion, sweeping the region and working from deep to superficial (Figure 31-4). Liposuction is performed in the traditional method (suction-assisted lipectomy, or SAL), as power-assisted liposuction, or as ultrasound-assisted liposuction. More concentrated liposuction may be routinely performed in the upper midline to enhance or create the appearance of defined rectus abdominis muscles. The VASER ultrasound cannulas have been used to further etch horizontal depressions on either side

of midline to create the appearance of rectus abdominis muscle fitness in men. The endpoint of liposuction is a visibly pleasing result, without any regions of overresection or completely defatted skin. Incisions are closed with a single #4-0 permanent monofilament suture to allow approximation and further drainage of tumescent solution. Gauze or absorbent pads may be placed flat against the incisions to be covered by foam pads with a silicone layer placed against the skin. Occlusive dressings are not recommended as they do not allow adequate drainage of fluid which may lead to skin irritation or infection. The patient is placed into a binder. Drainage tubes are not used. For patients desiring fat grafting to the face or other body regions, fat may be harvested from the abdomen. Manual harvest without aggressive vacuum is necessary to avoid trauma to the adipocytes. Tulip syringes with a Johnnie lock system provide adequate negative pressure. The aspirate is allowed to layer into components: tumescent solution, adipocytes, and oil (Figure 31-5). The fat may be washed with saline if there is blood staining. A centrifuge may be used to optimize layering of the aspirate. The adipocytes are transferred to 10 cc syringes and are then ready for injection through specialized, small, blunt cannulas to the recipient site, such as the nasolabial folds, lips, or glabella (Figure 31-6).

157 A Sweeping motion of probe...

B

...working from deep to superficial

...until all fatty areas are reduced

Figure 31-4 Oil

Fat injected in “tracts” through a small blunt cannula

Adipocytes

Tumescent solution

Figure 31-5

Figure 31-6

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Chapter 31 • Abdominal Liposuction

POSTOPERATIVE CARE Abdominal liposuction may be performed as an outpatient, but once volumes aspirated are greater than 4–5 liters, overnight observation is warranted. Foley catheter placement prior to surgery to follow fluid status during surgery and immediately postoperatively is recommended. Patients require hydration to flush their kidneys from fat that may enter their systemic bloodstream and embolize. Fluid status must be monitored and the patient needs to ambulate well. Hydration is encouraged for the first week after liposuction. Arnica montana herbal pills may be taken immediately preoperatively and then postoperatively to reduce edema and bruising. After initial recovery, the topical ointment or gel may be massaged into the skin while also taking the oral medication. Physical limitations last for about a week. Patients may shower immediately and foam pads and binder are recommended for the first week but not required. Using compression does help optimize reduction of bruising and swelling.

PITFALLS Abdominal scars may be hiding abdominal hernias, and this is particularly important in the setting of prior abdominal radiation treatment or complicated wound healing. Liposuction must not be performed across abdominal scars to avoid potential intra-abdominal perforation which will result in necrotizing fasciitis of the abdominal skin and wall in addition to bowel injury. Patients with round abdomens need to be carefully examined. Particularly in

men, fat may be primarily intra-abdominal and not in the subcutaneous plane. Abdominal liposuction must be performed cautiously in conjunction with abdominoplasty techniques. Abdominal liposuction may impair circulation to the abdominal skin flap, so it should not be performed in undermined skin detached from its blood supply, except for upper midline etching. Liposuction in body regions adjacent to the abdomen such as the hip complements the abdominal contour well and is safe. Fat emboli are a valid concern with higher volumes of liposuction. Hydration cannot be overemphasized, and 100% supplemental oxygen is required if fat embolism is suspected, particularly with desaturation. These patients are worked up like patients with pulmonary embolism. Foam with a silicone backing is gentle to the skin and provides excellent compression. Abdominal liposuction may lead to skin laxity where full subcutaneous fatty pockets existed, particularly in the epigastrium. This results in the skin folding when patients sit and possibly in any position. Discussion with patients prior to surgery must inform them of this possibility, and the potential upside/downside of liposuction versus abdominoplasty, allowing for staging of these two procedures as needed.

TIPS Compression, while not required, helps optimize alleviation of bruising and swelling. Foam and binder compression may be substituted by girdle apparel starting a week after surgery.

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A

B

C

D

Figure 31-7A–D. A, B. This 30-year-old woman desired contouring of the abdomen, back, and outer thigh. She had power-assisted liposuction performed, including removal of 900 cc of aspirate from the abdomen. C, D. Her postoperative photographs were taken 13 months after surgery.

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Chapter 31 • Abdominal Liposuction

A

B

C

Figure 31-8A–E. This 18 year old was born with a cleft lip-nose deformity. She presented for revision of the lip to improve symmetry as well as scar revision of the nose. Fat was harvested from the abdomen, being careful to avoid her midline scar. (continued)

161

D Figure 31-8A–E.

E Postoperative results are shown 14 months after surgery. (Continued)

Chapter 32.

Abdominoplasty with Abdominal Wall Plication

INTRODUCTION

mate closure. If liposuction of the back will be performed, these marks are made as well.

Abdominoplasty is one of the most common plastic surgical procedures performed, addressing skin and abdominal wall laxity and smoothing contour. This is the procedure that rejuvenates the abdomen after childbearing, abdominal surgery, and significant weight loss.

DETAILS OF PROCEDURE The patient is brought into the operating room and anesthesia is induced. Positioning includes arms at no greater than 90 degrees from the body, placed in supination on egg crate to avoid nerve compression. A urine catheter is placed, unless the procedure is outpatient and will take no longer than 2 hours. The knees are placed on a pillow to encourage flexion, and antiembolism support stockings and sequential compression devices are initiated prior to anesthesia (Figure 32-2). The abdomen is prepared and draped in sterile fashion, placing an upper or lower body-warming blanket to avoid hypothermia. Incision is made around the umbilicus. Incision is then made in the suprapubic region up to the hip on either side (Figure 32-3). Dissection is taken through subcutaneous fat to the abdominal wall and then superior dissection elevating the skin flap up to the umbilicus is performed. If there is significant lower abdominal scar, then it is best to work from known, unscarred territory to the scarred region. Lower abdominal skin is split in the midline from the umbilicus to the pubis, and dissection is then taken over the abdominal wall to the xiphoid (Figure 32-4). At this point, umbilical and incisional hernias may be easily corrected. If diastasis rectus is noted, midline plication of the abdominal wall is performed with interrupted, figureof-eight #1 braided silk sutures. The plication may be performed over a pain pump catheter and another catheter may be placed over top of the plication for postoperative comfort (Figure 32-5). The umbilicus may be marked at the superior position with a suture to ease finding the umbilicus and properly orienting it when ultimately bringing it through the skin. After hemostasis is achieved, the skin is excised and temporary closure is performed with staples (Figure 32-6). The patient may be flexed on the bed to allow closure, particularly if the patient has a positive prognosis for healing. If all of the skin cannot be

INDICATIONS Abdominoplasty treats excess skin and fat of the abdomen, as well as weak abdominal musculature. With a low enough scar, skin excess extending into the mons pubis can be satisfactorily treated. Patients who are good candidates include women who have lost skin and abdominal tone after childbearing and particularly caesarian section and multiple births, individuals with significant lower abdominal scarring and denervation with abdominal laxity, and patients who have lost significant weight who have reached satisfactory body mass index with associated skin excess. Both men and women are candidates for abdominoplasty. Abdominoplasty does not treat lipodystrophy in the peritoneal cavity nor does it reduce subcutaneous fat as liposuction at the time of abdominoplasty may present potential danger to healing. Liposuction in the adjacent flank and waist region is safe and complementary. Liposuction in the mid upper abdomen to sculpt the area between the rectus muscles presents minimal concern to healing and improves shape. Many with massive weight loss will achieve a better result with extension of the abdominoplasty into the back, a belt lipectomy.

MARKINGS The patient is marked in the standing position. A mark is made on the pubis, and a guideline for distance is 7 cm above the pubic cleft. The incision is extended along the upper lateral thigh to the waist. An upper mark is estimated, crossing the umbilicus (Figure 32-1). A ruler or grid is helpful in ensuring symmetry of marks and ulti-

162

163

Umbilical mark Midline mark Pillow under knees Ted hose and SCDs

7 cm

Arms padded at no greater than 90 degrees Hands supinated Figure 32-2

Figure 32-1

Xiphoid process Flap undermined to xiphoid Abdominal soft tissue elevated Umbilicus marked with suture

Umbilicus incised

Rectus fascia Lower incision created from hip to hip

Soft tissue pads remain over femoral triangle Diastasis

Figure 32-3

Figure 32-4

164

Chapter 32 • Abdominoplasty with Abdominal Wall Plication

removed, an inverted “T” incision is created between the native umbilical opening and the pubis. If inability to close is anticipated preoperatively, a higher incision on the pubis should be planned. One to two Jackson-Pratt drains are placed in the subcutaneous space and sutured into position. A new umbilical position is marked in the shape of a “V” on the abdomen. The abdominal wound is then approximated over two 10-mm closed drains with interrupted #2-0 braided absorbable suture or a running barbed suture of that caliber to approximate Scarpa’s fascia. The dermis is approximated with interrupted, buried, absorbable #3-0 monofilament suture, followed by a running intracuticular #4-0 absorbable monofilament suture. The “V” for the umbilicus is incised to the abdominal wall, the umbilicus is brought through the new skin open-

ing, and the umbilicus is approximated with #3-0 absorbable monofilament suture in the dermis and interrupted #4-0 permanent monofilament suture on the skin (Figure 32-7). Petrolatum gauze and absorbent pads are placed over the incisions, and the patient is placed into an abdominal binder which is snug but not tight. The pain pump catheters are connected to a pain pump filled with 0.25% bupivacaine. If back liposuction is planned, this is best done prior to the abdominoplasty procedure. The patient would be intubated on the stretcher and rotated into the prone position on the operating room table. Liposuction would proceed, and then the patient would be turned back into the supine position to perform the abdominoplasty.

165

A

Pain pump

Midline plication of the abdominal wall with figure-ofeight #1 braided permanent sutures

New umbilical position marked Excess skin marked and removed

B

Pain pump catheter Figure 32-6

Figure 32-5

#3-0 absorbable monofilament in dermis Pain pump catheters Dermis closed with #3-0 monofilament

Scarpa’s fascia closed with #2-0 braided absorbable suture Skin closed #4-0 intracuticular absorbable suture

Figure 32-7

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Chapter 32 • Abdominoplasty with Abdominal Wall Plication

POSTOPERATIVE CARE Abdominoplasty may be performed as an outpatient for the candidate who is fit and has an ideal body mass index. Before leaving the recovery room, the patient must be able to urinate, ambulate, and take adequate oral fluids. Patients who are obese, have had a great deal of skin removed, or who may need more time for recovery require an overnight stay. If they stay, the urine catheter may be maintained overnight and antithromboembolism precautions are taken with sequential compression devices and prophylactic heparin or enoxaparin dosing. The patient returns 1 week after surgery for the first postoperative visit. When drains are 40 cc or less per day, they are removed. Most often the patient will need to return the next week to have the second drain removed. The pain catheters are removed by the patient approximately 5–6 days after surgery. Sutures are typically removed from around the umbilicus in the office 2 weeks after surgery unless both drains are removed at 1 week, and in that case, umbilical sutures come out after 1 week since healing is optimal. Physical limitations within the abdomen last for a month, including sexual activity. Patients may shower several days after the procedure, and binder is recommended for 1 week after the last drain is removed. Scar management is important after surgery. For the first 2 weeks a gentle moisturizer such as petrolatum is recommended. After that, scars should be managed with cocoa butter, shea butter, and/or vitamin E at least twice a day. Silicone sheeting may be used. If hypertrophic scar develops at the pubis, dilute steroid injection may be tried.

PITFALLS Optimal healing strongly depends on whether the patient is an ideal candidate, without medical issues, active smoking, or obese weight. If patients are obese and/or have multiple medical problems, this may not be the procedure for them. Conservative panniculectomy or weight loss may be the answer. Repairing hernias like those resulting from open gastric bypass surgery may require opening the previous midline incision scar. Particularly if the pannus is heavy, it

may be difficult to dissect as high as necessary to reach the xiphoid and the full extent of laxity and herniation, meriting opening the prior upper midline scar. This may result in wound healing problems at the junction of this midline closure and the pubis. Minimizing tension at this point is recommended to optimize healing. Patients with full abdomens need to be carefully examined. Particularly in men, fat may be primarily intra-abdominal and not in the subcutaneous plane. Abdominoplasty undermining must also be more conservative in the presence of prior subcostal scars. The area between the subcostal scar and the incision site may be vascularly compromised and result in wound healing problems after surgery, a risk that can be reduced with minimal undermining. If the patient has significant skin excess above the scar, however, the scar may be undermined and completely removed or merged into the skin closure. Oftentimes, discussion about abdominal contouring ranges from abdominal liposuction to abdominoplasty. With abdominoplasty there is improvement in stretch marks, skin redundancy, and abdominal wall laxity without thinning the abdomen. With liposuction, one gets a thinner abdomen but there may be skin laxity after surgery analogous to massive weight loss. This possibility needs to be discussed with the patient prior to surgery. The possibility of a T closure must also be discussed in thin patients in whom complete skin removal is not assured, as they could get upset after surgery without forewarning.

TIPS In consultation with individuals interested in abdominal body contouring, it is important to carefully examine and elicit a history but also to discuss the shortcomings of procedures such as liposuction (lack of skin removal) versus abdominoplasty (no treatment of abdominal lipodystrophy, scars, recovery, time in the operating room). Furthermore, the patient must understand the limited region treated with abdominoplasty, so the hip area will remain full and the epigastrium may be too high to flatten. Managing expectations is very important in assuring patient satisfaction.

167

A B Figure 32-8. A. This 39-year-old woman had abdominoplasty performed to remove painful scar from a past lower midline exposure. Mastopexy was also performed. B. Her postoperative photographs were taken 6 months after surgery.

Chapter 33.

Mini-abdominoplasty Combined with Liposuction

INTRODUCTION

traditional abdominoplasty. A ruler or grid is helpful in ensuring symmetry of marks and ultimate closure, although preoperative asymmetry must be taken into consideration.

Mini-abdominoplasty is a procedure far less often performed than traditional abdominoplasty because it is applicable to a limited population. It combines the benefits of liposuction with suprapubic tightening and a shortened scar.

DETAILS OF PROCEDURE The patient is brought into the operating room and anesthesia is induced. Positioning includes arms at no greater than 90 degrees from the body and placement in supination on egg crate to avoid nerve compression. A urine catheter may be considered. The knees are placed on a pillow to encourage flexion, and antiembolism support stockings and sequential compression devices are initiated prior to anesthesia (Figure 33-2). The abdomen is prepared and draped in sterile fashion, placing an upper or lower body-warming blanket throughout the surgery to avoid hypothermia. Tumescent solution is infiltrated for hemostasis and anesthetic benefit. This solution includes 30 cc of 1% lidocaine and 1 cc of 1:1000 epinephrine per liter of Lactated Ringers. If only the abdomen will be addressed, 50 cc of 1% lidocaine may be used in the tumescent solution recipe. The solution must be allowed to permeate within the tissues for at least 8 minutes for the full epinephrine effect to reduce blood loss. The tissue is inflated until flaccid. Liposuction (suction-assisted lipectomy, power-assisted liposuction, or ultrasound-assisted liposuction) is then performed in the areas designated (Figure 33-3). After liposuction is complete, incision is made in the suprapubic marking. Dissection is taken through subcutaneous fat to the abdominal wall and then superior dissection elevating the skin flap up to the umbilicus is performed (Figure 33-4). For patients with significant diastasis, the umbilicus may be disconnected from the abdominal wall, and a midline

INDICATIONS Mini-abdominoplasty is a great procedure for patients with limited skin excess or an unsatisfactory suprapubic scar who desire skin tightening. The ideal candidate is someone who already has a suprapubic horizontal scar, such as for caesarean section, and who is young and fit except for some lower abdominal muscle weakness. Umbilical hernias are also well treated with this technique. The umbilicus is not transposed on the skin in this procedure, so if floated downward, the umbilical descent should not be too great leading to a distorted, aberrantly low position. Liposuction may be performed liberally because of the limited undermining.

MARKINGS The patient is marked in the standing position, and a contour map is drawn with concentric circles, the central-most circle indicating the thickest subcutaneous fat layer. Most of the liposuction will be performed in the upper abdomen between the umbilicus and the costal margin, particularly over the linea alba and the flank areas (Figure 33-1). The marks for lower abdominal excision resemble a trapezoid, and the patient needs to clearly understand the scar length, as these patients are typically not interested in the longer scar associated with

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169

Pillow under knees Ted hose and SCDs

Areas marked for liposuction

Skin to be excised

7 cm Arms on padded boards

Figure 33-1

Figure 33-2

Liposuction performed in tumescent infused areas

Honey combing of subcutaneous fat where lipo performed Diastasis rectus

Figure 33-3

Figure 33-4

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Chapter 33 • Mini-abdominoplasty Combined with Liposuction

plication is performed using interrupted #1 braided permanent figure-of-eight suture (Figure 33-5). Plication may be performed over a pain pump catheter for postoperative analgesia. Umbilical hernias are also easily corrected. The umbilicus is then sutured back down to the abdominal wall, adjusting placement depending on skin excision (Figure 33-6). The skin is excised and temporary closure is performed with staples. A 10-mm closed drain is placed in the subcutaneous space and sutured into position. The Scarpa’s fascia is then approximated with

interrupted #2-0 braided absorbable suture or a running barbed suture of that caliber. The dermis is approximated with interrupted, buried, absorbable #3-0 monofilament suture, followed by a running intracuticular #4-0 absorbable monofilament suture (Figure 33-7). Tissue glue may be placed on the incision. Absorbent pads are placed over the incision and foam compression with a silicone layer against the skin is placed on the abdomen, under an abdominal binder which is snug. The pain catheter is attached to a pump with 0.25% bupivacaine.

