Body Contouring and Liposuction E-Book
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1241 pages
English

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Description

Master the full spectrum of "body sculpting" procedures with Body Contouring and Liposuction by J Peter Rubin, MD, FACS, Mark L Jewell, MD, Dirk Richter, MD, PhD, and Carlos O Uebel, MD, PhD! From fat grafts and liposuction through total body lift following massive weight loss surgery, full-color photos and procedural videos show you exactly how to proceed, step by step, and achieve gratifying results.

  • Consult this title on your favorite e-reader with intuitive search tools and adjustable font sizes. Elsevier eBooks provide instant portable access to your entire library, no matter what device you're using or where you're located.
  • Exceed your patients' expectations thanks to expert, multimedia guidance from many of today's most accomplished experts in aesthetic plastic surgery.
  • Know what to look for and how to proceed thanks to videos and full-color illustrations demonstrating brachioplasty, breast reshaping after massive weight loss, thigh and buttock contouring, combining abdominoplasty and mastopexy, and other in-demand procedures.
  • Find the answers you need quickly through a user-friendly organization.
  • Access the complete contents online, as well as videos and downloadable illustrations, at www.expertconsult.com.

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Publié par
Date de parution 26 octobre 2012
Nombre de lectures 1
EAN13 9781455737963
Langue English
Poids de l'ouvrage 6 Mo

Informations légales : prix de location à la page 0,0925€. Cette information est donnée uniquement à titre indicatif conformément à la législation en vigueur.

Exrait

with Body Contouring and Liposuction by J Peter Rubin, MD, FACS, Mark L Jewell, MD, Dirk Richter, MD, PhD, and Carlos O Uebel, MD, PhD! From fat grafts and liposuction through total body lift following massive weight loss surgery, full-color photos and procedural videos show you exactly how to proceed, step by step, and achieve gratifying results.

  • Consult this title on your favorite e-reader with intuitive search tools and adjustable font sizes. Elsevier eBooks provide instant portable access to your entire library, no matter what device you're using or where you're located.
  • Exceed your patients' expectations thanks to expert, multimedia guidance from many of today's most accomplished experts in aesthetic plastic surgery.
  • Know what to look for and how to proceed thanks to videos and full-color illustrations demonstrating brachioplasty, breast reshaping after massive weight loss, thigh and buttock contouring, combining abdominoplasty and mastopexy, and other in-demand procedures.
  • Find the answers you need quickly through a user-friendly organization.
  • Access the complete contents online, as well as videos and downloadable illustrations, at www.expertconsult.com.

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Body Contouring and Liposuction

J. Peter Rubin, MD, FACS
UPMC Endowed Professor of Plastic Surgery, Chair, Department of Plastic Surgery, Director, Life After Weight Loss Body Contouring Program, University of Pittsburgh, Pittsburgh, PA, USA

Mark L. Jewell, MD
Assistant Clinical Professor of Plastic Surgery, Oregon Health Science University, Portland, OR
Jewell Plastic Surgery Center, Eugene, OR, USA

Dirk F. Richter, MD, PhD
Associate Professor, University of Bonn, Chief, Department of Plastic and Reconstructive Surgery, Director of the Dreifaltigkeits, Krankenhaus, Wesseling, Germany

Carlos O. Uebel, MD, PhD
Associate Professor, Division of Plastic Surgery, PUCRS University, Porto Alegre, Brazil
Saunders
Table of Contents
Instructions for online access
Cover image
Title page
Copyright
Preface
List of Contributors
Dedications
Introduction: Body contouring surgery – a fifty year perspective
Part 1: Patient evaluation and safety
Chapter 1: Patient safety in body contouring
Introduction
Preoperative Assessment and Patient Selection
Intraoperative Management
Staging
Postoperative Management
Postoperative Nausea and Emesis (PONV)
Patient Safety in Your Practice
Complications and Their Management
Conclusion
Part 2: Upper extremity contouring
Chapter 2: Liposuction of the upper extremities
Introduction
Preoperative Preparation
Surgical Technique
Forearm
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Conclusion
Chapter 3: Brachioplasty with bicipital groove scar
Introduction
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Chapter 4: Brachioplasty – the double ellipse technique
Introduction
Preoperative Preparation
Surgical Technique
Postoperative Care
Optimizing Outcomes
Complications and Their Management
Conclusion
Chapter 5: Brachioplasty with liposuction resection
Introduction
Preoperative Preparation
Surgical Technique (Fig. 5.3)
Optimizing Outcomes
Postoperative Management
Complications and Their Management
Conclusion
Chapter 6: Limited scar brachioplasty
Introduction
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications
Conclusion
Part 3: Breast
Chapter 7: Fat grafting to the breast
Introduction
History of Fat Grafting
Principle of Low Pressure Fat Harvesting
Autologous Fat Grafting to the Breast
Postoperative Care
Fat Grafting for Implant Failure
Fat Grafting in Conjuction with Mastopexy
Fat Grafting for Augmentation
Fat Grafting Over Existing Implants
Fat Grafting for Breast Reconstruction
Fat Grafting for Congenital Breast Deformities
Optimizing Outcomes
Conclusion
Chapter 8: Ultrasound-assisted breast reduction
Introduction
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Clinical Results
Complications and Their Management
Conclusion
Chapter 9: Combined abdominal contouring and mastopexy
Introduction
Abdominoplasty
Postoperative Remarks and Optimizing Outcomes
Complications and Their Management
Conclusion
Chapter 10: Breast reshaping using autologous tissues after massive weight loss
Introduction
Clinical Approach
Preoperative Preparation
Surgical Technique
Postoperative Care
Complications and Their Management
Conclusion
Chapter 11: Combined abdominoplasty and breast enlargement by autologous tissue transfer or transabdominal implant placement
A Augmentation Mammaplasty by Reverse Abdominoplasty
B Transabdominal Breast Augmentation
Chapter 12: Mammaplasty with L-shaped scar
Introduction
Proportions and Anatomy of the Beautifully Shaped Breast
Measurement
Surgical Technique
Mammaplasty with L-Shaped Scar
Chapter 13: Breast reshaping after massive weight loss: Autologous tissue techniques
Introduction
Preoperative Preparation
Surgical Procedure
Optimizing Outcomes
Postoperative Care
Complications
Conclusions
Chapter 14: Breast reshaping after massive weight loss, implant based
Introduction
Preoperative Preparation
Preoperative Planning – Primary Augmentation Mammaplasty
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Conclusion
Part 4: Upper trunk contouring
Chapter 15: Liposuction of upper back/bra rolls
Introduction
Anatomical Aspects
Surgical Treatment
Postoperative Care and Results
Complications
Conclusion
Chapter 16: Transverse upper body lift
Introduction
Preoperative Preparation
Surgical Technique
Postoperative Care
Complications and Management
Conclusion
Chapter 17: Upper body lift with lateral excision
Introduction
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Conclusion
Part 5: Abdominal contouring procedures
Chapter 18: Aesthetic classification of the abdomen
Introduction
Preoperative Preparation
Options
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Prevention, Diagnosis, and Management
Conclusion
Chapter 19: Anatomy of the abdominal wall and aesthetic classification
Introduction
Anatomy of the Anterior Abdominal Wall and its Surgical Implications on Abdominoplasty
Preoperative Preparation
Optimizing Outcomes
Postoperative Care
Local Complications and Their Management
Conclusion
Chapter 20: Lipomyosculpture
Introduction
Preoperative Preparation
Morpho-Histology of Subcutaneous Adipose Tissue
Surgical Technique
Postoperative Care
Complications
Conclusion
Chapter 21: Classic abdominoplasty with adhesion tension sutures
Introduction
Surgical Technique
Seven Comments
Chapter 22: Lipoabdominoplasty with previous flap resection
Introduction
Preoperative Preparation
Surgical Technique
Postoperative Care
Complications and Their Management
Comments and Conclusion
Chapter 23: Reverse abdominoplasty
Introduction
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Conclusion
Chapter 24: Endoscopic plication techniques for the treatment of abdominal contour
Introduction
Basic Science
Diagnosis/Patient Presentation
Patient Selection
Surgical Technique
Postoperative Care
Outcomes, Prognosis, and Complications
Chapter 25: High lateral tension abdominoplasty
Introduction
Preoperative Preparation
Anatomy
Surgical Technique
Postoperative Care
Optimizing Outcomes
Complications and Their Management
Conclusion
Chapter 26: Fleur-de-lis abdominoplasty including mons contouring
Introduction
Preoperative Preparation
Surgical Technique
Postoperative Care
Complications and Their Management
Conclusion
Chapter 27: Panniculectomy in patients with super obesity
Introduction
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Treatment
Complications and Their Treatment
Conclusion
Chapter 28: Lipoabdominoplasty
Introduction
History
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Conclusion
Summary of Advantages
Summary of Disadvantages
Summary of Steps
Introduction
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Conclusion
Chapter 29: Umbilicoplasty
Introduction
Preparation, Diagnosis, and Patient Presentation
Surgical Technique
Postoperative Care
Outcomes, Prognosis, Complications
Chapter 30: Combining abdominal contouring with hernia repair
Introduction
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Conclusion
Chapter 31: Liposuction of the abdomen and trunk
Introduction
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Conclusion
Chapter 32: Belt lipectomy/circumferential abdominoplasty
Introduction
Relevant Anatomy
Disease Process
Diagnosis and Presentation
Preoperative Preparation
Surgical Technique
Postoperative Care
Complications and Their Management
Conclusion
Chapter 33: Progressive tension sutures in abdominoplasty
Introduction
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Conclusion
Part 6: Thigh, buttock and lower extremity contouring
Chapter 34: Transverse medial thigh lift
Introduction
Preoperative Preparation
Anatomical Considerations
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Clinical Cases
Conclusion
Chapter 35: Vertical medial thigh lift with liposuction
Introduction
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Conclusion
Chapter 36: Short vertical scar medial thigh lift
Introduction
Applied Anatomy
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Conclusion
Acknowledgments
Chapter 37: Autologous gluteal augmentation with mid-pedicle superior pole perforator flaps
Introduction
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Conclusion
Chapter 38: Liposuction and circumferential lower truncal dermatolipectomy
Introduction
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Conclusion
Chapter 39: Gluteal contouring and rejuvenation
Introduction
Preoperative Preparation
Surgical Technique
Postoperative Care
Complications
Conclusion
Chapter 40: Buttock implants
Introduction
Evolution of Technique
Indications
Why Is the Subfascial Plane Recommended?
Preoperative Preparation
Liposculpting and Gluteal Implants
Surgical Procedure
Optimizing Outcomes
Adjunctive Procedures
Postoperative Care
Outcomes and Results
Complications and Their Management
The Problems of Superficial Planes: Subcutaneous and Subfascial
The Advantages of the Intramuscular Plane
Principles for Intramuscular Undermining
Surgical Technique
Postoperative Care
Complications
Implant Choice
Introduction
Anatomy
Surgical Technique
Postoperative Care
Discussion
Conclusion
Chapter 41: Buttock contouring with liposuction and fat injection
Introduction
Preoperative Preparation
Preparation in OR
Fat Injections
Postoperative Care
Chapter 42: Liposuction of the lower extremities and leg reshaping with fat
Introduction
Preoperative Preparation
Alternative Treatment
Optimizing Outcomes
Complications
Results
Conclusion
Chapter 43: Calf and thigh implants
Introduction
Background
Anatomy
Materials and Methods
Surgical Technique
Discussion
Postoperative Care
Complications and Their Management
Conclusion
Part 7: Liposuction and fat grafting
Chapter 44: Lipoplasty – history and principles
Introduction
Evolution of Lipoplasty
Lipoplasty Begins and Gains Popularity in the US
Fundamentals of Lipoplasty
Secondary Lipoplasty
Postoperative Management
Conclusion
Chapter 45: Tumescent local anesthesia for liposuction
Introduction
Historical Background
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Contraindications
Chapter 46: Treatment of liposuction complications
Introduction
Complications and Their Management
Conclusion
Chapter 47: Fat grafting in body contouring surgery
Introduction
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Conclusion
Chapter 48: Minimal scar breast augmentation using autologous fat grafting
Introduction
Preoperative Preparation
Surgical Technique
Preparation Procedures of Graft Materials
SVF Isolation Procedure
Optimizing Outcomes
Pre- and Postoperative Care
Complications and Their Management
Conclusion
Chapter 49: Principles of new invasive modalities
A Laser-Assisted Liposuction
B Cryolipolysis
C External Ultrasonic Devices
Chapter 50: Ultrasonic liposuction
Introduction
Basic Physics of Ultrasonic Liposuction
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
UAL Complications and Their Management
Conclusion
Part 8: Body contouring with HIFU or injectables
Chapter 51: High intensity focused ultrasound and non-invasive body contouring
Introduction
Ultrasonic Energy
Tissue Thermodynamics
Tissue Effect and Biology of Thermal HIFU
Thermal HIFU as A Noninvasive Body Contouring Device
Clinical Research Results
The Liposonix Process
The Business of Noninvasive Body Contouring
The Future
Conclusion
Chapter 52: Mesotherapy for body contouring and cellulite
Introduction
Selection of Patients for Mesotherapy
Formulations
PrepAration for Mesotherapy
Injections
Side Effects and Treatment
Conclusion
Part 9: Special considerations for the massive weight loss patient
Chapter 53: Describing the deformities
Introduction
Anatomic Considerations
Surgical Considerations
Chronology
Conclusion
Chapter 54: Psychological and nutritional evaluation
Introduction
Nutritional Considerations for the Post-Bariatric Patient
Perioperative Considerations
Psychological Considerations for the Bariatric Patient
Discussion
Chapter 55: Staging and combining procedures
Introduction
Understanding Body Image and Weight Loss
Preoperative Evaluation of the Massive Weight Loss Patient
Patient Selection
Overview of Staging Strategies
Abdominoplasty/Mastopexy
Lower Body Lift/ Vertical Medial Thigh Lift
Upper Body Lift/Brachioplasty
Upper Body Lift/Lower Body Lift
Abdominal Wall Reconstruction/Abdominoplasty
Conclusion
Index
Copyright

SAUNDERS is an imprint of Elsevier Inc.
© 2013, Elsevier Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions .
This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
ISBN: 978-1-4557-0544-3
E-ISBN: 978-1-4557-3796-3
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Preface
Body contouring and liposuction is a wonderfully challenging and constantly evolving field at the intersection of surgical skill, artistry, and new technology. Through this highly impactful practice, we reshape the bodies and the lives of our patients.
This book was designed around a simple concept: to provide a comprehensive reference for the full spectrum of principles and techniques in body contouring and liposuction, as taught by the masters in the field across the globe. The resulting compilation truly covers all aspects of the specialty and puts into perspective applied anatomy, physiology, patient selection, safety, technical aspects, problem-solving, and management of complications.
The most up-to-date concepts are presented by leaders in the field. Important principles, some rooted in the early history of plastic surgery and others of more modern origin, come together to form the foundation of current practice. It is wonderful to see the evolution of this specialty, as well as the breadth and scope of the creative solutions we can use to sculpt the human form.
The international editorial team is greatly indebted to the numerous contributors from around the world who have so expertly composed the chapters in this book. The high quality of this book is a result of the time and effort they have spent distilling their techniques into such clear and well written monographs. Additional thanks goes to the talented members of the Elsevier staff who shepherded this project from inception to final form.

J. Peter Rubin, MD

Mark L. Jewell, MD

Dirk F. Richter, MD, PhD

Carlos O. Uebel, MD, PhD
2013
List of Contributors

José H. Aboudib, MD
Professor of Plastic Surgery President of Brazilian Society of Plastic Surgery Rio de Janeiro, Brazil

Al S. Aly, MD, FACS
Professor Director of Aesthetics Aesthetic and Plastic Surgery Institute The University of California Irvine Orange, CA, USA

Noriyuki Aoi, MD
Graduate student Department of Plastic Surgery University of Tokyo Graduate School of Medicine Tokyo, Japan

Shannon D. Armstrong, MD
Chief Resident Division of Plastic Surgery GRMEP/Michigan State University Grand Rapids, MI, USA

Ricardo A. Arnt, MD
Private Practitioner Adjunct Secretary of Brazilian Society of Plastic Surgery Porto Alegre, Brazil

Juarez Avelar, MD
Voluntary Assistant Professor Plastic Surgery Unit Medical School of Marilia Marilia, Brazil

Sergio Fernando Dantas de Azevedo, MD
Specialist member Brazilian Society of Plastic Surgery Sao Paulo, Brazil

Ana Z.D. Badin, MD, MS
Technical Director Department of Plastic Surgery Athena Medical Center Curitiba, Paraná, Brazil; MS in Surgery Federal University of Paraná (UFPR) Curitiba, Brazil

Ricardo Baroudi, MD
Private Practitioner Campinas São Paulo, Brazil

Catherine Bergeret-Galley, MD, FACS
Plastic Surgeon Private Practice Paris, France

Reena A. Bhatt, MD
Assistant Clinical Professor Department of Plastic Surgery Miriam and Rhode Island Hospitals The Warren Alpert Medical School Brown University Providence, RI, USA

Matheus Monseff Vieira Borela, MD
Resident Department of Plastic Surgery Santa Cecilia University São Paulo, Brazil

Ronald P. Bossert, MD
Assistant Professor of Surgery; Director Life After Weight Loss Program University of Rochester Medical Center Rochester, NY, USA

Antonio R. Bozola, PhD
Head of Plastic Surgery Department University of Medicine São José do Rio Preto, Brazil

Joseph F. Capella, MD, FACS
Chief, Post-Bariatric Body Contouring Division of Plastic Surgery Hackensack University Medical Center Hackensack, NJ, USA

Jennifer M. Capla, MD
Division of Plastic Surgery North Shore – LIJ Lenox Hill Hospital; Director Body Contouring Surgical and Medical Associates, PLLC New York, NY, USA

Robert F. Centeno, MD, MBA, FACS
Medical Director St Croix Plastic Surgery & MediSpa; Chief Medical Quality Officer Governor Juan F Luis Hospital & Medical Center Christiansted, VI, USA

Sydney R. Coleman, MD
Clinical Assistant Professor Department of Plastic Surgery New York University Medical Center New York, NY; Assistant Clinical Professor Department of Plastic Surgery University of Pittsburgh Medical Center Pittsburgh, PA, USA

Pablo Silva Frizzera Delboni, MD
Member of the Brazilian Society of Plastic Surgery Vitória, Espirito Santo, Brazil

Mauro F. Deos, MD
Private Practitioner Porto Alegre Rio Grande do Sul, Brazil

Barry E. DiBernardo, MD, FACS
Clinical Associate Professor Department of Surgery Division of Plastic Surgery University of Medicine and Dentistry of New Jersey Newark, NJ; Director New Jersey Plastic Surgery Montclair, NJ, USA

Kentaro Doi, MD
Graduate student Department of Plastic Surgery University of Tokyo Graduate School of Medicine Tokyo, Japan

Susan E. Downey, MD, FACS
Clinical Associate Professor of Plastic Surgery Keck School of Medicine University of Southern California Los Angeles, CA, USA

Hitomi Eto, MD
Graduate student Department of Plastic Surgery University of Tokyo Graduate School of Medicine Tokyo, Japan

Antonio Luiz Rocha Gesualdi Fernandes Neto, MD
Plastic Surgeon Associate Member of Brazilian Society for Plastic Surgery Hospital Mater Dei, Belo Horizonte Minas Gerais, Brazil

Madelyn H. Fernstrom, PhD, CNS
Professor of Psychiatry, Surgery, and Epidemiology Departments of Psychiatry and Surgery University of Pittsburgh School of Medicine Pittsburgh, PA, USA

Lydia M. Ferreira, MD, PhD, MBA
Head and Full Professor Division of Plastic Surgery Federal University of São Paulo São Paulo, Brazil; Coordinator Medicine III CAPES/Researcher CNPq

Peter B. Fodor, MD, FACS
Private Practice Los Angeles; Associate Clinical Professor Plastic Surgery UCLA Medical Center Los Angeles, CA, USA

James D. Frame, FRCS, FRCS(Plast)
Professor of Aesthetic Plastic Surgery Anglia Ruskin University Chelmsford, UK

Onelio Garcia, Jr., MD, FACS
Voluntary Assistant Professor Division of Plastic Surgery University of Miami Miller School of Medicine Miami, FL, USA

Alberto di Giuseppe, MD
Associate Professor Lipoplasty University of Austin Austin, TX, USA; Senior Surgeon Plastic Surgery Department University of Ancona Ancona, Italy

Raul Gonzalez, MD
Associate Professor of UNAERP Universidade De Ribeirao Preto Ribeirão Preto, São Paulo, Brazil

Renato Nelson de Moura Guerra, MD
Plastic Surgeon Associate Member of Brazilian Society for Plastic Surgery Hospital Mater Dei, Belo Horizonte, Minas Gerais, Brazil

Rodrigo Nelson de Moura Guerra, MD
Plastic Surgeon Associate Member of Brazilian Society for Plastic Surgery Hospital Mater Dei, Belo Horizonte Minas Gerais, Brazil

Sebastião Nelson Edy Guerra, MD
Full member of SBCP – Sociedade Brasileira de Cirurgia Plástica (Brazilian Society of Plastic Surgery); Past President, Brazilian Society of Plastic Surgery Chairman, Department of Plastic Surgery Professor and Provost, Training Center in Plastic Surgery Hospital Mater Dei, Belo Horizonte, Minas Gerais, Brazil

Hüseyin Güner, MD
Aesthetic and Reconstructive Surgeon Chief and General Manager Plastic, Aesthetic and Reconstructive Surgery Superplast Aesthetic and Eye Surgery Hospital Nisantasi, Istanbul, Turkey

Eduardo I. Gus, MD
Private Practitioner Porto Alegre Rio Grande do Sul, Brazil

Moustapha Hamdi, MD, PhD
Professor and Chairman of Plastic and Reconstructive Surgery Department of Plastic Surgery Brussels University Hospital Brussels, Belgium

Dennis C. Hammond, MD
Clinical Assistant Professor Department of Surgery Michigan State University College of Human Medicine East Lansing; Associate Program Director Plastic and Reconstructive Surgery Grand Rapids Medical Education and Research Center for Health Professions Grand Rapids, MI, USA

Charles K. Herman, MD, FACS
Chief Medical Executive Chairman Department of Surgery Chief Division of Plastic and Reconstructive Surgery Pocono Health Systems East Stroudsburg; Clinical Professor of Surgery The Commonwealth Medical College Scranton, PA; Clinical Assistant Professor of Surgery Albert Einstein College of Medicine New York, NY, USA

Erik A. Hoy, MD
Breast and Aesthetic Surgery Fellow Maxwell Aesthetics Nashville, TN, USA

Joseph P. Hunstad, MD, FACS
Associate Consulting Professor Division of Plastic Surgery The University Of North Carolina Chapel Hill; Section Head of Plastic Surgery Department of Surgery Carolinas Medical Center University Hospital, Charlotte; President The Hunstad Kortesis Center for Cosmetic Plastic Surgery Huntersville, NC, USA

Dennis J. Hurwitz, MD, FACS
Clinical Professor of Plastic Surgery University of Pittsburgh Medical Center Pittsburgh, PA, USA

Harunosuke Kato, MD
Graduate student Department of Plastic Surgery University of Tokyo Graduate School of Medicine Tokyo, Japan

Kim Youn Hwan, MD, PhD
Assistant Professor Department of Plastic and Reconstructive Surgery University of Hanyang Seoul, South Korea

Jordan Jacobs, MD
Assistant Professor Department of Surgery (Plastic) New York Medical College Valhalla, NY, USA

James L. Jewell
Medical Student University of Wollongong New South Wales, Australia

Mark L. Jewell, MD
Assistant Clinical Professor of Plastic Surgery Oregon Health Science University Portland, OR; Jewell Plastic Surgery Center Eugene, OR, USA

Hwang Weon Jung, MD, PhD
Plastic Surgeon J-One Aesthetic Clinic Seoul, South Korea

Kamran Khoobehi, MD, FACS
Clinical Professor of Surgery, Director of Aesthetic Surgery Training Louisiana State University New Orleans, LA, USA

Christopher D. Knotts, MD
Aesthetic Surgery Fellow The Hunstad-Kortesis Center for Cosmetic Surgery Charlotte, NC, USA

Bill G. Kortesis, MD
Partner Hunstad-Kortesis Center for Cosmetic Surgery Charlotte, NC, USA

Hermann Lampe, MD
Plastic Surgeon Private Practice Frankfurt, Germany

Angela S. Landfair, MD, MPH
Plastic Surgeon Kaiser Permanente Medical Group Walnut Creek, CA, USA

Peter Lin, MD
Chief Resident University of California Irvine Aesthetic & Plastic Surgery Institute Orange, CA, USA

Michael Loffredo, MD
Plastic Surgeon Cape and Islands Plastic Surgery Hyannis, MA, USA

José Fernando López-Salguero, MD
Associate Professor Institute of Plastic Surgery Mexico City, Mexico

Alan Matarasso, MD, FACS
Department of Plastic Surgery Manhattan Eye, Ear & Throat Hospital Lenox Hill Hospital North Shore-Long Island Jewish Health System New York, NY, USA

Vinicius Aref M. Maykeh, MD
Resident Division of Plastic Surgery Federal University of São Paulo São Paulo, Brazil

Constantino G. Mendieta, MD, FACS
Private Practice Miami, FL, USA

Arnaldo L. Miró, MD
Director Plastic and Reconstructive Clinic Private Practice Curitiba, Brazil

Luis Montellano, MD
Associate Professor Gama Fillho University of Rio de Janeiro Rio de Janeiro, Brazil

Lea M. Moraes, MD
Plastic Surgeon Special and Titular Member of the Brazilian Society of Plastic Surgery; Graduate, Federal University of Paraná (UFPR) Medical School; Residency in General Surgery Hospital of Our Lady of Grace Curitiba-PR; Residency in Plastic Surgery Hospital for Facial Defects São Paulo, Brazil

Luis Humberto Uribe Morelli, MD
Resident Plastic Surgery Department UNISANTA Plastic Surgery Service Sao Paulo, Brazil

Donald S. Mowlds, MD, MBA
Resident Physician The Aesthetic and Plastic Surgery Institute University of California, Irvine Orange, CA, USA

Sang Myun Cha, MD, PhD
Director; Plastic Surgeon Sein Aesthetic Plastic Clinic Seoul, South Korea

Fabio X. Nahas, MD, PhD, MBA, FACS
Associate Professor Division of Plastic Surgery Federal University of São Paulo; Associate Professor, Division of Plastic Surgery State University of Rio de Janeiro São Paulo, Brazil

