(A) Epigastrium
(B) Flanks
(C) Periumbilical region
(D) Suprapubic region
(E) Umbilicus

The correct response is Option D.

Following abdominoplasty, skin necrosis is most likely to occur in the suprapubic region. The blood supply to the abdominoplasty is derived from the lateral interstitial vessels; because of this, the lower midline region of the flap is most at risk for devascularization. In addition, downward transposition of any pre-existing scars on the upper abdomen will limit blood flow and ultimately inhibit flap vascularization.

Because the epigastrium and flanks are in close proximity to the base of the elevated skin flap, they are better protected and at less risk for development of necrosis. Although umbilical necrosis is rare, it can occur as a result of excessive defatting of the umbilical stalk, tension during attachment to the abdominal skin, or compression of the stalk during plication of the rectus.

References
1. Huger WE Jr. The anatomic rationale for abdominal lipectomy. Am Surgeon. 1979;45:612-617.
2. Matarasso A. Liposuction as an adjunct to a full abdominoplasty. Plast Reconstr Surg. 1995;5:829-836.
3. Mladick RA. Body contouring of the abdomen, thighs, hips, and buttocks. In: Georgiade GS, Riefkohl R, Levin LS, eds. Textbook of Plastic, Maxillofacial and Reconstructive Surgery. 3rd ed. Baltimore, Md: Williams & Wilkins; 1997:674-684.

A 43-year-old woman who recently lost 45.5 kg (100 lb) has severe skin laxity of the arms with moderate fat deposition. The most likely cause of her current findings is loosening of which of the following fascia?

(A) Clavipectoral
(B) Colles'
(C) Deltoid
(D) Pectoralis major
(E) Scarpa's

The correct response is Option A.

This patient's skin laxity is most likely caused by a loosening of the clavipectoral fascia. Anatomic studies have shown that in youth the soft tissues of the posteromedial arm are firmly suspended to a tough yet dynamic fascial system sling that ultimately gains its strength from the clavicular periosteum by means of the clavipectoral and axillary fasciae. The clavipectoral fascia lies deep to the pectoralis major muscle and extends from the clavicle to the dome of the axillary fascia. Loosening of these connections, combined with relaxation of the fascia itself with age, weight fluctuations, and gravitational pull, results in significant ptosis of the posteromedial arm. Other mechanisms contributing to arm ptosis include relaxation and stretching of the skin and superficial fascial system of the arm, as well as flaccidity of the posterior arm muscles resulting from age and lack of exercise. Fascial anchoring brachioplasty is used to correct this deformity.

Fascial anchoring and suspension of the superficial fascial system can be used in body contouring of other sites in the trunk and extremities, including Colles' fascia in the medial thigh lift and Scarpa's fascia in abdominoplasty. The deltoid and pectoralis major fascia have no effect on upper arm laxity.

References
1. Lockwood T. Brachioplasty with superficial fascial suspension. Plast Reconstr Surg. 1995;96:912-920.
2. Lockwood TE. Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast Reconstr Surg. 1991;87:1009-1018.
3. Teimourian B, Malekzadeh S. Rejuvenation of the upper arm: concept. Plast Reconstr Surg. 1998;102:545-551.

Which of the following is the most common complication of performing full abdominoplasty in combination with suction lipectomy?

(A) Infection
(B) Nerve injury
(C) Seroma formation
(D) Skin necrosis
(E) Wound dehiscence

The correct response is Option C.

The most common complication of a full abdominoplasty performed in conjunction with suction lipectomy is the formation of seromas. Although this remains a serious problem, steps that can be taken to reduce the potential risk for the development of seromas include avoiding electrocoagulation for dissection, limiting the quantity of local anesthetic used, securing the flap with quilting sutures, and maintaining adequate wound drainage.