171

Umbilicus elevated with flap from abdominal wall

Honey combing of subcutaneous fat where lipo was performed

Midline diastasis plicated with figure of eight sutures

Midline diastasis plicated with figure-of-eight sutures

Figure 33-5

Umbilicus sutured over plicated rectus abdominus muscle at level of ASIS

3-0 braided absorbable suture

Figure 33-6

Drains

Figure 33-7

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Chapter 33 • Mini-abdominoplasty Combined with Liposuction

POSTOPERATIVE CARE Mini-abdominoplasty may be performed as an outpatient. Before leaving the recovery room, the patient must be able to urinate, ambulate, and take adequate oral fluids. Arnica montana herbal pills may be taken immediately preoperatively and then postoperatively to reduce edema and bruising. After initial recovery, topical ointment or gel may be massaged into the skin while also taking the oral medication. Physical limitations within the abdomen last for a month. Patients may shower several days after the procedure, and foam pads and binder are recommended for the first week. The drain is typically removed after a week.

diastasis repair, particularly as the distance increases from the suprapubic access incision. It is critical to replace the umbilicus in the midline, and this should be definitively checked. Midline staple can be placed when draping to assist in placement. In some cases, patients may not have a completely centralized umbilicus preoperatively, and this should be noted and brought to the patient’s attention. Patients can get into trouble with seromas if their activity level is too great within weeks of the operation. Compression assists with protecting against this problem. Liposuction should not be performed prior to hernia repair if there is a hernia. Blind liposuction runs the risk of injuring intra-abdominal contents.

PITFALLS

TIPS

Overzealous repair of a diastasis rectus can lead to irregular bunching of the overlying skin. This may require further lateral undermining, but caution is encouraged if significant liposuction has been performed as well. Vascular compromise is possible. Plication needs to be performed up to the xiphoid notch. The mistake often seen is incomplete or inadequate

Pick your patients carefully. Skin removal here is limited, and patients seeking this technique are looking for short scars. They must be informed of the limitations of this technique with minimal skin removal allowed with a minimal scar.

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A

B

C

D

E

Figure 33-8A–E. A–C. This 47-year-old woman complained of abdominal laxity not responsive to exercise. In addition to a miniabdominoplasty with umbilical hernia repair, abdominal wall plication, and scar revision, she had power-assisted liposuction performed on the abdomen and back. D, E. Her postoperative photographs were taken 6 months after surgery.

Chapter 34.

Reverse Abdominoplasty urine catheter is placed if the procedure is due to take more than 2 hours. The knees are placed on a pillow to encourage flexion, and antiembolism support stockings and sequential compression devices are initiated prior to anesthesia. The breast and abdomen are prepared and draped in sterile fashion, placing a lower body warming blanket throughout the surgery to avoid hypothermia. Staples are placed on the hatch marks, so the marks are not lost. Incision is made in the inframammary fold crossing the center (Figure 34-2). Undermining is performed under Scarpa’s fascia layer in the upper abdomen, lifting the tissue to achieve the desired tension (Figure 34-3). The abdominal skin flap is split in the center to a level of desired tension and temporarily fixed with staples. Several of these cuts may be made on either side of midline to fine-tune closure through tailor tacking, so it is neither too loose nor too aggressive. The cross cuts are connected and the upper abdominal tissue is excised. The wounds are irrigated and hemostasis is achieved. Bupivacaine may be injected along the intercostal spaces and in the abdominal wall, or a pain pump catheter may be placed on each side. Closure is performed in three layers. The deepest layer is the Scarpa’s fascia layer that is fixated up to the rib periosteum at the level of the inframammary fold. The surgeon must ensure that the same rib level is used on both sides. Pain pump catheters may be threaded into this area above the ribs. The dermis is then approximated with buried, interrupted #3-0 absorbable monofilament suture to be followed with a running #4-0 absorbable monofilament intracuticular suture (Figure 34-4). Tissue glue may then be applied to the skin surface. No drains are used. Foam compression may be applied to the skin to promote adherence. The patient is placed into a well-fitting bra that is not too tight across the incision line and an abdominal binder.

INTRODUCTION Reverse abdominoplasty comprises removal of the upper abdominal skin excess that may be too high to reach with traditional abdominoplasty. This procedure is often performed secondary to a traditional abdominoplasty to tighten the upper abdomen and remove epigastric skin excess.

INDICATIONS Reverse abdominoplasty reduces skin excess in the epigastric region, between the inframammary fold and the umbilicus. The massive weight loss patient population may have extra skin pockets and folds that are unsafely or inadequately addressed with traditional abdominoplasty. Reverse abdominoplasty is nicely performed in conjunction with breast surgery where the fold may be positioned at a higher level.

MARKINGS The patient is marked in the standing position. The inframammary fold is marked continuous and traversing the midline. The lax skin of the upper abdomen is pulled upward and marked for the proposed level of resection. Hatch marks across the upper and lower marked incisions will help with approximation of unequal widths of tissue (Figure 34-1).

DETAILS OF PROCEDURE The patient is brought into the operating room and anesthesia is induced. Positioning includes arms at no greater than 90 degrees from the body and placed in supination on egg crate to avoid nerve compression. A

174

175

Crescent of skin and soft tissue removed as well as midline wedge

Midline marked as reference

Undermined Excess skin measured and marked for excision

Areas undermined

Direction of flap elevation Figure 34-1

Figure 34-2

B Scarpa’s fascia Midline excision Excess skin and soft tissue elevated, marked, and removed

A Figure 34-3

1. Scarpa’s fascia fixed to rib periosteum with #1 braided suture Drain

2. Dermis approximated with #3-0 absorbable sutures Skin closed with #4-0 absorbable sutures

Figure 34-4

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Chapter 34 • Reverse Abdominoplasty

POSTOPERATIVE CARE

TIPS

Patients may be discharged immediately with adequate pain management; otherwise, they should be kept for overnight observation with pain relief. Care must be taken in cleansing the area well in the inframammary fold and avoiding shearing and rubbing on the incision by padding it well with dressings and a soft, well-fitting bra. Physical activities must be limited for a month after the surgery. The pain pump catheters are removed by the patient approximately 5–6 days after surgery. Patients are seen 1 week after surgery. If the patients have done well, they are seen back in 4–6 weeks.

The smoothest result in the upper abdomen will occur by creating a scar that traverses the midlower chest across the xiphoid notch, otherwise fullness of the upper midabdomen will result. Postoperative attention to scar healing and optimizing scar outcome is necessary across the xiphoid. The pain pump is an excellent way to combat the pain that results from suspension sutures from the upper abdominal skin flap to the ribs. Patients will suffer significant discomfort with rib suspension. Reverse abdominoplasty can be secondarily achieved during breast lifting or breast reduction with resected lower breast skin. To achieve the upper abdominal lift, further de-epithelialization may be performed into the upper abdomen, and without any abdominal undermining, the inframammary fold closure is performed suspending the lower flap to the rib using permanent suture. This sets the fold and lifts the upper abdomen. This works best for thin patients with significant skin laxity.

PITFALLS Considering safety and optimal wound healing, direct reverse abdominoplasty should not be performed at the same time as a traditional abdominoplasty. Furthermore, tension lines for reverse abdominoplasty and traditional abdominoplasty oppose each other, resulting in banding between the incisions. Breast surgery may be safely performed at the time of reverse abdominoplasty and is actually complementary.

177

A

B

C D Figure 34-5A–D. A, B. This is a 51-year-old woman who lost 100 lb after open gastric bypass surgery, moving from a body mass index of 47 to 29. She had lower body lift with abdominoplasty, back lift, thigh lift, and outer-thigh liposuction and brachioplasty followed 2 months later with a reverse abdominoplasty combined with breast lift and autologous augmentation with axillary tissue. C, D. The photographs were taken 2 months after the second surgical procedure.

Chapter 35.

Panniculectomy

INTRODUCTION

DETAILS OF PROCEDURE

Panniculectomy technically means removal of pannus. Panniculectomy is designed for patients who have symptomatic skin excess but who cannot tolerate the healing that undermining and abdominal wall plication require.

The patient is brought into the operating room and anesthesia is induced. Positioning includes arms at no greater than 90 degrees from the body and placement in supination on egg crate to avoid nerve compression. A urine catheter is placed. The knees are then placed on a pillow to encourage flexion, and antiembolism support stockings and sequential compression devices are initiated prior to anesthesia. The abdomen is prepared and draped in sterile fashion, placing an upper body-warming blanket throughout the surgery to avoid hypothermia. Upper and lower abdominal incisions are made. Dissection is taken through subcutaneous tissue straight down to the abdominal wall, perpendicular to skin at the superior incision and more oblique up to the abdominal wall at the lower incision, limiting dead space. The midline incision is made, and the abdominal skin and subcutaneous tissue are elevated off the abdominal wall (Figure 35-2). Careful attention must be paid in case of latent hernias. Vascular structures may be large, dilated, and under high pressure, so an automatic clip applicator should be readily available to ligate veins and arteries. After the tissue is removed, careful hemostasis is achieved. The wound is copiously irrigated. Closure is temporarily performed with staples. Three drains are placed, one at either end and the other exiting just to the side of the pubis. The wound is then closed in layers. Scarpa’s fascia layer may be closed with #2-0 absorbable interrupted suture or running absorbable barbed suture of the same caliber. The dermis is approximated with interrupted, buried, absorbable #3-0 monofilament suture, followed by a running #4-0 intracuticular absorbable monofilament suture (Figure 35-3). The skin may be stapled to quicken closure instead of the intracuticular suture. Dressings include petrolatum gauze and absorbent pads, paired with a large abdominal binder.

INDICATIONS Panniculectomy is performed for morbidly obese patients and/or patients with medical comorbidities or significant abdominal scars that may compromise wound healing. The umbilicus is not involved in the surgery, and all the excision is limited to the lower portion of the abdomen and superior pubis. Massive weight loss patients who are still obese yet have plateaued in their weight loss are good candidates for this technique. This is also a good procedure to pair with incisional hernia repair leaving the two operative fields distinct, limiting dead space and communication of complications that may occur in either field. This is not a procedure that should be offered to morbidly obese patients seeking an easy method of weight loss: patients should be required to lose weight on their own through medical or surgical means before being offered surgery. These patients represent high risk and should do their best to achieve a lower risk category prior to panniculectomy surgery.

MARKINGS The patient is marked in the standing position which helps highlight the degree of pannus overhang with relation to the pubis and therefore the likely degree of reasonable skin removal. The midline is marked as a landmark. A line is then drawn connecting the suprapubic region to the hips in the abdominal crease or within the redundant mons pubis to allow pubic reduction. The superior mark is drawn at the level where the abdomen overlaps the pubis, connecting to the hip incision, and allowing for exact closure with no tension and minimal dead space (Figure 35-1).

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179

Midline landmark

Superior mark at level abdominal crease Suprapubic/hip mark in abdominal crease

Figure 35-1

Upper and lower abdominal incisions made Pannus split in middle and removed from central to lateral

Figure 35-2

Closure in layers At least 3 drains placed in subcutaneous space

Figure 35-3

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Chapter 35 • Panniculectomy

POSTOPERATIVE CARE When surgery is completed, patients must be kept for overnight observation and should be moved into a hospital bed in the flexed position. Foley catheter is maintained through the night to assess fluid status and to protect the patient from having to ambulate. Antiembolism support stockings and sequential compression devices or foot pumps should remain in place overnight, and the patient should get prophylactic dosing of unfractionated or lowmolecular-weight heparin until discharge. An extra dose each day should be considered for patients with body mass index (BMI) of 35 or greater. Intravenous fluid hydration helps maintain fluid status and improves nausea and dizziness resulting from dehydration. A postoperative hematocrit check is necessary to confirm adequate blood level and should be checked in the recovery room if there is concern about significant blood loss. Patientcontrolled anesthesia with intravenous morphine or hydromorphone (Dilaudid) is recommended for overnight discomfort. The patient must ambulate well down the hall and up and down limited stairs with the physical and occupational therapy teams to prevent venous thromboembolism (VTE). Patients are safe for discharge when they urinate adequate volumes spontaneously after urine catheter removal, take a diet well, and can ambulate independently. The first postoperative visit occurs within a week of surgery. Drain outputs are assessed and removed for output less than or equal to 40 cc/day. Patients are followed on a weekly basis until all drains are removed. The patient continues to wear a binder for 1 week after the last drain is removed and may continue beyond this

if she believes it helps with optimizing resolution of edema. The patient should limit her physical activity with regard to lifting and exercise for a month. Walking is encouraged. A home care nurse should be arranged to check on the patient after surgery several times a week in the first week or so.

PITFALLS These tend to be higher risk patients whose surgery may be complicated by wound healing problems, seromas, anemia, and VTE. Care must be intensive, and if the patient or the home care nurse calls in with concerns, there should be a low threshold for seeing these patients back and admitting as needed. Larger patients can hide large hematomas or seromas which must be investigated radiographically if symptomatic. These patients may experience significant scrotal or pubic lymphedema after surgery: their concerns should be alleviated. The swelling will slowly resolve within weeks to months after surgery.

TIPS Resection must be conservative in these patients to avoid tension and dead space. Heavier patients may need greater dosing for prophylactic anticoagulation. With BMI of greater than 40, the surgeon should consider consulting a hematologist or vascular surgeon for recommendations about VTE prophylaxis. A two-team approach is recommended in the operating room to reduce the risk of blood loss, hypothermia, and prolonged anesthesia times, and makes closure more efficient.

181

A

B

C D Figure 35-4A–D. A, B. This 49-year-old woman lost 100 lb through open gastric bypass surgery: her body mass index decreased from 43.2 to 37.6. She had panniculectomy performed, as well as brachioplasty and breast lift, with skin removal of 7 lb. Conservative panniculectomy was planned because of a large right subcostal scar, leading to concerns about wound healing from abdominoplasty. C, D. The postoperative photographs were taken 12 months after surgery.

Chapter 36.

Massive Panniculectomy the abdominal pannus on either side of midline, and a gauze roll is run through the eyes of the clamps on either side (Figure 36-2). Each roll is then tied on itself and suspended to chain links from the ceiling or a stable bar with the bed in a raised position. The bed is then slowly lowered as the pannus elevates off the body. With elevation of the pannus, lymphatic, venous, and arterial blood is drained from it, making dissection easier and lessening blood loss. A urine catheter is placed. The knees are then placed on a pillow to encourage flexion, and antiembolism support stockings and sequential compression devices or foot pumps are initiated prior to anesthesia. The abdomen is prepared and draped in sterile fashion, wrapping the towel clips in a sterile towel and placing an upper body-warming blanket throughout the surgery to avoid hypothermia. Upper and lower abdominal incisions are made. Dissection is taken through subcutaneous tissue straight down to the abdominal wall, perpendicular to skin at the superior incision and more oblique up to the abdominal wall at the lower incision, limiting dead space created. The midline incision is made, and the abdominal skin and subcutaneous tissue are elevated off the abdominal wall from medial to lateral (Figure 36-3). Careful attention must be paid in case of latent hernias. Vascular structures may be large, dilated, and under high pressure, so an automatic clip applicator with large clips should be readily available to ligate veins and arteries as dissection carries on. After the tissue is completely excised on either side, the gauze roll suspending the pannus is cut and the tissue is removed from the field. The wound is copiously irrigated and careful hemostasis is achieved. Closure is temporarily approximated with staples. Three to four drains are placed, one at either end and the other one or two exiting just to the side of the pubis. The wound is then closed in layers. Scarpa’s fascia layer may be closed with #2-0 absorbable interrupted suture or running, absorbable barbed suture of similar caliber. The dermis is approximated with interrupted, buried, absorbable #3-0 monofilament suture, followed by a running intracuticular absorbable #4-0 monofilament suture (Figure 36-4). The skin may be stapled instead of the running intracuticular suture to shorten time on the operating room bed. Dressings include petrolatum gauze and absorbent pads, paired with a large abdominal binder.

INTRODUCTION Massive panniculectomy is performed for morbidly obese patients with large, heavy panniculi. These are demanding cases, presenting the risk of significant blood loss, the challenge of intraoperative positioning, and the need for aggressive perioperative patient care.

INDICATIONS Massive panniculectomy is performed for morbidly obese patients with panniculi that are large and heavy. The umbilicus is not involved in the surgery, and all of the excision is limited to the lower portion of the abdomen and superior pubis. Massive weight loss patients who are still obese yet have plateaued in their weight loss are good candidates for this technique. This is also a good procedure to pair with incisional hernia repair leaving the two operative fields distinct, limiting dead space and communication of complications that may occur in either field. This is not a procedure that should be offered to morbidly obese patients seeking an easy method of weight loss: patients should be required to lose weight on their own through medical or surgical means before being offered surgery.