Pierre Nicolau, MD
Consultant Plastic Surgeon Department of Plastic Surgery and Burns Unit Saint Louis University Hospital Paris, France

Mário Farinazzo de Oliveira, MD
Preceptor of Rhinology Division of Plastic Surgery Federal University of São Paulo São Paulo, Brazil

Luiz Haroldo Pereira, MD
Consultant Plastic Surgeon Department of Plastic Surgery LH Clinic Rio de Janeiro, Brazil

Ewaldo Bolivar de Souza Pinto Sr., PhD, MD
Chairman of the Department of Plastic Surgery Santa Cecilia University São Paulo, Brazil

Ivo Pitanguy, ISAPS, FICS, FACS
Head-Professor Plastic Surgery Department Pontificial Catholic University Carlos Chagas Institute of Post-Graduate Medical Studies Rio de Janeiro, Brazil

Harlan Pollock, MD
Private Practice North Dallas Plastic Surgery; Instructor Department of Plastic Surgery The University of Texas Southwestern Medical School Dallas, TX, USA

Todd Pollock, MD
Private Practice North Dallas Plastic Surgery; Instructor Department of Plastic Surgery The University of Texas Southwestern Medical School Dallas, TX, USA

Jason N. Pozner, MD, FACS
Affiliate Assistant Professor of Clinical Biomedical Science Charles E. Scmidt College of Medicine Florida Atlantic University Boca Raton; Adjunct Clinical Faculty Department of Plastic Surgery Cleveland Clinic Florida Weston, FL, USA

Oscar M. Ramirez, MD, FACS
Clinical Assistant Professor The Johns Hopkins University School of Medicine Baltimore, MA; Adjunct Clinical Faculty Plastic Surgery Division Cleveland Clinic Florida Weston, FL, USA

Cassio Eduardo Raposo-Amaral, MD
Plastic Surgeon Institute of Plastic and Craniofacial Surgery-SOBRAPAR Campinas São Paulo, Brazil

Lawrence S. Reed, MD
Clinical Assistant Professor of Surgery (Plastic Surgery) Weill Cornell Medical College New York, NY, USA

Dirk F. Richter, MD, PhD
Associate Professor University of Bonn Chief, Department of Plastic and Reconstructive Surgery Director of the Dreifaltigkeits Krankenhaus Wesseling, Germany

Alberto Romão
Resident Division of Plastic Surgery Federal University of São Paulo São Paulo, Brazil

J. Peter Rubin, MD, FACS
UPMC Endowed Professor of Plastic Surgery Chair, Department of Plastic Surgery Director, Life After Weight Loss Body Contouring Program University of Pittsburgh Pittsburgh, PA, USA

Neil S. Sadick, MD
Clinical Professor of Dermatology Weill Cornell Medical College New York, NY, USA

José Abel de la Peña Salcedo, MD, FACS
National Secretary Ibero-American Federation of Plastic Surgery, Aesthetic and Reconstructive (FILACP); Director of the Institute of Plastic Surgery Hospital Angeles de las Lomas Col.Valle de las Palmas Huixquilucan, Mexico

Cristianna Bonneto Saldanha, MD
Resident General Surgery Service Santa Casa of Santos Hospital São Paulo, Brazil

Osvaldo R. Saldanha, MD
Chair of UNISANTA Plastic Surgery Service São Paulo, Brazil

Osvaldo R. Saldanha Filho, MD
Residant UNISANTA Plastic Surgery Service São Paulo, Brazil

Renato Saltz, MD, FACS
Saltz Plastic Surgery and Spa Vitoria Salt Lake City and Park City, UT, USA

Gerhard Sattler, MD
Director Rosenparkklinik Darmstadt, Germany

Thomas Scholz, MD
Resident Physician Department of Aesthetic and Plastic Surgery University of California, Irvine Orange, CA, USA

Jeffrey L. Sebastian, MD
Assistant Clinical Professor of Surgery David Geffen School of Medicine UCLA, Los Angeles; Private Practice Santa Monica, CA, USA

Cemal enyuva, MD
Professor of Plastic, Reconstructive and Aesthetic Surgery Private Practice Istanbul, Turkey

Fernando G. Serra, MD
Plastic Surgeon Department of General Surgery Rio de Janeiro State University (UERJ) Rio de Janeiro, Brazil

Marion Shapiro, MD
Dermatologist Private Practice New York, NY, USA

Miguel A. Soto-Miranda, MD
Associate Professor Institute for Plastic Surgery Mexico City, Mexico

Aris Sterodimas, MD, MSc, PhD
Head Department of Plastic Surgery IASO General Hospital Athens, Greece

Alexander Stoff, MD, PhD
Assistant Professor Department of Plastic and Reconstructive Surgery University of Bonn Dreifaltigkeits-Hospital Wesseling Wesseling, Germany

Berish Strauch, MD
Chairman Emeritus Department of Plastic and Reconstructive Surgery; Professor of Plastic Surgery Albert Einstein College of Medicine New York, NY, USA

Steven Teitelbaum, MD, FACS
Assistant Clinical Professor of Plastic Surgery David Geffen School of Medicine University of California Los Angeles, CA, USA

Serhan Tuncer, MD
Associate Professor Department of Plastic, Reconstructive, and Aesthetic Surgery Gazi University Faculty of Medicine Ankara, Turkey

Carlos O. Uebel, MD, PhD
Associate Professor Division of Plastic Surgery PUCRS University Porto Alegre, Brazil

Ismael Santiago Vásquez, MD
Plastic Surgeon Associate Member of Brazilian Society for Plastic Surgery Hospital Mater Dei, Belo Horizonte Minas Gerais, Brazil

Garrett A. Wirth, MD, MS, FACS
Associate Clinical Professor Department of Plastic Surgery Aesthetic & Plastic Surgery University of California – Irvine Medical Center Orange, CA USA

Scott Woehrle, MS, PA-C
Physician Assistant Capella Plastic Surgery Ramsey, NJ, USA

Marianne Wolters, MD
Plastic Surgeon Private Practice Frankfurt, Germany

Kotaro Yoshimura, MD
Associate Professor Department of Plastic Surgery University of Tokyo Tokyo, Japan

V. Leroy Young, MD
Director Body Aesthetic Research Center St Louis, MO, USA

Richard Zienowicz, MD
Associate Professor Department of Plastic Surgery Rhode Island Hospital The Warren Alpert Medical School Brown University Providence, RI, USA
Dedications
To my wife, Julie, whose love and support are boundless, and our children, Eliana, Liviya, Zachary, and Talya, who teach me about the important things in life every day.

J. Peter Rubin, MD
To Mary, the love of my life; our children, Mark II, James, and Hillary; Shelley, and Reed.

Mark L. Jewell, MD
To my family with love; my wife Katja, my children Moritz and Leonie and with respect and thanks to my parents.

Dirk F. Richter, MD, PhD
To my dear wife Walderez, who is a constant source of support and encouragement to me. To our children Juliane and Hiddo; Paulo and Mariana; and to our grandson Matheus who makes my life worthwhile.

Carlos O. Uebel, MD, PhD
Introduction
Body contouring surgery – a fifty year perspective

Ivo Pitanguy
Body contouring surgery is a collection of procedures with the goal of volumetric manipulation of superficial tissue, usually the adipose, with or without removal of excess skin (dermolipectomies). Etiology of these deformities may be primary (i.e., congenital or constitutional) or secondary (i.e., weight gain or severe weight loss). In a broader sense, this may include contouring of the face and breast. It is therefore understandable that contouring surgery may include most of the operations performed by the plastic surgeon.
Concepts of beauty have been continuously evolving throughout the history of mankind. The voluptuous figures that were idealized by artists in the past have been substituted by slimmer forms. Until the second half of the 20th century, contour deformities were mostly hidden under heavy clothing and were reluctantly accepted. With fashion promoting body-revealing attire and outdoor exposure, and the emphasis on fitness and good health, people have sought to reflect these trends by demonstrating youthfulness and vitality in their bodies. The subliminal as well as overt message is that these are desirable requirements for maintaining sensuality, social acceptance and professional success.
On the other hand, sedentary lifestyle and dietary excesses, associated with factors such as genetic determination, pregnancy and the aging process, contribute to corporeal alterations that result in the loss of the individual’s body image. This creates a strong psychological motivation for surgical correction. Localized fat deposits and skin flaccidity are sometimes resistant to the most sincere efforts in weight loss and sport activities. Bariatric surgery by itself has created a whole new field of medicine, where a multidisciplinary team will include the work of the plastic surgeon.
Body contour deformities may involve one single anatomical region or extend to multiple body regions. They may be treated by a one-stage operation or may require more complex combined procedures. In some cases, multiple or severe deformities will be approached serially, such as in patients who have undergone dramatic weight loss. Planning and final results must be carefully discussed with the patient, as well as location and extension of scars.
As the reader will appreciate in this book, the ever-increasing request for contour surgery has been met by safe and efficient surgical techniques, resulting in a high degree of patient satisfaction. Personally, it has been fascinating to follow the development of these procedures over the span of some 50 years.
The concepts and principles that we have proposed for body contouring are based on preservation of function, acceptable location and extension of scars and an esthetic correction of the deformity for a final, pleasing result. This is exemplified by our approach to abdominoplasty. Many different incisions had been forwarded to correct the abdominal wall defect, with varying opinions regarding muscle diastasis. Our methodology established an incision, following a natural crease, which was adequately hidden under beachwear. Emphasis was given to the functional aspect, with plication of the rectus abdominis muscle without opening of the aponeurosis. Likewise, other regions were addressed aiming to achieve a satisfying, long-term result with preservation of function.
Breast reduction up until the late 1950s was usually performed with extensive dissections and undermining that often resulted in large dead space with subsequent collection and skin necrosis. Resections that involved the upper pole caused early flattening and sagging, with an upward projection of the nipple.
I was also concerned with other anatomical regions that comprise body contouring, including correction of other deformities of the breast (hypertrophy, ptosis and hypomastia; gynecomastia, and deformities of the nipple–areola complex), the abdomen (lipodystrophy and atypical deformities), the upper limbs, and the lower limbs (lipodystrophy and flaccidity of the inner thighs and the trochanteric region), and the “riding-breeches” (or “saddlebag”) defect.
Of course, many of these techniques were placed in a different perspective with the introduction of suction-assisted lipectomy. Rapidly, plastic surgeons adopted this procedure to safely and efficiently remove localized adiposity through minimal incisions. Seemingly overnight, gone were most of the indications for large incisions and extensive procedures, with consequent faster recovery and reduced problems of wound healing and unesthetic scars.
Currently, it is interesting to notice that a cycle closes. To address excess cutaneous tissues in post-obese patients, plastic surgeons are bringing back principles that were in vogue in the past. To cite two procedures that we proposed, the thoracobrachial dermolipectomy and the “riding breeches” deformity, fundamental concepts are being reviewed: no dead space is created by unnecessary dissection, scars are planned in natural creases, and the positioning of nonundermined flaps is done by rotation, instead of simply by pulling.
Finally, the precise methodology for combining procedures was also a matter of interest, so as assure patient safety while at the same time optimizing surgical timing and post-operative down-time.
I am honored by this opportunity to introduce the book Body Contouring and Liposuction . As Dr. Rubin and his colleagues stated in their gracious invitation, I have been a direct witness to the evolution of these myriad techniques, and have seen paths that led to successful results and others that failed. In the end, we must base our practice on basic principles: careful surgical indication with an open discussion with our patient; planning incisions and number of proposed procedures, including surgical revisions; and close postoperative care. As an almost encyclopedic text, this book presents a culmination of years of development of body contouring surgery, which is certain to remain the solid reference on this subject. Congratulations to the editors – Drs. Rubin, Jewell, Richter and Uebel – and their collaborators on this magnificent achievement.

Further Reading

Pitanguy I. Breast hypertrophy. In: Transactions of the 2nd Congress of the International Society of Plastic Surgeons. 1960. p. 509.
Pitanguy I. An eclectic approach to breast problems. Rev Bras Cir . 1961;41:179–196.
Pitanguy I. Une nouvelle technique de plastique mammaire: Etudes de 245 cas consecutifs et presentation d’une technique personelle. Ann Chir Plastique . 1962;7:199–208.
Pitanguy I, Lima J. Treatment of some deformities of the lower extremity. In: Young H, ed. The Year Book of Orthopedics, Traumatic and Plastic Surgery . Chicago: Mosby Year Book; 1963:538–590.
Pitanguy I, Torres E. Histopathological aspects of mammary gland tissue in cases of plastic surgery of the breast. Br J Plast Surg . 1964;17(3):297–302.
Pitanguy I. Trochanteric lipodystrophy. Plast Reconstr Surg . 1964;34:280–286.
Pitanguy I. Transareolar incision for gynecomastia. Plast Reconstr Surg . 1966;38(5):414–419.
Pitanguy I. Abdominal lipectomy: an approach to it through an analysis of 300 consecutive cases. Plast Reconstr Surg . 1967;40(4):384–391.
Pitanguy I. Surgical treatment of breast hypertrophy. Br J Plast Surg . 1967;20:78–85.
Pitanguy I. Thigh lift and abdominal lipectomy. In: Goldwyn RM, ed. Unfavorable Results in Plastic Surgery . Boston: Little Brown; 1972:387.
Pitanguy I. Lipectomy abdominoplasty and lipodistrophy of the inner side of the arm. In: Grabb W, Smith J. Plastic Surgery: a Concise Guide to Clinical Practice . 2nd ed. Boston: Little Brown; 1973:1005–1013.
Pitanguy I. Abdominal lipectomy. Clin Plast Surg . 1975;2:401–410.
Pitanguy I. Correction of lipodystrophy of the lateral thoracic aspect and inner side of the arm and elbow dermosenescence. Clin Plast Surg . 1975;2(3):477–483.
Pitanguy I. Personal preferences for reduction mammaplasty. Plastic and Reconstructive Surgery of the Breast. Goldwyn RM, ed. Plastic and Reconstructive Surgery of the Breast , vol.2. Little Brown: Boston, 1976:167–179.
Pitanguy I. Dermolipectomy of the abdominal wall, thighs, buttocks and upper extremity. Reconstructive Plastic Surgery, 2nd ed. Converse JM, ed. Reconstructive Plastic Surgery , vol.7. Saunders: Philadelphia, 1977:3800–3823.
Pitanguy I, Cavalcanti MA. Methodology in combined aesthetic surgeries. Aesth Plast Surg . 1978;2:331–340.
Pitanguy I. Transareolar incision for augmentation mammaplasty. Aesth Plast Surg . 1978;2(4):363–372.
Pitanguy I. The breast. In: Aesthetic Plastic Surgery of Head and Body . Berlin: Springer-Verlag; 1981:3–62.
Pitanguy I, Ceravolo M. Our experience with combined procedures in aesthetic plastic surgery. Plast Reconstr Surg . 1983;71(1):56–63.
Pitanguy I. Reduction mammaplasty by the personal technique. In: Chang WHJ, ed. The Breast: an Atlas of Reconstruction . Baltimore: Williams & Wilkins; 1984:75–160.
Pitanguy I. Aesthetic Surgery of Head and Body . Berlin: Springer Verlag; 1984.
Pitanguy I. Treatment of abdominal wall eventrations associated with abdominoplasty techniques. Aesth Plast Surg . 1984;8:173–179.
Pitanguy I. Upper extremity: dermolipectomy. In: Aesthetic Surgery of Head and Body . Berlin: Springer Verlag; 1984:153–158.
Pitanguy I. Body contour. Am J Cosm Surg . 1987;4:283–293.
Pitanguy I. Thigh and buttock lift. The Art of Aesthetic Surgery. Lewis JR, ed. The Art of Aesthetic Surgery , Vol 2. Little Brown: Boston, 1989:1060–1067.
Pitanguy I. Personal preferences for reduction mammaplasty. In: Georgiade ND, ed. Aesthetic Surgery of the Breast . Philadelphia: WB Saunders; 1990:167.
Pitanguy I. Reduction mammaplasty: a personal odyssey. In: Goldwyn RM, ed. Reduction Mammaplasty . Boston: Little, Brown; 1990:95.
Pitanguy I. Abdominoplasty: Classification and surgical techniques. Rev Bras Cir . 1995;85:23–44.
Pitanguy I, Radwanski HN. Philosophy and principles in the correction of breast hypertrophy. In: Mang WL, Bull HG. Ästhetische Chirurgie . Germany: Einhorn-Presse Verlag; 1996:216–232.
Pitanguy I. Evaluation of body contouring surgery today: A 30-year perspective. Plast Reconstr Surg . 2000;105:1499.
Pitanguy I, Radwanski HN, Matarasso A. Approach to the face and neck after weight loss. In: Rubin P, Matarasso A. Aesthetic Surgery after Massive Weight Loss . New York: Elsevier; 2007:21–35.
Pitanguy I, Radwanski HN. Relative implant volume and sensibility alterations after breast augmentation. Aesth Plast Surg . 2007:238–243.
Pitanguy I, Radwanski HN. The Pitanguy breast reduction. In: Aston S, ed. Aesthetic Plastic Surgery . China: Elsevier; 2009:609–620.
Part 1
Patient evaluation and safety
Chapter 1 Patient safety in body contouring

V. Leroy Young, Angela S. Landfair

Key Points

• Complications of tobacco use are avoidable with a concerted effort by both the patient and the surgeon. Preoperative and postoperative urine cotinine testing make detection of tobacco use straightforward and not reliant on patient self-respect.
• A thorough preoperative assessment should be performed well in advance of the surgical date to allow adequate time for necessary behavior modification (i.e., tobacco cessation), medical modification (improved glycemic control in a diabetic patient), preoperative tests (i.e., sleep study for undiagnosed sleep apnea), and preoperative consultation with appropriate specialists (i.e., hematologist for family history of thrombophilia). Rushing to the operating table can impede a meticulous and safe preoperative investigation.
• Hypothermia is a common preventable condition with straightforward preoperative and intraoperative measures such as warm irrigation and preoperative warming blankets. These measures are essential in long body contouring cases with wide exposure.
• Surgical site infections should be prevented at every step, with appropriate preoperative disinfection, perioperative antibiotics, and close glycemic control.
• Thromboembolic events are largely preventable with comprehensive preoperative evaluation and appropriate consultation, mechanical and chemical prophylaxis, patient education, and high levels of alertness and suspicion in the postoperative period.

Introduction
The current climate of plastic surgery engenders a culture of safety that promotes careful patient selection, streamlined perioperative care, and structured systems of safety measures in and out of the operating room. Ultimately, vigorous training of medical professionals who can recognize, prevent, and appropriately treat potential complications may play the most salient role in ensuring safe clinical practices.
Body contouring surgery is fraught with potential for complications due to the lengthy and complex nature of the procedures and inherent patient demographics. Appropriate patient selection and vigilant perioperative care is expected and warranted. Body contouring is elective surgery in which the tolerance for complications should be low.
In the end the science of human factors (HF) should be foremost in our minds in designing a system of checks and balances in a given clinical situation. 1 A group of well-trained surgeons and health care professionals can still miss a step or two among the hundreds we take from the time the patient enters the clinic for preoperative consultation to the time the patient exits the clinic from the final postoperative visit. In every scenario: the initial consultation, the preoperative assessment, the preop holding area, the operating room, the postoperative care on the wards and in the office, a detail missed can lead to grave consequences. While this chapter is in no way comprehensive, it should aid a surgeon in developing his or her own standardized model for safe clinical practice.

Preoperative Assessment and Patient Selection
The value of comprehensive history taking at the initial consultation cannot be overstated. Overlooking a critical detail in the patient’s medical history can lead to mishap and preventable disasters. Our specialist colleagues should be brought into consultation whenever the patient has significant comorbidities or when we suspect an undiagnosed condition that can negatively impact surgical outcome.

Medical Assessment
Cardiac clearance is often a nebulous concept that may get glossed over. Cardiac tests are doled out according to patient age and prior history, and too often, according to institutional guideline. Often a “normal” electrocardiogram tells us very little about the patient. The patient’s functional status should be assessed using exercise tolerance, stress tests, and if deemed appropriate, a cardiology consultation with further noninvasive and invasive studies. All too often, patients are deemed “cleared for surgery” by a physician who is both unfamiliar with the surgical procedure, as well as the duration of recovery and rehabilitation afterwards. Family history is crucially important when a seemingly healthy patient presents to us, since a patient with no apparent cardiac history in the family is a different beast from the patient with three close relatives suffering an early cardiac event. Hypertensive patients should be carefully monitored in the perioperative period because their antihypertensive regimen may have to be changed during periods of fluid shifts, body weight change, and postoperative anemia. 2
Patients with significant cardiovascular history deserve special attention. Elective surgery should be delayed until adequate preoperative clearance and tests are attained. If a patient has undergone cardiac intervention, the timing of elective surgery is crucial. Perioperative stent thrombosis is associated with high mortality and morbidity and should not be taken lightly. Patients undergoing noncardiac surgery within 1–2 weeks after placement of a bare-metal stent are at high risk of stent thrombosis and death even if perioperative antiplatelet therapy is continued. Perioperative thrombosis of drug-eluting stents has been reported as late as 21 months after stent implantation. A cardiologist should be consulted to determine both the appropriate surgery date and the appropriate stop date for antiplatelet agents. If elective surgery is pursued too quickly, patients are at risk for stent thrombosis because of increased thrombotic state parlayed by surgery and by the therapeutic absence of antiplatelet agents. In general, elective surgery should be delayed until 6 weeks after balloon angioplasty or bare metal stents, and a year after drug-eluting stents. Patients should be continued on their preoperative beta blockers throughout and post surgery, barring unexpected hypotension. 3
Close attention must be paid to the patient’s personal and family history of coagulopathy 4 ( Tables 1.1 and 1.2 ). Hereditary thrombophilia is surprisingly common – with approximately 5% of patients displaying factor V Leiden mutation and 2–4% of the population testing positive for antiphospholipid syndrome. Recent data suggest that the family history of a thrombotic event even in the absence of hereditary thrombophilia significantly increases the likelihood that the patient will have a postoperative thromboembolism. In women who smoke, hormone therapies (including oral contraceptives) should ring warning bells, as should a history of multiple miscarriages. Bleeding disorders are rarely life-threatening, but a 2% incidence of Von Willebrand’s in the general population is no small figure. The risk of bleeding should be carefully considered, especially if the patient is about to undergo multiple procedures over large anatomic areas.
TABLE 1.1 Prevalence of Molecular Abnormalities   Healthy Subjects First VTE Episode Antithrombin deficiency 0.02 1 Protein C deficiency 0.3 3 Protein S deficiency ? 1–2 Factor V Leiden 5 20–40 Prothrombin gene mutation 1–2 6 Fasting homocysteine >95th % 5 23 Anti-phospholipid antibodies 3 16
TABLE 1.2 Indications for a Laboratory Workup for Thrombophilia

Venous thrombosis before 40–50 years of age
Unprovoked thrombosis at any age
Recurrent thrombosis at any age
Unusual sites such as cerebral, mesenteric, portal, or hepatic veins
Positive family history for thrombosis
Thrombosis during pregnancy, oral contraceptives, or hormone replacement therapy (HRT)
Unexplained abnormal laboratory test such as prolonged PTT
Connective tissue diseases are frequently under good medical control when a patient is cleared for surgery. However, connective tissue disorders are independent predictors of thromboembolic events and patients should be informed of this risk factor. Steroids and other immunosuppressants are frequently used in medical management of connective tissue disorders and can place a patient at risk for wound healing complications. 5
Pulmonary disease, especially when undiagnosed and undertreated, can have grave consequences in the postoperative period. In patients with pre-existing pulmonary conditions such as chronic obstructive pulmonary disease (COPD) or asthma, their medical management should be optimized well before the patient is placed on the surgical schedule. Perioperatively, these patients require a more aggressive pulmonary toilet and often pharmacotherapy, regardless of whether they took any at home.
Obstructive sleep apnea (OSA) is a frequently underdiagnosed condition that affects 24% of men and 9% of women. OSA diagnosis can pose a challenge in the preoperative interview because, very frequently, the patients are unaware of the symptoms. Physiologically, the parapharyngeal fat pads narrow the airway, causing restrictive ventilation defects, and resulting in measurable decreases of functional residual capacity and total lung capacity. Of note, over 80% of patients with OSA are undiagnosed, and up to 80% of elderly patients may be affected. Periodic apnea/hypopnea can result in hypertension, arrhythmias, increased intrathoracic negative pressure, and decreased restorative sleep. 6
During the consultation, it is often more useful to ask a patient’s significant other about the sleep habits, as patients themselves may be unaware. Male, obese, hypertensive patients are at an elevated risk. When sleep apnea is suspected, the symptom checklist should include choking, restless sleep, impaired sleep maintenance, daytime sleepiness, frequent awakening, hypersomnia, depressed mood or mood swings, fatigue, gasping, gastroesophageal reflux disease, and snort arousals. Sixty to 90% of people with OSA are obese and frequently have a neck circumference measuring >40 cm. While weight loss improves OSA symptoms, many patients may have incomplete symptom relief and still require continuous positive airways pressure (CPAP) postoperatively. There is no effective pharmacologic therapy for sleep apnea.
Close preoperative monitoring is especially important in patients with diabetes. 7 While the presence of diabetes itself should not preclude surgery, poorly controlled diabetes should halt surgery until better medical management is achieved. HgbA1C is a useful screening tool to check for patient compliance and an index of overall glycemic control, and should be included in the preoperative workup. Even patients who are no longer on insulin will frequently require perioperative insulin to compensate for the stress of surgery as well as diet fluctuations in the postoperative period.
Clinical obesity is common in the body contouring population even after massive weight loss. Many clinicians employ a BMI “cutoff” in their practice, but in reality many patients will end up on the operating room table while still obese. Obesity increases every type of surgical complication especially pulmonary, thromboembolic, and wound complications. Undiagnosed obstructive sleep apnea is frequent in obese patients and should be carefully assessed. Medication doses should sometimes be adjusted as well to compensate for obesity. There is some indication that obese patients should be treated with a higher dose of Lovenox when used as a chemoprophylactic agent.

Nutritional Assessment
In the bariatric population, preoperative screening should include nutritional screening. Protein malnutrition is possible even in weight stable patients, and routine screening of protein malnutrition is reasonable. Due to physiologic changes and changes in their GI tract and their dietary patterns, anemia can result from deficiencies in iron and vitamin B12. All massive weight loss patients need a preoperative complete blood count prior to undergoing surgery.