Infection, nerve injury, skin necrosis, and wound dehiscence are all less common complications. The prophylactic use of antibiotics and antibiotic irrigation will help to minimize the potential for wound infection. The risk for skin necrosis and skin slough is increased when abdominoplasty procedures are combined with suction lipectomy; a history of smoking or diabetes mellitus, as well as the presence of abdominal scars, can also increase the patient's risk for necrosis. Wound dehiscence can result from inferior surgical techniques, excess wound tension, and insufficient placement of deep dermal sutures.

References
1. Matarasso A. Liposuction as an adjunct to a full abdominoplasty. Plast Reconstr Surg. 1995;5:829-836.
2. Mladick RA. Body contouring of the abdomen, thighs, hips, and buttocks. In: Georgiade GS, Riefkohl R, Levin LS, eds. Textbook of Plastic, Maxillofacial and Reconstructive Surgery. 3rd ed. Baltimore, Md: Williams & Wilkins; 1997:674-684.

A patient develops a supraumbilical bulge after undergoing full abdominoplasty and suction lipectomy of the abdomen and flanks. Which of the following is the most likely cause?

(A) Failure to plicate the rectus muscle
(B) Inadequate skin resection
(C) Inadequate suction lipectomy
(D) Loose fascial suspension
(E) Umbilical malpositioning

The correct response is Option A.

In this patient who has developed a supraumbilical bulge after undergoing a combined full abdominoplasty and suction lipectomy procedure, the most likely cause is a failure to plicate the rectus muscle. In standard abdominoplasty procedures, a low horizontal or W-shaped skin incision is made. The rectus diastasis is typically marked and then directly plicated both above and below the umbilicus and tapered superiorly toward the xiphoid. Alternately, the surgeon can create an incision into the fascia and then plicate the muscle in the same manner. If neither of these techniques is performed, a relative laxity of the upper abdominal region can develop, resulting in the appearance of a supraumbilical bulge.

Fixation of the skin flap to the umbilicus will relieve tension in the lower portion of the flap. Telescoping of the umbilicus is performed in the midline at the level of the anterosuperior iliac spine. Suction lipectomy is typically used for reduction of redundant fat deposits along the flanks, waistline, and iliac regions. The suctioning should be adjusted on a patient-by-patient basis. Repair of the superficial fascial system will diffuse tension on the skin flap, lift areas of soft-tissue excess more effectively, and provide lasting support. This technique is now considered critical to the success of body contouring procedures involving the trunk and extremities.

References
1. Lockwood TE. Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast Reconstr Surg. 1991;87:1009-1018.
2. Ramirez O. Abdominoplasty and abdominal wall rehabilitation: a comprehensive approach. Plast Reconstr Surg. 2000;105:425-435.

A 45-year-old man desires cosmetic improvement of skin ptosis of the posteromedial arms. He has lost 50 lb over the past year, but is currently 20 lb above his ideal body weight. Which of the following is the most appropriate management?

(A) Continued weight loss
(B) Exercise program
(C) Brachioplasty
(D) Suction-assisted lipectomy
(E) Ultrasound-assisted lipectomy

The correct response is Option C.

The most appropriate next step in the management of this patient with arm ptosis is brachioplasty. Brachioplasty is most effective in patients with extensive skin ptosis of the arm. This condition is caused by loosening of the connections of the superficial fascial system of the arm to the axillary fascia. It may occur in conjunction with the aging process or with gravitational pull and/or fluctuations in body weight. During the surgical procedure, the arm flap is securely anchored to the axillary fascia. Complications following this procedure are minimal.

Instead of helping to resolve the ptosis, further weight loss can actually worsen it. In the same way, suction-assisted lipectomy can worsen the ptosis by creating further laxity in the overlying skin. A regimented exercise program is only effective for patients with minimal skin and soft-tissue laxity. The thermal effect of ultrasound-assisted lipectomy will tighten the skin but will not correct the underlying ptosis.

References
1. Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96:912-920.
2. Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg. 1998;102:545-553.