MARKINGS The patient is marked in the standing position which helps highlight the degree of pannus overhang with relation to the pubis, and therefore the likely degree of reasonable skin removal. The midline is marked as a landmark. A line is then drawn connecting the suprapubic region to the hips in the abdominal crease or within the redundant mons pubis to allow pubic reduction. The superior mark is drawn at the level where the abdominal skin overlaps the pubis, ultimately connecting to the hip incision, and allowing for exact closure with no tension and minimal dead space (Figure 36-1).

DETAILS OF PROCEDURE The patient is brought into the operating room and anesthesia is induced. Positioning includes arms at no greater than 90 degrees from the body and on egg crate in supination to avoid nerve compression. Three to four penetrating towel clips are clamped through the skin of 182

183

B

Midline marked

Pannus elevated to assist in hemostasis and dissection

Mark where pannus overlies groin

A Figure 36-1

Figure 36-2

A

Incisions through pannus to rectus sheath

Lower abdominal skin removed below umbilicus

Closure in layers over 4 drains

B Figure 36-3

Figure 36-4

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Chapter 36 • Massive Panniculectomy

POSTOPERATIVE CARE

PITFALLS

When surgery is completed, patients should be moved into a hospital bed in the flexed position. These patients must be kept for overnight observation. Foley catheter is maintained through the night to assess fluid status and to protect the patient from having to ambulate. Antiembolism support stockings and sequential compression devices or foot pumps should remain in place until the patient is ambulatory, and prophylactic dosing of unfractionated or lowmolecular-weight heparin must be administered in at least one extra dose per day until discharge. Intravenous fluid hydration helps maintain fluid status and improves nausea and dizziness resulting from dehydration. A postoperative hematocrit check is necessary to confirm adequate blood level and should be checked in the recovery room if there is concern about significant blood loss. The physical and occupational therapy teams should be consulted to assist the patient in ambulating well down the hall and up and down limited stairs to prevent venous thromboembolism (VTE). Patients are safe for discharge when they urinate adequate volumes spontaneously after urine catheter removal, take a diet well, and can ambulate independently. The first postoperative visit occurs within a week of surgery. Drain outputs are assessed and removed for output less than or equal to 40 cc/day. Patients are followed on a weekly basis until all drains are removed. Sclerosis of drains may be initiated at 3–4 weeks if drain outputs continue to be greater than 100 cc per day. The patient continues to wear a binder for 1 more week after the last drain is removed and may continue beyond this if she believes it helps with optimizing resolution of edema. The patient should limit her physical activity with regard to lifting and exercise for a month. Walking is encouraged. A home care nurse should be arranged to check on the patient after surgery several times a week in the first week or so.

These tend to be higher risk patients whose surgery may be complicated by wound healing problems, seromas, anemia, and VTE. Special attention must be paid to the issue of VTE prior to surgery, asking the patients specifically if they have ever experienced a DVT or PE, and if they ever had an inferior vena cava filter placed. Prophylaxis with prolonged administration of low molecular weight heparin and/or warfarin after surgery, or caval filter prior to surgery, must be considered for this high risk patient population. Care must be intensive, and if the patient or the home care nurse calls in with concerns, there should be a low threshold for seeing these patients back and admitting as needed. Larger patients can hide large hematomas or seromas which must be investigated radiographically either through ultrasound or computed tomographic scan if symptomatic. These patients may experience significant scrotal or pubic lymphedema after surgery: their concerns should be alleviated. The swelling will slowly resolve within weeks to months after surgery.

TIPS Resection must be conservative in these patients to avoid tension and dead space. This procedure cannot be paired with a back lift. For body mass index of greater than 40, the surgeon should consider consulting a hematologist or vascular surgeon for recommendations about VTE prophylaxis. A two-team approach is recommended in the operating room to reduce the risk of blood loss, hypothermia, and prolonged anesthesia times, and makes closure more efficient.

185

A

B

C

D

Figure 36-5A–D. A, B. This is a 48-year-old man who lost 204 lb to a body mass index of 34.6 from 63.8. He underwent conservative panniculectomy without undermining, with removal of 15.4 lb of tissue. C, D. His postoperative photographs were taken 2 months after surgery.

Chapter 37.

Ventral Hernia Repair and Abdominoplasty

INTRODUCTION

localized through palpation or by asking the patient to indicate the area of fullness and/or pain. A line connects the suprapubic region to the hips on either side. The umbilicus is marked and a line connects the umbilicus to the lateral hip to complete the markings for the proposed abdominal skin removal (Figure 37-1).

Hernia repairs combined with panniculectomy procedures have become more prevalent with open Roux-en-Y gastric bypass surgery and subsequent massive weight loss (MWL).

INDICATIONS

DETAILS OF PROCEDURE

Incisional hernias resulting from upper midline abdominal surgical approaches are common. In patients who sustain MWL after open Roux-en-Y gastric bypass surgery, the abdomen transforms from protuberant to concave, and prior fascial closure may loosen with volumetric change, placing these patients at risk for incisional hernia. Because in abdominoplasty the abdominal wall is directly viewed, that is the best time to repair hernias. With a heavy pannus, the prior midline scar is excised so that the hernia may be repaired directly, and the full extent including the superior-most portion is tightened. If panniculectomy is performed at the same time as hernia repair in the morbidly obese patient with heavy pannus, the panniculectomy should be conservative with minimal dead space and no communication to the hernia repair site. In many patients the hernia and panniculectomy site are connected, and after hernia repair, plication of lax fascia is performed from xiphoid to pubis.

The patient is brought into the operating room and anesthesia is induced. Positioning includes arms at no greater than 90 degrees from the body and egg crate to avoid compression. Prophylaxis against thromboembolism includes compression hose, sequential compression devices and a pillow under the knees (Figure 37-2). The abdomen is prepared and draped in sterile fashion, placing a lower body forced warming blanket to avoid hypothermia throughout the duration of surgery. Incision is made around the umbilicus and in the suprapubic area toward the hip. Dissection is taken through subcutaneous fat up toward the umbilicus centrally and toward the costal margin on each side. The lower abdominal skin flap is split and dissection is then taken around the umbilicus superiorly. Incision is made in an elliptical fashion around the upper midline scar, and dissection is taken through subcutaneous fat down to the abdominal wall. Careful dissection is performed to avoid injury to the hernia sac (Figures 37-3 and 37-4). After the abdominal scar is removed, the hernia is dissected carefully. The sac is opened and the adhesions dissected off the hernia edges (Figure 37-5). Most often, adhesions involve the

MARKINGS The patient is seen in the preoperative area. An ellipse is marked around the upper midline scar. The hernia is

186

187

Planned elliptical incision around existing scar

Excess tissue to be removed

Palpable hernia edge

Incisions

Anticipated skin removal from panniculectomy

Upper and lower extremities padded, with pillow under knees

Figure 37-1

Figure 37-2

A Abdominal skin flap split at midline and elevated above level of umbilicus being careful to avoid injury to hernia sac

Rectus fascia

Xiphoid process Skin ellipse with soft tissue dissected free

Diastasis Hernia sac

Attenuated hernia sac excised to medial edge of rectus abdominus m.

Omentum

Figure 37-3 and 4

Attenuated fascia and adhesions dissected free

Figure 37-5

Omentum

B Suture to orient umbilicus

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Chapter 37 • Ventral Hernia Repair and Abdominoplasty

omentum. The hernia sac and attenuated fascia are removed. The abdominal wall is checked for any other hernias, and if there are any, all hernias are connected and intervening attenuated fascia is removed. The hernia is then closed using interrupted #1 figure-of-eight braided permanent sutures (Figure 37-6). If tissue is of poor quality or the hernia is recurrent, onlay Marlex mesh is placed. If the hernia repair is communicating in an open space with the lower abdominal wall which is loose, then plication over the hernia repair and of the lower abdominal fascia is performed with interrupted #1 figure-of-eight braided permanent sutures. A pain pump catheter should be placed between the hernia repair and the fascial plication (Figure 37-7). The

abdominal skin is approximated in the midline with staples, and the amount of abdominal skin that can be removed from the lower abdomen is determined and excised (Figure 37-8). Two to three drains are placed under the skin in the subcutaneous space and the abdominal wound is closed. Closure is temporarily approximated with staples. Scarpa’s fascia layer may be closed with #2-0 absorbable interrupted suture or running barbed suture of similar caliber. The dermis is approximated with interrupted, buried, absorbable #3-0 monofilament suture, followed by a running intracuticular absorbable #4-0 monofilament suture (Figure 37-9). Dressings include petrolatum gauze and absorbent pads, paired with an abdominal binder.

189 To pain pump

Direct hernia repair with #1 braided permanent figure-of-eight sutures Second layer of figure-of-eight sutures plicate rectus fascia

Diastasis rectus

Pain pump catheters

Figure 37-6

Figure 37-7

To pain pumps

Skin temporarily closed with staples

Pull-down of excess skin and soft tissue

Figure 37-8

Skin overlapping hip/pubic incision trimmed Drains

Figure 37-9

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Chapter 37 • Ventral Hernia Repair and Abdominoplasty

POSTOPERATIVE CARE When surgery is completed, patients should be moved into a hospital bed in the flexed position. These patients must be kept for overnight observation. Foley catheter is maintained through the night to assess fluid status and to protect the patient from having to ambulate. Antiembolism support stockings and sequential compression devices or foot pumps should remain in place until patients are ambulatory, and prophylactic dosing of unfractionated or lowmolecular-weight heparin should be given until discharge. An extra dose each day should be considered for patients with body mass index of 35 or greater. Intravenous fluid hydration helps maintain fluid status and improves nausea and dizziness resulting from dehydration. A postoperative hematocrit check is necessary to confirm adequate blood level. Patient-controlled anesthesia with intravenous morphine or hydromorphone (Dilaudid) is recommended for overnight discomfort. The patient must ambulate well down the hall and up and down limited stairs to prevent venous thromboembolism, and the physical and occupational therapy teams should be consulted. Patients are safe for discharge when they urinate adequate volumes spontaneously after urine catheter removal, take a diet well, and can ambulate independently. The first postoperative visit occurs within a week of surgery. Drain outputs are assessed and removed for output less than or equal to 40 cc/day. The pain catheters are removed by the patient approximately 5–6 days after surgery. Patients are followed on a weekly basis until all drains are removed. The patient continues to wear a binder for 1 week after the last drain is removed and may continue beyond this if she believes it helps with optimizing resolution of edema. The patient should limit her physical activity with regard to lifting and exercise for a month.

Walking is encouraged. A home care nurse should be arranged to check on the patient after surgery several times a week in the first week or so.

PITFALLS With MWL, there is often excess attenuated tissue, not a paucity of tissue. Mesh overlay for hernia repair is not necessary with enough good tissue due to risks of seroma, neuroma, infection, and rejection. In some cases, hernias are complex and this may become apparent only at the time of surgery. If adhesions to bowel are evident, a general surgeon should be called into the operating room to assist in abdominal exposure and adhesion takedown. Furthermore, sometimes the upper midline hernias extend to the level of the umbilicus, and particularly in secondary repairs, the patient should be forewarned that the umbilicus may need to be sacrificed due to poor nutrient blood supply.

TIPS Hernia repair must be performed under complete observation. If a hernia is present it needs to be opened, the contents identified and freed from the edges, and the repair performed primarily. Blind fascial plication could lead to suture placement through underlying bowel leading to enterocutaneous fistula, or incarceration of intraperitoneal contents. Treating the hernia and pannus individually through different approaches assists in limiting complications associated with these procedures such as wound healing problems, infections, and seromas. This is best done in the morbidly obese patient or patient with significant medical comorbidities.

191

A

B

C

D

E

F

Figure 37-10A–F. A, B. This is a 58-year-old woman who lost 125 lb after open gastric bypass surgery, moving from a body mass index of 51.5 to 29.4. C, D. She had conservative abdominoplasty due to her right subcostal incision, with removal of 4.1 lb of tissue. The hernia was large and communicated with the base of the umbilicus, and due to lack of blood supply to the umbilicus, it was sacrificed. After primary hernia repair the abdominal wall was plicated from xiphoid to pubis. E, F. The postoperative photographs were taken 22 months after her surgical procedure.

Chapter 38.

Umbilical Hernia Repair at the Time of Abdominoplasty

INTRODUCTION

MARKINGS

Umbilical hernias are common in postpartum women or in those who have had laparoscopic procedures. While repair of an isolated umbilical hernia is straightforward, many women with these hernias desire abdominoplasty, so to take care of both issues, the lax abdomen and skin as well as the umbilical hernia is efficient but needs careful planning to avoid necrosis of the umbilicus.

The patient is marked for abdominoplasty, and the location of the umbilical hernia is marked as well. The patient should be asked where maximal fullness or tenderness is located to confirm location of the hernia.

DETAILS OF PROCEDURE Traditional abdominoplasty proceeds to the point where the lower abdominal skin is split and dissection is taken over the abdominal wall to the xiphoid. The umbilical hernia is then dissected and accessed directly if the area is focal or indirectly through the abdominal wall adjacent to the hernia if there is involvement of the umbilical stalk. (Figure 38-1). The hernia is repaired intra-abdominally to avoid overdissection of the umbilicus on the abdominal wall to preserve circulation to the umbilicus. Interrupted simple and figure-of-eight #1 braided nylon sutures are placed (Figure 38-2). Abdominal wall plication and the remaining steps of the abdominoplasty may then proceed (Figures 38-3 and 38-4).

INDICATIONS Umbilical hernias present the risk of incarceration of the bowels, particularly if the patient is already complaining of pain in the hernia. If a patient presents for abdominoplasty, he/she should be examined for the presence of an umbilical hernia so that discussion may take place on repair. More often than not, the patient comes in for abdominoplasty evaluation and on examination is incidentally found to have an umbilical hernia. Access to the umbilical hernia will depend on whether the abdominoplasty is a miniabdominoplasty or a traditional abdominoplasty.

192

193

A

Umbilical stalk B Hernia sac bulging through umbilical stalk Incision through hernia sac extending into peritoneum

Omentum

Omentum in hernia sac dissected and returned to abdominal cavity Figure-of-eight sutures passed through base of hernia sac

Peritoneal incision closed at linea alba Figure 38-1

Figure 38-2

To pain pump

Diastasis repaired with #1 braided figure-of-eight sutures

Drains

Pain pump catheter

Figure 38-3

Figure 38-4

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Chapter 38 • Umbilical Hernia Repair at the Time of Abdominoplasty

If a miniabdominoplasty is being performed, the lower skin excision should take place and undermining follows up to the umbilicus. The umbilicus is elevated off the abdominal wall and hernia sac, and further dissection more superiorly on the abdominal wall is performed (Figure 38-5A). The umbilical hernia is visualized, any incarcerated contents of omentum are carefully dissected off the sac and placed back into the peritoneal cavity, and

the fascial opening is closed with #1 braided nylon sutures. Plication of the abdominal wall as needed follows (Figure 38-5B). The umbilicus is sutured with two braided #3-0 absorbable mattress or simple sutures on either side of midline to the abdominal wall after it is determined where the umbilicus will “float” to allow closure of the abdomen (Figure 38-5C). Liposuction may be safely performed after hernia repair and not before.

195 Figure-of-eight suture closes hernia

Umbilical stalk elevated off hernia sac ASIS Diastasis

Diastasis closed to midline Pain pump catheter A Umbilical stalk sutured to plicated diastasis rectus at or just below level of ASIS

Figure 38-5

C

B

196

Chapter 38 • Umbilical Hernia Repair at the Time of Abdominoplasty

POSTOPERATIVE CARE See “Abdominoplasty” and “Miniabdominoplasty” chapters.

PITFALLS The big risk here is umbilical healing. The umbilicus must remain attached primarily to the abdominal wall or abdominal skin for viability. It is dangerous to perform blind liposuction in the presence of an umbilical hernia, as intra-abdominal contents may be injured. It is recommended that hernias

be visualized and addressed prior to liposuction being performed.

TIPS Be clear with the patient that the umbilicus may necrose in the setting of a hernia. This happens rarely, but if it does, the patient will be mentally prepared and not consider the outcome unanticipated. If the umbilicus necroses, wound care with wet-to-dry saline dressings should be performed twice a day. Wound healing ultimately will lead to a contracted scar which closely resembles a tight umbilicus.

197

A

B

C

Figure 38-6A–C. This is a 33-year-old woman who lost 140 lb after laparoscopic gastric bypass surgery, moving from a body mass index of 64.2 to 38. She had conservative abdominoplasty with repair of an umbilical hernia probably from a cannula insertion site related to the laparascopic surgery. The photographs were taken during her surgical procedure. These hernias on the umbilicus in combination with abdominoplasty require a focal approach to minimize devascularization of the umbilical pedicle.

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Section 6 Back Chapter 39. Back Presentation for Contouring Chapter 40. Back—Anatomy Chapter 41. Back Liposuction and Fat Grafting Chapter 42. Upper Back Lift Chapter 43. Upper Body Lift with Autologous Breast Augmentation Chapter 44. Lower Back Lift Chapter 45. Belt Lipectomy with Autologous Gluteal Augmentation

Chapter 39.