Psychiatric and Behavioral
Tobacco use is an independent risk factor for wound complications and cessation should be the rule in body contouring surgery. According to CDC data as of November 2007, 20.8% of adults in the United States smoke cigarettes. The health risks of habitual tobacco use are profound, but in the plastic surgery population, the risk immediately impacts postsurgical outcome.
First and foremost, smokers are prone to pulmonary complications due to chronic airway inflammation and decreased pulmonary function. Smokers are more prone to postoperative atelectasis and hypoxia, even in the absence of a diagnosis of COPD.
Second, tobacco impacts wound healing in numerous pathways. Tobacco use reduces cutaneous blood flow in a significant and meaningful way even in light smokers by impairing microvascular vasodilation. Wound healing, immune, and inflammatory responses are blunted in smokers, and collagen deposition and remodeling are decreased. Smoking has been associated with increased wound complications in both aesthetic and reconstructive patients. There is no consensus as to when patients should quit smoking prior to surgery, as benefits of quitting have been found whether a patient quit for 3 weeks, 4–8 weeks, or greater than 2 months. There is no definitive consensus that quitting for a longer period necessarily improves outcome, but the current CDC recommendation is to halt tobacco for 30 days prior to surgery. Self-report of smoking cessation is notoriously unreliable, especially when a patient is incentivized to lie in order to attain the go-ahead for plastic surgery. Objective tests of smoking cessation, such as urine cotinine, may be warranted in order to ensure patient safety. 8 – 14
While tobacco use is a behavior that can be monitored objectively, the plastic surgeon is often faced with a patient who is medically stable, but displays poor judgment, immaturity, unrealistic expectations, or psychiatric illness. Body dysmorphic disorder (BDD) is a DSM diagnosis marked by obsession over a perceived defect that results in compulsive behavior and illogical methods to hide or transform the perceived defect. This is most commonly seen in rhinoplasty patients, but is seen with greater frequency than in the general population among cosmetic patients. BDD is a clear psychiatric contraindication for plastic surgery and patients who are suspected of this condition should receive a psychiatric evaluation, not surgery. 15
Psychiatric history should be a routine part of the history and physical examination. Body contouring patients are at an increased risk for depression and anxiety disorders compared to the general population. These patients are often labeled as having BDD, when in fact their concern is realistic based on the extreme deformity after massive weight loss. These patients are often former over-eaters who have a psychological barrier against self-discipline and equilibrium. Occasionally, massive weight loss patients have difficulty forming a marriage of their former self image and the new image in the mirror before them. The plastic surgeon should learn basic psychiatric assessment and ascertain that any prior psychiatric illness is stabilized prior to embarking on surgical treatment.
One specific concern for body contouring patients can be the high incidence of maladaptive eating patterns, especially binge eating disorder. In concert with nutritional difficulties presented by the physiology of weight loss, this can lead to poor perioperative nutritional status or weight fluctuations. Psychiatric history should include eating and dieting patterns. Patients with a history of binge eating disorder, in particular, should be carefully assessed to make sure that they have not recently engaged in pathologic eating behaviors. 16
Patients who have undergone massive weight loss are also at an increased likelihood of having personality disorders compared to the general population. These are difficult to diagnose and can prevent optimizing the postoperative course. Personality disorders are often insidious and, unlike AXIS I disorders, are pharmacologically untreatable. When faced with a particularly difficult patient, surgeons should beware that a patient with personality disorder may be particularly threatening to his/her reputation and office morale, and that these patients’ disorders are at best slightly ameliorated by preoperative psychiatric intervention.

Intraoperative Management
Hypothermia has been shown to increase postoperative complications in body contouring patients by inhibiting tissue oxygen delivery, impairing wound healing, and leading to a three-fold increase in wound infections. 17
Due to length of surgeries and large areas of physical exposure, body contouring patients are at particular risk of hypothermia. Studies have shown that unwarmed patients almost always become hypothermic. Maintaining normothermia is an active process that should begin in the preoperative holding area and be carefully checked throughout the perioperative period. Preoperative warming with forced air for 60 minutes is the most effective way of warming the patient so that core temperature remains normal. Prewarmed patients cool at about half the rate of patients who are not prewarmed, and core temperature can be maintained even through a multi-procedure, lengthy operation. Other measures should be engaged to maintain core temperature, including covering areas not being worked on, continuous forced air heating, maintaining ambient room temperature at 23°C (73°F), and warming the irrigation fluids.
Malignant hyperthermia is a rare but serious complication that has a 70% mortality rate without proper treatment ( Box 1.1 ). The surgeon should be aware of the signs. A thorough preoperative history should ask about family history of sudden death during or after anesthesia. The most consistent sign should be a rapid rise in end tidal CO 2 , along with high fever, rigidity, acidosis, and tachycardia. The surgery center should always be fully stocked with dantrolene, with the understanding that obese patients require much more dantrolene for symptom reversal than their nonobese counterparts.

Box 1.1
Questions to Ask About Malignant Hyperthermia

Routine Preoperative Questioning
All patients about to undergo general anesthesia should be asked these specific questions as part of a medical history:

• Is there a family history of MH?
• Have there been unexpected deaths or complications arising from anesthesia (including the dental office) with any family members?
• Is there a personal history of a muscle disorder (e.g., muscle weakness)?
• Is there a personal history of dark or cola-colored urine following anesthesia?
• Is there a personal history of unexplained high fever following surgery?

Intraoperative Preparedness
The following precautions should be taken in order to detect MH in its early stages, when it is usually amenable to treatment without sequelae:

Planning Ahead

• A written treatment plan should be posted in a conspicuous place. A plan is available from the Malignant Hyperthermia Association of the United States (MHAUS); http://www.mhaus.org
• A kit or cart containing drugs necessary for the treatment of MH should be immediately available to all operating rooms. Each kit should contain 36 vials of dantrolene, bacteriostatic water for injection, and bicarbonate. MHAUS offers a brochure listing the recommended supplies.
• A refrigerator unit near the operating room should be stocked with iced saline. Ready access to an ice machine is important.
• All operating and recovery room personnel should be trained in the recognition and treatment of MH. Periodic dry-runs of an MH emergency are recommended. In-service materials can be provided by MHAUS.

During Surgery

• Evaluate any unexpected hypercarbia, tachycardia, tachypnea or arrhythmia (e.g., arterial and venous blood gases). Avoid suppressing tachycardia with beta blockers until MH has been ruled out.
• Core temperature should be monitored in all patients given general anesthesia for 30 minutes or more. Acceptable core temperature sites include: distal esophagus, nasopharynx, axilla, rectum, bladder and pulmonary artery. Skin temperature may not adequately reflect core temperature during MH episodes. Consider MH in the differential diagnosis of any temperature rise.
• Stop inhalation anesthetic and succinylcholine if masseter rigidity occurs. If surgery must continue, immediately switch to nontriggering anesthetics.
• Do not give triggering agents to patients with Duchenne dystrophy, central core disease, myotonia and other forms of muscular dystrophy.
• Sudden cardiac arrest in a young male with normal oxygenation should be considered as secondary to hyperkalemia and so treated.

Treating the Known or Suspected MH-Susceptible Patient

Preoperative Preparations:

• Anesthesia machine:
• Remove vaporizers, if possible. Otherwise, drain and disconnect or tape in the off position.
• Flow 10 l/m O 2 through circuit for at least 20 minutes. If fresh gas hose is replaced, 10 minutes is adequate. During this time a breathing bag should be attached to the Y-piece of the circle system and the ventilator set to inflate the bag.
• Use new or disposable breathing circuit.
• Take a preoperative creatine kinase (CK) and CBC.
• Place a cooling blanket on the table.

Dantrolene Prophylaxis
Dantrolene prophylaxis should be considered on an individual patient basis but is not recommended for most MH susceptibles. When used, dosage is 2.5 mg/kg IV starting 30 minutes prior to anesthesia. For consultation, contact MHAUS.
NOTE: Dantrolene can worsen muscle weakness in patients with muscle disease and should be used with caution. For procedures with local anesthesia only, dantrolene prophylaxis may be omitted.

Intraoperative Considerations

• Techniques of choice
• Spinal, epidural, regional or local, if possible.
• Safe drugs
• Local: No local anesthetics trigger MH; thus any type of regional anesthesia is safe for MH susceptibles.
• General: Benzodiazepines, opioids, barbiturates, propofol, ketamine, nitrous oxide, etomidate. Pancuronium, atracurium, vecuronium, pipecuronium, mivacurium, doxacurium, or curare may be used for relaxation. Neostigmine and atropine are used for reversal by some; others disagree on their safety.
• Unsafe drugs/MH triggers
• Halothane, enflurane, isoflurane, desflurane, methoxyflurane, ether, cyclopropane, sevoflurane, ether.
• Succinylcholine.
• Monitoring
• Essential: blood pressure, central temperature, ECG, pulse oximeter, and capnograph or capnometer.
• Strongly suggest respirometer.
• Use arterial line, CVP or other invasive monitors as appropriate for the surgery.

Postoperative Procedure

• If the anesthetic course has been uneventful:
• Continue to monitor temperature and ECG for 1 to 2 hours. No further dantrolene is necessary.
• If MH has occurred:
• Recover patient in an ICU for 24–48 hours.
• Continue IV dantrolene for 48–72 hours, titrated to alleviation of muscle rigidity, tachycardia, acidosis, and CK levels. Suggested dantrolene dosage is at least 1 mg/kg q 6 hours IV. After that, 1 mg/kg may be given q 6 hours orally × 24 hours.
• Monitor the patient’s coagulation status, watching for DIC.
• Look for myoglobinuria and renal failure, and treat as needed.
• Use potassium-containing solutions with caution.
• Monitor potassium and CK levels q 6 hours at least.
• Monitor urine output.
• Register patient with North American MH Registry. Forms are available by contacting North American MH Registry, Pennsylvania State University, College of Medicine, Dept of Anesthesia, PO Box 850, Hershey, PA 17033–0850, (717) 531–6936.
• Alert family to the dangers of MH in other family members.
• Refer for testing at nearest center (list available from MHAUS).
This protocol may not apply to every patient and must of necessity be altered according to specific patient needs.From the MHAUS website www.mhaus.org/
Prevention of surgical site infections is of utmost importance. Preoperative antibiotics should be chosen based on type of organisms encountered, and the patient’s unique infectious disease history. Too frequently, antibiotics are administered as an afterthought after the operation has already begun. Surgical patients should receive antibiotics 30 minutes to 1 hour prior to incision, and before any tourniquet is applied, although this is less relevant in body contouring surgery. Vancomycin and fluoroquinolones take longer to infuse and should be started in the preoperative area, about 2 hours prior to incision time. A study of over 3000 surgical patients found an increased rate of surgical site infections if the antibiotics were administered more than 1 hour prior to incision, at the time of incision, or after the incision was already made. Antibiotics should be re-dosed during lengthy procedures and more frequently if there is significant blood loss (>1.5 L). There is no evidence that shows continuing prophylactic antibiotics beyond 24 hours postoperatively is beneficial. In fact, routine use of postoperative antibiotics increases the likelihood of drug resistance and places the patient at risk for clostridium difficile infections. 18, 19
Shaving increases ( Table 1.3 ) the likelihood of surgical site infection (SSI) fourfold. Clipping is less likely to increase surgical site infections, although the risk is not zero. Locally, trauma to the epithelial barrier caused by both shaving and clipping is likely to place the patient at risk for contamination and even infection. Patients should be instructed not to shave the operative site the week prior to surgery.

TABLE 1.3 Hair Removal
Artificial nails are another potential source of SSI. The glue used to adhere the artificial nail to the nail plate rapidly becomes colonized with bacteria and patients often run their fingers over their incisions and can inoculate their wounds with the colonized bacteria which are often Gram negative. Artificial nails should be removed at least 1 week before surgery and surgical staff should never wear artificial nails or jewelry in the operating room.

Staging
There is great debate as to (1) how long is too long and (2) how many procedures are too many. Unfortunately, there is no simple answer. On the plus side, combining procedures is simply more convenient and more cost effective-, for both the patient and the surgeon. 20 In a healthy patient who presents a low risk overall, combining procedures is unlikely to lead to serious detriment. However, surgical site infections and thrombotic risk are shown to increase along with the length of operation and these risks should not be taken lightly.

Postoperative Management

Postoperative Antibiotics
SSI is a common adverse event in the plastic surgery patient, and is particularly devastating when the surgery was elective and cosmetic in nature. Plastic surgeons are apt to place patients on antibiotic regimens based upon anecdotal evidence. Large studies have shown no decrease in SSI with postoperative antibiotics. So far, practices such as placing patients on oral antibiotics due to a new implant or while drains are in place have no scientific evidence to support them. 21

DVT Prophylaxis
Assessment of thromboembolic risk is the most crucial part of reducing events. However, simple maneuvers should be undertaken (making sure sequential compression devices (SCDs) are in fact on the patient and functioning preoperatively) to continue to reduce risk. Daily rounds should include ensuring the patient has adequate assistance to get out of bed and ambulate in the hallway, and that ambulation is happening as often as can be tolerated. Chemoprophylaxis is frequently indicated, especially in instances where patients are relatively immobile due to postsurgical pain. At this time, there is no evidence that chemoprophylaxis increases the risk of postoperative return to the operating room for a bleeding event. The details of assessing thromboembolic risk and perioperative management will be covered in greater detail in Chapter 4 .

Antiplatelet and Beta-blockers
While it is universally agreed that patients should stop certain medications and herbal supplementation that can increase bleeding risk, there is less certainty about medically necessary medications. Antiplatelet agents should not be stopped perioperatively for 1 year after stents, and should be restarted quickly after surgery. If the planned surgery does not require a great deal of undermining, continuing one antiplatelet agent (i.e., hold Plavix but continue aspirin) may be a safe and viable option. 3
Beta-blockers should be continued throughout the perioperative period with hold parameters for hypotension. 22 Numerous studies and large meta-analyses have shown that beta-blockers are cardioprotective when used in the perioperative period in patients with cardiac risk factors. Beta-blocker therapy appears effective when started several weeks prior to surgery, and long-acting agents appear more successful than short-acting agents. Currently there is no reason to start a beta-blocker for a healthy patient without significant cardiac risk factors.

Glycemic Control
Patients with diabetes are at an increased risk for wound infection due to impaired immunity, microvascular changes and delayed healing mechanisms. Hyperglycemia before and after surgery increases the likelihood of surgical sight infection by three to fourfold. According to Olsen et al, a serum glucose level of greater than 125 before or after surgery parlayed into a more than fourfold increase in surgical site infections. 19 In addition, diabetics are also at risk of noninfectious complications including seromas and ischemic necrosis. HgbA1C should have been included in the preoperative workup. The standard diabetic sliding scales would accept glucose levels of 125. Therefore, tight glycemic control (glucose <110) should be the goal of medical protocol postoperatively. If a standard sliding scale is deemed inadequate or the patient has a history of difficult glycemic control, IV insulin and endocrinology consultation should be utilized in the immediate postoperative period.

Postoperative Nausea and Emesis (PONV)
PONV, while not life-threatening, can delay patient clinical course and discharge from hospital care, and can negatively impact patient satisfaction. Risk factors for PONV include female gender, history of motion sickness, history of PONV, preoperative opioids, and nonsmoking ( Table 1.4 ).
TABLE 1.4 Important Risk Factors for VTE

Prior history of DVT/PE
Malignancy (active or in patient history)
Thrombophilia disorders (inherited or acquired)
Obesity (risk may be highest for those younger than 40)
General anesthesia (risk rises with each hour in surgery, regardless of procedure)
Age ≥40 years (risk rises as age rises)
Use of estrogen-containing drugs
Varicose veins
Abdominal surgery
Smoking
Recent surgery of any kind
Prolonged travel by air, train or car
The plastic surgery population usually has several risk factors for PONV, and the outcome of PONV can be temporary hypertension and increased risk of bleeding. The best method of PONV prevention appears to be employment of multiple agents. The triple cocktail of Benadryl, dexamethasone, and Zofran appears to be 98% effective in preventing PONV. Emend, an oral agent taken preoperatively, appears to be as effective as IV Zofran and has an effect lasting for 48 hours. 23

Respiratory Management
In patients with a diagnosis of obstructive sleep apnea, CPAP should be made immediately available at the preoperative settings. The patient should be carefully monitored in PACU for their respiratory status. Supine position is suboptimal and should be avoided even during sleep. Supplemental oxygen should be expected. Patients with obstructive sleep patterns have a respiratory status that is more sensitive to pain medications and sedatives. Additional monitoring may be necessary in a patient who has undergone a lengthy and painful procedure and requires narcotics in the postoperative period.

Patient Safety in Your Practice
A well choreographed preoperative, intraoperative and postoperative clinical regimen should optimize risk reduction. During the first visit, a thorough history should be taken so that any “warnings” in the history can generate a proper workup ( Fig. 1.1 ). While it’s tempting to have the patient obtain medical clearance from his or her internist, additional specialists should weigh in prior to a complex surgery with a long recovery. Age-based preoperative labs and testing may not apply to the massive weight loss population with multiple comorbidities.

FIG. 1.1 Two-group comparison of prewarming.
Complete smoking cessation is ideal and patients should be educated fully on the wound healing complications of nicotine use. Getting in the habit of checking patients for tobacco use with cotinine urine tests the month prior to surgery can eliminate guesswork.
Skin folds of massive weight loss patients can harbor high bacterial colony counts and yeast infections that can predispose to surgical site infections. Topical creams and powders should be religiously applied to get rid of yeast infection before surgery. Patients should be provided with Hibiclens with which to shower prior to surgery, and instructed not to shave in or near surgical zones the week prior to surgery.
In the preoperative area, forced-air prewarming for at least 45 minutes prior to the operation can deter hypothermia. Intermittent pneumatic compression devices (IPCs) should be on and functioning on the patient at least 30 minutes prior to surgery to allow for optimal fibrinolysis.
Appropriate parenteral antibiotics should be administered within 60 minutes before incision. The drug protocol to prevent PONV should be initiated.
Once the patient reaches the operating room, the battle against hypothermia begins. The room temperature should be set at 23°C (73°F). Continuing active warming with forced air throughout surgery will help, as well as keeping parts of the body that do not need to be visualized during a portion of the operation covered. Using warmed (41°C) irrigation and/or IV fluids can help, particularly if incisions are large and the patient’s core is exposed for a significant period of time.
Weight loss patients who have recovered from diabetes may need insulin during and briefly after surgery. Glucose should be checked periodically and IV insulin utilized to keep the patient normoglycemic ( Fig. 1.2 and Table 1.5 ). A Foley catheter should be utilized in longer body contouring cases, particularly when large volume liposuction is planned and guidelines for catheter removal followed. Proper padding and gel heel protectors to prevent traction or pressure injury should be used, and all pressure points should be rechecked when patient position is changed during surgery. If the patient is prone, the face should be checked periodically to make sure there is (1) no pressure over the globe and (2) no pressure from the endotracheal tube or tubing against skin surface.

FIG. 1.2 Impact of postoperative glucose control on SSI rates after beginning tight insulin protocol.
From Furnary AP, Zerr KJ, Grunkheimer GL, et al. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg 1999;67:352–62.
TABLE 1.5 Tight Glucose Control and SSI HbA1c Level (%) Plasma Glucose Level (mg/dL) 6 135 7 170 8 205 9 240 10 275 11 310 12 345
Maintaining a HbA1c level < 7 is associated with decrease in infectious complications across a variety of surgical procedures.
Odds ratio of 2.13.
95% CI.
P value of 0.007.
From Dronge AS, Perkal MF, Kancir S et al. Long-term glycemic control and postoperative infectious complications. Arch Surg. 2006;141:375–80.
Two hours before the end of surgery, Zofran should be administered for patients at high risk of PONV ( Table 1.6 ). Continuing 80% FiO 2 for 2 hours with a nonrebreather face mask can reduce the risk of pulmonary complications. The pneumatic compression devices should be on and continuing to function in the postoperative period.
TABLE 1.6 PONV Risk Factors

Female gender
History of PONV or motion sickness
Non-smoker
Perioperative opioid treatment PONV Risk Stratification # of Risk Factors Risk of PONV 0 10% 1 20% 2 40% 3 60% 4 80%
Many of our patients have at least 3 risk factors: female gender, nonsmoking, and perioperative opioids.
In the postoperative period, the focus should be on adequate pain control, maintenance of fluid balance, and early ambulation. If PONV develops, alternate agents to the ones that have already been used should be employed. Continued supplemental oxygen throughout hospitalization to maintain SpO 2  > 90% is ideal. In OSA patients, a CPAP device should already be in the hospital room if the patient utilizes one at home.
Incentive spirometry and pneumatic compression devices should not only be ordered, but the surgeon should check to make sure these devices are being utilized properly. Beginning chemoprophylaxis at 12 hours postop is ideal, barring any bleeding complications.
The Foley catheter should be discontinued as soon as it is reasonable, to prevent catheter-related urinary tract infections. Antibiotics should not be given for more than 24 hours after a routine clean elective body contouring operation.

Complications and Their Management
Nowhere is a cliché truer than this: the best way to manage complications is to prevent them from happening in the first place. Risk prevention, not risk management, is the primary objective. Problems occur when the surgeon is too hasty in his or her decision to operate and misses a vital piece of information, or over-relies on others to carry out the risk-prevention protocols. Even despite our best efforts, complications can occur in the practice of the most careful clinician. The key is to make the steps of the risk-prevention easily administered, orderly, clearly laid out, and unvaried from patient to patient.
The study of HF is a division of psychological studies that exclusively deals with the inevitability of human error in all systems. The science is used to create systems that optimize performance and minimize error. Simple steps such as always arranging pneumatic compression and a warming blanket to arrive to the preoperative area with the patient, making standardized order forms always available for DVT prophylaxis and antibiotics, and having automatic urine cotinine test administered routinely, can contribute to minimizing patient risk.

Conclusion
This chapter should serve as a rough guideline toward developing one’s own clinical protocol to optimize safety and minimize risk. While surgery itself is an imperfect art, it is amenable to continued improvement. The art of minimizing risk and optimizing perioperative management should advance along with the techniques to achieve optimal surgical outcomes.

References

1 Reason J. Understanding adverse events: human factors. Qual Health Care . 1995;4:80–89.
2 Eagle KimA., Chair., Task Force Members: Raymond J. Gibbons, Elliott M. Antman, Peter B. Berger et al. ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery – Executive Summary. Anesthes Analges . 2002;94(5):1052–1064.
3 Grines CL, Bonow RO, Casey DE, et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents. A science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. Circulation . 2007;115:813–818.
4 Friedman T, Coon DO, Michaels JV, et al. Hereditary coagulopathies: practical diagnosis and management for the plastic surgeon. Plasts Reconstr Surg . 2010;125:1544–1551.
5 Harris EN, Boey ML, Mackworth-Young CG, et al. Anticardiolipin antibodies: detection by radioimmunoassay and association with thrombosis in systemic lupus erythematosus. The Lancet . 1983;322(8361):1211–1214.
6 Jain SS, Dhand R. Perioperative treatment of patients with obstructive sleep apnea. Curr Opin Pulm Med . 2004;10(6):482–488.
7 Jacobers SJ, Sowers JR. An update on perioperative management of diabetes. Arch Int Med . 1999;159:2405–2511.
8 Centers for Disease Control and Prevention (CDC). Smoking and tobacco use: fact sheet. Online. Avaialbe lfrom http://www.cdc.gov/tobacco/data_statistics/fact_sheets/index.htm (accessed 20 March 2012)
9 Monfrecola G, Riccio G, Savarese C, et al. The acute effect of smoking on cutaneous microcirculation blood flow in habitual smokers and non-smokers. Dermatology . 1998;197:115–118.
10 Manassa EH, Hertl CH, Olbrisch RR. Wound healing and problems in smokers and non-smokers after 132 abdominoplasties. Plast Reconstr Surg . 2003;111:2082–2087.
11 Theadom A, Cropley M. Effects of preoperative smoking cessation on the incidence and risk of intraoperative and postoperative complications in adult smokers: a systematic review. Tob Control . 2006;15:352–358.
12 Spear SL, Ducic I, Cuoco F, et al. The effect of smoking on flap and donor-site complications in pedicled TRAM breast reconstruction. Plast Reconstr Surg . 2005;116:1873–1880.
13 Bluman LG, Mosca L, Newan N, et al. Preoperative smoking habits and postoperative pulmonary complications. Chest . 1992;113:883–889.
14 Warner MA, Offord KP, Warner ME, et al. Role of preoperative cessation of smoking and other factors in postoperative pulmonary complications: a blinded prospective study of coronary artery bypass patients. Mayo Clin Proc . 1989;64:609–616.
15 Sarwer DB. Awareness and identification of body dysmorphic disorder by aesthetic surgeons: Results of a Survey of American Society for Aesthetic Plastic Surgery Members. Aesthet Surg J . 2002;22(6):531–535.
16 Kinzl JF, Trefalt E, Fiala M, et al. Psychotherapeutic treatment of morbidly obese patients after gastric banding. Obes Surg . 2002;12(2):292–294.
17 Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. New Engl J Med . 1996;334:1209–1216.
18 Classen D, Menlove RL, Burke JP, et al. Surgical site infections. N Engl J Med . 1992;325:281–286.
19 Olsen MA, Nepple JJ, Riew KD, et al. Risk factors for surgical site infection following orthopaedic spinal operations. J Bone Joint Surg Am . 2008;90:62–69.
20 Cárdenas-Camarena LMD, González LEMD. Large-volume liposuction and extensive abdominoplasty: a feasible alternative for improving body shape. Plast Reconstruct Surg . 1998;102(5):1698–1707.
21 Perrotti JA, Castor SA, Perez PC, et al. Antibiotic use in aesthetic surgery: a national survey and literature review. Plast Reconstruct Surg . 2002;109(5):1685–1693.
22 Auerbach AD, Goldman L. Beta blockers and reduction of cardiac events in noncardiac surgery. JAMA . 2002;287:1435–1444.
23 Peach MJ, Rucklidge MWM, Lain J, et al. Ondansetron and dexamethasone dose combinations for prophylaxis against postoperative nausea and vomiting. Anesth Analg . 2007;104(4):808–814.
Part 2
Upper extremity contouring
Chapter 2 Liposuction of the upper extremities

Cemal enyuva, Hüseyin Güner

Key Points

• Patient selection is crucial and the skin quality of the target region should be assessed.
• Deformities should be classified, and simultaneous or late excisional surgery should be discussed with the patient.
• Conventional technique can be used or energy delivering technology can be used to get better skin retraction.
• Gentle surgical technique should be used and soft tissue thickness should be even and esthetic contours should be achieved at the end of the procedure.
• To get a smooth result the surgery should be extended to the entire esthetic unit of the arm.

Introduction
The basic principles of arm liposuction are no different from those for other parts of the body. A plastic surgeon should also assess the skin tone, quality, topographic mapping of fat deposits, retraction capacity of the skin, and the general health of the patient. The patient should be informed that a brachioplasty could be needed during the initial procedure or later on if the liposuction cannot produce acceptable results.

Preoperative Preparation

Patient Selection
Patients with fat deposits in their arms are candidates for arm liposuction. Body mass index is an important factor in liposuction, along with general health. Morbidly obese patients who need bariatric surgery are not candidates for arm liposuction.
The classification of Teimourian 1 has been generally accepted for esthetic deformities of the arm ( Table 2.1 ). Besides Teimourian, other classifications reported by El Kathib 2 and Appelt 3 can also be used. While liposuction can be used alone in class 2 deformities, it can be used alone or can be combined with a brachioplasty technique in class 3 deformities.
TABLE 2.1 Teimourian Classification Group 1 Minimal to moderate subcutaneous fat with minimal skin laxity Group 2 Generalized accumulation of subcutaneous fat with moderate skin laxity Group 3 Generalized obesity and extensive skin laxity Group 4 Minimal subcutaneous fat and extensive skin laxity
Chamosa’s cadaver study 4 on fat deposits supports our clinical findings. Fat deposits in the arms are mostly located at the posterior area. Superficial fascia separates the fat layer into superficial and deep compartments and the storage of fat occurs in each compartment. Skin retraction is better in superficial liposuction technique. When combined with the use of internal ultrasonic and laser systems, better skin retraction is obtained due to increased dermal thermal energy.
Surgical anatomy may differ in fat and thin patients. In fat patients, increased fatty tissue is observed in the whole posterior compartment, part of the brachioradialis, deltoid, triceps and, rarely, the lateral head of biceps regions. In thin patients, there is more fat accumulation in the posterior compartment and less in the brachioradialis and triceps regions. Treatment of the whole fat accumulation, more or less, is important for a perfect result.

Surgical Technique
Preoperative drawings are done while the patient is standing. Deformities will be evident with the upper arm abducted 90° and lower arm flexed 90°. Photographs should be taken from front and back in this position and should involve both arms together and also separately. Arm circumferences should be measured at the proximal and distal 1/3 levels of the arms. Anterior and posterior arm pinch tests should also be applied to the proximal and distal 1/3 levels of the arms.
We usually use liposuction in the posterior half of the arm to avoid the irregularities caused by circumferential liposuction and because accumulation of fat occurs in the posterior arm. Lesser amounts of fat could be taken from the lateral region of the deltoid and triceps muscles, brachioradialis and sometimes from the posterior region of the lateral head of biceps. The brachial groove in the medial arm and the groove between the biceps and triceps in the lateral arm should be marked.
The procedure is performed under general anesthesia. Sedation with local anesthesia may be preferred if only liposuction is going to be performed. Multiple procedures may be started under local anesthesia and sedation; general anesthesia may be administered if needed from the beginning of the treatment.
The techniques currently being used are the conventional suction-assisted lipectomy (SAL), the third generation solid probe ultrasonic-assisted liposuction system (UAL; VASER), or laser-assisted techniques.

SAL
The Toomey or a vacuum-motored technique may be used. A stab incision located on the elbow should be sufficient. Rarely, a secondary stab incision located on the proximal arm is necessary for the cross tunnel technique. A wetting solution including 1/1 000 000 epinephrine (adrenaline) and local anesthetic is infiltrated with blunt cannulas. The amount of infiltration is calculated in accordance to soft tissue turgor or with a super wet technique (1 ml infiltration for 1 ml aspiration). Liposuction cannulas which are used parallel to the arm axis and skin surface and 2, 3, or 4 mm in diameter are preferred.
There are two basic operating positions during infiltration and liposuction. The arm should be held perpendicular and the forearm should be flexed into the first position ( Fig. 2.1 ). In this way, the posterior arm can be kept stretched to ease the operation. In the second position, the surgical assistant should lift the arm to a 90° degree angle by holding the wrist. In this way, contours of the posterior arm become visible due to gravity. Using the pinch test, the thickness of adjacent esthetic units, which is the target thickness, can be gauged. The procedure should carry on until the desired thickness is achieved. After the desired thickness and esthetic contour has been achieved, four tests should be applied, which are similar to those applied to other body parts. After rubbing, pinch, active pinch and comparison tests, additional adjustments should be done to complete the procedure if needed. Stab incisions may be closed as two layers with separate 5/0 Monocryl sutures or kept open for drainage. A liposuction arm corset should be applied to the arm.

FIG. 2.1 The basic position with the arm held in vertical position and forearm held in flexion to ease the operation.

VAL (VASER)
Third-generation solid probe ultrasound liposuction systems that were introduced in 2001 for use in other body parts may also be used for the correction of arm fat deposits. In this procedure, fat fragmentation and emulsification is obtained by ultrasound energy in the first step. For this purpose, 2.9 or 3.7 mm diameter probes may be used. The 2.9 mm probes include three rings, which enable penetration and delicate shaping. The 3.7 mm probes may include one, two, or three rings. Probes with one ring have more penetration ability and the ultrasound energy is denser at the tip of the probe. The energy is higher at the sides in the probes with three rings. The same arm positions and stab incisions are used as for the SAL technique. Skin protectors should be used and should be sutured with 3/0 silk materials to prevent the incision edges from heat trauma. Klein solution is infiltrated. At least 100 ml wetting solution infiltration is recommended for each 1 minute of ultrasound application.
Probe choice is determined according to the fibrous content of the fat tissue and also the resistance to the probe. Energy amplitude (ranged 0–100) and mode of energy transfer (continuous or intermittent) is set. VASER application for the posterior arm usually lasts between 3 and 4.5 min. VASER is carried out with depletion of the resistance in fatty tissue and the second phase is initiated. Aspiration is made with 3, 3.7, and 4.6 mm blunt-windowed VentX® liposuction cannulas in the second stage.
Lipoaspiration is terminated when desirable esthetic contours are achieved and the pinch test thickness is equalized with adjacent esthetic units. Stab incisions may be closed as two layers with separate 5/0 monocryl sutures or kept open for drainage. A liposuction arm corset should be applied to the arm.

Laser-Assisted Liposuction (LAL) and Laser Tissue Interaction
The laser method has two main aims:

1. To selectively break down fat cells and separate fat lobules into small pieces.
2. To stretch and remodel the dermal collagen and the dense nondermal collagen, which is found in the connective tissue between muscle and dermis.
The distinctive features of laser treatments are their selectivity. Laser therapies are selective, unlike other techniques. There are two target chromophores in our area of liposuction: triglyceride and water. Fat cells and lobules are composed of 90% triglyceride and all other tissues are 60% water. With the wet technique, triglyceride concentration in fat cells decreases to 80% and water concentration in other tissues increases significantly to 80–90%. For the wet technique, there are two chromophores with the same concentrations subcutaneously.
According to the laser laboratory studies, it has been seen that although the 924 nm laser beam is absorbed very well by triglyceride, it is absorbed less well by water – the other chromophore in the operative area. This type of photothermal selectivity allows for the absorption of the light into the targeted adipose tissue, while leaving the adjacent tissue relatively undamaged. This type of selectivity is particularly useful when in the superficial layer of the tissue, near the dermal junction. As the dermal tissue contains a large amount of water, any water-only absorption-based system (YAG laser based) can present problems with burns or necrosis as a result of overheating.
The goal is to minimize thermal damage on the peripheral tissues while melting fat with 924 nm laser. This way, selective laser lipolysis can be done. By heating the water with 975 nm laser, the deep dermis and dense collagen tissue in the connective tissue are stimulated. Both acute and augmented dermal and subcutaneous retraction is targeted. There is an additional effect of the diffusion of the heat created in the adipocytes from the 924 nm laser by selective absorption into the triglyceride. As the connective tissue is 90% embedded in the fat cells, this type of diffusion allows for a more controlled method of collagen contraction. In the SlimLipo system, these two wavelengths are transferred to subcutaneous fat tissue by a 1.5 mm fiberoptic cable. The power may be set to 0–20 W for 924 and 975 nm, which is 40 W in total. We can accomplish a safe lipolysis and dermal subdermal retraction by using those two laser wave lengths separately or simultaneously with this laser liposuction system.

Surgical Technique for LAL on the Upper Arm
LAL resembles classic liposuction. It is important that the operation be done under slight sedation for the patient to maintain position. A good result in liposuction surgeries very much depends on good patient positioning. For the posterior upper arm, the best position is while the patient is lying down lateral supine, the shoulder is on 90° abduction and flexion, the elbow is flexed 90°, and the patient is holding the other forearm with the operative side hand. The entire operation can be done in this position. While the fat tissue on the deltoid or brachioradialis area is treated, the arm is simply adducted and the forearm is extended so that the operation can continue smoothly.
At the start of the operation, 1/500 000 epinephrine (adrenaline) and 0.8 g/l lidocaine Ringer’s lactate solution is infiltrated in such a manner that the lidocaine dosage is not over 55 mg/kg. Following the infiltration, laser is started by inserting a 1.5 mm fiber into the subcutaneous fatty tissue.
For arms with thick fat and sufficient turgor, 3040 W blend mode of 924 and 975 nm laser is used together in equal amounts or in different ratios. In total, 15–20 kJ is applied equally to the overall area. Following this, a sufficient amount of liposuction must be done by inserting a 2 mm suction cannula. As sufficient tissue heating and retraction may not always be achieved with the 924 nm wavelength alone, the 975 nm wavelength is also available to be combined or used independently. The 975 nm wavelength is highly absorbed by water, and as there is sufficient water content in the tissue adjacent to the adipocytes, this high absorption coefficient allows for some rapid heating. It is important to remember that this water-absorption based heating is rather hard to contain as there is high water content in much of the adjacent tissue. The 975 nm wavelength should not be used in high wattage in the superficial levels of tissue nearest the dermal tissue. External cooling can help with overheating.
Older patients or those with a medium amount of fat and diminished skin tone and who do not want an incision are generally difficult cases. Conventional liposuction will not produce a satisfactory outcome. For these patients no suction-only laser liposuction application or laser liposuction application with less suction will result in better outcomes. While the fat tissue is discharged in months, the skin will be retracted slowly. This application must be done very carefully. The 924 nm wavelength must be used at about 10–20 W and no tissue other than fat tissue must be harmed. If the fat amount in the arms is large, and for faster heating, 975 nm wavelength can be added in small doses. In careful and delicate applications there will be controlled fat necrosis and fat cell apoptosis. Since vascular and lymphatic tissues and connective tissue in the same compartment will stay intact, fat necrosis will be absorbed in weeks. It may take several months to produce the final outcome. These patients must be well documented photographically and must understand that results come over time.
The incisions are immediately sutured with 6/0 Prolene or Monocryl following the surgery and the patient dressed with an upper arm corset.

Forearm
A forearm application is rarely done. Most of these patients are over 60 years old. Their complaints are mostly not being able to wear a watch or jewelry.
While the patient is lying down supine, the forearm is placed on the surgical table and the wrist is flexed slightly. Following local solution infiltration with 1/500 000 epinephrine (adrenaline), laser liposuction is applied with 924 nm wavelength at about 10–20 W alone or with blending of the 975 nm wavelength, not exceeding 4–8 W. Following the application, suction from the forearm and/or dorsum of the hand is done with a 1.5 mm blunt-faced cannula. Incisions are closed with 6/0 Prolene and a hand wrist bandage with mild compression is applied to the dorsum.

Optimizing Outcomes
Patient selection is important. Also, the patient should have realistic expectations. The surgery should be performed smoothly and a gentle surgical technique should be used. To get skin retraction and a smooth surface without waviness the surgery should be performed on the whole esthetic arm unit extensively and soft tissue thickness should be even at the end of the operation ( Figs 2.2 – 2.4 ).

FIG. 2.2 Arm liposuction: preoperative and postoperative view of the patient.

FIG. 2.3 Axillary lipodeposits before and after LAL.

FIG. 2.4 Patient with lipodeposits on her forearms: preoperative and postoperative view after LAL.

Postoperative Care
A special arm corset should be applied to the arm postoperatively. If the patient has an intravenous line in the upper extremity, a corset on that side should be deferred until the removal of the intravenous line. In this case, the upper arm is wrapped with cotton and bandaged loosely. Except for showering, the arm corset should be used for 2 weeks continuously. Progressive soft tissue indurations and alterations in sensation regress after the third postoperative week. In the third postoperative month, a visit should be arranged for photographing, and arm circumference and tissue thickness measuring.

Complications and Their Management
Careful patient selection and accurate surgical planning is essential for a good esthetic result in arm liposuction. Complications such as bleeding, infection, prolonged soft tissue indurations, burns, or seroma may occur. However, in our clinical experience, seroma is the only complication that is observed in other parts of the body and none of those complications have been observed in our clinical experience on the arm. None of our patients who had arm liposuction necessitated or demanded additional brachioplasty.

Conclusion
In conclusion, liposuction in the arm region is a simple surgical procedure and anatomic structures are avoided as long as the procedure is applied to the suprafascial plane. SAL, VAL, or laser liposuction may be used alone for patients without soft tissue laxity and ptosis. Patients with minimal ptosis and loose skin may benefit from VAL or laser liposuction, which provide better skin retraction. In patients with ptosis, liposuction is used only to facilitate brachioplasty.

References

1 Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg . 1998;102:545–551.
2 El Khatib HA. Classification of brachial ptosis: Strategy for treatment. Plast Reconstr Surg . 2007;119:1337–1342.
3 Appelt EA, Janis JE, Rohrich AJ. An algorithmic approach to upper arm conturing. Plast Reconstr Surg . 2006;118:237–246.
4 Chamosa M, Murillo J, Vazquez T. Lipectomy of arms and lipograft of shoulders balance the upper body contour. Aesth Plast Surg . 2005;29:567–570.
Chapter 3 Brachioplasty with bicipital groove scar

Susan E. Downey

Key Points

• The patient must be willing to accept the possibility of visible and even poor scarring.
• Improvement in contour must be significant to justify the visible scarring.
• The arm must be adequately deflated before brachioplasty.
• If there is laxity on the lateral chest wall consideration should be given to extending the excision to the inframammary fold.
• In massive weight loss patients, a Z plasty is not usually necessary in the axilla.

Introduction
The increase in obesity in the United States of America and the concurrent meteoric rise in bariatric surgery has led to an increasing interest and popularity of the brachioplasty procedure. Statistics from the American Society of Plastic Surgeons have borne this out, with an increase in the number of brachioplasties from 2516 in 1997 to 16 102 in 2009. 1 Massive weight loss patients make up the bulk of brachioplasty patients. As is true in all parts of the body after massive weight loss, the deformities can be highly varied. Some patients do not have much loss of fat from their arms and require debulking before a formal brachioplasty. Other patients have truly deflated arms and describe “pinching” of the loose skin as it is folded into their clothing.
Esthetic brachioplasty was first described by Correa-Inturraspe and Frenandez 2 in 1954. Lockwood (1995) 3 described the superficial fascial repair of the arm, but as was the case with his work on lower body lifts, most of his patients were complaining of aging and not massive weight loss. However, until the avalanche of massive weight loss patients entered the plastic surgeon’s office there was little interest in the procedure. That said, many plastic surgeons were still reluctant to perform the procedure due to concerns about scars and axillary contractures. The massive weight loss patients have helped change the plastic surgeons’ minds, focusing the improvement of contour with fewer concerns about scars. Plastic surgeons of course, however, continue to try and improve the scars and argue about scar placement. Some plastic surgeons advocate a scar along the most inferior point of the upper arm 4 and others have recommended a sinusoidal type of scar placement. 5 At polls taken during plastic surgery meetings the most common scar placement has been reported to be within the bicipital groove (Downey S, personal communication). A survey taken of the general public, plastic surgeons and patients confirmed that the most acceptable position of a scar is along the bicipital groove. 6 Many plastic surgeons are now continuing the excision proximally into the axillary area 7 and in some massive weight loss patients this excision may be extended down the trunk to the inframammary fold. 8, 9

Preoperative Preparation
The evaluation of patients presenting for brachioplasty involves consideration of how much residual fat is present and the looseness of the skin. One of the first considerations will be whether there is enough laxity to justify a scar from elbow to axilla or longer ( Figs 3.1 and 3.2 ). Patients with minimal looseness may benefit from looking at pictures of patients who have undergone brachioplasty in order to understand the length of the scars and the typical “rope-like” appearance of the scar near the elbow. Some clinicians have advocated drawing the proposed scar on the patient so they can live with the proposed scar for a while and see if it is something that they can accept.

FIG. 3.1 Preoperative massive weight loss patient before brachioplasty.

FIG. 3.2 Six weeks following bicipital groove brachioplasty.
The second type of patient is the opposite – the patient who has had minimal deflation of their arms. These patients will not have a satisfactory result from a brachioplasty without deflation. Attempts to perform a brachioplasty will lead to an arm still very full, but now with the addition of a long scar. There are two schools of thought: liposuction at the time of brachioplasty, and liposuction or deflation followed at a later interval (usually several months) by the formal excision. In many cases the arms are not the patient’s first priority and the deflation can be combined with the first excisional procedure the patient is undergoing (for example, an abdominoplasty) and then the formal brachioplasty could occur at a later time. Often this is a very acceptable plan for the patient as the deflation will allow the patient to wear more normal clothes or clothes that better fit their torso even though the arms are still loose ( Fig. 3.3 ).

FIG. 3.3 Massive weight loss patient before (A) and after (B) deflation (liposuction) of arms.
The third type of patient has adequate deflation and enough looseness that they will have enough improvement in contour to justify the scar. Evaluation of these patients needs to include the skin of the forearm as well as the excess and laxity of the lateral chest wall. Rotation of the skin/fat flap in an upwards and inwards manner will somewhat improve the loose skin of the forearm, but not significantly. This upward/inward rotation will leave an excess or dog-ear in the axilla. To excise this dog-ear and to give patients an even better outcome the excess can be excised down to the inframammary fold. Patients often consider this a real benefit as they object to the “bra roll” fat. 9 This fat or roll may not be visible to the plastic surgeon unless the patient has on or puts on their bra during the consultation. Even male weight loss patients may benefit from this extension down the chest wall as many male shirts now are more body revealing and a smooth contour in this area is desirable. Even in these patients who will have a significant improvement in contour it is advisable to show them pictures of brachioplasty patients so that they are aware of the length of the scars, the scar position, and the length of time that it will take the scars to mature.
Preoperative consultation not only should include discussions as to the improvement to be seen in the arms but also the limits. Many patients are concerned about the lower arm. Often the lower arm exhibits laxity but not enough looseness to justify extending the incision below the elbow. Many patients who have experienced extreme weight loss will always have more laxity to their skin and no surgical procedure to date will improve this. The scar of a brachioplasty needs to be discussed in detail with patients. In general, the scar closest to the axilla will do the best while the scar closest to the elbow will do the worst ( Figs 3.4 and 3.5 ). This is, of course, opposite to what the patient (and surgeon) wishes. Although the scar close to the elbow will eventually settle down and become flatter, it is often a long process and may require not only a lot time but topical therapy such as taping or even steroid injections. In some cases the scars are thick and wide ( Fig. 3.6 ).

FIG. 3.4 Preoperative massive weight loss patient before brachioplasty.

FIG. 3.5 Postoperative scars 3 months following bicipital groove brachioplasty. Note scar is better in axillary area and worsens as the scar approaches the elbow.

FIG. 3.6 Extensive scarring after brachioplasty.

Surgical Technique
The markings for a brachioplasty should be done with the patient in the standing position ( Fig. 3.7 ). Patients should hold their arms at 90° to their body with the elbow flexed. A horizontal line should be drawn from the axilla to the elbow marking the desired position of the final incision line along the bicipital groove. The high point of the axilla should be marked. This will represent the high point position of the flap to be excised from the upper arm as it is rotated up and in. A horizontal line should be marked, which corresponds to the inframammary fold, to mark the end of the lateral chest excision. The excess tissue of the back should be pulled forward and then a vertical line drawn, which now represents the desired position of the final incision line along the lateral chest. The excess skin and fat of the chest wall should then be pinched, utilizing the marked posterior line as the final extent of the excision. Care should be taken to observe the breast to make sure that the breast tissue is not pulled posterior and the lateral aspect of the breast is not violated. The excess tissue to be excised is then marked. This excision of the lateral chest wall tissue allows the skin and fat of the upper arm to be rotated up and in and the resultant dog-ear to be excised along the lateral chest wall.

FIG. 3.7 Preoperative markings for bicipital groove brachioplasty.
For female patients, the excision within the axilla will include all or most of the hair-bearing skin. For male patients this needs to be modified as the normal male has hair in his axilla ( Fig. 3.8 ). The incision can be moved posterior to leave behind hair-bearing skin, which also helps camouflage the scar.

FIG. 3.8 Positioning of scar in axilla of male patient to maintain normal hair-bearing pattern.
For massive weight loss patients a Z plasty has not been found to be necessary in the axilla. The incision and eventual scar in the axilla will recruit some of the residual laxity from the surrounding upper thorax area, which adds to the eventual cosmetic outcome of the procedure ( Figs 3.9 and 3.10 ).

FIG. 3.9 Male massive weight loss patient after brachioplasty with extension down thorax to inframammary fold.

FIG. 3.10 Full extension of arm after brachioplasty without Z plasty in axilla.
The procedure is done with the patient in the supine position with both arms extended. The arms should be prepped circumferentially to allow for movement and the lateral chest prepped and draped as well. The incision is made along the markings and dissection is carried down to the fascia of the arm musculature. At this juncture the loose inferior skin and fat is elevated off the arm musculature dissecting towards the inferior aspect of the arm. The skin and fat is then rotated up and in, in order to improve looseness around the elbow as well as remove the excess of the lower upper arm. This maneuver creates a dog-ear in the axilla, which is then taken out with the upper lateral chest excision. Once the excess skin and fat is elevated, the assistant should hold the upper skin and fat in place so that the incision lies in the desired position along the biciptial groove. The excess skin and fat can then be marked for excision without any fear of inability to close the wound. The excess of the upper lateral chest is excised directly using the preoperative marking. Once the excess skin and fat is excised then the wound is closed over a closed suction drain which is exited through the inferior portion of the lateral chest excision. Closure can be done in a single layer. Use of barbed sutures can make the closure quicker ( Fig. 3.11 ). If cyanoacrylate is used to seal the wound then no dressings are needed. Many surgeons have found that patients do well without compression garments. Compression garments may pinch the arm skin, especially around the axilla and can in some cases cause areas of uneven swelling. A drain may be placed and, if it is used, the drain should exit along the chest wall for the patient’s comfort.

FIG. 3.11 Intraoperative view.

Optimizing Outcomes

1. Manage expectations with detailed preoperative counseling on scar length, position, and quality.
2. Modify the excision for male patients to leave some axillary hair-bearing skin.
3. On-table marking of excision prevents over-resection and inability to close.

Postoperative Care
Early on in the experience with brachioplasty many surgeons advocated compression garments or wrapping the arms. In some patients this led to pinching of the skin especially when ace wraps were used. From the experience of patients who could not tolerate the wrapping, the technique has evolved to not using compression garments. With the use of cyanoacrylate as a wound sealant, dressings are also unnecessary and the avoidance of dressings means less chance of pinching and asymmetric swelling.
If a drain is used then it can be removed when the surgeon feels that the drainage has decreased sufficiently. Most patients are able to undergo this procedure, when done alone, as an outpatient. The most common complaint is tightness under the axilla, which generally resolves in a few weeks to months.
As mentioned earlier, the scars from a brachioplasty can take a long time to settle down. The scars nearer the axilla improve earlier than the scars near the elbow. This is frustrating to both the surgeon and the patient as the scars near the axilla are less visible. The patient will need to be reassured that the scars near the elbow will eventually settle down as well, although this process may take up to a year or even longer. Steroid injections, taping of the scars and/or silicone sheeting, massage and other usual scar management modalities can help the process along.

Complications and Their Management
Wound dehiscence can be seen primarily in the axillary area where the wound is under tension; the area can be moist and the movement of the arm can lead to disruption. In most cases these areas are small and can be handled with local wound care only.
Hematomas can occur and should be dealt with if possible as soon as identified. If the hematoma is not fully evacuated there can be scar contracture, which is a more difficult problem in the long term. Seromas are sometimes seen as well. Seromas are usually small and most often are seen near the elbow although they can occur anywhere along the incision. Serial aspiration of the small seromas usually is adequate.
Despite not using a Z plasty in the axilla, scar contracture is rarely seen in the axilla in the massive weight loss patient. Some patients report feeling tight across the axilla in the first few weeks following the operation. In these patients stretching exercises can help the natural relaxation of the scar. Massive weight loss patients typically have a lot of looseness to their upper torso and the body recruits this surrounding loose tissue to relax the scar. The side benefit to this process is an improvement in the contour of the upper torso.

References

1 American Society for Aesthetic Plastic Surgery. Online. Available from http://www.surgery.org/sites/default/files/Stats2010_1.pdf (accessed 8 March 2012)
2 Correa-Inturraspe M, Fernandez JC. Dermatolipectomia braquial. Prensa Med Argent . 1954;34:24–32.
3 Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg . 1995;96:912–920.
4 Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg . 1995;96:912–920.
5 Aly A, Cram A. Brachioplasty. In: Aly A, ed. Body Contouring after Massive Weight Loss . St. Louis: QMP, 2006.
6 Strauch B, Greenspun D. Approach to the arm after weight loss. In: Rubin JP, Matarasso A. Aesthetic Surgery after Massive Weight Loss . Oxford: Elsevier, 2007.
7 Samra S, Sawh-Martinez RM, Kiu Y, et al. Plast Reconstr Surg . 2010;126:77.
8 Rubin JP, Michaels J. Correction of arm ptosis with a medial bicipital scar. In: Strauch B, Herman C. Encyclopedia of Body Sculpting after Massive Weight Loss . New York: Thieme, 2010.
9 Downey S, Gross J. Lateral thoracic excisions in the post massive weight loss patient. Clin Plast Surg . 2008;35(1):115–120.
Chapter 4 Brachioplasty – the double ellipse technique

Al S. Aly, Peter Lin

Key Points

• Upper arm excess in massive weight loss patients most often crosses the axilla onto the lateral chest wall.
• Since upper arm excess most often crosses the axilla onto the chest wall, the resection needs to cross the axilla.
• The arm is a cylindrical structure with a hard inner core that is noncompressible.
• It is important to account for the distance between the pinched fingers in the marking process to prevent over-resection during the operative procedure.
• A complete tailor tacking of the arms prior to making the incisions during brachioplasty will prevent over-resection and banding.
• It is dangerous to leave the arm wound open for any considerable time during a brachioplasty procedure.
• The advantages of a posterior scar in brachioplasty include less visibility in normal life animation and less risk to important anatomic structures.