Back Presentation for Contouring

Individuals presenting for contouring of the back present with excess skin and/or fat, and the mode of treatment depends on the proportion of skin and fat in the back. The upper and lower back are generally managed as discrete regions, particularly when discussing the massive weight loss patient.

torso with improvement in the waistline. Some patients present to reduce gluteal lipodystrophy which must be performed judiciously to avoid ptosis.

MASSIVE WEIGHT LOSS (UPPER BACK) With growing participation in surgical and medical weight management programs, morbidly obese individuals are losing greater than 100 lb, leading to significant skin laxity in the body from head to toe. The torso is the most common body region addressed in patients sustaining massive weight loss. Subsequent to massive weight loss, many men and women present with significant skin excess in the upper back, contiguous with the chest. For best results, this presentation responds best to removal of excess skin and fat, not liposuction. For women, this tissue may be recycled for autologous augmentation of the breast, leaving it attached to perforators from the intercostal arteries. Removal of back tissue can also be transitioned into the chest for gynecomastia treatment or into the upper abdomen for a reverse abdominoplasty.

LIPODYSTROPHY Both men and women present with fullness in the back which primarily comprises subcutaneous fat. Women more typically present for upper back contouring as the lipodystrophy leads to issues with fullness around the bra line and dissatisfaction with appearance in clothing that is fitted in the torso. Women and men present with lipodystrophy in the waist and hip/flank region, which is often part of a circumferential process. The back typically houses fibrous fat and relatively thick skin which contracts well after liposuction, particularly techniques augmented with power or ultrasound. Liposuction of the back often nicely complements abdominoplasty in men and in women to give a more global improvement in the

200

201

Figure 39-1. Lipodystrophy—This patient carries significant subcutaneous fat deposits in the upper and lower back, with good skin quality. She is an excellent candidate for back liposuction.

A

B

C

Figure 39-2. Massive Weight Loss (Upper Back)—This massive weight loss patient lost 300 lb through diet and exercise followed by gastric bypass surgery. Although she also requires attention to the lower torso, her upper torso carries significant skin excess in the back and upper abdomen. Consideration of autologous augmentation of the breast with back tissue would apply to this patient. Transitioning the back excision to an upper reverse abdominoplasty would work well in this patient.

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Chapter 39 • Back Presentation for Contouring

MASSIVE WEIGHT LOSS (LOWER BACK) The back is often addressed in conjunction with the abdomen and/or thigh as part of the belt lipectomy or lower body lift. Many of these patients present with significant volume loss in the gluteal region, requiring techniques to augment fullness in the buttock that may be performed in conjunction with back lift. Lower back lift leads not only to direct lift of the buttock region but also secondary lift of the inner and outer thigh.

AMPLIFICATION OF VOLUME NEEDED Men and women as they age or lose significant weight tend to lose volume and contour in the buttock. Some

complain that they have pain on sitting or with physical activities such as horseback riding. Many are interested in increasing the fullness of the gluteal region for aesthetics and functionality. This may be accomplished by moving tissue vascularized from gluteal artery perforators from the waist and hip area down into the buttock region or by performing fat grafting, particularly from the waist. The combination of fat removal from the waist and hip area with fat augmentation in the gluteal region can greatly enhance gluteal aesthetics. More women are presenting for cosmetic buttock augmentation without a history of weight loss, and these patients are often great candidates for fat grafting, with contouring and harvest of fat from the waist to complement results.

203

A

B

C

Figure 39-3. Massive Weight Loss (Lower Back)—This woman lost 90 lb after laparoscopic gastric bypass surgery, resulting in significant buttock ptosis and volume loss, with symptomatic skin redundancy in the upper thigh and poor contour to the abdomen. She is a perfect candidate for a lower body lift with autologous gluteal augmentation, an upper thigh lift, and abdominoplasty.

A

B

Figure 39-4. Amplification of Volume Needed—This woman lost 140 lb after laparoscopic gastric bypass surgery, bringing her to a body mass index of 21. She has redundant overhanging skin of the waist region, hiding a nonexistent buttock. She is an excellent candidate for movement of the excess tissue of the hip into the gluteal region.

Chapter 40.

Back—Anatomy

Fascia of gluteus media

A Trapezius m.

J

B Infraspinatus fascia

K Gluteus maximus m.

C Scapula

L

D Latissimus dorsi m.

M Sciatic n.

Posterior femoral cutaneous n.

E

Intercostal arterial perforators

N Medial cluneal nerves

F

External oblique m.

O Superior cluneal nerves

G Thoracolumbar fascia

P

Spinal nerves (lateral cutaneous branches of dorsal rami of T7–12)

H Petit’s triangle I

Q Spinal nerves (medial cutaneous branches of dorsal rami of C4–T6)

Posterior superior iliac spine

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205

A

B C Q D

E P F

O

G H I J

N M L

K

Chapter 41.

Back Liposuction and Fat Grafting most circle indicating the thickest subcutaneous fat layer. A diamond may be marked at the sacral region if full with planning to better define the gluteal anatomy. The larger, outer circles define the geographic region in the upper or lower back (Figure 41-1). Preoperative markings are critical. They are confirmatory to the patient who should understand the exact areas to be addressed. It is important to mark the patient standing, as distortion may result when the patient lies supine. Specific areas to mark include the braline region in the upper back, the hips, and the presacral region.

INTRODUCTION Liposuction of the back primarily reduces subcutaneous fat. Liposuction may result in skin retraction, more so in the upper back than in the lower back, due to the thicker skin and more fibrous fat found in the upper back. Liposuction can be performed through traditional tumescent technique or through augmented technologies such as power-assisted liposuction (PAL) and ultrasound-assisted liposuction (UAL).

INDICATIONS

DETAILS OF PROCEDURE

This procedure applies to individuals who have localized fat in the upper and lower back. Liposuction of the back can decrease fullness in the upper back with reduction of subcutaneous fat and can result in skin retraction, particularly with UAL and PAL. Liposuction of the back is a nice complement to abdominoplasty to achieve a global improvement in contour of the torso. Liposuction of the upper and lower back secondarily unmasks and enhances the buttock region as well. The sacrum often has a fatty deposit that responds well to liposuction and also helps contour the buttock. This procedure is applicable to both men and women. Liposuction of the back is not a procedure often applied to massive weight loss patients who have achieved a body mass index of less than 30, as their issue is more skin redundancy and lax tissue rather than subcutaneous fat.

The patient is brought into the operating room and anesthesia is induced. A urine catheter is placed. The patient is intubated on the stretcher and turned prone onto the operating room bed, with a small gel roll across the chest and axillary regions and a larger gel roll across the lumbar region. Positioning includes arms at no greater than 90 degrees from the body, elbows no greater than 90 degrees, and egg crate to avoid compression (Figure 412). The axillary regions must be supported to avoid brachial plexus injury. Antiembolism support stockings and sequential compression devices are initiated prior to anesthesia. The back is prepared and draped in sterile fashion, placing a forced lower or upper body-warming blanket to protect against hypothermia.

MARKINGS The patient is marked in the standing position, and a contour map is drawn with concentric circles, the central-

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207

Back markings

Figure 41-1. The central circles identify the thicker, fuller regions of fatty deposits, while the outer circles guide the transition of liposuctioned areas with unoperated areas.

Axillary gel roll

Figure 41-2

Lumbar gel roll

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Chapter 41 • Back Liposuction and Fat Grafting

Stab incisions are made in the midline of the upper and lower back and in the infragluteal region. Incisions should be made bilaterally in the upper back and hip. More incisions can be made for better access to the regions being addressed. These incisions should be made outside of the area being addressed, not within it, and should preferentially be placed in areas that are well camouflaged, such as the infragluteal fold and between the buttocks at the sacrum. Tumescent solution is infiltrated for hemostasis and anesthetic benefit. This solution includes 30 cc of 1% lidocaine and 1 cc of 1:1,000 epinephrines per liter of Lactated Ringers at room temperature. The solution must be allowed to permeate within the tissues for at least 8 minutes for the full epinephrine effect to help reduce blood loss. For recommended volume of tumescent solution, a ratio of 1–2 times the amount of anticipated aspirate should be infused. The tissues should be flaccid with fluid. The amount of tumescent solution should be recorded and equivalent on each side in the mirror image region. After adequate time has been allowed for hemostatic effect, liposuction begins. Cannulas of varying lengths and calibers are chosen to address areas of concern. The 3.7-mm Mercedes-style cannula is one of the more versatile cannulas for the back and 4.6 mm is good for fuller areas. Liposuction is performed with constant motion, sweeping the region and working from deep to superficial. The region of fat should be envisioned by the surgeon according to anatomic expectation and addressed in this way, for example, understanding the anatomy of the waist and the geometry of the fat there (Figure 41-3A, B). Liposuction is performed in the traditional method (suction-assisted lipectomy, or SAL), as PAL, or as UAL. The endpoint of liposuction is a visibly pleasing result, without any regions of overresection or completely defatted skin. Recorded volumes of tumescent solution in and aspirate out should be close in mirror image regions and may be equivalent. Incisions are closed with a single #4-0 permanent monofil-

ament suture to allow approximation and further drainage of tumescent solution (Figure 41-4). Gauze or absorbent pads may be placed flat against the incisions to be covered by foam pads with a silicone layer placed against the skin. Occlusive dressings are not recommended as they do not allow adequate drainage of fluid which may lead to skin irritation or infection. The patient is placed into a binder. Drainage tubes are not used. For patients desiring fat grafting to the buttock or facial region, fat may be harvested from the waist. This not only provides valuable graftable fat but also enhances the buttock region by cleaning out the waistline, providing more gluteal definition. Manual harvest without aggressive vacuum is necessary to avoid trauma to the adipocytes. For recipient areas requiring small volumes, such as the nasolabial fold or lip, tulip syringes with a Johnnie lock system provide adequate negative pressure to harvest fat. For larger recipient areas such as the buttock and thigh, traditional suction-assisted liposuction may be performed with larger caliber cannulas to avoid breaking adipocytes, and the aspirate is collected in sterile canisters. Augmented technologies such as PAL and UAL may traumatize adipocytes. When larger volumes are harvested, the fluid is strained off from the fatty component of the aspirate. The aspirate is allowed to layer into components: tumescent solution, adipocytes, and oil. The fat may be washed with saline if there is blood staining. A centrifuge may be used to optimize layering of the aspirate. The adipocytes are transferred to 10 cc syringes and are then ready for injection through specialized, small, blunt cannulas to the recipient site, such as the nasolabial folds, lips, or glabella. Larger syringes and injection cannulas are used for larger recipient sites. The fat is grafted as atraumatically as possible through multiple passes into muscle and subcutaneous regions which are well vascularized and can support the grafted material.

209

A

Access incisions

Hip and waist musculo-fascial anatomy should be envisioned by the surgeon contouring the subcutaneous fat in the region Figure 41-3A

Liposuction guided by contour map B

Figure 41-3B. liposuction.

Access incisions are outside the regions of

Figure 41-4. Incisions are closed with a single interrupted monofilament suture to allow egress of fluid.

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Chapter 41 • Back Liposuction and Fat Grafting

POSTOPERATIVE CARE Back liposuction may be performed as an outpatient, but once volumes aspirated are greater than 4–5 liters, overnight observation is warranted. Foley catheter placement prior to surgery to follow fluid status during surgery and immediately postoperatively is recommended. Patients require hydration to flush their kidneys from fat that may enter their systemic bloodstream. Fluid status must be monitored and the patient needs to ambulate well. Hydration is encouraged for the first week after liposuction. Arnica montana herbal pills may be taken immediately preoperatively and then postoperatively to reduce edema and bruising. After initial recovery, topical ointment or gel may be massaged into the skin while also taking the oral medication. Physical limitations last for about a week. Patients may shower immediately and foam pads and binder are recommended for the first week, but not required. Using compression does help optimize reduction of bruising and swelling.

PITFALLS Fat emboli are a valid concern with higher volumes of liposuction. Hydration cannot be overemphasized, and 100% supplemental oxygen is required if fat embolism is suspected, particularly with desaturation. These patients are worked up like pulmonary embolism patients.

Foam with a silicone backing is gentle to the skin and provides excellent compression. Back liposuction may lead to skin laxity where full subcutaneous fatty pockets existed, particularly in the hip. When done in conjunction with abdominoplasty, back liposuction may lead to significant laxity which might require extension of the incisions from the abdominoplasty into the back, possibly requiring a complete back lift. Discussion with patients prior to surgery must inform them of this possibility, and the potential upside/downside of liposuction versus back lifting, allowing for staging of these two procedures as needed.

TIPS Discussion with anesthesia colleagues is important toward developing a mutual understanding about necessary intravenous fluid administration during liposuction surgery. Anesthesiologists may see several liters aspirated and think that this volume needs to be resuscitated back, which is not the case. They must understand that the removal of aspirate is not from the intravascular space. The patient needs maintenance fluids. Aspirate should not be bloody, and liposuction should stop if the aspirate becomes frankly bloody. Compression, while not absolutely required, helps optimize alleviation of bruising and swelling. Foam and binder compression may be substituted by girdle apparel starting a week after surgery.

211

A

B

C

Figure 41-5A–C. This 47-year-old man desired contouring of the abdomen and back. He had abdominoplasty and power-assisted liposuction performed on the back, including removal of 2200 cc of aspirate which is shown. (continued)

212

Chapter 41 • Back Liposuction and Fat Grafting

D Figure 41-5D, E.

E His postoperative photographs were taken 7 months after surgery. (Continued)

213

A

C

B

D

Figure 41-6A–C. This is a 24 year old woman desiring improved gluteal contour and fullness. (B) Preoperative markings demonstrate plans to harvest fat in the waist area and inject this fat into the gluteal region. (C) On the table view of improved contour of waist and gluteal region with lipotransfer. (D) Four month postoperative view with improved gluteal fullness and contour.

Chapter 42.

Upper Back Lift

INTRODUCTION

DETAILS OF PROCEDURE

Upper back lift is an excisional technique designed to treat upper back fullness related to a predominance of excess skin, not fat. This leaves a scar that should fall under the braline. This may either be performed in a single stage with a chest reduction/contouring procedure or as a second-stage procedure after prior chest contouring.

The patient is brought into the operating room and anesthesia is induced. A urine catheter is placed. The patient is intubated on the stretcher and turned prone onto the operating room bed, with a small gel roll across the chest and axillary regions and a larger gel roll across the lumbar region. Positioning includes arms at no greater than 90 degrees from the body and egg crate to avoid compression of weight-bearing surfaces (Figure 42-2). Antiembolism support stockings and sequential compression devices are initiated prior to anesthesia. The back is prepared and draped in sterile fashion, placing a lower body-warming blanket to avoid hypothermia. A tailor tack technique may be performed by creating the upper incision in the back, elevating the back tissue inferiorly off of the latissimus fascia, and scoring through the elevated tissue to determine the exact degree of tissue removal. Alternatively, the markings may be definitively incised superiorly and inferiorly, with an incision created in the midline. These cuts are deepened to the fascia overlying the back musculature and the tissue may be removed from central to lateral (Figure 42-3). Staples temporarily close the incision. A 10-mm drain is placed laterally on each side into the space and sutured into position. The back incision is then closed in layers with a running #0 absorbable barbed suture or #2-0 braided absorbable interrupted sutures in Scarpa’s fascia layer; interrupted #3-0 monofilament absorbable dermal sutures; and a running #4-0 monofilament absorbable intracuticular suture (Figure 42-4).

INDICATIONS Upper back lift, analogous to the lower back lift, treats excess skin and fat of the upper torso. This particularly applies to massive weight patients with upper body rolls or in patients with upper back lax skin who are not candidates for liposuction. Upper back lift may also be performed to rescue lax skin resulting from overaggressive liposuction.

MARKINGS The patient is marked in the upright position. Superior and inferior marks are made across the upper back, and the distance between them is determined by pinch test. Crosshatches are made across the horizontal marks to ease closure. The excision needs to be tapered into the chest region, either into a gynecomastia or mastopexy pattern, into a reverse abdominoplasty in the inframammary fold, or into chest scars from prior surgery (Figure 42-1).

214

215

Back markings

Midaxillary line Excision continues anteriorly in inframammary fold

Axillary gel roll

Lumbar gel roll

Figure 42-2

Figure 42-1

#4-0 monofilament absorbable intracuticular suture

Skin and Scarpa’s fascia removed to midaxillary line Hatch marks aid in approximation

#2-0 braided absorbable sutures close Scarpa’s fascia

#3-0 monofilament absorbable dermal sutures Drain placed laterally into back Figure 42-3

Figure 42-4

216

Chapter 42 • Upper Back Lift

Medical glue is placed on the incision line to seal it. The patient is then turned supine and the back closure is tapered anteriorly. This may be tapered anteriorly into an upper abdominoplasty. Tissue is removed from the upper abdomen below the inframammary fold just deep to Scarpa’s fascia. The excised edge of the upper abdomen is then closed to the inframammary fold with suspension to rib periosteum to set the fold using #1 braided permanent sutures in an interrupted fashion (Figure 42-5). A pain pump may be threaded in as postoperative discomfort

may be significant, and may be upgraded in severity as the pain is considered to be “chest pain.” Skin is approximated superficially with #3-0 buried monofilament absorbable dermal sutures and a #4-0 running subcuticular monofilament absorbable suture (Figures 42-6 and 42-7). Tissue glue may then be placed on the skin surface. The patient may be dressed with foam compression or absorbent pads on the back and placed into a bra or binder to hold dressings in place.