Introduction
Individuals that have experienced massive weight loss will often present with significant upper arm deformities. As with the other areas of the body such as the breasts, abdomen, buttocks, and thighs, significant fat reduction in the upper arms results in excess hanging skin and varying amounts of remaining fat. Many patients will call these their “bat wings.” These deformities can lead to embarrassment, rashes, and discomfort in clothing. Patients are unhappy with this stigma of their previous obesity, which has led to the authors’ development of the presented technique.
In the development of the presented technique, the senior author had to recognize the basic nature of the deformity in the upper arm of the massive weight loss patient. The excess was noted to be located within the posterior axillary fold as it extends from the axilla to the upper arm. Thus, since the posterior fold traverses from the upper arm to the axilla and onto the lateral chest wall, the excess also involved the upper arm, axilla, and the lateral chest wall (see Fig. 4.1 ). This was a major advancement in knowledge, which led to the authors’ technique of crossing the axilla with the resection. Other authors have since developed other methods of resection, but they are all based on the need to cross the axilla with the resection onto the chest wall.

FIG. 4.1 The typical “bat wing” deformity in a massive weight loss patient.
The yellow mark demonstrates how the excess crosses from the upper arm onto the lateral chest wall.
Another important concept that the senior author introduced to brachioplasty surgery is the understanding of the anatomy of the arm as it relates to the dynamics of surgery. The arm is a cylindrical structure with a hard non-compressible inner core made up of the musculoskeletal system. The inner core is covered by the skin–fat envelope, which makes up a small percentage of the entire cross-sectional area of the arm. This creates a potentially dangerous situation because the skin–fat envelope cannot tolerate even a moderate amount of swelling, as the hard inner core will not compress to accommodate that swelling. Thus this led to the discovery that allowing the arm to develop any significant amount of swelling while performing a brachioplasty can lead to one of two bad outcomes. First, if the technique allows adjustment for intraoperative swelling then less tissue is resected than ideal. Second, if the surgeon commits to the proposed amount of resection and swelling is allowed to occur in the skin–fat envelope, then the wound will not close.
The technique presented here accounts for these two major discoveries: the resection should cross the axilla and minimal to no swelling should be allowed to occur during the procedure. 1, 2

Preoperative Preparation
Included in the initial evaluation of the patient is a thorough examination of the arms. The upper arm meets the chest wall at a junction bordered by the anterior and posterior axillary folds and the hair-bearing axilla. The degree of horizontal and vertical excess is noted as well as the degree of skin laxity. The quality of the skin envelope is analyzed in relationship to the overall bulk of the arm.
Photographs of the patient should be taken with the arms abducted at 90° from the lateral chest wall, with elbows straight and then bent at 90°. Anterior and posterior views should be obtained. Lateral views with the elbows at 90° are also advisable. A careful assessment of the arms will reveal the redundant tissue is in the posterior axillary fold, which, as discussed above, crosses the axilla onto the lateral chest wall.
Patients may be categorized into three subsets. The first group of patients is those with significantly deflated arms and a thin layer of remaining subcutaneous fat. These patients are ideal candidates for excisional brachioplasty. The second group of patients presents with a large amount of persistent subcutaneous fat in their arms following massive weight loss. These patients should be treated in a staged fashion with aggressive liposuction of the upper arms as the first procedure. Then in 3 to 6 months they can undergo an excisional procedure, as a second stage. The third group of patients presents with an intermediate amount of subcutaneous tissue. These patients may choose between undergoing excisional brachioplasty with a less-than-ideal result or a staged procedure with liposuction first.
The goals of the brachioplasty procedure are to remove the horizontal upper arm soft tissue and skin excess that occur from massive weight loss and create a smooth transition from the lateral chest wall to the upper arm. The authors prefer placing the scar on the most inferior aspect of the arm in the abducted position because, when facing an observer and animating the arms, this area is least visible. Final scar position will differ based on surgeon preference.

Surgical Technique
Regardless of the brachioplasty technique chosen, the surgeon must strike a balance between resecting enough skin and soft tissue to create an attractive contour and over-resecting at the risk of not being able to close the wound. As mentioned above, the upper arm should be thought of as a cylinder with a hard, noncompressible inner core composed of bone and muscle mass, surrounded by soft tissue and skin. Aggressive resection will result in compression of soft tissues against the hard, noncompressible inner core, leading to increased risk of neurovascular compromise and possibly even inability to close the defect. To avoid this complication we employ the “double ellipse marking technique”. The outer ellipse is based on anatomic reference points that outline the extent of the upper arm deformity including the lateral chest wall and, if necessary, across the elbow. The inner ellipse is based on the outer ellipse but adjusted to allow closure of the wound around a cylindrical core.

Preoperative Markings: Double Ellipse Technique

1. Patient seated with arms abducted to 90° and elbows flexed at 90°.
2. At the axillary crease, located at the junction of the arm with the chest wall, excess skin and subcutaneous tissues are pinched just below the musculoskeletal complex. The anterior and posterior margins of this pinch are marked.
3. This process of pinching just below the musculoskeletal system is repeated at multiple points along the entire upper arm. In some patients the excess will have to be followed past the elbow.
4. The pinching of excess tissue is continued onto the lateral chest wall.
5. The marks are then all connected, both anteriorly and posteriorly, to create the first ellipse. This ellipse does not account for the distance between the pinching fingers and if used to resect tissues will not allow enough skin to be left behind to close the arm.
6. A second ellipse is created, based on the first ellipse, which accounts for the distance between the pinching fingers. Thus at multiple points along the upper arm, this pinch is repeated and the distance between the pinched fingers is noted. Marks that move in from the original ellipse edges by half the distance of the pinch are then made.
7. This process is repeated along the extent of the arm but not the lateral chest wall, since the resection is not around a cylinder at this point.
8. The second set of marks is then connected to create the inner ellipse.
9. Horizontal hatch marks are made at varying distances along the length of the ellipse to assist with final closure (see Fig. 4.2 ).

FIG. 4.2 The double ellipse markings.
The outer ellipse is based on the pinch of the soft tissues just below the musculoskeletal anatomy of the arm. The inner ellipse is created as an adjustment of the outer ellipse, based on the need to leave enough skin behind to account for the distance between the pinched fingers. Note that once the resection moves onto the lateral chest wall, the outer ellipse is reverted to.

Surgical Sequence

1. If a brachioplasty alone is to be performed the patient is placed in the supine position, with arm tables on either side, so that the arms can be manipulated in a variety of positions during the surgery. In the case of combining brachioplasty with an upper body lift, the patient is placed in the lateral decubitus position and turned to the other side when the other side is approached.
2. Intravenous lines should be avoided in the upper extremities. If a line in the arm is required for induction of general anesthesia, this should be moved to the foot or other location prior to prepping.
3. Assistants during surgery are required to stand above the head of the patient so the patient’s head is either turned 180° away from anesthesia or the operating room table is moved away from the anesthesia machine to allow the assistants enough room.
4. The inner ellipse is injected with a small amount of epinephrine-containing anesthetic to reduce bleeding at incision and the patient is prepped and draped.
5. The inner ellipse is then tailor tacked with staples in its entirety, simulating a complete resection and closure. With the tailor tack in place, the entire arm is observed for the tightness and evenness of the proposed resection. The markings are adjusted to avoid areas of under-resection and over-resection. It is especially important to avoid areas of “spot tightness” which will lead to tight bands if not appropriately adjusted for with the markings. After the markings are adjusted, the staples are removed. This tailor tacking step virtually eliminates the chance of over-resection.
6. The resection starts distally by incising both sides of the ellipse up to the first hatch mark. The skin and underlying fat are elevated off the underlying muscle fascia, starting at the distal end of the ellipse and up to the hash mark. There should be no vital neurovascular structures in this layer.
7. After obtaining excellent hemostasis, the skin edges of the ellipse are re-approximated using temporary skin staples.
8. This same process of resecting and temporarily closing the wound with staples is repeated from hash mark to hash mark in what the authors call the “segmental resection-closure technique”. While the arm is open, swelling can and will occur, thus it behoves the surgeon to work efficiently till the temporary staples are in place. The temporary closure prevents any further swelling from taking place.
9. In the region of the axilla, the resection should be more superficial than the muscle fascia to preserve as many lymphatics as possible.
10. After the entire resection is complete and the temporary staples are in place, they are replaced with sutures. The authors prefer to use 2-0 long lasting nonpermanent monofilament interrupted/inverted sutures that re-approximate all of the deep soft tissues in one layer, interspersed with subcuticular nonpermanent staples. Sometimes a more superficial 3-0 monofilament short-lasting suture is placed in a continuous subcuticular fashion. The skin is then covered with glue.
11. Drains are not utilized.

Postoperative Care
At the conclusion of the procedure the arms are elevated on multiple pillows with a slight bend at the elbow. No compression sleeves or wrappings are used. The arms are kept elevated above the heart for 2 to 3 weeks but patients are allowed to lower them for brief periods of time to perform necessary activities. Swelling in the arms and hands is not uncommon and typically resolves in 1 to 2 weeks. Patients can usually return to normal vigorous activity 3 to 6 weeks after surgery.
It is not unusual for patients to experience small areas of wound separation, especially in the axilla. The authors prefer to leave a few external skin staples around the axilla, to help reduce that risk.

Optimizing Outcomes
Because of the nature of closing around a cylinder the resultant healing scar often has a scalloped appearance that tends to resolve over a 6 to 12 month period. Patients are often concerned about scalloping unless they are counseled about its likely presence for a period of time after surgery. It is also the authors’ experience that scar quality takes longer to reach maturity than most scars in the body. The technique described in this chapter leads to a more posteriorly positioned scar when compared to the previously more popular bicipital groove scar. The position of the scar in brachioplasty is a matter of surgeon preference, with no right or wrong position. The authors’ preference for a posterior scar is based on a number of issues. First, the most visible aspect of the arm during normal animation of an individual facing an observer is the bicipital groove. The posterior scar is essentially invisible in that situation. Second, resections that are centered on the bicipital groove may injure the medial antebrachial cutaneous nerve, as well as a relatively lymph-rich area of the arm. The potential negative aspect of a posterior scar is that an observer standing behind a patient may see part of the scar.
The technique described in this chapter is quite effective in reducing upper arm access, reducing axillary laxity, and because of the lateral chest wall component of the excision, can also be utilized to decrease horizontal thoracic excess. In the authors’ experience the technique is far more effective than the previously popular “T” type brachioplasty technique, especially when the excess is of a severe nature. 3, 4 A typical early postoperative result of the technique discussed in this chapter is shown in Fig. 4.3 .

FIG. 4.3 A patient is shown preoperatively (a) and early in the postoperative period (B) after brachioplasty performed utilizing the technique discussed in this chapter.

Complications and Their Management
General risks of surgery should always be discussed with the patient, including infection and bleeding. Specific to brachioplasty, superficial nonhealing areas tend to be the most common complication. They often occur in the region of the axilla and can mostly be allowed to heal by secondary intention. Deeper dehiscences are less frequent in the experience of the authors and may or may not require formal closures.
Patients should also be made aware of the risks of potential seromas, which tend to occur right above the elbow, but can be located anywhere. They are treated initially by repeated aspirations, progressing to the use of sclerosing agents, and finally they are exteriorized by opening the scar over the area of the seroma and leaving a wick in place to allow for drainage and closure from deep to superficial. Infections are uncommon but tend to occur in association with seromas. Initial treatment is decompression and antibiotic treatment and then exteriorization.
Historically, poor scarring has always been a problem with brachioplasty. Even with the use of deep sutures to support the superficial fascial system, scars often appear raised and cordlike. It is presumed that the etiology of poor scaring is tension on closure but it is not clear that this is more of a problem with the arms than other areas of the body. Thus it may also be related to the intrinsic nature of arm skin. Despite the poor quality of many arm scars, especially within the first year, it is the impression of the authors that they eventually mature, similar to other scars, but take considerably longer, up to 2 years, to mature.
A distal dog-ear can result distally if there is considerable forearm excess. In those instances, the authors do not hesitate to cross the elbow. This can be performed during the original brachioplasty operation or revised in a subsequent procedure. If the excess extends all the way to the wrist, the resection is limited to 8 to 10 cm below the elbow in the preliminary procedure. Subsequently, after the lymphatic drainage of the arm is re-established, a secondary final excision can be undertaken in a secondary procedure.
While the brachioplasty resection is performed superficial to the muscle fascia, thus sparing the deep vital structures, some skin sensory nerves are necessarily resected. This will cause some degree of sensory loss in the upper arm that is difficult to avoid.
The lymphatic drainage of the arm is often temporarily compromised after brachioplasty, which can lead to early postoperative edema. This usually resolves in 1 to 2 weeks. However, if extensive lymphatic interruption occurs, which is more likely to be associated with bicipital scar position, there is potential for permanent lymphedema. To help reduce the risk, leaving behind some intact lymphatics in the axilla is advantageous.
Inability to close a brachioplasty incision is a difficult problem. It may manifest as a very tight closure that compromises skin vascularity or loss of distal pulses. Once encountered, the area of greatest constriction has to be identified and the sutures in that segment released. An option at this juncture is to utilize some of the resected skin as a full thickness skin graft to bridge the gap. Another option, especially if the problem is felt to be secondary to intraoperative swelling rather than over-resection, is to lightly wrap the arm for a few days to allow the swelling to resolve, then attempt closing the arm without tension. Of course, it is best to avoid this problem in the first place by following some of the recommendations mentioned in this chapter.
Another problem with a brachioplasty closure that is overly tight is compression of the deeper motor nerves, particularly the ulnar nerve. This can create a scenario similar to compartment syndrome. Treatment of this requires release of the tension and close follow up to evaluate the extent of injury as well as to monitor return of function.

Conclusion
Massive weight loss patients often present with a “bat wing” deformity that extends to the lateral chest wall. This type of deformity requires that the resection cross the axilla from the upper arm onto the lateral chest wall to allow for maximal improvement. Multiple checks during the marking process and the surgical procedure allow for accurately approximating the amount to be resected and prevention of problems with under- or over-resection. Efficient surgical technique will also prevent intraoperative swelling leading to an inability to close the arm. Finally, although scar position in brachioplasty is a matter of surgeon preference, placing the scar in a posterior aspect of the arm effectively hides the scar during normal daily activities and avoids potential medial antebrachial cutaneous nerve injury and may lead to less injury of the lymphatics of the upper arms.

References

1 Aly AS, Cram AE. Brachioplasty. In: Aly AS, ed. Body Contouring after Massive Weight Loss . St Louis: Quality Medical Publishing; 2006:303–333.
2 Aly A, Pace D, Cram A. Brachioplasty in the patient with massive weight loss. Aesth Surg J . 2006;26:76–84.
3 Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstruct Surg . 1995;96(4):912–920.
4 Baroudi R. Body sculpturing. Clin Plast Surg . 1984;11(3):419–443.
Chapter 5 Brachioplasty with liposuction resection

Dennis J. Hurwitz

Key Points

• Include the deformity of the axilla and upper chest in the arm reduction plan.
• Close the excision along the posterior half of the medial arm and zigzag across the axilla.
• Fully remove excision site fat and reduce excess fat elsewhere through liposuction.
• Anchor the proximal posterior flap to deltopectoral fascia.
• Close in two layers using barbed sutures.

Introduction
The female arm has a smoothly full but adherent skin covering that reflects the underlying musculature. The sensuous and undulating axillary hollow is created by retention of strands of fascia emanating from the chest wall to the clavipectoral fascia.
Aging as well as weight loss lead to undesirable excess skin and fat. When severe, the hanging skin is hard to cover and painful during waving. There is a canopy-like sagging of the posterior upper arm, which can be weighted down further by excessive adipose. The posterior arm junction to the chest descends, creating a broad wing-like attachment. The lateral chest has transversely oriented sagging rolls of skin lateral to the breast.
The operative strategy relates to the magnitude of deformity. 1 For the vast majority of presentations, arm skin reduction surgery is needed from the axilla to elbow. 2 – 4 Experience with severe arm and upper body deformity after massive weight loss (MWL) led to the design of the inclusive L-brachioplasty, so named for the L shaped pattern of excision with the long limb from the elbow to the axilla and the short limb extending at right angles through the axilla and along the lateral chest. 5, 6

Preoperative Preparation
Suitable candidates for L-brachioplasty desire correction of their excess skin and fat of the arm and axilla and at times the upper lateral chest. These patients accept the possibility of long, possibly hypertrophic scars, asymmetry, inadequate resections, scar contracture across the axilla, delayed wound healing, and the general medical risks inherent in this operation. Poor candidates have excessive adiposity. Arms distended by adiposity, or chronic swelling due to lymphatic and/or venous incompetence are contraindications.
Meticulous surgical markings permit expeditious conservative excision of the excess skin and fat, leaving symmetrical closures. The free hand markings are followed by linear distance measurements, creating equal lengths of anterior and posterior incision lines. Thus, there should be little need for intraoperative skin adjustment, except for the heavier, adipose laden arms, requiring considerable liposuction (see video demonstration). At the time of closure, if the resection proves to be inadequate then another centimeter excision along either resection line perimeter can be performed.
The L-brachioplasty marking begins with a hemi-elliptical skin excision of the medial arm, with the anterior straight line at or slightly above the bicipital groove and the descending curved line along the posterior arm. The six critical points are found with the patient’s arm abducted and the forearm flexed 90°. Ink dots are made at point 1 at the deltopectoral groove, point 2 at the widest portion of the mid arm near the bicipital groove, and point 3 the termination of the brachioplasty about the medial elbow or beyond. The straight or slight bowed line connecting these points is the anterior incision line ( Fig. 5.1 ). The width of the mid-arm excision is determined next by gathering and pinching excess skin and fat posterior to the mid-arm point 2 to mark point 4 along the mid-posterior margin of the arm ( Fig. 5.1 , upper). With the arm raised and the skin put on stretch, a straight line is drawn from that widest posterior arm point 4 to meet the anterior line termination at point 3 . The proximal portion of the posterior incision line is then drawn by finding the critical point 5 that can be advanced to the deltopectoral point 1. Pinching the approximation of point 5 to the deltopectoral groove point 1 advances the posterior axillary fold to tightly suspend the posterior arm ( Fig. 5.1 , lower). So far an incomplete hemi-ellipse has been drawn. The anterior incision from deltopectoral groove point 1 to the elbow point 3 is measured by tape measure to confirm it is equal in length to the curved posterior incision from elbow point 3 to the advancement point 5 . With the arm extended, the posterior line continues across the axilla, staying several centimeters away from the posterior axillary fold to descend to a tapered lateral chest point 6 as the posterior incision line of the lateral chest. The length of this line (points 5 to 6 ) will vary according to the skin laxity and rolls of the lateral chest. A line roughly perpendicular to 1–3 descends from the deltopectoral groove through the axilla and posterior to the lateral pectoral fold to taper to point 6 . The skin excision between these last two lines ( 5 – 6 and 1 – 6 ) removes the excess skin of the axilla and lateral chest ( Fig. 5.2 ).

FIG. 5.1 These are color-coded preoperative markings for the L-brachioplasty.
The ink dots 1–6 are placed sequentially freehand as described in the text. The dots are connected to create upper arm hemi-elliptical and lateral chest elliptical excisions. After the lines are drawn the linear distances are measured and adjusted so that 1–3 equals the distance from 3–5 , and the distance 5–6 equals the distance from 1–6 . Inset shows that the outstretched arm better demonstrates these relationships. If the arm deformities are symmetrical then these measured distances, as well as the width from point 2 to point 4 , will be the same or otherwise adjusted.

FIG. 5.2 (A) The advancement point 5 is being dotted with a surgical marker, as it is found along the posterior incision line by pinch approximation to the deltopectoral groove. (B) Connecting the dots point 4 to point 5 completes the descending limb of the hemi-ellipse.

Surgical Technique ( Fig. 5.3 )
If brachioplasty is an isolated procedure, the arms, axillas and upper chest are prepped while the patient is sitting and then dressed in a paper surgeon’s gown. Lay the patient supine, and abduct the arms about 80° on arm boards. Under deep sedation of general anesthesia, sterile draping is completed. We avoid arm intravenous infusion. The width of resection is rechecked. About 150 ml of saline with 1 mg of epinephrine (adrenaline) and 30 ml of 1% Xylocaine per liter are infused through a thin multiholed, blunt tipped needle. If only excision site liposuction (ESL) is being done, limit the infusion to within the borders of the planned excision so the closure is not compromised. The subcutaneous fat within the arm excision site is suctioned as completely as possible, and the author favors preliminary application of ultrasonic energy. The remainder of the arm can have fat suctioned as needed, with care taken to minimize trauma to the closure margins (see video).

FIG. 5.3 Operative sequence for L-brachioplasty.
(A) The right arm has been marked and then circumferentially prepped. The patient was dressed in a paper surgeon’s gown, which was cut open after being positioned supine and the arm was placed on an arm board angled 80 ° from the operating room table. (B) Complete liposuction of the excision site is being completed as the 4 mm multiple holed suction cannula is pulled up against the dermis, revealing the thinned tissues. (C) The perimeter incision has been completed through the skin and subcutaneous tissue and with about a centimeter of undermining of the wound edges. (D) The full thickness skin and fat excision of the right lateral chest has been done. (E) The skin excision is completed with a scalpel assisted avulsion from proximal to distal. A lattice work of connective tissue with preserved neurovasculature lies in the wound bed. (F) The subcutaneous layer has been closed using a single Quill #1 PDO 30 cm long suture. A second layer of 3-0 Monoderm follows.
The final adjustment for the adequacy of the width of resection is aided by temporary staple or towel clip closure. Then the posterior arm incision is made through the skin and superficial fascia with traction anteriorly on the arm skin. Once through the fascia the incision pops open and then is undercut about 1 cm. The posterior incision is then continued across the axilla and along the lateral chest to the tapered end at point 6 . The anterior straight line arm incision is similarly made, undermined, and continued across the axilla and descends as the anterior incision of the lateral chest to a depth of the serratus fascia. If breast augmentation or a spiral flap breast reshaping is to be performed, the anterior limb of the chest ellipse is not incised until the mastopexy/ augmentation is completed, because the recruitment of skin flaps in a breast augmentation reduces the need for lateral chest skin resection. 7
The skin resection begins with thick full thickness skin and subcutaneous tissue resection from the chest and continues through the thin axillary tissues over the clavipectoral fascia. Stay immediately subdermal to avoid entering the axilla and damaging neurovasculature. Distal traction of the arm skin produces avulsion removal, assisted by scalpel along the exposed dermis. Little bleeding is encountered as the arm skin is removed like a full thickness skin graft. Superficial veins, lymphatics, and sensory nerves are preserved on the arm, within a latticework bed of connective tissue nearly empty of adipose tissue.
A nonundermined proximal posterior triangular flap is advanced to the deltoid fascia at the groove with the pectoralis using several 2-0 braided absorbable sutures. Undermining of this flap threatens the vitality of this precarious skin blood supply. Upon closure across the axilla there will be fullness that over time will recontour to a natural axillary hollow. Using the preoperative hatch marks as a guide, the incisions are then aligned with towel clamps. Excess skin can be resected along the wound edge if needed.
While any continuous horizontal running 2-0 absorbable suture could approximate the subcutaneous fascia, the author prefers the even and reliable long-term retention of the knotless, 0 or #1 PDO double armed barbed Quill (Angiotech Pharmaceuticals, Vancouver, British Columbia, Canada). The 24 cm long #1 barbed PDO comes on a 38 mm tapered needle that is passed through as a running horizontal mattress suture, starting from the center of the wound and advancing distally (elbow) and proximally (deltopectoral groove). To start the closure, two horizontal bites are taken away from the center with each needle and the Quill suture is pulled taut. After two passes of the suture on either side of the wound, the barbed suture is cinched and secured under the appropriate tension. As the suturing proceeds, the barbs keep the closure from slipping. Thus there is no segmental slippage as may occur with other running sutures. At the end of the wound, the barbed suture is returned back for several throws, forming a J, and the end is then cut. The series of dermal dimpling caused by the horizontal suture pull of the subcutaneous fascia to the dermis will disappear over several months. A second continuous barbed intradermal suture closure follows, using 3-0 Monodern Quill SRS. Dermal glue or taping completes the closure.
Only late lymphoceles, rather than early seromas, can be a problem. As such, suction drains are unnecessary and we believe are contraindicated as negative pressure encourages flow from damaged lymphatics. The operative time for each arm is approximately 40 minutes. The incisions are covered with foam dressing and then wrapped in ace bandages with the hands elevated. Before and after photographs are seen in Figs 5.4 – 5.6 . The result of an L-brachioplasty with circumferential liposuction is seen in Figs 5.7 – 5.9 . Please see the accompanying video for this chapter for this surgical technique.

FIG. 5.4 Before and 7 months after L-brachioplasty frontal views with a 7 kg (15 pound) weight gain for the 51-year-old patient (BMI 28) seen in the operative sequence in Fig. 5.4 . The preoperative drawings are seen. The hanging posterior skin is gone. The incompletely faded scar curves from the axilla down to the mid arm and then slightly ascends to the elbow.

FIG. 5.5 Before and 7 months after L-brachioplasty posterior views for the patient seen in the operative sequence in Fig. 5.4 . Despite her 7 kg (15 pound) weight gain, her arms are smaller and better shaped.

FIG. 5.6 Before and 7 months after L-brachioplasty left oblique views for the patient seen in the operative sequence in Fig. 5.4 . The full course of the brachioplasty scar is seen as it crosses the axilla and descends on the chest. The arm, axilla and lateral chest are well shaped and reduced.

FIG. 5.7 Before and 1 year after frontal views of a L-brachioplasty with circumferential liposuction in a 48-year-old MWL patient with a BMI of 35.5. The upper arm sagging skin has been improved.

FIG. 5.8 Before and 1 year after left oblique views of a L-brachioplasty with circumferential liposuction in the same 48-year-old MWL patient with a BMI of 35.5. The axillary and chest wall improvement is seen.

FIG. 5.9 Before and 1 year after posterior views of a L-brachioplasty with circumferential liposuction in the same 48-year-old MWL patient with a BMI of 35.5. The overall arm and arm to chest attachment improvement is seen.

Optimizing Outcomes

1. The positioning and precise geometry of the surgical markings are standardized, thereby increasing symmetry, expediting the operation, and leaving the least conspicuous scar.
2. The posterior V-shaped advancement flap is firmly secured to the deltopectoral fascia, assisting vertical lift and minimizing distal scar drift.
3. Thorough excision site liposuction (ESL) of the anticipated hemi-elliptical arm excision allows for excision of skin only, preserving the neurovasculature; thereby eliminating chronic edema and lymphoceles.
4. A two-layered absorbable horizontal running barbed suture closure reduces operative time, improves wound retention and the incidence of delayed healing.

Postoperative Management
The arms are elevated on pillows for 3 days. The sponge and ace bandages are removed and replaced with securely fitting elastic sleeves at 3 days. Complete maturation of the scars with massage and a variety of topical agents takes over 2 years.

Complications and Their Management
While under-resection results in inadequate treatment, partial recurrence can result even with adequate resection, from inherent tissue laxity, which is common after MWL. Over-resection of skin is difficult to close and can lead to incision line dehiscence or vascular compromise to the hand. Skin edge necrosis and delayed wound healing may lead to widened and hypertrophic scars, and contractures across the axilla. Chronic swelling, lymphoceles, sensory loss and muscular paralysis due to radial nerve and musculocutaneous nerve injury and pain are recognized but uncommon complications.
Since using the modifications described here, complications have been reduced and satisfaction improved. The markings are more precise, leading to expeditious surgery. The anchoring to deltopectoral fascia is more secure with less distal drifting of the axillary scar. Over the past 4 years, there were 13 women and 2 males treated. There have been no seromas or lymphoceles. Appreciable swelling has resolved in all cases within a month, with no cases of prolonged edema.
Incision dehiscence was limited to less than 1 cm in five patients. Tip necrosis of the V advancement flap occurred in three arms, leaving small wounds in the axilla to heal secondarily. Secondary skin reduction was not needed. There were no contractures across the axilla in this group of patients.

Conclusion
The originally designed L-brachioplasty is commonly used for the MWL arm deformity. 5 With our better understanding of the esthetics and the four modifications described herein, we have improved our results and lowered complications. 6 We have gone beyond the concept of arm reduction surgery to sculpturing a region to esthetic beauty. 7 It is better to leave a little extra tissue than compromise shape or hazard serious complications. Already a commonly accepted procedure, 8 with the improvements in shape, scar placement, and reduced complications, L-brachioplasty can take its place as the optimal cosmetic operation for moderate to severe skin and fat redundancy of the upper arm.

References

1 El Khatib HA. Classification of brachial ptosis; strategy for treatment. Plast Reconstr Surg . 2007;119:1337–1342.
2 Aly A, Soliman S, Cram A, et al. Brachioplasty in the massive weight loss patient. Clin Plast Surg . 2008;35:141–147.
3 Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg . 1995;96:912–920.
4 Pitanguy I. Correction of lipodystrophy of the lateral thoracic aspect and inner side of the arm and elbow. Clin Plast Surg . 1975;2:477–483.
5 Hurwitz DJ, Holland SW. The L Brachioplasty: An innovative approach to correct excess tissue of the upper arm, axilla and lateral chest. Plast Reconstr Surg . 2006;117:403–411.
6 Hurwitz DJ, Jerrod K. L-Brachioplasty: an adaptable technique for moderate to severe excess skin and fat of the arms for featured operative techniques. Aesth Plast Surg. J . 2010;July–August:620–629.
7 Hurwitz DJ, Agha-Mohammadi S. Post bariatric surgery breast reshaping: the spiral flap. Ann Plast Surg . 2006;569(5):481–486.
8 Symbas L, Losken A. An outcome analysis of brachioplasty techniques following massive weight loss. Ann Plast Surg . 2010;64(5):588–591.
Chapter 6 Limited scar brachioplasty

Lawrence S. Reed

Key Points

• Good for many, but not all, cases of brachial dermatolipodystrophy in non-massive weight loss patients. The vertical height from the mid-humerus to the most dependent portion of the mid-upper arm (with the arm at 90° to the body) should be no greater than 10 cm. For excessive upper dermatolipodystrophy, the traditional method should be used.
• The tailor tack method should always be used intraoperatively to confirm the accuracy of the preoperative markings. This should be done after any liposuction, if necessary, is performed. Corrections or modifications can be made at this time. The tailor tack closure should always be checked with the patient in the upright position and the arm at a 90° angle to the lateral chest.
• A superficial plane should be used for the resection of the involved area, taking only a thin layer of fat with the resected specimen.
• The elbows should not be raised above the level of the shoulders until 3 weeks postoperatively.
• During the preoperative marking, the transverse axis width of the incision (in the axillary fold) should stop at 1.5–2 cm medial to the visible portion of the axillary crease on the anterior and posterior shoulder. This helps in preventing the final scar from extending into visible areas.
• Undesirable anterior axillary and post-axillary fullness can also be corrected during this procedure.
• 12% of patients need some form of revisional surgery performed at 1 year or later. The most common reason is for scar correction.

Introduction
There is an ever increasing demand, mainly in women, for correction of brachial dermatolipodystrophy. Most patients, however, are not willing to accept the traditional brachioplasty scar that extends, in various configurations, from the axilla, running along the inner arm to the elbow. Following the seminal paper by Pollock, 1 which described his technique for the treatment of hidradenitis suppurativa by excision of the involved axillary area followed by direct closure, I began to adapt this approach for esthetic brachioplasty. I now have 25 years of experience with this approach. There have been numerous refinements over the years. 1 – 8 The minimal incision brachioplasty (MIB) technique is the preferred approach for most patients that I see, save for those with excessively dependent dermatolipodystrophy of the upper arms (as commonly seen in massive weight loss patients). In all other cases, it provides predictably good results that are equal to those achieved in comparable patients with the traditional approach. I am most frequently asked how simply tightening the skin of the axilla, in the minimal incision approach, can replicate the result achieved when the customary extended incision method is employed. This is best demonstrated by referring to the mechanics of the classic bamboo finger trap ( Fig. 6.1 ), which when pulled on just one end circumferentially tightens the entire length of the tube.

FIG. 6.1 The bamboo finger trap aptly demonstrates the principle of the transaxillary brachioplasty in which traction in the axilla narrows the circumference of the upper arm.
(A) Finger trap with no traction on it. (B) Traction on one end of finger trap narrows its entire circumference.

Preoperative Preparation
Patients are instructed not to shave their axillary hair for 48 hours before surgery. Standard preoperative laboratory testing is performed, as indicated by age and medical history.

Surgical Technique

Markings

1. Marking is performed in the preoperative holding area with the patient in the upright position. With arms against sides, mark the anterior and posterior shoulders at the junction of the axilla with the shoulder. The final scar should not be visible beyond these markings ( Fig. 6.2A ).
2. Mark longitudinal axis from central inner arm, through center of axilla, to the midlateral chest area ( Fig. 6.2B ).
3. Mark the transverse axis from anterior shoulder to posterior shoulder in the axillary crease or fold. This line should stop 1.5–2 cm medial to the anterior and posterior axillary crease–shoulder junction. This helps avoid a scar that will extend into a visible area of the shoulder ( Fig. 6.2B ).
4. Determine the longitudinal length of excision using the pinch technique. First, move the skin of the triceps towards the transverse axis line until the arm has a pleasing contour. Then move the lateral chest skin towards the transverse axillary line. It is important to advance the lateral chest skin towards the transverse axillary crease to fix and stabilize the upper arm correction ( Fig. 6.2C, D ).
5. Mark areas that require liposuction. These should include, if indicated, the area of lipodystrophy of the upper outer breast/anterior axillary area as well as the posterior shoulder/axillary area. Both of these areas of lipodystrophy – which patients frequently point out as being of concern – can be easily corrected during the MIB procedure by liposuction and the subsequent axillary skin tightening.

FIG. 6.2 (a) With the patient standing with arms at the side (adducted), the visible portions of the anterior and posterior axillary folds are marked with a triangle. This mark is used to determine the transverse diameter of the planned exposure, which extends 1 to 1.5 cm medial to the point of each triangle. (b) The arm is sufficiently abducted to mark the axillary hollow or crease apex. This line is then shortened so that it stops about 1.5 cm before hitting the axillary fold marks. The line is bisected and carried up the arm and down the chest wall to mark the meridian of the axilla. (c) The arm is abducted 90°, and the excess skin of the triceps area is forcefully advanced toward the axillary crease and marked as point A . (d) Next, the skin of the chest wall is next similarly advanced toward the axillary crease with force adequate to balance the tension (point B ). The points are connected to make an oval area of proposed resection.

The Procedure

1. Place patient on operating room table with arms outstretched.
2. Circumferentially prep arms and chest and apply appropriate draping.
3. Infiltrate tumescent solution into the areas to be liposuctioned (approximately 1 : 1).
4. Infiltrate dilute local anesthesia (1% Xylocaine plain 50 ml and 0.25% Marcaine 50 ml, 1 ml 1 : 1000 epinephrine (adrenaline) plus 150 ml normal saline) into areas of planned surgical resection.
5. Carry out liposuction on both upper arms.
6. Use the tailor tack method to check the accuracy of the preoperative markings. It is important to check the tailor tack closure with the patient in the upright position and the arm at 90° to the lateral chest. Make any revisions necessary in the initial preoperative markings. At this time also check for any abnormal folds or rotations in the skin of the arm. Adjust the tailor tack suture placements to correct these as well. After necessary adjustments have been made, remark the planned surgical site ( Fig. 6.3A ).
7. Remove the tailor tack sutures or Adairs, and with the patient in the recumbent position, excise the involved area with just a thin layer of fat attached ( Fig. 6.3B ).
8. Clean area with 5% Betadine and mark out the area of the axillary crease ( Fig. 6.3C ).
9. Wound closure:
a. First layer 1 Vicryl which incorporates the base of the wound in the area of the axillary fold ( Fig. 6.4 )
b. Two layered closure with 2-0 14×14 PDS Quill suture
c. Final layer running 3-0 plain gut vertical mattress suture.
10. Concealing the scar: In many cases the closure of the surgical site can cause the final scar to extend into the visible portions of the anterior or posterior shoulder, or both. This should be addressed at the time of closure using the purse string technique:
a. Undermine the involved area and defat if necessary ( Fig. 6.5 )
b. Use a 2-0 7×7 Quill suture anchored in the axillary fold to bring the visible portion of the scar back into the axillary fold. This will leave some bunching and a dog-ear. These largely disappear in 3–6 months ( Figs 6.6 and 6.7 )
c. After the purse string correction, complete the closure in the standard fashion ( Fig. 6.8 ).
11. Selective use of bolster dressing. In those cases where it is felt that the axillary fold may be difficult to recreate or there is obvious tension, use a bolster dressing made from a rolled up ABD pad.

FIG. 6.3 (a) Final determination of the amount of tissue to be removed is made during surgery, using the tailor tack method. (b) Intraoperative view of axillary area of resection measuring 17 × 9 cm. (c) This intraoperative view demonstrates the amount of tissue removed as well as the remarking of the axillary crease with methylene blue. Note the presence of subcutaneous fat remaining on the axillary fascia.

FIG. 6.4 After the axillary tissue is excised, the axillary crease is marked again. The fold is recreated during closure, incorporating the fascia into each stitch, using 1.0 Vicryl.

FIG. 6.5 The extended visible portion of the incision is first undermined and then defatted to the dermis before executing the purse string closure.

FIG. 6.6 After the incision is defatted at its ends in the subdermal plane, it is closed with a purse string stitch, using 2.0 Quill suture, thus pulling the wound edges further back into the axilla. This bunched tissue usually settles in 3 to 6 months.

FIG. 6.7 Area of gathered skin at the wound after the purse string suture closure. This area usually settles out after 3 to 6 months.

FIG. 6.8 View of final closure with purse string correction of elongated anterior axillary incision.
Prior to beginning closure of the wound, place four #1 retention sutures, placed 3 cm from the wound edges. These sutures should pass carefully through the base of the wound. After the final closure, these sutures will be used to snug the bolster dressing in place. The bolster is normally left in place from 2 to 4 days. No drains are used. Bacitracin and gauze are placed on the surgical sites. No arm wraps or surgical arm garments are used ( Fig. 6.9 ).

FIG. 6.9 Bolster dressing in place at end of procedure helps to recreate axillary fold.

Optimizing Outcomes

1. Patient selection. Ideal candidates have skin laxity that can be well corrected by axillary skin excision alone. Patients with excessive skin laxity should be counseled about a standard brachioplasty.
2. Careful preoperative markings.
3. Always employ the tailor tack method prior to surgical excision and check it in the upright position with the arm at 90° to the lateral chest. Any abnormal folds of the upper arm skin can also be addressed at this time.
4. Do not be timid in executing the correction. Remember you will check the accuracy of your preoperative markings with the tailor tack method.
5. If the axillary fold is not well defined or in more fatty arms, a bolster dressing should be considered. It may be necessary to defat the area of the axillary fold for better definition using direct excision or liposuction.

Postoperative Care

1. No surgical dressings or garments.
2. Encourage patients to limit arm motion as much as possible.
3. Wash surgical area 24 hours after surgery unless bolster dressing is in place. In those cases, area should be kept dry until bolster is removed, normally in 2 to 4 days.
4. Use Purell® or similar waterless sanitizer or rubbing alcohol four times a day on incision sites.
5. Do not raise elbows above level of shoulders for 3 weeks.
6. After 3 weeks, begin active (no passive therapy) elevation of arms.

Complications
Complications in a series of 650 cases have included two infections, both of which responded to conservative antibiotic therapy. In 8% of patients small wound separations (1–2 cm) occurred, usually after 14 days. All healed by secondary intention after wet-to-dry dressings and topical antibiotic ointments.
Two complete wound dehiscences; both after an arm was fully extended above the shoulder, occurred at 7 and 10 days post operation. These were corrected on the days of the injuries and went on to uneventful, satisfactory healing.
In 10% of patients, hypertrophic or unacceptable scarring occurred. All revisions on nonacute surgical complications are carried out at 1 year.
There may be bow-stringing or “bat wing” deformity secondary to tension. This is treated with a Z plasty or other skin lengthening technique with scar release. We use bolster dressings for 3–5 days. The more commonly seen presentation is bow-stringing or “bat wing” deformity secondary to distraction or separation of the axillary skin from the base of the wound. One can check for distraction by seeing how easily the involved area of skin can be pushed up into the axillary hollow. This is treated with scar excision only. Place sutures for the bolster dressing and tack the edges of the wound to the axillary base in line with the axillary fold. Close the incision and leave the bolster dressing in place for 3–5 days. The bow-string deformity is not uncommonly seen in patients with macromastia or heavy pendulous breasts. For these patients, wearing a good, supportive bra will lessen or eradicate the bow-string presentation. A reduction mammoplasty should also be considered. It is important to recognize this phenomenon and discuss these options with the patient during the initial consultation.
No hematomas or seromas were observed. No neurovascular, lymphatic, or musculoskeletal problems occurred.

Conclusion
The minimal incision transaxillary brachioplasty should be the procedure of choice for all those patients requesting recontouring and rejuvenation of the upper arm who do not have excessively dependent dermatolipodystrophy. Please refer to Figs 6.10 – 6.14 for a representative selection of before and after surgery results. It is a simple procedure that delivers predictably good results, comparable to those results achieved with the traditional approach, while confining the scar to the axillary area.

FIG. 6.10 (A–D) Views of 63-year-old woman before surgery and 4 months postoperatively.

FIG. 6.11 (A, B) Views of 47-year-old woman before surgery and 6 months postoperatively.

FIG. 6.12 (A, B) Views of 32-year-old woman before surgery and 11 months postoperatively.

FIG. 6.13 (A, B) Views of 43-year-old woman before surgery and 5 months postoperatively.

FIG. 6.14 (A, B) Views of 43-year-old woman before surgery and 5 months postoperatively.

References

1 Pollock WJ, Virnelli FR, Ryn RF. Axillary hidradenitis suppurativa: a simple and effective surgical technique. Plast Reconstr Surg . 1972;49:22–27.
2 Correa-Iturraspe M, Fernandez JC. Dermolipectomia braquial. Prensa Med Argent . 1954;41:2432.
3 Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg . 1998;102:545–551. discussion 552–3
4 Abraham DL. Minibrachioplasty: minimizing scars while maximizing results. Aesth Surg J . 2003;114:1631–1638.
5 Richards ME. Reassessing minimal incision brachioplasty. Aesth Surg J . 2004;25:175–179.
6 Richards ME. Minimal incision brachioplasty: a first choice option in arm reduction surgery. Aesth Surg J . 2001;21:301–310.
7 Trussler AP, Rohrich RJ. Limited incision medial brachioplasty: technical refinements in upper arm contouring. Plast Reconstr Surg . 2008;121:305–307.
8 Reed LS, Hyman JB. Minimal incision brachioplasty: refining transaxillary arm rejuvenation. Aesth Surg J . 2007;27(4):433–441.
Part 3
Breast
Chapter 7 Fat grafting to the breast

Kamran Khoobehi

Key Points

• Fat harvesting should be done with maximum care and minimal negative pressure to prevent damage to the fat cells.
• Patient selection and education to manage expectations will maximize patient satisfaction.
• The fat should be injected in multiple layers to prevent pooling and cyst formation.
• The use of 3D imaging will help to quantify the pre- and post-injection breast volume. This will help to measure the fat survival percentage.
• Fat harvested from different donor sites should be mixed before injection to have a similar fat cell population in both breasts.
 For additional online content visit http://www.expertconsult.com

Introduction
Autologous fat grafting is a well-established technique that is practiced by many plastic surgeons. Fat cell abundance and ease of harvesting make fat grafting a logical choice for soft tissue defect restoration and augmentation. The technique of fat grafting varies from surgeon to surgeon, and there are no standardized harvesting, preparation and injection techniques.
The current popularity of fat grafting, in many ways, is because of the work done by Dr. Sydney Coleman. He popularized the technique for harvesting the fat using a handheld syringe and centrifuging for compaction. 1
The need for large volume fat harvesting and injection could not be met by the current techniques due to the length of time needed to harvest fat and centrifuge the fat. The average time for harvesting, processing and injecting fat by the Coleman technique is 100 cm 3 of fat in 1 hour. 2

History of Fat Grafting
The history of fat grafting goes back to 1893 when Neuber used it for facial defects. 3 In 1895, Czerney used fat grafting for chest wall deformity post mastectomy. 4 The early experimentation with fat grafting was not popular because, at a time when little was known about tumescent liposuction, most fat harvesting was performed by excision. The use of tumescent liposuction has given us the ability to harvest large amounts of fat with minimal donor site morbidity.
In 1987, Mel Bircoll published his work on fat grafting to the breast. 5, 6 The shortcomings of his work were poor long-term follow-up and a lack of mammographic studies as indicated by letters to the editor from 1987. 7 American Society of Plastic Surgeons (ASPS) published a position paper in 1987 “Deploring the use of fat injection in breast augmentation” due to the fear of interference with breast cancer detection. 8 The main concern at that time was that calcification from necrotic fat would cause interference with breast tissue evaluation by mammogram. At the same time published papers stated that surgical procedures such as breast reduction, 9, 10 augmentation 11, 12 and any breast procedure can also cause calcification. Further studies indicated that calcification from fat necrosis is easily distinguished from breast cancer calcification. 13 – 20
There was a long gap before any work was published on fat grafting to the breast. Dr. Coleman published his work on fat grafting to the breasts in 2007. His results were remarkable and showed long-term survival of the injected fat. 2
In 2007, ASPS and The American Society for Aesthetic plastic surgery (ASAPS) jointly and strongly supported the ongoing research efforts that would improve the safety and efficacy of the procedure 21 but also cautioned against fat grafting for breast augmentation.
The future of fat grafting depends on the establishment of a standardized harvesting, processing, injection technique, long-term follow up for safety and efficacy, and also establishment of a data base for all the fat grafting patients.

Principle of Low Pressure Fat Harvesting
Handheld syringe aspiration is accepted as a gentler technique for fat harvesting. There are no published data to support this claim. We at LSU division of Plastic and Reconstructive Surgery undertook the study to find out the negative pressure that is generated by handheld syringes and liposuction machines. The graph in Fig. 7.1 shows the in-situ maximum pressure within the 1, 3, 5, 10, 30 and 60 cc syringes. Negative pressures were measured in vitro and in situ with 1, 2, 3, and 10  cc pull on a 10 cc Luer-Lock syringe as well as a conventional liposuction machine at 254 mmHg, 381 mmHg, and 762 mmHg ( Figs 7.1 , 7.2 , and 7.3 ).

FIG. 7.1 The graph shows the in-situ maximum pressure within the 1, 3, 5, 10, 30, and 60 cm 3 syringes.

FIG. 7.2 The graph shows the negative pressure produced in a 10  cm 3 syringe to be as high as 660 mmHg with full pull and 280 mmHg with only 1  cm 3 pull on the 10  cm 3 syringe.

FIG. 7.3 Negative pressure measurements for liposuction machine at different setting in situ.
The graph in Fig. 7.2 shows the negative pressure produced in a 10 cc syringe to be as high as 660 mmHg with full pull and 280 mmHg with only 1 cc pull on the 10 cc syringe.
The constant negative pressure at the low setting (254 mmHg) by a liposuction machine is 220 mmHg. This is less than the negative pressure in a 10 cc syringe only pulled back 1 cm 3 . Most liposuction machines have a control for adjusting the negative pressure.
In order to evaluate the extent of damage to fat cell caused by all harvesting techniques, lipoaspirant samples were analyzed using lactate dehydrogenase (LDH) and triglyceride levels ( Fig. 7.4 ). Glucose-3-phosphodiesterase (G3PD) assay was used to measure cell viability ( Fig. 7.5 ). LDH and triglyceride are intracellular components and their presence in the aspiration fluid indicates cell damage and cell wall disruption. The results suggests that the samples harvested with the low negative pressure liposuction machine were lower in LDH and triglycerides. The G3PD assay suggests cell viabilities were high in samples from the low-pressure liposuction machine in comparison to the handheld syringe, which indicates more viable cells by the low pressure technique.

FIG. 7.4 Basis of fat grafting – biochemical markers.

FIG. 7.5 Assessment of viability – G3PD activity.
Harvested fat cells were stained with fluorescent dyes for imaging using scanning electron and confocal laser electron microscopes ( Fig. 7.6 ). The slides show the outer cell layers bursting from the negative pressure.


FIG. 7.6 Basis of fat grafting – microscopic analysis.
FIG 7.6 APPEARS ONLINE ONLY
The low-pressure liposuction method removes the human factor and variation of the pull on the syringe and provides consistent negative pressure that helps to decrease operating room time and also prevents the surgeon’s hand fatigue. This technique yields large volumes of fat in a short period of time and minimizes the damage to the fat cells.

Autologous Fat Grafting to the Breast
In June 2008 at Louisiana State University Health Science Center in New Orleans, we started an IRB approved study on fat grafting to the breast. So far we have had more than 276 patients in this study and collection of the data has started for the follow up studies. Currently, fat grafting to the breast is a treatment option in conditions such as micromastia, breast ptosis, post mastectomy breast reconstruction, asymmetric breast, congenital malformation of the breast, and for treatment of complications associated with implant augmentation mammoplasty.

Technique

Harvesting

Local Infiltration
The solution that is used is 20 cm 3 of lidocaine 1% with epinephrine, plus 2 cm 3 epinephrine 1/1000 in 1 liter of lactated Ringer. The volume of tumescence is 10–20% more than the aspirate. It is imperative to wait 20 min. post infiltration to maximize vasoconstriction and minimize blood loss.

Cannulae
A blunt 5 mm Mercedes tip cannula is used for harvesting the fat. The common belief is that a large cannula will damage the donor site, but our experience with large cannulae has been the opposite. The other belief is that a large cannula will produce large particles of fat, which will make it hard to reinject with a small cannula (11 gauge) but our experience also has been contrary to current belief.

Fat Cell Preparation
The process of centrifugation increases the risk of contamination and cell damage. One advantage of centrifugation is to compact the fat cells. Another advantage of centrifugation is the ability to separate damaged cells from intact cells. Centrifugation at a low speed for a short period (100  g /30 s) will give the same compaction as a higher speed and longer period (1400  g /3 min). Refer to Fig. 7.7 . The other observation is the lack of oil on the top of the syringe with low pressure fat harvesting. This observation is consistent with our study showing that the fat cells harvested by low pressure are damaged less, and less oil leaks out.

FIG. 7.7 The picture shows the lack of free oil on the top after centrifugation at 100 g and 1500 g.
The drawback of not centrifuging the fat is overestimation of the amount of actual injected fat. We adjust the actual injected fat by 20% to correct for this if we do not centrifuge the fat before injection.

Fat Injection
After the fat has been decanted, the fluid in the bottom of the jar is discarded and the fat cells transferred to 30 cm 3 syringes and then from 30 cm 3 to 10 cm 3 syringes with a male-to-male connecter. Fat cells are then injected in a multilayer technique while withdrawing. Each 10 cm 3 syringe will require at least five to seven passes to finish. The cannula for injection is an 11 gauge blunt tip single-side port cannula. A double-sided port causes trapping of the ligaments and clogging. Injection is started in the submuscular plane, then at the subcutaneous layer and finally, the subglandular planes.


FIG. 7.8 For patients with saline implants the implants are deflated under local anesthesia 2 weeks before the planned surgery to give the tissue time to contract.

Postoperative Care
In our practice the recovery from fat grafting is fast and much less painful than with implant breast augmentation. Most patients complain more about the donor site than the breast pain. There is usually swelling that resolves in a few weeks. The breast volume will finalize at 3 months post injection. Massaging of the breast is discouraged during the first few days to prevent pooling of the fat.
A preoperative mammogram, 3D imaging and photographs are obtained on all patients as well as a postoperative mammogram and 3D imaging a year after the surgery. Patients follow the American Cancer Society guidelines for follow up breast cancer screening.
Our experience with patient satisfaction has centered around long-term volume retention. Most patients are concerned about the loss of volume. The use of 3D imaging, patient education and also consistent photographic documentation is a must. Patients emphasizing the size rather than the quality of the result are not good candidates for fat grafting.