217 Lax upper abdominal skin removed

B Sutures from Scarpa’s fascia to rib periosteum at IMF

A #1 braided permanent sutures suspend abdominal Scarpa’s fascia to rib periosteum Figure 42-5

#4-0 monofilament absorbable subcuticular suture

Upper abdomen lifted

Dermis approximated with #3-0 monofilament buried sutures Figure 42-6

Figure 42-7

218

Chapter 42 • Upper Back Lift

POSTOPERATIVE CARE This procedure may be performed as an outpatient for the candidate who is fit and has an ideal body mass index. Before leaving the recovery room, the patient must be able to urinate, ambulate, and take adequate oral fluids. Patients who are obese, have had a great deal of skin removed, or who may need more time for recovery require an overnight stay. If they stay, the urine catheter may be maintained overnight and antithromboembolism precautions are taken with sequential compression devices and prophylactic heparin or enoxaparin dosing. The patient returns 1 week after surgery for the first postoperative visit. When drains are 40 cc or less per day, they are removed, typically, on the first postoperative visit. Outputs tend to be low for this operation. Physical limitations for the upper body last for a month. Patients may shower several days after the procedure, and bra or binder is recommended for 1 week after drain removal. Scar management is important after surgery. For the first 2 weeks, a gentle moisturizer such as petrolatum is

recommended. After that scars should be managed with cocoa butter, shea butter, and/or vitamin E at least twice a day. Silicone sheeting may be used.

PITFALLS Upper back lift is best performed at a different time than lower back lift, in any order. The opposing lines of tension reduce optimal tissue removal and may cause banding across the back. Furthermore, there may be impaired circulation with both procedures performed at the same time.

TIPS Medical glue is applied to the back to create a seal and to take tension off the wound. The running barbed suture for Scarpa’s fascia closure may improve the speed of closure. Running barbed suture may also be considered to approximate the dermis. Pain pumps may be considered for postoperative comfort.

219

A

B,C

E,F D Figure 42-8A–F. A–C. This 51-year-old woman lost 125 lb through open gastric bypass surgery: her body mass index decreased from 47.9 to 27.8. She had upper back lift and mastopexy performed as a second stage after prior lower body lift with abdominoplasty, lower back lift, and thigh lift through a proximal approach. She had prior breast reduction operation when she was obese, so the back tissue was not used for augmentation because of concerns about potential ischemia of the back tissue and breast. D–F. The postoperative photographs were taken 13 months after surgery.

Chapter 43.

Upper Body Lift with Autologous Breast Augmentation may be used to develop the space in which the back tissue will be rotated.

INTRODUCTION Women with upper back fullness and involutional breast changes benefit from this technique that converts unfavorable excess back tissue into favorable tissue to augment the breast.

DETAILS OF PROCEDURE The patient is brought into the operating room and anesthesia is induced. A urine catheter is placed. The patient is intubated on the stretcher and turned prone onto the operating room bed, with a small gel roll across the chest and axillary regions and a larger gel roll across the lumbar region. Positioning includes arms at no greater than 90 degrees from the body and egg crate to avoid compression. Antiembolism support stockings and sequential compression devices are initiated prior to anesthesia. The back is prepared and draped in sterile fashion, placing a lower body forced warming blanket to avoid hypothermia (Figure 43-2). The upper back tissue marked is deepithelialized laterally to the midaxillary line except the skin at the midline which will be excised full thickness (Figure 43-3). The upper and lower incisions are made in the back and the tissue is elevated off the latissimus fascia from central to lateral on each side (Figure 43-4). The central-most tissue is removed to assess tissue vascularity. The back incision is then closed in layers with a running #0 absorbable barbed suture or #2-0 braided absorbable interrupted sutures in Scarpa’s fascia layer, interrupted #3-0 monofilament absorbable dermal sutures, and a running #4-0 monofilament absorbable intracuticular suture (Figure 43-5). Tissue glue is placed on the wound closure

INDICATIONS This technique particularly applies to massive weight patients with upper back rolls and involutional breast changes requiring augmentation who have not had prior breast reduction surgery, which could impair intercostal perfusion of the back tissue. This technique is also useful for the unique situation in which a breast cancer patient with upper back fullness requires tissue in the chest to improve coverage of an implant.

MARKINGS The patient is marked in the upright position. Superior and inferior marks are made across the upper back, and the distance between them is determined by pinch test. Crosshatches are made across the horizontal marks to ease closure. The back markings are connected into breast lift markings (Figure 43-1). Breast lift marks on the chest may be Wise pattern or vertical pattern. For those patients who do not have require breast lift, a lateral incision in the inframammary fold (IMF) of the chest, analogous to an incision used for implant breast augmentation

220

221

Back markings include all of redundant back skin and subcutaneous tissue

Intercostal artery perforator vessels

B

A

Back markings continuous with breast markings

Axillary roll

Lumbar roll

Figure 43-2

Figure 43-1

A

B Skin de-epithelialized

Breast and chest markings

Figure 43-3

Scarpa’s fascia and skin closed

Tissue to be excised to assess distal perfusion to flaps Elevated flap rolled and placed in a sterile bag

Flaps elevated to midaxillary line to intercostal perforating arteries Figure 43-4

Figure 43-5

Drain enters back subcutaneous space bilaterally

222

Chapter 43 • Upper Body Lift with Autologous Breast Augmentation

to seal it. The elevated back tissue at either axillary line is packaged into sterile laparoscopy bags or wrapped in antimicrobial surgical clear adhesive drape. The patient is then turned supine and the breast is prepared and draped in sterile fashion, removing the flap tissue from the bags. The dissection from the back typically reaches as far anterior as needed. The Wise pattern breastlift proceeds, with de-epithelialization of the central pedicle, and lateral and medial triangles. Upper abdominal tissue may also be deepithelialized in continuity if upper, reverse abdominoplasty will be incorporated into the procedure. (Figure 43-6) The Wise pattern skin flaps are elevated, and in deflated thin and massive weight loss patients, the flaps will be dissected directly off of the pectoralis major muscle fascia. Adequate flap thickness is critical to viability of the skin flaps, so erring on the side of more thick is recommended. The medial triangle flap of breast tissue is elevated off the chestwall medially toward the central pedicle, being careful to maintain perforating arteries close to the central mound. (Figure 43-7) The back tissue in con-

tinuity with the lateral triangle of tissue is then sutured to the central pedicle, as is the medial triangle of breast tissue. (Figure 43-8). The augmented central mound may then be stabilized to the chest wall as needed to maintain its central position with #2-0 braided absorbable suture medially, laterally and superiorly. The skin is approximated in a layered fashion, continuous with the back closure. Upper abdominal skin in continuity with the IMF may be removed to perform an upper abdominal lift, and #1 permanent braided sutures from the abdominal skin flap Scarpa’s fascia layer are suspended to rib periosteum and Scarpa’s fascia of the IMF to set the fold (Figure 43-9). With vertical lifting, a lateral and superior space is created into which to rotate the back tissue. If no lift is being performed, the space for the back tissue is created, and sutures need to be progressively placed lateral to the sternum to the tip of the flap and tied down after all sutures are placed. A 10-mm closed drain is placed into the back donor site on each side and sutured into position. The breast incisions are then closed in layers.

223

Medial breast tissue elevated medially to central pedicle Breast de-epithelialized to Wise pattern markings Junction between breast and upper abdominal de-epithelialized tissue Figure 43-6

Lateral breast tissue continuous with back flap tissue Figure 43-7

A

Center breast pedicle elevated and sutured to rib periosteum

Back tissue sutured along lateral edge central pedicle Figure 43-8

B Upper abdominal lift

Closure with #3-0 dermal, #4-0 monofilament intracuticular sutures Figure 43-9

Abdominal Scarpa’s fascia elevated and secured to rib periosteum at inframammary fold

224

Chapter 43 • Upper Body Lift with Autologous Breast Augmentation

POSTOPERATIVE CARE This procedure may be performed as an outpatient for the candidate who is fit and has an ideal body mass index. Before leaving the recovery room, the patient must be able to urinate, ambulate, and take adequate oral fluids. Patients who are obese, have had a great deal of skin removed, or who may need more time for recovery, require an overnight stay. If they stay, the urine catheter may be maintained overnight and antithromboembolism precautions are taken with sequential compression devices and prophylactic heparin or enoxaparin dosing. The patient returns 1 week after surgery for the first postoperative visit. When drains are 40 cc or less per day, they are removed, typically, on the first postoperative visit. Physical limitations for the upper body last for a month. Patients may shower several days after the procedure, and bra or binder is recommended for 1 week after drain removal. Scar management is important after surgery. For the first 2 weeks, a gentle moisturizer is recommended. After that scars should be managed with cocoa butter, shea but-

ter, and/or vitamin E at least twice a day. Silicone sheeting may be used.

PITFALLS Upper body lift is best performed at a different time than lower body lift, in any order. The opposing lines of tension reduce optimal tissue removal and may cause banding across the back. Furthermore, there may be impaired circulation with both procedures performed at the same time. Back tissue circulation may be impaired if there was prior breast reduction or brachioplasty extending down the side of the chest wall. Tissue circulation also may be impaired in patients with significant medical comorbidities or who are older than 50 years.

TIPS Patients who are concerned about axillary fullness may best benefit from implant reconstruction as they may get some fullness in the axilla from rotation of the back tissue into the chest.

225

A

D

B,C

E,F

Figure 43-10A–F. A–C. This 52-year-old woman lost 117 lb through laparoscopic gastric bypass surgery: her body mass index decreased from 48 to 30.7. She had upper back lift and mastopexy performed with autologous breast augmentation from the back. D–F. The postoperative photographs were taken 5 months after surgery.

Chapter 44.

Lower Back Lift

INTRODUCTION

on the stretcher and turned prone onto the operating room bed, with a small gel roll across the chest and axillary regions and a larger gel roll across the lumbar region (Figure 44-2). Positioning includes arms at no greater than 90 degrees from the body and egg crate to avoid compression. Antiembolism support stockings and sequential compression devices are initiated prior to anesthesia. The legs are spread on spreader bars. The back and posterior thigh are prepared and draped in sterile fashion, placing an upper body-warming blanket to avoid hypothermia. If liposuction of the outer thigh is planned, tumescent solution may be infused in the outer thigh. The upper incision is then made in the back and the back tissue is elevated inferiorly off the lower back/gluteal fascia (Figure 44-3A). The degree of tissue removal is assessed with a tailor tack method, using staples to temporarily close the incision. The best scar is in the shape of gull wings over the buttock. This scar defines the buttock region and does not break up the buttock aesthetic unit (Figures 44-3B, C). Liposuction of the outer thigh can take place before or after closure but is best performed prior to closure as liposuction reduces subcutaneous tissue and loosens adherent zones, optimizing further tissue removal in the upper outer thigh (see the “Lower Extremity Liposuction” section). The back incision is closed in layers with interrupted #1 braided permanent sutures in Scarpa’s fascia layer, interrupted #3-0 monofilament absorbable dermal sutures, and a running #4-0 monofilament absorbable intracuticular suture. Scarpa’s layer may also be closed with absorbable, braided #2-0 suture (Figure 44-4). Drains may be placed prior to closure of the back, or if abdominoplasty is planned, drains may be placed during abdominoplasty and passed into the back, one on each side. Skin closure glue is placed on the wound closure to seal it.

Lower back lift addresses excess skin folds in the lower back as well as ptosis of the buttock.

INDICATIONS Lower back lift is performed in patients who have skin excess of the back, including buttock and lateral thigh ptosis, who are thin with skin laxity, or who have sustained massive weight loss. Many of these patients have “saddlebag” collections of fat along the outer thigh, and liposuction can not only greatly enhance contour but also assist in elevating the outer thigh and optimizing removal of maximal skin redundancy. Oftentimes, an abdominoplasty alone will not adequately address the torso, and lower back lift may be performed at the same time as abdominoplasty, or as a second stage. Combining abdominoplasty, lower back lift, and thigh lift comprises a lower body lift.

MARKINGS The patient is marked in the standing position. Superior and inferior marks are made across the lower back, and the distance between them is determined by pinch test. Crosshatches are made across the horizontal marks to ease closure (Figure 44-1). These marks are connected anteriorly into the abdominoplasty markings if abdominoplasty will be performed at the same time.

DETAILS OF PROCEDURE The patient is brought into the operating room and anesthesia is induced. A urine catheter is placed if the procedure will extend beyond 3 hours. The patient is intubated

226

227

Skin markings Skin markings

Redundant skin and soft tissue to be removed

Excess tissue to be removed Hatch marks guide apposition in closure Gel roll Figure 44-2

Figure 44-1

Undermined

B

#1 braided permanent suture approximates Scarpa’s fascia

Fascia of lower back A

Amount of excess tissue assessed with tailor-tack method

Incision connects to abdominoplasty markings or prior abdominoplast scar C Lateral thigh lift with approximation Figure 44-3A–C

#4-0 absorbable monofilament subcuticular closes skin

“Gull wing” closure accentuates buttock shape Figure 44-4

#3-0 interrupted monofilament absorbable sutures close dermis Drain

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Chapter 44 • Lower Back Lift

POSTOPERATIVE CARE This procedure may be performed as an outpatient but requires an overnight admission if the back lift is performed in conjunction with abdominoplasty and/or thigh lift. Before leaving the next day or the day after that, the patient must be able to urinate, ambulate, and take adequate oral fluids. Inpatient rehabilitation consult with physical therapy or occupational therapy can help with this. Antithromboembolism precautions are taken with sequential compression devices and prophylactic heparin or enoxaparin dosing until ambulation is ensured. The patient returns 1 week after surgery for the first postoperative visit. When drains are 40 cc or less per day, they are removed. Physical limitations including no lifting or exertion, pushing, or pulling, last for a month. Patients may shower several days after the procedure, and binder is recommended for 1 week after final drain removal. Foam padding may be considered over the back and under the binder immediately after drain removal, particularly if drains have been in place longer than 1 month. Scar management is important after surgery. For the first 2 weeks, a gentle moisturizer such as Vaseline or Aquaphor is recommended. After that scars should be managed with cocoa butter, shea butter, and/or vitamin E at least twice a day. Silicone sheeting may be used.

PITFALLS The surgeon should not commit to a skin excision until he/she is sure it can be approximated and that the excision is an optimal as it can be. Excision must be performed in a stepwise fashion or through tailor tack technique. Fortunately, the back is more forgiving than the arm or thigh if overresection is performed, and undermining may be performed as needed to approximate closure. The midline of the back often lacks significant redundancy and has significant adherence, so less tissue is removed in the middle and the markings are flared to allow a broader tissue resection more lateral to the midline. Seroma risk is higher when the back lift is performed in conjunction with abdominoplasty, particularly in patients with body mass index greater than 35. Back lift should be considered in a separate stage from the abdominoplasty in patients with high body mass index or with significant medical comorbidities such as diabetes, asthma, and smoking.

The back lift/thigh lift combination can be painful after surgery due to permanent suture suspension and lack of tissue mobility. This is the most taxing in terms of recovery of all the body lifts. Bending over and sitting down can be strenuous, leading to the recommendation to leave the urinary catheter in place for the first days of recovery.

TIPS The merits of back lift versus hip/waist liposuction are often weighed in surgical planning for patients who have lipodystrophy associated with skin excess of the lower back, continuous with the abdomen. Liposuction, and particularly ultrasound-assisted modalities, which allow more skin retraction, may be totally appropriate to treat this area of the back to reduce fullness. Liposuction will not lift the buttock region. Liposuction of the lower back in combination with fat grafting of the buttock may give the impression of a buttock lift, in the proper patient. It is best to prepare patients for the possibility that they may require skin excision in a separate procedure after liposuction to address residual laxity that might occur with liposuction deflation of the back tissue. It is best to avoid liposuction on the area being addressed with excision, as liposuction may impair healing or exacerbate seroma formation and increase drainage. While liposuction of the outer thigh is complementary to the back lift procedure, liposuction of the adjacent back may be harmful. Liposuction distinctly apart from the lower back dissection in the upper back may enhance results. Lower back lift is best performed in a procedure distinct from upper back lift or upper body lift. Bowstringing may develop between the two areas that are experiencing opposite axes of pull. Furthermore, a second stage always helps fine-tune the initial attempt at tightening, as there may be rebound laxity after body-lift procedures. Medical glue is useful in helping avoid dressing placement on the back, providing a seal as well as relieving tension further. If liposuction is performed, a girdle with foam on the outer thigh may be used to decrease edema and bruising. Arnica montana pills or lotion may also help reduce inflammation.

229

A

B

C D Figure 44-5. A–C. This is a 36 year old male who lost 177 lbs through diet and exercise, decreasing his BMI from 57 to 35. D–F. Postoperative photographs 2 years after backlift, abdominoplasty, and thighlift, and removal of 13 lbs of tissue.

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Chapter 44 • Lower Back Lift

E Figure 44-5E–F.

F (Continued)

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A

B

C

D

Figure 44-6A–D. A, B. This is a 26-year-old woman who lost 300 lb after gastric bypass surgery, with body mass index decreasing to 31.9. She had lower body lift with abdominoplasty, thigh lift, and lower back lift, involving removal of 20 lb of tissue. C, D. The photographs were taken 6 months after surgery.