Fat Grafting for Implant Failure
The use of the implant for breast augmentation is the accepted treatment that works well in the majority of patients. Complications from augmentation include capsular contracture, rippling, bottoming out, infection, palpable implants, visible implants, and an unsatisfactory shape and size. The use of silicone gel has helped in certain patients to decrease rippling and palpable implants. For patients that do not want implants anymore, or have failed with these treatments, fat injection is an alternative.
For patients with saline implants, these are deflated under local anesthesia 2 weeks before the planned surgery to give the tissue time to contract ( Fig. 7.8B, C ). Figure 7.9 shows the same patient 2 weeks later. The amount of tissue retraction and improvement is impressive.


FIG. 7.8 For patients with saline implants the implants are deflated under local anesthesia 2 weeks before the planned surgery to give the tissue time to contract.


FIG. 7.9 (A) Patient 5 years post saline breast augmentation by another surgeon. (B) Immediate post saline implant deflation under local anesthesia. (C) 2 weeks post deflation only.
FIG 7.8B, C , 7.9 , 7.10 , 7.11 . APPEARS ONLINE ONLY
During the surgery the fat graft is performed first and then the deflated implant is removed and a drain placed in the pocket. The protocol is different for patients with saline implants ( Fig. 7.10 ) vs. silicone gel implants ( Fig. 7.11 ). For silicone gel implants, I would remove the implants and capsule first with limited fat grafting to prevent fat collection in the explanted implant pocket. The final fat grafting is performed 3 months later.


FIG. 7.10 (A) Sub glandular saline implant. (B) Immediate post deflation. (C) 1 year post one session of fat grafting (R 350 cc and L 430 cc).

FIG. 7.11 (A) Patient 25 years after silicone gel breast augmentation,capsular contracture and implant rupture. (B) One year post implant removal and fat grafting (R 267cc and L 280 cc) in one session.
The mammograms before explantation show minimal breast parenchyma visualization and blockage of the breast tissue by the implant. In mammograms after explantation and fat grafting, full breast tissue can be evaluated. Figures 7.12 and 7.13 show mammograms before and 1 year after fat grafting.

FIG. 7.12 Mammogram before and one year after implant removal and fat grafting.


FIG. 7.13 Mammogram before and 1 year after fat grafting.
FIG 7.13 . APPEARS ONLINE ONLY

Fat Grafting in Conjuction with Mastopexy
The aim of any mastopexy operation is repositioning of a sensate and viable nipple to an esthetically pleasing point on the breast mound with minimal scars and augmentation or creation or improvement of upper pole fullness with minimal scars. Therefore, the ideal approach to rejuvenate and lift the breast requires the surgeon to address the issue of simultaneous volume augmentation. The concept of a single stage mastopexy with implant augmentation is an attractive concept but raises debates amongst most plastic surgeons. 22 The complications are attributed to the contradicting forces that the breast parenchyma is subjected to during an augmentation/mastopexy, along with the alteration in the architecture of the breast and the blood supply to the mammary tissue and its nipple–areola complex. The complications range from dehiscence, poor scarring, recurrent ptosis, areola asymmetry, nipple ischemia, deflation, capsular contracture, misplacement, and infection. In fact, Spear et al reported a complication rate of 17.4% with a revision rate of 8.7% for primary augmentation/mastopexy in his 3-year review. Another recent publication reported a complication rate of 10.6% with a revision rate of 14.6% for augmentation/mastopexy over a 14-year period. 23
Furthermore, superior pole fullness is usually lacking in the majority of patients undergoing this procedure and postoperative “bottoming out” of the implant is a common long-term problem. In order to avoid the use of implants with mastopexy, multiple procedures are reported in the literature utilizing various flaps to provide superior pole fullness along with repositioning of the nipple and tightening of the skin envelope.

Preoperative Preparation
Patients are instructed to not gain or lose weight before surgery. All patients are prepped with antibacterial soap the night and morning of the surgery. We require a preoperative mammogram and postoperative mammogram 1 year after surgery.

Surgical Technique
Fat harvesting is performed based on the described protocol. Fat injection is performed with a blunt 11 gauge cannula through small 2 mm stab incisions on the medial and lateral aspects of the breasts. Liposculpting is performed by deploying the fat in a layering fashion into the subpectoral and prepectoral planes as well as into the subcutaneous planes. With each pass approximately 1–2  cm 3 of fat is deposited into the target area. All patients with congenital tubular breasts underwent a circumareolar mastopexy, and the remaining patients underwent a vertical mastopexy with a small horizontal component ( Figs 7.13 , 7.14 , 7.15 , 7.16 , 7.17 & 7.18 ). Parenchymal suspension is performed by suturing lateral breast tissue to the lateral edge of the pectoralis muscle.

FIG. 7.14 (A, B & C) Preoperative marking shows the target area for fat grafting. Fat grafting is done for the upper pole and then mastopexy is performed. (B & C) Preoperative marking shows the target area for the fat grafting. Fat grafting is done for the upper pole and then mastopexy is performed.

FIG. 7.15 Preoperative (A) and (B) 1 year after mastopexy and fat grafting, abdominoplasty, and liposuction.
Right 710 cm 3 , left 710 cm 3 .

FIG. 7.16 Preoperative (A) and (B) 1 year after mastopexy and fat grafting, abdominoplasty and liposuction.
Right 710 cm 3 , left 710 cm 3 . Total OR time for the mastopexy, fat grafting, abdominoplasty and liposuction was 5 hours and 17 min.


FIG. 7.17 Pre and post mastopexy and fat grafting 9 months post mastopexy.
Right 405 cm 3 , left 400 cm 3 .

FIG. 7.18 Pre (A) and post (B) abdominoplasty, mastopexy, and fat grafting 6 months postoperative.
Right 230 cm 3 , left 270 cm 3 .
FIG 7.17 , 7.18 . APPEARS ONLINE ONLY
Volume augmentation with autologous fat grafting obviates the need for the creation of a pocket and circulatory compromise to the nipple. As the fat is layered in multiple planes and deposited in small increments, it further minimizes trauma to the nipple–areola complex circulation from the underlying blood vessels.
The placement of the fat into the subpectoral and suprapectoral planes in the superior pole of the breast helps to maintain the transplanted fat in the area that is most desired and least addressed by other methods. The cleavage area can be enhanced by liposculpting the breast with subcutaneous fat placement along the medial aspects of the breasts. Symmetry can also be accurately addressed with precise placement of the volume of fat grafts into the deficient areas.

Fat Grafting for Augmentation
There are a group of patients that do not want implants. These patients want a more natural look and feel. We have found that these patients tend to be older, have been pregnant, have lost the upper fullness, and most of them want only minimal size change. Fat grafting can provide the size and natural feel without the use of implants. The most important thing is the emphasis on quality rather than quantity.
Fat grafting patient education includes 3D imaging and using software to give the patient realistic expectations before surgery.
The pictures suggest that the greatest enhancement are at the cleavage, an area not often enhanced by submuscular implants ( Figs 7.19 , 7.20 , 7.21 , 7.22 and 7.23 ). Full disclosure about the risks, including cyst formation, calcification, and the possible need for biopsy, is a must.

FIG. 7.20 Preoperative (A) and (B) 1 year post fat grafting.
Right 570 cm 3 , left 500 cm 3 , total OR time 110 min.

FIG. 7.21 Preoperative (A) and (B) 6 months post fat grafting.
Right 345  cm 3 , left 345  cm 3 .

FIG. 7.22 Same patient as in Fig. 7.21 , 3D imaging.


FIG. 7.19 A fat-grafted patient at 1-year postoperative.
Right 200 cm 3 , left 200 cm 3 .

FIG. 7.23 Same patient as in Fig. 7.21 with view of the cleavage, 3D imaging.
FIG 7.19 , 7.23 . APPEARS ONLINE ONLY

Fat Grafting Over Existing Implants
For patients that are happy with their implants but want more cleavage, less rippling and softer breasts, fat grafting can be an option. Fat grafting can be done at the subcutaneous plane to give more coverage to the implants. I would recommend that back-up implants be available, and patients should be informed about the possibility of rupturing the implant and the need for an implant exchange. The use of fat grafting on the top of silicone implants should be done with extreme caution to prevent damage to the implant ( Fig. 7.24 ).

FIG. 7.24 Fat grafting over saline implants for rippling. 6 months postoperative.
Right 200 cm 3 , left 200 cm 3 .

Fat Grafting for Breast Reconstruction
The use of fat grafting for revision of breast reconstruction (implants or autologous) post mastectomy is the most common use of fat grafting.
The most common findings after the use of the free flap for breast reconstruction are upper pole depression, volume asymmetry, indentations, and a need for more projection. Fat grafting can help to add volume, enhance cleavage, and give projection and upper pole fullness.
Fat grafting can be used in combination with implants for reconstruction. Implant and acellular dermal matrix can be used at the first stage and then fat grafting later, to enhance and add volume and soften the breast tissue. Fat grafting has been shown to improve the radiated breast tissue ( Figs 7.25 , 7.26 , and 7.27 ).

FIG. 7.25 Patient with bilateral mastectomy; post bilateral DIEP flap breast reconstruction, and 6 months post fat grafting.
Right 390  cm 3 , left 440  cm 3 .


FIG. 7.26 Patient with bilateral mastectomy; post bilateral DIEP flap breast reconstruction, and 6 months post fat grafting.
Right 390  cm 3 , left 440  cm 3 .

FIG. 7.27 Patient after right mastectomy, DIEP flap reconstruction and 1 year post fat grafting.
Right 250  cm 3 .
FIG 7.26 , 7.27 . APPEARS ONLINE ONLY

Fat Grafting for Congenital Breast Deformities
Patients with tubular breasts, Poland syndrome, and severe breast asymmetry are candidates for fat grafting. The procedure is individualized based on the physical findings. There may be a need for the Brava System for tissue expansion before fat grafting. It can also be done in combination with a mastopexy to achieve the desired outcome.
For the patient with tubular breasts, circumareolar mastopexy in combination with fat grafting is necessary. In these patients there is a connection between the lower pole of the breast and skin and pectoralis muscle that needs to be excised. Patients with Poland syndrome may need to have autologous breast reconstruction as the first stage and fat grafting for result enhancement ( Figs 7.28 – 7.31 ).

FIG. 7.28 Patient with severe tubular breast. 9 months post fat grafting and circumareolar mastopexy.
Right 420  cm 3 , left 470  cm 3 ,

FIG. 7.29 3D imaging can be used for measuring the fat graft take.

FIG. 7.30 Patient with Poland syndrome and GAP flap post fat grafting.
Right 240 cm 3 , left 300 cm 3 , total OR time 166 min.

FIG. 7.31 Same patient as in Fig. 7.30 with Poland syndrome.

Optimizing Outcomes
See Box 7.1 .

Box 7.1
Optimizing Outcomes

1. Under promise and over deliver.
2. Fat grafting is not a good option for patients that keep discussing size. The best patient is the one that talks more about quality than quantity.
3. Patients with saline implants that request implant removal and fat grafting will need implant deflation 2 weeks before surgery. Patients with silicone gel implants will need two-stage surgery.
4. I always talk about second fat grafting surgery and give patients a discount (50% off) for the second stage if the patient wants more volume later on.
5. Postoperative care for the breast is minimal. I recommend my patients not to massage their breasts. I treat my patients with antibiotics after surgery for a week. I recommend Endermologie treatment 10 days after fat harvesting and grafting to help the donor sites. The treatment protocol is Endermologie twice a week for 5 weeks.
6. Complications and their management. The most common complications specific to fat grafting to the breast are calcification, oil cyst formation, and nodules in the breast. The local radiologist should be informed about the fat grafting. The need for biopsy can be minimized if the radiologists are aware of the changes that are common with fat grafting. The pattern of calcification from fat grafting is different than from breast cancer. The other common complication is patient dissatisfaction with breast size. This is a common problem with implant augmentation too. Patient education, patient selection and realistic expectations will prevent an unhappy patient.

Conclusion
Fat grafting has unlimited potential to be used as a soft tissue filler and for tissue rejuvenation. The current research on stem cells from fat is showing enormous potential to change the medical treatments. These cells have the potential to differentiate into any cell lines. 24 Stem cells have the promise of cure for diabetes, liver failure, cardiomyopathy, arthritis, macular degeneration, and any disease that would benefit from cell therapy. The advantage of stem cells from fat in comparison to embryonic or bone marrow stem cells is the ease of harvest and large amount of donor fat.
The great potential of fat grafting to the breast is as an adjuvant to implants for breast reconstruction as well as in cosmetic breast augmentation.


 Bonus images for this chapter can be found online at http://www.expertconsult.com
Fig. 7.6 , 7.8B, C , 7.9 – 11 , 7.13 , 7.17 – 19 , 7.23 , 7.26 , 7.27 can be found online.

References

1 Coleman SR. Long-term survival of fat transplants: Controlled demonstration. Aesth Plast Surg . 1995;19:421.
2 Coleman SR, Saboeiro AP. Fat grafting to the breast revisited: safety and efficacy. Plast Reconstr Surg . 2007;119:775–785.
3 Neuber F. Fettransplantation. Chir Kongr Verhandl Dsch Gesellch Chir . 1895;22:66.
4 Czerny A. Plastischer Ersatzder Brustdruse durch ein lipoma. Chir Kongr Verhandl . 1895;216:2.
5 Bircoll M. Cosmetic breast augmentation utilizing autologous fat and liposuction techniques. Plast Reconstr Surg . 1987;79:267.
6 Bircoll M, Novack BH. Autologous fat transplantation employing liposuction techniques. Ann Plast Surg . 1987;18:327.
7 Plastic & Reconstructive Surgery, February 2008, Volume 121, Issue 2, p 701.
8 ASPRS Ad-Hoc Committee on New Procedures. Report on autologous fat transplantation. September 30, 1987
9 Brown FE, Sargent SK, Cohen SR, et al. Mammographic changes following reduction mammaplasty. Plast Reconstr Surg . 1987;80:691.
10 Miller CL, Feig SA, Fox JWT. Mammographic changes after reduction mammaplasty. Am J Roentgenol . 1987;149:35.
11 Benjamin JL, Guy CL. Calcification of implant capsules following augmentation mammaplasty: Case report. Plast Reconstr Surg . 1977;59:432.
12 Koide T, Katayama H. Calcification in augmentation mammaplasty. Radiology . 1979;130:337.
13 Kneeshaw PJ, Lowry M, Manton D, et al. Differentiation of benign from malignant breast disease associated with screening detected microcalcifications using dynamic contrast enhanced magnetic resonance imaging. Breast . 2006;15:29.
14 Chala LF, De Barros N, De Camargo Moraes P, et al. Fat necrosis of the breast: Mammographic, sonographic, computed tomography, and magnetic resonance imaging findings. Curr Probl Diagn Radiol . 2004;33:106.
15 Fischer U, Baum F, Obenauer S, et al. Comparative study in patients with microcalcifications: Full-field digital mammography vs screen-film mammography. Eur Radiol . 2002;12:2679.
16 Yunus M, Ahmed N, Masroor I, et al. Mammographic criteria for determining the diagnostic value of microcalcifications in the detection of early breast cancer. J Pak Med Assoc . 2004;54:24.
17 Danikas D, Theodorou SJ, Kokkalis G, et al. Mammographic findings following reduction mammaplasty. Aesth Plast Surg . 2001;25:283.
18 Hogge JP, Robinson RE, Magnant CM, et al. The mammographic spectrum of fat necrosis of the breast. Radiographics . 1995;15:1347.
19 Abboud M, Vadoud-Seyedi J, De Mey A, et al. Incidence of calcifications in the breast after surgical reduction and liposuction. Plast Reconstr Surg . 1995;96:620.
20 Mendelson EB. Evaluation of the postoperative breast. Radiol Clin North Am . 1992;30:107.
21 Gutowski KA. ASPS Fat Graft Task Force. Plast Reconstr Surg . 2009;124(1):272–280.
22 Spear SL. Plast Reconstr Surg . 2006;118(7S):133S–134S.
23 Spear SL, Boehmler JHIV, Clemens MW. Plast Reconstr Surg . 2006;118(7S):136S–147S.
24 Behr B, Ko SH, Wong VW, et al. Stem cells. Plast Reconstr Surg . 2010;126(4):1163–1171.
Chapter 8 Ultrasound-assisted breast reduction

Alberto di Giuseppe

Key Points

• Breast reduction with Vaser (ultrasound-assisted energy) is described.
• Scarless breast reduction is outlined.
• The Passot breast reduction (no vertical scars) combined with Vaser is described.
 For additional online content visit http://www.expertconsult.com

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

Preoperative Preparation

Patient Selection
The ideal candidates for a breast reduction with ultrasound-assisted lipoplasty (UAL) are patients with juvenile breasts, which usually have fatty parenchyma, or patients with postmenopausal involution parenchyma, with good skin tone and elasticity present. Between 60 and 70% of women with large breasts are candidates for reduction with UAL. The preoperative assessment includes a mammographic study, breast clinical history, evaluation of breast ptosis, and evaluation of the consistency of breast parenchyma.

Preoperative Mammography
Preoperative mammograms (anteroposterior and lateral views), the so-called Ecklund view, are taken to evaluate the nature and consistency of the breast tissue (fibrotic, mixed or fatty parenchyma ), distribution of the fat, presence of calcifications, and areas of dysplasia or nodularity that might necessitate further studies ( Fig. 8.1 ). The presence of fibroadenomas, calcifications, and other suspected or doubtful radiologic findings should be double-checked with ultrasound and a radiologist experienced in breast tissue resonance.

FIG. 8.1 Mammographic evaluation of candidates for breast reduction with the use of ultrasound-assisted lipoplasty (UAL).
(A) A typical fatty breast. This patient is an ideal candidate for UAL. (B) Fibrotic glandular tissue is a contraindication for UAL .(C) Fibrotic mixed tissue. This patient is a candidate for UAL of the posterior upper and lower cone.

Contraindications
In the author’s study, patients with a history of breast cancer or mastodynia were not considered and nor were those fearful of potential sequelae from this new technique.
Furthermore, because the amount and distribution of the breast fat is variable, not all women are candidates for breast volume reduction with UAL. If fat and glandular tissue are mixed, penetration of the tissue may be impossible, as noted by Lejour 13 and Lejour and Abboud. 14 If the breast tissue is primarily glandular, the technique is not indicated.

Preoperative Planning
The distance from infraclavicular notch and nipple is drawn by hand ( Fig. 8.2 ). Circles indicate the area of major volume to be addressed. A circle of about 5 cm diameter is marked around the nipple.

FIG. 8.2 Distance from infraclavicular notch and nipple: circles indicate the area of major volume to be addressed and a circle of about 5 cm diameter is marked around the nipple.
This area is not addressed by ultrasound as it clearly contains 90% of the breast tissue. Ultrasound energy targets only the fatty tissue of the breast, sparing the parenchymal components.

Surgical Technique

Infiltration
Infiltration should be divided into the three different layers of the breast: deep, intermediate, and superficial ( Fig. 8.3 ).

FIG. 8.3 The three different layers of infiltration (superwet infusion) of the breast: deep, intermediate, and superficial.
In deeper and intermediate layers I expect a 1.5 : 1 ratio between infiltration and aspirate; in the superficial layer I normally infiltrate twice what I expect to extract (2 : 1 ratio). I use blunt infiltration cannulas, as described by Klein, 15 15–20 cm long.
It is essential to perform meticulous infiltration of the superficial layers, then to wait a minimum of 15 minutes to allow the epinephrine (adrenaline) to take effect, before starting ultrasound.
In a total of 500 ml of infiltration, normally 400 ml are for deeper and intermediate layers, and 100 ml are for superficial layers.

Skin Incisions
The operation begins with the introduction of the skin protector placed at the incision site, normally placed 1 cm below the inframammary crease. Another incision is normally placed at the axilla, at the same length.
A further incision is placed around the areola margin, and is utilized to address the superficial layers of the upper quadrants, if required. This skin port is designed to protect against friction injuries by the probe during its continuous movement.
The fatty breast is emulsified in the lateral and medial compartments, the upper quadrants and the inferior aspect of the periareolar area. All the periareolar area, where most of the glandular tissue is localized (5 cm circumference around the nipple–areola complex), is preserved.
The deep portion is also emulsified, allowing the breast mold to regain a natural shape through upward rotation, thus increasing the elevation from its initial position, taken from the midclavicular notch. Up to 4 cm of elevation is obtained after proper reduction and stimulation to allow skin retraction and correction of the ptosis.
Two 1.5–2.0 cm stab incisions, one at the axillary line and the other 2 cm below the inframammary crease, are made to allow entrance of the titanium probe.
Through these incisions the surgeon can reach all the breast tissues, working in a criss-cross manner. Recently, the ultrasound device software has been upgraded to provide the same degree of cavitation with less power, which reduces the risk of friction injury and burn at the entrance site; this even allows discontinuing the use of the skin protector.

Probes
With existing technology, a solid probe is more efficacious than a hollow probe for cavitation, which is the physical phenomenon that allows fat fragmentation and destruction. Moreover, the level of ultrasound energy conveyed by a hollow probe is limited, and consequently the level of the cavitations obtained in the tissue is diminished.
The Vaser system (Sound Surgical Technologies, Denver, CO, USA) provides different sizes and lengths of solid titanium probes ( Box 8.1 ) expressly designed to fulfill all purposes in body contouring, as well as being capable of emulsification through the cavitation effect produced by the ultrasound energy. The piezoelectric transducer transforms electric energy into “vibration energy”, thus allowing the solid titanium probe to emulsify the target fat cells.

Box 8.1
Four Different Probe Diameters are Actually Provided by the Manufacturers

2.2 mm diameter, for face.
2.9–3.7 mm diameter, for body contouring, including breasts.
4.1 mm diameter, for larger areas and big volumes of fat.
3.7 mm diameter probe with a special “cone tip” designed to emulsify male breasts, but very aggressive also in fibrous tissue ( Fig. 8.4 ).
The efficacy of these probes, which are narrower than the previous technologies available on the market, is connected to their design, as they are provided with rings (one, two, or three) at the tip of each probe. These rings have two special functions:

1. To enhance the efficiency of the emulsification, which is not limited to the tip, but extends to the last 1.5 cm of the shaft.
2. To allow a greater selection of options for targeting the various tissue types (purely fat, mixed, fibrotic), by utilizing different probes.
The number of rings to be chosen depends on the type of tissue: the most fibrotic is treated with one ring, the less dense tissue (pure fat ) with three rings.
These options are not purely an academic difference: the energy and the wavelength of each probe is selected for the target tissue, avoiding unnecessary extra power and wasted energy, which is a potential cause of secondary unwanted complications (already seen with previous technologies).
In breast reduction with pure Vaser, I prefer the 2.9 mm probe, with one ring, for deep layers, and the 3.7 mm, with three rings, for superficial layers.

Technique
The Vaser surgeon may now utilize two further options:

1. The 4.5 mm large probe, for larger volumes, with a higher percentage of fat emulsification, for 1 minute,depending on the diameter of the probe.
2. The “cone” tip probe, which is very aggressive in fibrous tissue, and has been designed for male breast tissue (gynecomastia) destruction ( Fig. 8.4 ).

FIG. 8.4 Probes.
Larger probes are recommended in all massive volume cases, including large breasts, and the cone tips in really fibrotic breasts.

Fat Emulsification
In breast reduction with UAL the duration of the procedure varies depending on the volume of reduction, the type of tissue encountered, and the amount of skin retraction required. A breast with purely fatty tissue is easier to treat than one with mixed glandular tissue, in which fat cells are smaller, stronger, and denser ( Fig. 8.5 ).

FIG. 8.5 Probe emulsifying deep layers and undermining the superficial layers.
The author has started utilizing the Vaser ultrasound device with solid probes (2.9–3.7 mm wide). It delivers 50% of the ultrasound energy in comparison with the older Sculpture unit (SMEI, Casale Monferrato, Italy), which was used from 1990 to 2001, while emulsifying fatty tissue much more efficiently. Treatment of the target tissues starts with 10–15 minutes of ultrasound energy in fat tissue, which usually produces between 250 and 300 ml of emulsion.
The surgical planes, with good criss-cross tunneling and adequate undermining, are planned in the preoperative drawings. If large undermining is required for skin retraction, the superficial layers are treated initially. Then the deeper planes are reached, and more time is spent in thicker areas. Surgeons inexperienced in the procedure should be especially cautious when performing the technique, particularly in the subdermal planes. 9 – 12 , 15 – 19

Subcutaneous UAL Undermining
Together with UAL application to the fat layers, starting from the deeper layers and progressing to the more superficial ones, it is advisable to thin the superficial layer of the subcutaneous tissue of the upper and lower quadrants by using a different angle pattern, as in standard lipoplasty. 20, 21 This superficial undermining with low-frequency ultrasound energy helps to enhance the retraction of the breast skin and to redrape the breast skin to the newly shaped and reduced mammary cone ( Fig. 8.6 ).

FIG. 8.6 Incisions placed at the inframammary crease, axilla, and areola margin.

• Upper quadrants, superficial layers, 2–3 minutes
• Lower quadrants, deep layers, 7–20 minutes.

Optimizing Outcomes
To facilitate these maneuvers, I often place a second tiny incision at the axilla, and (sometimes) at the areola border. This helps the superficial work of the probe. The undermining has to be complete, with full liberation of all adhesions within the deeper layers.
Vaser is selective, and does not interfere with the vascular network of the dermal tissue, if properly made. It divides the connective and supporting structures of the skin. Rudolph (1991) 22 showed the great potential of the dermal layer in wound contracture. As much as the dermis is thinned, so much contraction will result, providing the tissue vascularization is preserved.
Tissues contract more easily, and when combined with the force of gravity, which helps the upward rotation of the gland (when decreased in weight), the final result is a greater contraction of the breast, with a superior antigravity effect.

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

Clinical Results
Results are visible immediately after surgery; the skin envelope is redraped nicely and the new breast shape and mold are contoured. The skin and treated breast tissue appear soft and pliable. The elevation of the nipple–areola complex resulting from skin contraction and the rotation of the breast mold is immediately visible.
The major postoperative nipple–areola complex elevation was 5 cm.
Emulsification of fatty breast tissue ranged from a minimum of 300 ml per breast in mild reductions and breast lifts to a maximum of 1200 ml of aspirate for each breast in large breasts.
Elevation of the nipple–areola complex up to 5 cm was obtained in large volume reductions in combination with thinning of the subcutaneous layer.
There was no evidence of suspicious calcification resulting from surgery at the 5-year postoperative follow up. Essentially, an increase in breast tissue fibrosis was noticeable in the postoperative mammograms, which was responsible for the new consistency, texture and tone of the breasts, and also responsible for the lifting of the breasts ( Figs 8.7 – 8.9 ).

FIG. 8.7 (A) Preoperative photograph of a 29-year-old woman with moderate breast hypertrophy. (B) Postoperative view 6 months after ultrasound-assisted lipoplasty through a submammary of 500 ml of fat per site.

FIG. 8.8 (A) Preoperative view of breast hypertrophy and planning; red dotted area indicated fibrotic breast tissue not to be addressed. (B) 1 year postop breast nipple raised from 21 to 18 cm from intrasternal notch.

FIG. 8.9 Patient 26 years old, 550 ml aspirate perside, UAL 21 minutes.
(A) Preoperative view. (B) postoperative view.

Mastopexy
Vaser can also be applied in clinical breast surgery cases that present minor degrees of glandular ptosis. As we know, by decreasing the volume of the breast, it is normal to have an upward rotation of the gland itself. Also, the areola tends to shrink when the underlying tissue is diminished in size and volume.
I have applied the technique in clinical cases with the patient expressively refused visible breast cutaneous scars, and the potential correction of ptosis with an anatomical implant. The upward rotation of the breast and the retraction can finally elevate the breast by 2–4 cm from its initial position ( Figs 8.9 and 8.10 ). A supporting bra has to be applied for the first 4 weeks after surgery; despite this, I strongly believe that a similar bra should be advised forever in patients with large breasts or a tendency to ptosis ( Fig. 8.11 ).

FIG. 8.10 Patient 24 years old, 450 ml of aspirate per side, UAL 22 minutes.
(A, C) preoperative views. (B, D) postoperative views.

FIG. 8.11 Patient 32 years old, 550 ml of aspirate per side, UAL 25 minutes.
(A,B) postoperative views.

Histologic Changes
The breast tissue that underwent emulsification with UAL was analyzed histologically by Chun, Taylor and Van Meter (2002) 23 who presented a paper at the American Society for Aesthetic Plastic Surgery (ASAPS) meeting in Las Vegas. They operated on 10 patients with large breasts using the Genesis Contour device (Mentor HS, Santa Barbara, CA, US), with breast UAL. Then, with open surgery, a breast specimen was removed, weighing 430–1530 g.
No gross pathological changes were noted at the time of surgery, and microscopic diagnosis included fibrocystic changes and stromal fibrosis.
No atypia and no malignancies were found. The long-term follow up shows clearly that the emulsified fat, when not aspirated, will dissolve in a few days or weeks.
An area of relative fibrosis may appear at 1 or 2 months, interval; palpable nodes or lumps were a rare event in the large series of patients operated on (from 2002 to 2006, 200 breast reductions and/or pexies were performed, alone or in combination with other body contouring procedures).
In 2006, at the ASAPS meeting in Orlando (FL, USA), Nagy and McCraw (Mississipi University Medical School, St Louis, Missouri, US) first presented the combination of breast fat emulsification by Vaser with open surgery breast reduction. They re-introduced the technique of Raymond Passot, a French surgeon, who in 1925 published the so-called “BUTTON” mammoplasty or the “ no vertical scar” reduction, which became the most common method of breast shaping in Europe before World War II ( Fig. 8.12 ).

FIG. 8.12 The Passot method.

Markings
I start marking the new nipple position, which is from 19–21 cm from the midclavicular point (as in all classic measurements – this is the Pitanguy referral point). Then I mark the inframammary fold, which ranges from 15–23 cm ( Fig. 8.13 ). The flap margin is 8–9 cm below the new nipple site.

FIG. 8.13 (A) Best range of visual is 15–23 cm; (B) Indicating the IM fold.
The existing inframammary fold is marked. Medial and lateral points are marked. The upper quadrants of the breast are infiltrated with tumescent solution, then Vaser is applied to emulsify the fat in this area. In this case, no skin protector is applied, as the skin in this area is due to be de-epithelialized for breast reduction.
After completing aspiration of emulsified fat, the lower flap is detached from the chest wall, with a central large inferior pedicle based on perforators from the pectoralis muscle. The upper quadrants, already treated with Vaser ( Fig. 8.14 ), show the network of the subcutaneous breast tissue, as it appears after emulsification of fat and aspiration. All the supporting structures of the skin (elastic bundles, vessels, nerves, connective supports) are conserved. This pattern is similar to what happens in closed breast reduction. As the flap is reduced, it is advanced to fill the empty space. The new nipple is positioned and centered on its pedicle.

FIG. 8.14 Vaser effect after 500 ml aspiration.
The Passot technique combined with Vaser has been applied to several types of breast ptosis. I have performed large reductions with this technique (up to 2900 g per side) ( Fig. 8.15 ), or operated on the so-called “long breast”.

FIG. 8.15 Large reduction, 2900 g per side.
The typical case where I actually combine the Passot technique with Vaser is a moderate degree of ptosis, 26–28 cm from the midclavicular point, with a mild to moderate hypertrophy ( Fig. 8.16 ). Results are satisfactory and tend to improve with time ( Box 8.2 ).

FIG. 8.16 A (A) Preoperative view. (B) Five months postop, 600 g per side.

Box 8.2
The Secrets of the Success of the Passot Technique Combined with Breast Reduction

1. Shaping, under control, the upper and lower quadrants of the breast
2. Maintaining the vascularization of the upper quadrants by using Vaser, as this is a selective technique of emulsification
3. Repositioning of the nipple–areola complex without tension, which ensures a good scar (no distortion, no widening)
4. Surgeons must possibly reconsider the priority in scar selection for breast reduction. For most women, the inframammary scar is preferable to the vertical scar, as it is less visible, despite being longer

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

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

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

Hematoma
Hematoma formation is another potential complication, though no cases occurred in this series. A photograph of a case of hematoma in a patient treated by another surgeon is shown in Fig. 8.17 . This hematoma was localized in the subaxillary region, where the tumescent infiltration was initially administered. The surgeon who performed the operation revealed that the anesthesiologist incorrectly used standard sharp needles rather than blunt infiltration cannulas. The formation of the hematoma, which appeared immediately after the infiltration, was thus related to an incorrect tumescent infiltration technique and not to the breast reduction with UAL.

FIG. 8.17 (A) S kin necrosis of the breast medial flap. The surgeon performed a standard breast reduction and then attempted to debulk the medial flap without infiltration of tumescent solution. Skin necrosis resulted, with spontaneous healing after 3 weeks. (Patient referred by another surgeon.) (B) Breast hematoma caused by infiltration of Klein solution with incorrect instrumentation. The anesthesiologist used a sharp needle rather than the classic atraumatic blunt needle. The hematoma required evacuation, after which regular healing followed. (Case referred by another surgeon.)

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

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

Selectivity and Specificity of Ultrasound
Large amounts of fat are often found in patients with breast hypertrophy, even among thin adolescents. Lejour and Abboud 14 emphasized that once the fat is removed by lipoplasty before breast reduction, the proportion of glandular tissue, connective tissue vessels, and nerves is increased.
These structures are important for maintaining vascularity, sensitivity, and lactation potential. Lejour 13 affirmed that if the breasts contain substantial fat, weight loss may result in breast ptosis. The degree of recurrent ptosis can be minimized if lipoplasty is performed preoperatively to reduce the fatty component of the breasts. This observation anticipated the great potential of UAL for breast surgery.
The clear limits of standard lipoplasty, with mechanical indiscriminate destruction of fat and surrounding elements followed by power aspiration of the destroyed tissue, are particularly enhanced in breast surgery, where specialized structures have to be carefully preserved.
Because it is a selective technique, UAL may be applied in breast surgery to destroy and emulsify only the fatty component of the breast tissue without affecting the breast parenchyma for which the ultrasound energy has no specificity. The specificity of the technique is connected with the cavitation phenomenon and the efficiency of the system hinges on the type of the titanium probe used and the energy level selected. Lejour 13 argued that the suctioning of breast fat also made the breast suppler and more pliable, which facilitates shaping, especially when the areola pedicle is long. This consideration is particularly important with fatty breasts, which have a less reliable blood supply. These benefits are significantly increased by the use of UAL because the specificity of this technique spares the vessel network.
The selectivity of UAL was demonstrated by Fisher, 24, 25 and Palmieri 26 in their studies on the action of the ultrasound probe in rat mesenteric vessels. Later, Scheflan and Tazi 25 introduced endoscopic evaluation of UAL. They used a Stortz endoscopic system and camera (Stortz, Tuttlingen, Germany) to videotape the action of the titanium probe within the ultrasound device in the superficial layers, verified by needle depth, after standard infiltration with the tumescent technique. UAL was performed with criss-cross tunnels, and the procedure was recorded on videotape. An adjacent area was treated with standard lipoplasty. The technique was compared with standard lipoplasty, which was also endoscopically assisted and monitored. The authors found that standard lipoplasty appears to be the more aggressive technique, with the mechanical destruction of the entire subcutaneous tissue, despite the use of 2–3 mm wide blunt cannulas.
By contrast, UAL spared vessels, nerves, and elastic supporting fibers. Alterations in breast tissue resulting from the use of UAL were a thickened dermal undersurface, markedly thickened vertical collagenous fibers, intact lymphatic vessels, and intact blood vessels. The horizontal and vertical thickening and shortening of the collagen in the dermis and ligamentous fibers are responsible for the remarkable skin tightening that follows subcutaneous stimulation with the ultrasound probe. This is of great value in breast surgery, where volume reduction has to be accomplished by skin redraping and recontouring of the breast shape.
As noted by Lejour, 13 retraction of the skin after standard lipoplasty cannot be expected to be sufficient to produce a satisfactory breast shape. Subcutaneous aspiration must be extensive to obtain the necessary skin retraction, and the risk of localized skin necrosis resulting from excessive superficial liposuction cannot be ignored. 28

Calcifications
Lejour 13 and Lejour and Abboud 14 argued that the risk of postoperative fat necrosis or calcifications was the reason many surgeons avoided the use of lipoplasty in the breast. The main cause of fat necrosis is breast ischemia brought about by extensive dissection or direct mechanical damage, with resultant venous drainage. Calcification in breast reduction surgery may derive from an area of fat necrosis or breast necrosis and subsequent scarring. Such calcifications are most often located at the incision lines (periareolar, or vertical scar in the inverted-T approach), where more tension is placed in approximating the lateral and medial flaps. However, when the tension is too high, areas of necrosis could arise from the approximating suture and later cause calcifications that are visible on mammography. However, the risk of such complications in UAL procedures is quite low.
Calcifications in breast parenchyma are to be expected after any mammoplasty procedure. In reduction mammoplasty, it is preferable that they be localized along the breast scars. 29 When lipoplasty is performed in addition to the mammoplasty procedure, benign macro-calcifications are slightly more numerous in the parenchyma than they are in breasts reduced without lipoplasty. This may occur because of the trauma caused by lipoplasty or because lipoplasty suction is applied to the most fatty breasts, which are more prone to liponecrosis. 30 However, 1 year after fatty breast reduction with UAL, follow up mammography revealed only a slight increase of small microcalcifications, similar to those found after other mammary procedures.

Potential Risks
In November 1998, a conference on UAL safety and effects was held in St Louis, MO, USA, sponsored by the ASERF and the PSEF. 31 The panel was organized in response to an article by Topaz 32 that raised questions about the safety of UAL. Topaz speculated that thermal effects and the free radicals generated during UAL might result in neoplastic transformation and other long-term complications, as a consequence of the physical effect known as sonoluminescence. Those attending the conference represented multiple scientific disciplines, including plastic surgery, physics, lipid chemistry, cancer biology, and mechanical biophysics. The participants agreed that scientists did not yet understand the mechanism of UAL action, though multiple mechanisms were probably involved, such as mechanical forces, cavitations and thermal effects.
Additional research has revealed that long-term complications or negative bioeffects (including DNA damage and oxidation free radical attack) are probably not serious safety concerns for UAL.
With reference to the application of UAL to breast surgery, we investigated the histology of the breast fat tissue before and after UAL breast surgery (with serial biopsies at 6 months and 1 year after surgery) and the mammographic appearance of the breast before and 1, 2 and 3 years after surgery, particularly with respect to calcification. The results were evaluated by a sonologist not directly involved with the clinical research. 33 Histologic studies revealed an increased fibrotic response to thermal insult, with a prevalence of fatty scar tissue, in all specimens evaluated.
Mammography showed a significant increase in breast parenchymal fibrosis. The calcifications that appeared were benign and were typically small, round, less numerous, and more regular than those characteristic of malignancy. Comparison of the mammographic results showed that microcalcifications are less likely to develop with UAL. It is likely that scar tissue caused by breast reduction with electrocautery or by necrosis resulting from the tension of internal sutures may more frequently cause calcifications or irregular mammographic aspects of the operated parenchyma. Particularly in standard breast-reduction surgery, they can appear at the areola line and at the site of the vertical scar.
From a mammographic viewpoint, the typical appearance of a breast reduction with UAL demonstrates predictably less scarring and fewer calcifications than occur in the standard open technique. Courtiss 34 reported similar mammographic evidence in a denser breast after breast reduction by lipoplasty alone. No malignancies were reported.
The question of whether potential lactation is affected by UAL remains unanswered. The technique was used for breast reduction and mastopexy in younger and older patients. In the younger group, 16 patients breast-fed their babies regularly. The other 14 patients were lost to follow up. However, none of these patients, or their gynecologists, reported any problems to the surgeon or to the hospital, and no complications have been reported by other surgeons around the world who use this technique.

Conclusion
The use of UAL for reduction of fatty breasts and mastopexy is effective and safe when applied in selected patients and performed by a surgeon with expertise in ultrasound- assisted body contouring. The selectivity of UAL enables emulsification of the fatty component of the breast parenchyma while sparing the glandular tissue and vascular network. Furthermore, long-term mammographic studies have revealed no alteration of morphology of the breast parenchyma resulting from this technique. The typical mammographic appearance of breast tissue after UAL is a denser breast. 35, 36

References

1 Zocchi M. Clinical aspects of ultrasonic liposculpture. Perspect Plast Surg . 1993;7:153–174.
2 Zocchi M. The ultrasonic assisted lipectomy (UAL): physiological principles and clinical application. Lipoplasty . 1994;11:14–20.
3 Zocchi M. Ultrasonic assisted lipectomy. Advances in Plastic and Reconstructive Surgery. [Vol. 11] Mosby Year Book: St Louis, MO, 1995.
4 Zocchi M. The ultrasonic assisted lipectomy, instructional course . San Francisco: ASAPS Annual Meeting; March 1995.
5 Zocchi M. The treatment of axillary hyperadenosis and hyperhidrosis using ultrasonically assisted lipoplasty. Presented at the Meeting of the International Society of Ultrasonic Surgery, Faro, Portugal, November 1995.
6 Zocchi M. Basic physics for ultrasound assisted lipoplasty. Clin Plast Surg . 1999;26:209–220.
7 Sampaio Goes JC. Periareolar mammoplasty: double skin technique with application of polyglactine or mixed mesh. Plast Reconstr Surg . 1996;97(5):959–968.
8 Benelli L. A new periareolar mammaplasty: round block technique. Aesth Plast Surg . 1990;14:93–100.
9 Di Giuseppe A. Mammoplasty reduction and mastopexy utilizing ultrasound liposuction. Mammographic study preoperative . Venice, Italy: 46° National Congress of Italian Society of Plastic Reconstructive and Aesthetic Surgery; June 1997.
10 Di Giuseppe A. Ultrasonically assisted liposculpturing. Am J Cosm Surg . 1997;14(3):317–327.
11 Di Giuseppe A. Reducion mamaria y pexia con la asistencia de la lipoplastia ultrasonida. Lipoplastia . 1998;1(1):16–26.
12 Di Giuseppe A. UAL for face-lift and breast reduction. Abstract for World Congress on Liposuction Surgery . California: Pasadena; October 1998.
13 Lejour M. Reduction of large breasts by a combination of liposuction and vertical mammoplasty. In: Cohen M, ed. Master of Surgery: Plastic and Reconstructive Surgery . Boston: Little, Brown, 1994.
14 Lejour M, Abboud M. Vertical mammoplasty without inframammary scar and with liposuction. Perspect Plast Surg . 1990;4:67.
15 Di Giuseppe A. Abstract at the 3rd European Congress of Cosmetic Surgery. Themes: Ultrasound Assistance for Body Contouring, Breast Reduction and Face Lift. How to do it?. [Berlin]. April 1999. p. 23–5
16 Di Giuseppe A. Abstract at the XV Congress of the International Society of Aesthetic Plastic Surgery (ISAPS). Themes: Harmonic Lift or Ultrasonically Assisted Skin Remodelling of Face (Video) . Tokyo: Ultrasonic Assisted Lipoplasty of the Breast (Poster); April 2000.
17 Di Giuseppe A. Ultrasonically assisted breast reduction and mastopexy. Int J Cosm Surg Aesth Dermatol . 2001;3(1):23–29.
18 Di Giuseppe A. Ultrasound assisted breast reduction and mastopexy. Aesth Surg J . 2001;21(6):493–506.
19 Di Giuseppe A. Breast reduction with ultrasound assisted lipoplasty. Plast Reconstr Surg . 112(1), 2003.
20 Teimourian B. Suction Lipectomy and Body Sculpturing . St. Louis, MO: CV Mosby; 1987.
21 Teimourian B, Massac E, Jr., Wiegering CE. Reduction suction mammoplasty and suction lipectomy as an adjunct to breast surgery. Aesth Plast Surg . 1985;9:97–100.
22 Rudolph, et al. Reconstructive Plastic Surgery, Volume 1. [Converse J. M.] Saunders, 1991.
23 Chun, Taylor & Van Meter 2002, ASAPS (American society Aesthetic Plastic Surgery) annual meeting in Las Vegas, communication (Abstract of meeting).
24 Gibson T, Kenedi RM. Factors affecting the mechanical characteristics of human skin. In: Proceedings of the Centennial Symposium on Repair and Regeneration . New York: McGraw-Hill Book Company; 1968:87.
25 Gibson T, Stark H, Kenedi RM. The significance of Langer’s lines. In: Hueston JT, ed. Transactions of the Fifth International Congress of Plastic And Reconstructive Surgery . Australia: Butterworths; 1971:1213.
26 Palmieri B. Studio sull’ azione degli ultrasuoni sul tessuto vasculare del ratio. Riv Ital Chir Plast . 1994;9:635–639.
27 Schleflan M, Tazi H. Ultrasonically assisted body contouring. Aesth Plast Surg . 1991;16:117–122.
28 Becker H. Liposuction of the breast. Presented at the Lipoplasty Society of North America meeting, September 1992.
29 Mitnick JS, Roses DF, Harris MN, Colen SR. Calcifications of the breast after reduction mammoplasty. Surg Gynecol Obstet . 1990;171:409–412.
30 Lejour M, Abboud M. Reduction of mammaplasty scars: from a short inframammary scar to a vertical scar. Ann Chir Plast Esthet . 1990;35(5):369–379.
31 Young VL, Schorr MV. Report from the conference on ultrasound assisted liposuction safety and effects. Clin Plast Surg . 1999;26:481–524.
32 Topaz M. Possible long-term complications in UAL induced by sonolution minescence, sonochemistry, and thermal effects. Aesth Surg J . 1998;18:19–24.
33 Di Giuseppe A, Santoli M. Ultrasonically assisted breast reduction and mastopexy. Int J Cosm Surg Aesth Dermatol . 2001;3(1):23–29.
34 Courtiss EH. Breast reduction by suction alone. In: Spear S, ed. Surgery of the Breast: Principles and Art . Philadelphia: Lippincott-Raven, 1998.
35 Di Giuseppe A. Vaser-assisted breast reduction. In: Shiffman M, ed. Mastopexy and Breast Reduction. Principles and Practice . New York: Springer, 2009.
36 Di Giuseppe A. Mastopexy (breast lift) with ultrasound assisted liposuction. In: Shiffman M, Di Giuseppe A. Liposuction Principles and Practice . New York: Springer, 2006.
Chapter 9 Combined abdominal contouring and mastopexy

Carlos O. Uebel

Key Points

• This is the most common combination in body contouring surgery.
• The population is comprised of females between their 30s and 50s.
• Several technical improvements have been described in the last 50 years.
• Liposuction techniques have laid the foundation for lipoabdominoplasty.
• There is a good safety profile for the combination of these procedures

Introduction
The combination of abdominoplasty and mastoplasty is very common, especially for patients post pregnancy or post weight loss with abdominal laxness, striae, muscle rectus diastases, and breast ptosis. It is most commonly performed in women in the age range 30–50. Many traditional abdominoplasty and mammaplasty techniques have been published in the last 50 years with extraordinary results, but with the introduction of liposuction, described by Illouz 1 in 1980, we had a new tool for body contouring surgery. This opened up a new treatment method for lipodystrophies in the epigastric, flank, dorsum, trochanteric, and buttock areas. The procedure combining abdominoplasty and liposuction was called “lipoabdominoplasty,” and since then many new techniques and modifications have been proposed.
Since abdominoplasty was first described by Callia 2 and Pitanguy, 3 many refinements have been published in the literature. 4 – 14 In 1975, Sinder 15 described the superior epigastric incision approach to estimate a safe inferior abdominal flap excision. Planas 16 published a similar procedure in 1978 and Serson Neto 17 and Pontes 18 described the geometrical inferior flap block resection. Mammaplasty, when combined with abdominoplasty, can take the form of breast augmentation, mastopexy, or breast reduction. For breast augmentation we prefer to use silicone texturized prostheses. For breast reduction we prefer the Silveira Neto dermoglandular rotation flap, published in 1976 19 and subsequently improved by Uebel in 1978. 20 For mastopexy we use the Pitanguy 21 or Ariê 22 techniques with a superior pedicle flap. There are many other techniques in the literature but these are the most used by us in body contouring surgery – very simple procedures that maintain physiological function and good esthetic results. Stemming from those techniques, we have introduced some important approaches and details to ensure consistency. This will be discussed further in this chapter.

Abdominoplasty
In this chapter we will address abdominoplasty combined with mammaplasty for patients with abdominal laxness, rectus muscle diastases, localized lipodystrophy with breast ptosis, hypomastia, or breast hypertrophy. These are very common pathologies after pregnancy and are also seen in post-bariatric surgical patients.

Preoperative Preparation
In a standing position we take pictures with a digital camera (10 megapixels) and we mark the incisions of the abdomen wall and breasts, as well as all the areas to be treated with liposuction. We estimate the amount of skin and breast tissue to be removed, and in the sitting position we estimate the amount of skin and fat to be removed from the abdominal wall ( Fig. 9.1A–E ).

FIG. 9.1 (a–e) Typical 42-year-old patient, pregnancy of 3 children, with abdominal laxness, striae, rectus muscles diastasis, and breast ptosis.
With the patient in a sitting position, we estimate the amount of skin resection needed. 23 We identify the lateral inguinal folds ( Fig. 9.2A , B ) and a low abdominal curved line is delineated approximately 8 cm from the labia major vertex.

FIG. 9.2 With the patient in a sitting position, we identify the inguinal groove extremities and the inferior suprapubic incision is outlined.


FIG. 9.2 With the patient in a sitting position, we identify the inguinal groove extremities and the inferior suprapubic incision is outlined.
FIG 9.2B APPEARS ONLINE ONLY
With the patient in a standing position, a line drawn from the superior umbilical region is connected to both extremities and the areas to undergo liposuction are outlined ( Fig. 9.3 ).

FIG. 9.3 With the patient in a standing position, we outline the supraumbilical incision connecting both extremities and we outline the areas to be loosened and undermined. A periareolar incision is outlined for breast prostheses inclusion

Anesthesia
High epidural anesthesia via catheter is almost always used, with insertion in the thoracic 11–12 spinal level and connected to a continuous infusion pump. A 15 ml solution of 7.5 mg/ml ropivacaine HCl (Naropin) and 30 mg sufentanil citrate is infused into the epidural space and an analgesic solution is prepared for postoperative administration via the infusion pump (100 mg sufentanil citrate and saline solution 0.9%, 100 ml at a speed of 5 ml per hour. 24 Elastic bandages are applied to the legs to prevent thrombovenous embolism ( Fig. 9.4A–D ).


FIG. 9.4 (a–d) Epidural anesthesia in the 11–12 thoracic spinal space with catheter for continuous analgesic infusion and leg bandages to prevent thrombovenous embolism.
FIG 9.4A–D APPEARS ONLINE ONLY

Surgical Technique

Tumescent Infiltration and Assisted Liposuction
All areas to be lipoaspirated and undermined are infiltrated with a saline solution containing epinephrine at 1 : 500 000 concentration to avoid excessive bleeding ( Fig. 9.5A, B ).


FIG. 9.5 All areas to be treated are infiltrated with a saline solution with epinephrine 1 : 500 000.
FIG 9.5 APPEARS ONLINE ONLY
The patient is positioned prone and the flank and trochanteric areas are manually lipoaspirated with a 3 mm cannula. The patient is then rotated to the supine position and extensive liposuction is performed on the entire abdomen and epigastric areas. It is important to reach the inframammary region and the xiphoid appendix, extending to the chondrocostal border to fully loosen this area, as described by Avelar 25 and Saldanha. 26 For this maneuver we use an angular cannula, described by Reggazzo (personal communication), to prevent internal perforations. The only region to be avoided is the lateral superior flank, in order to avoid damaging the neurovascular bundles that give arterial, venous, and neural support to the flap ( Fig. 9.6A, B ) ( Fig. 9.7A , B, C ).

FIG. 9.7 Suprachondrocostal area loosened by angular cannula. Flank lateral area is preserved.


FIG. 9.6 Dorsum and trochanteric areas treated.

FIG. 9.7 Suprachondrocostal area loosened by angular cannula. Flank lateral area is preserved.
FIG 9.6, 9.7C APPEARS ONLINE ONLY

Supraumbilical Incision and Epigastric Tunnel Undermining
A supraumbilical incision is first done and an epigastric tunnel is undermined to the xiphoid appendix. It is important to preserve the lateral superior flank area and to avoid damage to the neurovascular bundles that support the entire flap ( Fig. 9.8A , B, C ).

FIG. 9.8 Supraumbilical incision is done first and a tunnel is undermined to the xiphoid process, preserving the lateral neurovascular bundles.


FIG. 9.8 Supraumbilical incision is done first and a tunnel is undermined to the xiphoid process, preserving the lateral neurovascular bundles.
FIG 9.8B, C APPEARS ONLINE ONLY
We have already described this 27, 28 and proposed the mini-abdominoplasty technique ( Fig. 9.9A–F and Fig. 9.10A–H ), stressing the importance of preserving the lateral columns when undermining the long xiphopubic tunnel and total umbilical stalk section.

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