Chapter 45.

Belt Lipectomy with Autologous Gluteal Augmentation

INTRODUCTION

the border of the gluteus and another set marks the midaxillary line of the hip (Figure 45-1). The posterior marks are connected anteriorly into abdominoplasty markings. If liposuction of the outer thigh is planned, these marks are made as well.

Rather than dispose of the back tissue removed in lower back lift, this tissue can be recycled as vascularized flap tissue to reconstruct buttock fullness that many of these patients lack.

DETAILS OF PROCEDURE

INDICATIONS

The patient is brought into the operating room and anesthesia is induced. A urine catheter is placed. The patient is intubated on the stretcher and turned prone onto the operating room bed, with a small gel roll across the chest and axillary regions and a larger gel roll across the lumbar region. Positioning includes arms at no greater than 90 degrees from the body and egg crate to avoid compression (Figure 45-2). Antiembolism support stockings and sequential compression devices are initiated prior to anesthesia. The back and posterior thigh are prepared and draped in sterile fashion, placing an upper bodywarming blanket to avoid hypothermia. If liposuction of the outer thigh is planned, tumescent solution is first infused into the outer thigh. The gluteal flaps are deepithelialized on both sides (Figure 45-3). Tissue is then removed maintaining the vascularity of the flaps from central to lateral (Figures 45-4 and 45-5). Pockets are designed over the gluteal muscles and deep into the buttock area under which the flaps will be rotated. The pockets must be dissected inferiorly and medially to avoid high and lateral placement of the flaps. The pockets are

Lower back lift with autologous gluteal augmentation (AGA) is performed in patients who have back laxity with volume loss in the buttock. Many of these patients are symptomatic with pain on sitting or gluteal rashes from lack of soft tissue padding. Individuals who have sustained massive weight loss may require fullness in the buttock lost with significant fat reduction. Performing a belt lipectomy without gluteal reconstruction will result in a flat buttock without any waist or hip definition. Patients will complain that their pants do not stay up.

MARKINGS The patient is marked in the standing position. Superior and inferior marks are made across the lower back, and the distance between them is determined by pinch test. The proposed gluteal flaps are drawn between these marks and need to be low enough to allow rotation low into the buttock region. Crosshatches are made across the horizontal marks to ease closure: one set of marks defines

232

233 Hatch marks made across lateral border of gluteus and at lateral hip Excess tissue to be removed De-epithelialized flap design mirrors deflated buttock

Head in neutral position and cushioned Axillary and lumbar rolls

Legs stabilized on bed or extender bars and cushioned with SCDs in place

Figure 45-2

Figure 45-1

Flaps de-epithelialized

Figure 45-3

Superior and inferior gluteal arteries approximately 5cm from midline

Skin and Scarpa’s fascia removed to depth of gluteal fascia

Figure 45-4

Extent of undermining limited due to laxity of tissue and avoidance of injury to blood supply

Figure 45-5

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Chapter 45 • Belt Lipectomy with Autologous Gluteal Augmentation

elevated often off of the gluteal fascia because of significant volume loss in the buttock (Figure 45-6). The lateral limit of dissection is guided by the preoperative markings. The flap tissue is then gently elevated off of the underlying fascia, avoiding cauterization of arterial perforator vessels and allowed to rotate lateral 90 degrees and down into the dissected pockets (Figure 45-7). The flaps are stabilized in their rotated position to the gluteal muscles with #2-0 braided absorbable interrupted sutures. Liposuction of the outer thigh can then take place using power-assisted liposuction, ultrasound-assisted liposuction, or suctionassisted lipectomy (see the “Lower Extremity Liposuction” section). The back incision is then closed in layers with interrupted #1 braided permanent sutures in Scarpa’s fascia layer, interrupted #3-0 monofilament absorbable dermal sutures, and a running #4-0 monofilament absorbable intracuticular suture (Figure 45-8). Medical glue is placed on the wound closure to seal it. If lower body lift is planned, the thigh lift follows the back lift, proceeding with the posterior aspect of the APEX thigh lift or, if planning on the extended

thigh lift, the patient is turned supine (see Chapters 49—APEX (Proximal) Thigh Lift and 50—Extended Thigh Lift). Once the patient is turned supine, abdominoplasty is performed (see Chapter 32— Abdominoplasty with Abdominal Wall Plication). Abdominoplasty is then followed by the supine aspect of the APEX thigh lift or by the vertical extended thigh lift. The lateral back tissue at the junction of the abdomen is stapled shut prior to flipping the patient into the supine position. The patient is then turned into the supine position, and the abdomen and thigh are prepared and draped in sterile fashion. The abdominoplasty is performed, connecting laterally into the back incision. Two 10-mm closed drains are placed into either side laterally, one into the back subcutaneous space and the other into the abdominal subcutaneous space, making a total of four drains. These drains are sutured into position. A 2-catheter pain pump system is used, entering the upper portion of the abdomen and traveling along the costal margin into the back on each side. The abdominoplasty proceeds to closure. Thigh lift follows the abdominoplasty.

235

Pocket created deep to Scarpa’s fascia

Figure 45-6

B

Flaps rotated to distal end of undermined pocket

Figure 45-7

Augmented fullness in buttocks Outer thigh lifted Drains placed bilaterally

Figure 45-8

A

B'

A'

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Chapter 45 • Belt Lipectomy with Autologous Gluteal Augmentation

POSTOPERATIVE CARE This procedure requires an overnight admission. The patient may lie and sit on the buttock area immediately as the flaps are hardy and well vascularized. Before leaving the next day or the day after that, the patient must be able to urinate, ambulate, and take adequate oral fluids. Inpatient rehabilitation consult with physical therapy or occupational therapy can help with this. Foley catheter may remain in place for 5 days to ease toileting and hygiene. Antithromboembolism precautions are taken with sequential compression devices and prophylactic heparin or enoxaparin dosing until ambulation is ensured. The patient returns 1 week after surgery for the first postoperative visit. When drains are 40 cc or less per day, they are removed. Physical limitations for the lower body last for a month. Patients may shower several days after the procedure, and binder is recommended for 1 week after final drain removal. Scar management is important after surgery. For the first 2 weeks, a gentle moisturizer such as petrolatum is recommended. After that scars should be managed with cocoa butter, shea butter, and/or vitamin E at least twice a day. Silicone sheeting may be used.

PITFALLS Theoretically AGA should not be performed in conjunction with a thigh lift that involves the infragluteal fold

because circulation to the buttock skin may be threatened. We have not seen problems with this, but the proximity of the AGA surgery and APEX thigh lift surgery need to be considered. Vertical extended thigh lift poses no threat to healing of the AGA and may be performed safely, without problem. Oftentimes, wound healing problems will develop along the suture line overlying the gluteal flaps because of the significant undermining of gluteal skin that is necessary. It is important to ensure than skin circulation is adequate to avoid necrosis and subsequent wounds. If wounds do develop, healing proceeds well after debriding eschars because all tissues are autogenous.

TIPS Precise design of the gluteal pockets is critical in the best possible aesthetic outcome, with adequate inferior and medial dissection and careful lateral dissection. The AGA is based off the superior and/or inferior gluteal arteries. These vessels tend to lie 5 cm from the midline, and injury to them should be avoided to ensure proper vascularity of the flaps. The buttock tends to feel spongy and numb to the patient for about 6 weeks. This improves over time. Medical glue is useful in helping avoid dressing placement along the inner thigh and back region, providing a seal as well as relieving tension further.

237

A

B

C

D

Figure 45-9A–H. This is a 41-year-old woman who lost 167 lb after laparoscopic gastric bypass surgery, with body mass index decreasing from 50 to 22. She had lower body lift with abdominoplasty, thigh lift, and lower back lift with autologous gluteal augmentation. Outer thigh liposuction using power-assisted liposuction was also performed. (continued)

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Chapter 45 • Belt Lipectomy with Autologous Gluteal Augmentation

E

G Figure 45-9A–H. The photographs were taken 3 months after surgery. (Continued)

F

H

Section 7 Lower Extremity Chapter 46. Presentation for Lower Extremity Contouring Chapter 47. Lower Extremity—Anatomy Chapter 48. Lower Extremity Liposuction Chapter 49. APEX (Proximal) Thigh Lift Chapter 50. Extended Thigh Lift

Chapter 46.

Presentation for Lower Extremity Contouring

Patients present for thigh contouring to take care either of lipodystrophy or skin laxity. These are some common scenarios:

will probably require multiple procedures, including further liposuction or thigh lifting. Varicose veins will limit liposuction ability because of the risk of injuring veins causing bloody aspirate. Liposuction is not an appropriate method to treat generalized obesity.

LIPODYSTROPHY Patients often present with an interest in contouring of the leg, primarily in the inner and outer thigh, knee, and calf regions. The ideal patient for liposuction is the one who has localized regions of fat in the leg but is otherwise fit and does not have skin laxity. While the outer thigh has more fibrous fat and relatively hardy skin, the inner thigh and knee both house softer fat and thinner skin. Patients may present with disproportionately high fat distribution in the leg, which may be addressed with liposuction but

THE THIN PATIENT WITH SKIN LAXITY These patients are typically women who are otherwise physically fit but may have upper thigh laxity which they desire to have tightened. These patients are candidates for superior or extended thigh lifting techniques depending on their scar preference versus tightening of the full thigh.

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241

A B Figure 46-1. Lipodystrophy—Young fit patients with residual lipodystrophy resistant to exercise present for liposuction procedures. Other patients may have significant disproportionate fat in the lower extremity, possibly requiring multiple liposuction procedures followed by possible lifting.

Figure 46-2. The Thin Patient with Skin Laxity—These patients are typically women who are otherwise physically fit but may have upper thigh laxity which they desire to have tightened. This is the posterior view of such a patient, with a lax, redundant upper thigh skin and poor gluteal definition. Such patients are candidates for proximal apex thighlifting technique.

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Chapter 46 • Presentation for Lower Extremity Contouring

MASSIVE WEIGHT LOSS Individuals who have sustained massive weight loss through medical or surgical means comprise the most prevalent group seeking thigh-lifting procedures. While such patients demonstrate functional issues including rashes, pain, and possible impact on knee and hip

osteoarthritis, many massive weight loss patients pursue thigh lift to improve their self-esteem. Varicose veins may be prominent and require evaluation by a vein specialist before proceeding with thigh lift. Superior or extended thigh-lifting techniques apply depending on presentation, goals, and scar preference.

243

A

B

C Figure 46-3. Massive Weight Loss—Presentation is quite variable in massive weight loss and different thigh-lift approaches are available to address the different manifestations. A. The patient on the left has minimal excess mostly confined to the upper thigh requiring a proximal, APEX thigh lift. B. The patient on the right has poor skin quality with laxity and severe redundancy requiring extended thigh lift.

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Chapter 46 • Presentation for Lower Extremity Contouring

POST-SURGICAL INNER THIGH CONTOUR DEFORMITY Fat of the inner thigh is soft and the skin is thin, making it is relatively easy to over-suction the inner thigh. This may

then lead to laxity and redundancy of the upper thigh skin, with unfavorable creasing of the skin, after liposuction. Patients may also present with deformities after prior attempt at thighlift elsewhere, with widened, visible scars, spread labia, asymmetry and incomplete results.

245

A

B

Figure 46-4. Revision Patients—Patients have had either liposuction of the inner thigh resulting in skin excess afterward or thigh lifting resulting in inadequate skin removal and unsightly scars. These patients may require revision through a different technique. A, B. The first two patients had unsatisfactory appearance of scar. The third requires secondary thigh lift for inadequate resection with proximal approach.

A Figure 46-5.

B A. The fourth patient had overresection of inner thigh lipodystrophy with liposuction requiring proximal thigh lift (B).

Chapter 47.

Lower Extremity— Anatomy

A Iliac crest

K Common peroneal n.

B Superior cluneal ns.

L

C Gluteal medius m.

M Semimembranosus m.

D Subcutaneous fat

N Great saphenous v.

Popliteal a. and v.

E

Gluteus maximus m.

O Semitendinosus m.

F

Inferior cluneal n.

P

Gracilis m.

G Branches of lateral cutaneous n.

Q Accessory saphenous v.

H Branches of posterior femoral cutaneous n.

R Adductor magnus m.

I

Biceps femoris m.

S

Perforating cluneal n.

J

Tibial n.

T

Middle cluneal ns.

246

247

Thigh-Posterior View

A B C T D

E

S F G R Q H P

O N I J M L

K

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Chapter 47 • Lower Extremity—Anatomy

Adductor longus m.

A Superficial epigastric a. and v.

L

B Deep femoral a.

M Anterior femoral cutaneous ns.

C Femoral v.

N Vastus medialis m.

D Femoral a.

O Vastus lateralis m. Rectus femoris m.

E

Superficial external pudental a. and v.

P

F

Pectineus m.

Q Anterior femoral cutaneous n.

G Genital branch of genitofemoral n.

R Scarpa’s fascia

H Accessory saphenous v.

S

Femoral n.

I

Great saphenous v.

T

Superficial circumflex iliac a. and v.

J

Gracilis m.

U Lateral femoral cutaneous ns.

K Sartorius m.

249

Thigh-Anterior View

A

T

B C D

S

E

U

F R

Q

G

H I

P

J K L M

O N

250

Chapter 47 • Lower Extremity—Anatomy

A Gluteus maximus m. (cut)

I

Sciatic n.

B Piriformis m.

J

Biceps femoris m.

C Gluteus minimus m.

K Semitendinosus m.

D Inferior gluteal a. and n.

L

Perineal branches of posterior femoral cutaneous n.

E

Superior gemellus m.

M Ischial tuberosity

F

Obturator internus m.

N Perineal n.

G Inferior gemellus m.

O Posterior femoral cutaneous n.

H Gluteus maximus m. (cut)

P

Pundental n.

251

A

B

C

D

P O

N

E

F G H

M I L K

J

Chapter 48.

Lower Extremity Liposuction part of the plan for liposuction, then prone positioning is warranted. The patient may be intubated on the stretcher and rotated into the prone position onto the operating room table. A Foley catheter may be placed before turning the patient if 4 liters or greater of aspiration is planned. Gel rolls are used to avoid pressure: a small one may be placed across the axillary regions and a larger one across the lumbar region (Figure 48-2). The arms are placed at right angles to the body and the elbows are also placed at right angles. All pressure-bearing surfaces are padded with pillows or egg crate. An upper body-warming blanket is placed to avoid hypothermia. Lower extremity spreader bars may be used. Single stab incisions are made to address the areas of concern. For the outer thigh, incisions may be made laterally above and below the area of concern and also in the infragluteal fold. This incision may also be used for posterior access to the inner thigh. Incisions may also be made around the knee and calf region. Tumescent solution including 30 cc of 1% lidocaine with 1 cc of epinephrine 1:1,000 in a liter of lactated ringers solution is infused into the lower extremity until it is turgid. After adequate time is given for hemostatic effect of the epinephrine, a 3.0- to 3.7-mm cannula is used to perform liposuction (Figure 48-3). It is important to record the fluid put into the tissues as well as the fluid aspirated from the tissues to ensure that symmetrical treatment is taking place. Power-assisted, ultrasound-assisted, and traditional suction-assisted lipectomy are the primary methods available to perform suction lipectomy. When the desired contour is achieved, liposuction is complete. Access incisions are closed with a single #4-0 nylon suture (Figure 48-4). The patient is then turned supine and the areas to undergo liposuction are prepared and draped in sterile fashion. Areas that had liposuction posteriorly may be smoothed anteriorly. The patient may be placed into a compression girdle, using silicone-backed foam for compression under the garment. The girdle should provide coverage distal to the areas that underwent liposuction.

INTRODUCTION Liposuction in the leg is often requested by individuals desiring improved contour. The outer thigh tends to have great results with liposuction as the fat is relatively fibrous and the skin relatively hardy. The inner thigh and knee are more challenging, with soft fat and thin skin, making postoperative contour deformity and skin laxity risky.

INDICATIONS Lower extremity liposuction is perfect for fit patients with disproportional fat distribution in the leg. This procedure has limited results in the inner thigh and knee because the skin is relatively thin and the fat soft, so skin retraction is less likely than in hardier areas like the outer thigh. There is risk of contour deformity and skin laxity, which may result in the need for later thigh lift in the upper inner thigh or fat grafting in the knee. Liposuction in the knee and thigh therefore must be conservative. Some women have fullness in the calf, which is aesthetically displeasing and makes boots difficult to wear. Skin laxity is possible after liposuction and if this is anticipated, it is best to discuss the possible need for second-stage skin removal. Lower extremity liposuction may also be used to treat lymphedema that does not entirely resolve with nonsurgical measures.

MARKINGS Patients are marked standing up. Concentric circles are made at regions to be addressed with the central circle being the most prominent area and the outer circles for transitioning into the adjacent, nonliposuctioned area (Figure 48-1). Patients should understand what is marked and confirm that the areas to be addressed are correct. The stab incisions for cannula entry may also be marked so that the patient is fully aware of where these scars will be. The cannula entry sites should lie outside regions to undergo liposuction.

DETAILS OF PROCEDURE The patient is brought into the operating room and anesthesia is induced. If the outer thigh and calf are 252

253

Most prominent subcutaneous fat Transition zone with least prominent fatty tissue

Incision sites

A

B

Figure 48-1

A B

Lumbar roll

Spreader bars

Figure 48-2

Liposuction is performed with constant motion, deep to superficial and from multiple approaches Stab incisions closed

Figure 48-3

Figure 48-4

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Chapter 48 • Lower Extremity Liposuction

POSTOPERATIVE CARE With volumes of less than 4 liters, lower extremity liposuction is safe to perform as an outpatient. The patient should be warned that she may drain thin, bloodstained fluid for the first 48 hours and should sleep on impermeable pads or old towels. The patient may shower within days of the operation. After she showers, she may replace the foam and girdle. Walking and drinking fluids are highly encouraged after surgery. The first postoperative visit occurs a week after surgery, at which time the sutures are removed. The patient is instructed not to perform any lifting or lower extremity exercise for 1 week. The second postoperative visit occurs 6 weeks after the first, and then patients are followed as needed.

PITFALLS Contouring endpoints are at times challenging to decide. It is important to record volumes of tumescent solution infused and of fatty aspirate suctioned to ensure symmetrical treatment. Overresection in the medial thigh and knee is

easy to do because the skin tends to be relatively thin and the fat relatively soft. Ultrasound-assisted liposuction is the best option in these locations because there is a greater chance of skin retraction. Overresection of fat in the inner thigh may be remedied with thigh-lifting procedures. Overresection in the outer thigh and knee is unattractive and may require ultimate fat grafting. Overresection of the infragluteal, proximal thigh “banana roll” region may create blunting and/or asymmetry of the fold, a difficult problem to fix. There is no exact way to determine the amount of blood loss. Often, the amount of bleeding or blood aspirated is underestimated, particularly in higher-volume liposuction. Tachycardia, hypotension, and significant drainage on the girdle hint toward more significant blood loss and demand that a blood level be checked.

TIPS Compression is a great way to decrease edema and bruising after liposuction. Gentle foam with silicone sheeting is recommended. Arnica montana herbal medication, oral and topical, also may help in resolving edema and bruising. Some support the use of magnets for this purpose.

255

A B Figure 48-5. This 29-year-old woman had lipodystrophy of the outer thigh despite regular exercise routine. Power-assisted liposuction of the hips (400 cc aspirate from each side) and outer thigh (400 cc aspirate from each side) was performed.

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Chapter 48 • Lower Extremity Liposuction

A Figure 48-6. Postoperative photographs were taken 6 months after surgery.

B

257

A B Figure 48-7. A. This 57-year-old woman who is a massive weight loss patient has disproportionate fatty deposition in the knee, problematic with ambulation. Power-assisted liposuction of the knees (575 cc aspirate from each side) was performed. B. Postoperative photographs were taken 3 months after surgery.

Chapter 49.

APEX (Proximal) Thigh Lift

INTRODUCTION

A pinch test is performed to define the amount of skin that may be safely excised. If there is an upper thigh fold, often the marking may be just within the fold to avoid overresection.

Many who seek thigh lift want to improve the appearance of the thigh and knee. The anterior–posterior proximal extended (APEX) thigh lift allows a hidden scar while achieving powerful tightening of the superior thigh.

DETAILS OF PROCEDURE

INDICATIONS

Anesthesia is induced on the stretcher, and a Foley catheter is placed. Foot pumps are placed on the feet for thromboembolism prophylaxis and initiated prior to anesthesia induction. The patient is turned onto the operating room bed into the prone position. Prone positioning precautions must be taken with adequate padding on pressure-bearing surfaces, as well as lack of extended or improper positioning of the neck and joints. Ideally, there should be leg extension bars on the bed. The patient needs to be at a level on the bed so that the thighs are at the lower extremity split (Figure 49-2). Antiembolism support stockings and sequential compression devices or foot pumps are necessary. Adequate padding must be placed under the leg on the bars, and the legs should be wrapped with gauze so that they remain on the spreader bars throughout the procedure. An upper body-warming blanket is placed. The thigh, buttock, and back are prepared and draped in sterile fashion. If back lift will be performed, that should be completed before starting the thigh lift as the thigh lift incisions may elevate with back lift. Incision is made in the infragluteal crease from lateral to medial at the inner thigh. The lower incision line is then made to allow closure without too much tension. The skin is removed over the fascia overlying the thigh muscles and soft tissue padding is maintained on the ischial bone (Figure 49-3). The tissue is removed, and

Patients who are thin with skin laxity and those who have sustained massive weight loss (MWL) who also have skin laxity do well with thigh-lifting procedures. This procedure provides an excellent way to address redundancy of the thigh skin as well as the infragluteal, “banana roll” area, cleaning out the area between the medial inferior buttocks, and also allows thinning a widened mons pubis. Bringing the excision into the abdomen anteriorly and into the infragluteal fold posteriorly from the anterior superior incision along the groin crease allows more power in skin removal with scar in natural creases. This is not the procedure of choice for patients with significant skin laxity, poor skin quality, and skin excess down to or below the knee. This is also not the procedure for the obese patient with significant thigh lipodystrophy. This is the perfect procedure for individuals with good skin quality and skin laxity of the upper half of the thigh.

MARKINGS Patients are marked standing up. The groin crease is marked symmetrically along the mons pubis edge or within the lateral mons pubis to narrow it and create better dimensions. The incision is extended posteriorly into the infragluteal crease, and this is marked (Figure 49-1).

258

259

Markings

Figure 49-1

Lumbar roll

Spreader bars

Figure 49-2

Fascia over long head of biceps femoris and semitendinosis muscles

Figure 49-3

260

Chapter 49 • APEX (Proximal) Thigh Lift

hemostasis is achieved. The inferior thigh skin flap is approximated from the Scarpa’s fascia layer to the ischial periosteum using #1 braided permanent suture (Figure 49-4A). A good bite of periosteum must be ensured by pulling on the suture and confirming lack of mobility of the suture. The dermis is approximated with interrupted, buried, absorbable #3-0 monofilament suture, followed by a running intracuticular #4-0 absorbable monofilament suture (Figure 49-4B). Tissue glue is placed on the incision closure. The patient is then turned into the supine position. The legs are again padded and stabilized onto the leg extension bars (Figure 49-5). The abdomen and thighs are prepared and draped in standard fashion. If abdominoplasty is going to be performed, this must happen first, followed by the thigh lift as the incision lines may migrate up with abdominoplasty. The deep layer of the abdominoplasty should be closed, but the more superficial layers lateral to the pubis should not be closed as the thigh lift will merge into this portion of the incision. The incision is then made along or within the lateral pubis if the pubis needs to be

narrowed. The incision from the infragluteal crease is extended anteriorly for several centimeters, and the closure progresses from posterior to anterior in a stepwise fashion to avoid overresection. Tendency for overresection occurs at the junction of the posterior and anterior resections. The thigh skin Scarpa’s fascia layer is approximated to the pubic periosteum and Colles fascia with #1 interrupted braided nonabsorbable suture (Figure 49-6). A good bite of periosteum must be taken and confirmed by pulling up on the suture which should not give with pulling. Ultimately, there is no further pubis to which to suspend the tissue, and the closure is extended superiorly into the abdominal incision. The axis of pull transitions from obliquely inward to the pubis to superior at the junction of the upper thigh and abdomen. A #2-0 braided absorbable suture is used in Scarpa’s fascia layer superior to the pubis and at the abdomen, and the dermis is approximated with interrupted, buried, absorbable #3-0 monofilament suture, followed by a running intracuticular #4-0 absorbable monofilament suture. Tissue glue is placed on the incision closure. No drains and no dressings are necessary.

261

A

#1 interrupted braided suture approximate Scarpa’s fascia to ischial periosteum Hatch marks guide alignment Scarpa’s fascia of thigh elevated and sutured to periosteum of ischium

Ischial tuberosity (protected by overlying soft tissue)

Groin closure completed in supine position

Skin closed with #4-0 absorbable running monofilament B

Figure 49-4A, B

Excess skin remaining

Figure 49-5

Scarpa’s fascia attached to pubic periosteum and Colles fascia

Figure 49-6

Excess skin elevated and marked

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Chapter 49 • APEX (Proximal) Thigh Lift

POSTOPERATIVE CARE Walking and drinking fluids are highly encouraged and mandatory after surgery. Foot pumps are critical for thromboembolism prophylaxis. Urine catheter may be maintained in women for 3–5 days for comfort and ease with toileting. The first postoperative visit occurs a week after surgery, at which time any sutures are removed. The patient is instructed not to perform any lifting or lower extremity exercise for 1 month. Stair climbing must be minimized as well. The second postoperative visit occurs 6 weeks after the first as long as healing is proceeding well, and then patients are followed as needed.

PITFALLS Liposuction is okay for the knee but not the thigh where resection is being performed. Liposuction may lead to wound healing problems, infections, and chronic drainage. If patients have a thick subcutaneous fat layer, they should either lose more weight or have a first-stage liposuction followed by thigh lift several months later. MWL patients tend to have attenuated tissue. Excellent suspension to periosteum must be confirmed when performing proximal thigh lift. The weakest tissue will be in the thigh skin in the Scarpa’s fascia layer, not the periosteum, and too much tension will cause tearing of this tissue. The problem area with regard to higher tension typically occurs at the junction between anterior

and posterior incisions. Careful attention must be paid to not overresecting this area. Overresection will cause thicker scarring and may efface the junction between the thigh and the pubis, with possible labial retraction and visible scar. This technique addresses the upper third to half of the thigh. Many MWL patients present with a superior thigh pannus that responds well to this technique. This technique is not applicable to patients with significant skin laxity and redundancy along the length of the thigh: these patients require extended thigh lift.

TIPS Patients must be prepared preoperatively for the discomfort they may experience after this procedure. Suture suspension to periosteum is uncomfortable and limits bending at the waist, that is, for sitting and tying shoes. Bupivacaine pain pump catheter placement may help with this. As long as the expectation is there, the patients will neither be surprised nor upset. This thigh lift is well complemented by abdominoplasty and back lift, as well as outer thigh liposuction. The secondary thigh lift provided by belt lipectomy combined with direct thigh lift results in powerful results. If thigh lift is performed in combination with back lift, do the back lift first and adjust the markings as needed since the thigh will get some secondary lift from the back lift. Similarly, abdominoplasty should be performed prior to thigh lift anteriorly so that appropriate adjustments can be made in the thigh markings.

263

A

C

A

B

D

Figure 49-7A, B. This 26-year-old female lost 300 lbs through a combination of diet, exercise and laparascopic gastric bypass surgery. C, D: 11 months after lower body lift with backlift, abdominoplasty and APEX thighlift, demonstrating removing of lax, redundant inner thigh skin, with secondary improvement of buttock contour.

B

Figure 49-8A, B. This 49-year-old woman lost 90 lb after laparascopic gastric bypass surgery. She presented with an interest in lower body lift, including the lower torso and thigh. She had significant loss of fullness in the buttock area. The decision was made to proceed with APEX thigh lift in conjunction with a belt lipectomy and autologous gluteal augmentation. The postoperative photographs were taken 6 months after surgery.

Chapter 50.

Extended Thigh Lift

INTRODUCTION

be well-padded and stabilized on these bars to avoid neuropathy, and they can be spread to allow best access for excision and closure, allowing other team members to work outside the thigh to assist in proximal closure (Figure 50-2). Foot pumps are necessary for thromboembolism prophylaxis. Anesthesia is induced, and a Foley catheter is placed. An upper body-warming blanket is placed. The thighs are prepared and draped in sterile fashion. Incision is made distally, defining the anterior and posterior incisions, and made in a stepwise fashion proximally. The depth of excision should be just below Scarpa’s fascia but above the level of the saphenous vein. Injuring the saphenous vein may result in postoperative lymphedema. The Scarpa’s fascia is progressively approximated from distal to proximal with simple interrupted #2-0 braided absorbable suture or with an absorbable barbed suture of comparable caliber (Figure 50-3). Closure should be performed over a 10-mm drain. As excision progressed proximally, the markings are adjusted more widely or narrowly as needed to avoid over- or underresection. As the pubis is approached, resection occurs from proximal to distal with the bottleneck to meet the distal resection. Proximal resection does not need to extend superior to the pubis and may end midpubis. Suspension to the pubic and ischial periosteum should not be necessary as axis of pull is horizontal and not vertical. Excision in the groin area is very shallow to avoid injury to lymphatics and venous structures. The dermis of the thigh is approximated with interrupted, buried, absorbable #3-0 monofilament suture, followed by a running intracuticular #4-0 absorbable monofilament suture (Figure 50-4). Tissue glue is placed on the incision closure, preventing the need for dressings postoperatively.

Extended thigh lift is a classic example of the need for exchange of scar for contour, the most powerful technique we have for thigh shaping but with the associated elevated risk for complication and visible scarring.

INDICATIONS This procedure addresses skin excess of the thigh extending from pubis to knee that cannot be addressed with a proximal procedure alone. This is the procedure of choice for patients with significant skin laxity, poor skin quality, and skin excess down to or below the knee. Patients must understand and accept the scar that accompanies this procedure. Of note, this procedure is less painful than the proximal thigh lift as suspension to pelvic periosteum is not necessary.

MARKINGS Patients are marked standing up. The groin crease is marked symmetrically along the mons pubis edge. The incision is extended posteriorly into the infragluteal crease, and this is marked. A pinch test is performed to define the amount of skin that may be safely excised, and crosshatches are drawn to ultimately assist in closure. A “bottle neck” modification can be made at the mid to lower aspect of the pubis to minimize tension at the point between the pubis and the thigh (Figure 50-1). The goal is to have the scar on the thigh fall along the medial thigh so that it is not visible and appears smooth. If too anterior, it will be visible. If too posterior, full fat of the posterior thigh may cause irregularity of the scar contour with undesirable fullness.

DETAILS OF PROCEDURE To best execute this procedure, an operating room table with leg extender bars is recommended. The legs need to

264

265

Groin markings Thigh markings Bottleneck

Thigh markings Hatch marks Pinch test guides markings Figure 50-1

Figure 50-2

Sequential excision & closure from distal to proximal above plane of saphenous vein

Scarpa’s fascia approximated with running barbed suture Drain exits distal incision Figure 50-3 Axis of pull Skin closed with #3-0 monofilament dermal and #4-0 monocryl subcuticular sutures

Figure 50-4

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Chapter 50 • Extended Thigh Lift

POSTOPERATIVE CARE It is most advisable that patients be admitted for overnight observation after thigh lift, with the risk of thromboembolism that this procedure presents. The patients must be ambulatory and well hydrated. Foot pumps and subcutaneous heparin or unfractionated heparin are required for antithromboembolism prophylaxis. The urinary catheter in women may be maintained for the first 3–5 days for comfort and ease of toileting. Patients are encouraged to keep their legs elevated and wear antiembolism support stockings to avoid swelling below the knee. The first postoperative visit occurs a week after surgery, at which time the drain is typically removed. If draining more than 50 cc a day, it should be maintained longer, moving to sclerosis if the drainage does not appropriately decrease in the first 3 weeks. Continued drainage may indicate a lymphatic leak that may respond to sclerosis or aspiration and compression after the drain is removed. The patient is instructed not to perform any lifting or lower extremity exercise for 1 month. The second postoperative visit occurs 6 weeks after the first if drains are removed, and then patients are followed as needed.

PITFALLS Liposuction of the thigh at the time of thigh lift increases risk of seroma, wound healing, and lymphedema. While some surgeons encourage the use of liposuction to improve contouring outcome and assist in finding plane of resection, it is safer not to perform liposuction as better healing results. If the patient still has a thick thigh, further weight loss should be recommended, or if weight loss has plateaued, then liposuction may be considered as a firststage procedure, followed by a second-stage thigh lift. Many patients who present for thigh lift have ropey varicose veins in the thigh. As these present a risk for bleeding and increase the risk of thromboembolism, these patients should be seen by a vascular surgeon prior to plastic surgery to address these veins appropriately. The subcutaneous fat of the thigh differs anteriorly and posteriorly. Anteriorly, the thigh subcutaneous fat

layer tends to be thinner and softer. Posteriorly, fat tends to be denser, thicker, and more fibrous. Apposition of the anterior and posterior tissue may result in a full scar which is unsightly. The incision should be more anterior than posterior to avoid this irregularity in scar outcome. Adjusting excision width as thigh lift progresses is the best way to achieve the best contour under optimal tension which is not too tight. Higher tension closure may result in thicker scars or wound healing problems. This thigh lift is more often associated with lymphedema relative to the proximal thigh lift. If there is significant lymphedema or asymmetry in calf dimension, a very low threshold is necessary for venous duplex to rule out deep venous thrombosis.

TIPS The operating room table with leg extenders is key in best performing this operation. Pain pump catheters with 1⁄4% bupivacaine may be used, entering proximally and traveling in the subcutaneous plane distally, to assist in postoperative pain management. In consultation, patients will often pull their skin a certain way to demonstrate the tightened look they desire. Consultation is very important in discussing reasonable outcomes and the trade-offs that accompany certain approaches to thigh lift. While many patients are happy to exchange a visible scar for a more powerful contour result, others may prefer a hidden scar. The patient needs to elicit a response to the question of scar versus contour, and in some cases, the method of thigh lift may be a clear choice according to the surgeon’s experience. This must be communicated well to the patient. Some patients are best treated with extended thigh lift with visible scar if they have very lax, redundant skin along the length of the thigh: these patients are not candidates for proximal thigh lift. Tissue glue is great as a final layer to incision closure. With glue in place, the patients do not require dressings which are hard to maintain on the thigh. Elastic bandages on the thigh are particularly dangerous as they may become a tourniquet causing thigh necrosis.

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A

B

C D Figure 50-5A–D. A, B. This 49-year-old woman lost 150 lb after open gastric bypass surgery. She presented after prior abdominoplasty with an interest in thigh lift and arm lift. She had significant redundant skin along the length of the thigh with lax skin. In addition, she had a remote history of a lymph node dissection in the groin for Hodgkin’s lymphoma staging. The decision was made to proceed with extended thigh lift which would best address the skin laxity while also allowing limited dissection up to midpubis, avoiding the groin region altogether. C. The postoperative photographs were taken 8 months after surgery, and thigh healing occurred without any complications. D. The patient also under went lower backlift.

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Index Page numbers followed by f and t indicate figures and tables, respectively. A Abdomen, anatomy of, 152–153 Abdominal contouring surgery abdominal wall plication, 162–167 anatomy, 152–153 hernias, 148, 149f lipodystrophy, 144, 145f liposuction, 154–161 male body contouring, 146, 147f massive panniculectomy, 182–185 massive pannus, 150, 151f massive weight loss, 146, 147f mini-abdominoplasty, 168–173 panniculectomy, 178–181 postpartum woman, 144, 145f presentation for, 144–151 reverse abdominoplasty, 174–177 umbilical hernia repair, 192–197 ventral hernia repair, 186–191 Abdominal etching, 154 Abdominal hernias, 148, 149f Abdominal liposuction etching, 154 positioning, 154 postoperative care, 158 preoperative markings, 154 procedure, 154, 155f, 156, 157f secondary procedure, 154 Abdominal panniculectomy, 24f, 25f, 26f, 178–185 Abdominal scarring with deformity, 148, 149f Abdominal wall plication, 192, 194 Abdominoplasty, 20, 27f, 77f, 109, 119f, 181f, 226f, 229f, 234 abdominal contouring, presentation for, 144–151 with abdominal wall plication, 162–167 anatomy of abdomen, 152–153 liposuction, abdominal, 154–161 massive panniculectomy, 182–185 mini. See Mini-abdominoplasty panniculectomy, 178–181 traditional, 144 See also Reverse abdominoplasty; Umbilical hernia repair; Ventral hernia repair AGA (autologous gluteal augmentation). See Belt lipectomy Anatomy abdomen, 152–153 arm, 34–35 breast, 60–61 back, 204–205 chest, male, 104–105 thigh, 246–247 Anterior–posterior proximal extended thigh lift. See APEX (proximal) thigh lift

APEX (proximal) thigh lift care after operation, 262 complications, 262 markings of patients, 258, 259f operation procedure, 258, 259f, 260, 261f, 263f patient preparation, 262 patients for, 258 Arm anatomy of, 34–35 brachioplasty, extended, 48–51 brachioplasty, minimal incision, 52–55 brachioplasty, traditional, 42–47 liposuction. See Upper extremity liposuction presentation for contouring, 32–33 skin, excision of, 50 Arnica montana, 18, 38, 108, 158, 172, 210, 228, 254 Artery axillary, 34, 35f brachial, 34, 35f, 45f, 60, 61f deep femoral, 248, 249f femoral, 248, 249f inferior gluteal, 250, 251f intercostal arterial perforators, 60, 61f, 204, 204f internal thoracic, 104, 105f lateral mammary branches of lateral cutaneous branch of posterior intercostals, 104, 105f lateral mammary branches of posterior intercostal arteries, 60, 61f perforating arteries from internal thoracic, 104, 105f popliteal, 246, 247f superficial circumflex iliac, 248, 249f superficial epigastric, 248, 249f superficial external pudendal, 248, 249f Autoaugmentation of breast. See Wise pattern mastopexy autoaugmentation Autologous breast augmentation. See Upper body lift Autologous gluteal augmentation, 232–238, 263f. See also Belt lipectomy B Back anatomy of, 204–205 contouring amplification of volume needed, 202, 203f lipodystrophy, 200, 201f massive weight loss (lower back), 202, 202f massive weight loss (upper back), 200, 201f liposuction, 211f, 212f, 213f indications for, 206 operation procedure, 206, 207f, 208, 209f postoperation care, 210 patient markings, 206, 207f tissue circulation, 224 Backlift, 229f. See also Lower back lift; Upper back lift Bariatric surgery, 20

269

270

Index

Belt lipectomy, 202, 232–238 complications, 236 indications, 232 markings of patients, 232, 233f operation procedure, 232, 233f, 234, 235f, 237f, 238f postoperative care, 236 scar management, 236 BMI. See Body mass index Body mass index (BMI), 20, 47f, 51f, 77f, 181f Bone clavicle, 60, 61f scapula, 206, 207f sternum, 60, 61f, 70 ulna, 34, 35f Brachioplasty extended complications, 50 indications, 48 postoperative care, 50 procedure details, 48, 49f minimal incision, 28f indications, 52 limitations, 54 markings, 52 postoperative care, 54, 55f procedure details, 52, 53f traditional complications, 46 indications, 42 markings, 42 postoperative care, 46 procedure details, 42, 43f, 44, 45f, 47f Breast anatomy of, 60–61 augmentation, 47f, 86–93 autologous. See Upper body lift deformity, 59, 59f lifting, 58, 76, 92, 181f liposuction indications, 62 limitations, 64 markings, 62 postoperative care, 64 procedure details, 62, 63f presentation for contouring, 58–59 surgery for breast deformity, 59, 59f congenital breast asymmetry, 59 massive weight loss, 58, 58f postpartum woman, 58, 58f symptomatic macromastia, 59, 59f Bromelain, 18 C Caval filter, 26f Chest liposuction. See Liposuction of chest Chondroitin, 18 Complication management hematoma, 27–28 infection, 24 lymphedema, 26 neuromas, 28 neuropathy, 28 seromas, 22–24 venous thromboembolism, 26 wound healing complication, 22 Congenital breast deformity, 59, 59f, 103, 103f

D Dercum’s disease, 38 Dietary Supplement Health and Education Act of 1994, 18 Duplex ultrasound, 26 E Echinacea, 18 Ephedra (Ma-huang), 18 Etching, abdominal, 154 Extended thigh lift markings, 264, 265f operation procedure, 264, 265f, 267f patients for, 264 postoperative care, 266 risks, 266 F Fat emboli, 158 Fat grafting, 206–213 Female breast, anatomy of, 60–61 G Garlic, 18 Gastric bypass surgery, 20, 51f, 231f Ginger, 19 Gingko, 18 Ginseng, 18 Glucosamine, 18 Glue, medical, 216, 218, 228, 234, 236 Gluteal anatomy, 204–205 Gluteal contour, 213f Gluteal flaps, 233f Goldenseal, 19 Grape seed, 19 Gynecomastia anatomy of, 104–105 congenital breast deformity, 103, 103f correction, 109f, 119f excisional technique indications, 110 limitations, 112 markings, 110 postoperative care, 112 procedure details, 110, 111f J excision technique, extended chest contour, goal of, 140 limitations, 140 males with with congenital gynecomastia, 134 markings of patient, 134, 135f postoperative care, 140 procedure, 136, 137f, 138, 139f liposuction. See Liposuction of chest massive weight loss gynecomastia, 103, 103f vertical excision technique limitations, 128 males with congenital breast deformity, 128 markings of patient, 128 procedure, 128, 129f, 130, 131f wise pattern excision technique, 125f, 126f, 127f limitations, 124 males with massive weight loss, 120 patient markings, 120 postoperative care, 124 procedure, 120, 121f, 122, 123f

Index H Hematoma, 27–28 Herbal medications Arnica montana, 18 Bromelain, 18 Chondroitin, 18 Echinacea, 18 Ephedra (Ma-huang), 18 garlic, 18 ginger, 19 Gingko, 18 Ginseng, 19 glucosamine, 19 goldenseal, 19 grape seed, 19 kava, 19 milk thistle, 19 saw palmetto, 19 St. John’s Wort, 19 valerian, 19 vitamin A, 19 vitamin B12, 19 vitamin C, 19 vitamin E, 19 Hernia abdominal, 148, 149f repair, 186–190, 192–197 umbilical, 192–197 See also Umbilical hernia repair; Ventral hernia repair I IMF. See Inframammary fold Inframammary fold (IMF), 60, 61f, 86, 94, 104, 105f, 114, 120, 128, 174, 176, 220 Inner thigh contour deformity, 244, 245f J J excision technique, extended. See under Gynecomastia K Kava, 19 L Lidocaine, 62 Lipodystrophy, 32, 109, 144, 145f, 200, 201f, 228, 240, 241f, 255f Lipomatosis syndromes, 32, 33f Liposuction, 10, 13, 32, 36–41, 54, 106–113, 154–161, 168, 206–213, 252–257 abdominal. See Abdominal liposuction of back. See Back liposuction of breast. See Breast, liposuction of of chest, 113f indications, 106 limitations, 108 markings, 106 postoperative care, 108 procedure details, 106, 107f, 109f of thigh, See Thigh liposuction Lower back lift, 226–231 operation care after operation, 228 procedure, 226, 227f, 229f, 230f patient markings, 226 patients for, 226 risks, 228 care management, 228

271

Lower extremity anatomy of, 246–251 contouring lipodystrophy, 240, 241f massive weight loss, 242, 243f post-surgical inner thigh contour deformity, 244, 245f thin patient with skin laxity, 240, 241f liposuction markings, 252, 253f operation procedure, 252, 253f, 255f, 256f, 257f patients for, 252 postoperative care, 254 risks, 254 Lymphazurin dye injection, 24, 25f Lymphedema, 26, 28f, 32, 33f M Madelung’s deformity, 38, 39f, 40f Male chest anatomy of, 104–105 Massive pannus, 150, 151f Massive weight loss, 20–21, 23f, 32, 33f, 58, 58f, 146, 147f, 242, 243f, 262 Mastectomy (horizontal approach) limitations, 118 males with massive weight loss, 114 markings of patient, 114 postoperative care, 118 procedure, 114, 115f, 116, 117f Mastopexy, 72–77, 86–93, 167f technique, 58 vertical. See Vertical pattern mastopexy Medications, herbal. See Herbal medications Milk thistle, 19 Mini-abdominoplasty ideal candidates for, 168 liposuction, 168, 172 operation care after, 172 complications, 172 procedure, 168, 169f, 170, 170f patient markings, 168 plication, 172 Minimal incision brachioplasty. See under Brachioplasty Morbid obesity, 20 Muscle adductor longus, 248, 249f adductor magnus, 248, 249f biceps brachii, 34, 35f biceps femoris, 248, 249f brachialis, 34, 35f brachioradialis, 34, 35f external oblique, 204, 205f gluteus maximus, 204, 205f gracilis, 248, 249f internal oblique, 154, 155f latissimus dorsi, 34, 35f, 60, 61f, 104, 105f, 154, 155f, 204, 205f, 206, 207f longhead triceps, 34, 35f pectineus, 248, 249f pectoralis, 60, 61f pectoralis major, 104, 105f rectus abdominus, 154, 155f rectus femoris, 248, 249f sartorius, 248, 249f semimembranosus, 248, 249f

272

Index

Muscle (continued) semitendinosus, 248, 249f serratus, 60, 61f, 154, 155f serratus anterior, 104, 105f triceps, 34, 35f trapezius, 204, 205f transversalis, 154, 155f vastus lateralis, 248, 249f vastus medialis, 248, 249f MWL. See Massive weight loss N Nerve antebrachial cutaneous, 34, 35f anterior cutaneous branches of intercostals, 152, 153f anterior femoral cutaneous, 248, 249f biceps, 34, 35f brachial, 34, 35f brachial plexus, 34, 35f cluneal, 206, 207f, 248, 249f common peroneal, 248, 249f femoral, 248, 249f genital branch of genitofemoral, 248, 249f ilioinguinal, 152, 153f intercostal, 154, 155f medial antebrachial cutaneous, 34, 35f median, 34, 35f pectoralis major, 104, 105f posterior femoral cutaneous, 248, 249f radial, 34, 35f sciatic, 206, 207f tibial, 248, 249f ulnar, 34, 35f Neuromas, 28 Neuropathy, 28 Nipple grafting, 125f, 126f, 127, 133f in male, 103f See also Wise pattern superior pedicle breast reduction P PAL. See Power-assisted liposuction Panniculectomy abdominal, 24f, 25f, 26f conservative, 185f massive operation procedure, 182, 183f markings, 182 patients for, 182 postoperative care, 184 recommendations for, 184 risks involved, 184 for obese patients, 178 operative procedure, 178, 179f postoperative care, 180 patient markings, 178 patient preparation, 178 Pfannenstiel scar, 144 Poland syndrome, 59 Postpartum woman, 58, 58f, 144, 145f Power-assisted liposuction (PAL), 62, 109f, 154, 173f, 206, 208, 211f, 212f, 234, 237f, 255f, 257f Prone positioning precautions, 258 Psychiatric evaluation, 10–17 R Reverse abdominoplasty operative procedure, 174, 175f

pain management, 176 patient markings, 174 patients for, 174 rectus sheath, 154, 155f S Saw palmetto, 19 Scar management abdominoplasty, 166 belt lipectomy, 236 breast augmentation, 76 gynecomastia excisional technique, 110–112 J excision technique, 110–112 vertical excision technique, 132 wise pattern excision technique), 124 lower back lift, 228 mastectomy, 118 upper back lift, 218 upper body lift, 224 vertical pattern mastopexy, 92 wise pattern superior pedicle breast reduction, 98 Seromas, 22–24 abdominal, 24f Spiral computed tomography, 27f St. John’s Wort, 19 Steroid injection, 22, 46 for extended branchioplasty, 50 Superior pedicle breast reduction. See Wise pattern superior pedicle breast reduction T Thigh lift APEX (proximal). See APEX (proximal) thigh lift extended. See Extended thigh lift techniques, 229f, 231f, 240, 241f, 242 Thigh liposuction, 177f, 237, 262 U UAL. See Ultrasound-assisted liposuction Ultrasound-assisted liposuction, 41f, 102f, 106, 154, 206, 208, 234 Umbilical hernia repair, 144, 168, 170, 192–197 abdominoplasty evaluation, 192 markings of patient, 192 operation procedure, 192, 193f, 194, 195f risks in, 196 Upper back contouring, 200–203 Upper back lift limitations, 218 markings of patients, 214 operation procedure, 214, 215f, 216, 217f patients for, 214 postoperative care, 218 scar management, 218 Upper body lift breast lift markings, 220, 221f ideal patients for, 220 limitations, 224 operation procedure, 220, 221f, 222, 223f, 225f postoperative care, 224 scar management, 224 Upper extremity anatomy, 34–35 brachioplasty, extended, 48–51

Index brachioplasty, minimal incision, 52–55 brachioplasty, traditional , 42–47 contouring disproportionate arms with lipodystrophy, 32, 33f lax arm skin, 32, 33f lymphedema and lipomatosis syndromes, 32 massive weight loss, 32, 33f liposuction indications, 36 markings, 36 postoperative care, 38 procedure details, 36, 37f risk, 38 urachus, 154, 155f V VAC. See Vacuum-assisted closure Vacuum-assisted closure, 22, 98 Varicose veins, 240 Vein accessory saphenous, 248, 249f basilic, 34, 35f brachial, 34f, 35f femoral, 152, 153f, 248, 249f great saphenous, 248, 249f median, 34, 35f subclavian, 34, 35f superficial circumflex iliac, 248, 249f superficial epigastric, 152, 153f superficial external pudental, 248, 249f thoracic, 60–61 Venous duplex, 27, 27f, 28 Venous thromboembolism (VTE), 26, 180, 184 Ventral hernia repair care after operation, 190 indications for, 186 limitations, 190 operation procedure, 186, 187f, 188, 189f patient markings, 186 Vertical extended thigh lift, 236, 264–267 Vertical pattern breast reduction complications, 84 indications, 78 markings, 78

postoperative care, 84 procedure details, 78, 79f, 80, 81f, 82, 83f suggestions, 84 Vertical pattern gynecomastia mastectomy, 128–133 Vertical pattern mastopexy, 86–93, 93f, 133f complications, 92 indications, 86 markings, 86 postoperative care, 92 procedure details, 86, 87f, 88, 89f, 90, 91f Vitamin A, 19 Vitamin B12, 19 Vitamin C, 19 Vitamin E, 19 VTE. See Venous thromboembolism W Wise pattern breastlift, 72–77, 222 Wise pattern breast reduction indications, 66 limitations, 70 markings, 66 postoperative care, 70 procedure details, 66, 67f, 68, 69f Wise pattern mastopexy with autoaugmentation indications, 72 limitations, 76 markings, 72 postoperative care, 76 procedure details, 72, 73f, 74 Wise pattern superior pedicle breast reduction complications, 98 indications, 94 markings, 94 postoperative care, 98 procedure details, 94, 95f, 96, 97f, 99f Wound axillary, 50 care. See Surgical wound care healing complication, 22 Z Z-plasty scar revision, 46 in axilla, 48 scar revision, 46

273