(A) Direct undermining of the distal flap
(B) Performing suction lipectomy in conjunction with transverse thigh/buttock lift
(C) Suspension of the superficial fascial system
(D) Use of an anterior medial skin resection pattern

The correct response is Option C.

Suspension of the superficial fascial system of the inferior skin flap has decreased the incidence of unfavorable scars, vulvar traction, and ptosis deformities previously associated with the transverse thigh/buttock lift. Anchoring the skin flap to Colles' fascia anteriorly has lead to more consistent, reliable results following lifting. Other refinements such as direct undermining of the distal flap, performing adjunctive suction lipectomy, and using an anterior medial skin resection pattern have been associated with an improvement in overall results in those patients undergoing transverse thigh/buttock lifts but have not specifically decreased scar widening, traction deformities, and recurrent ptosis. Direct undermining, 3 to 4 cm beyond the planned line of resection, releases the superficial fascial attachments distally and allows for a greater lift. Suction lipectomy addresses fatty contour deformities that do not lie within the planned resection areas of the lift. The anterior medial skin resection pattern addresses skin laxity at the junction of the anterior and medial thigh and eliminates the need for incisions within the posterior buttock folds.

References
1. Lockwood T. Lower body lift with superficial fascial system suspension. Plast Reconstr Surg. 1993;92:1112-1125.
2. Lockwood T. The role of excisional lifting in body contour surgery. Clin Plast Surg. 1996;23:695-712.

A 43-year-old woman is unable to depress the left side of her lower lip after undergoing submental suction lipectomy. On follow-up examination three months later, she has persistent weakness of the lower lip. Which of the following is the most appropriate next step in management?

(A) Reassurance and continued observation
(B) Surgical exploration and nerve repair
(C) Injection of botulinum toxin into the unaffected side
(D) Nerve grafting
(E) Innervated free muscle transfer for facial reanimation

The correct response is Option A.

In this patient who has persistent weakness of the lower lip following submental suction lipectomy, the most appropriate next step is reassurance of the patient and continued observation. Submental suction lipectomy is considered to be a safe procedure as long as the cannula is passed superficial to the platysma; however, if the cannula is placed beneath the platysma, injury to the marginal mandibular branch of the facial nerve may result. According to one study, 81% of dissections found the marginal mandibular branch to be positioned above the inferior border of the mandible, while in 19% of dissections the nerve was positioned 1 cm below the mandible. Large studies of suction lipectomy patients have reported a rate of nerve injury of less than 1%. Because nerves and blood vessels are typically not transected during suction lipectomy, any resulting injuries are likely to be neurapraxias, which in most patients will completely resolve within three months.

Surgical exploration is unnecessary in a patient who has only a slight risk for nerve transection. Injection of botulinum toxin may result in facial symmetry but may also worsen symptoms or make common tasks (such as applying lipstick) more difficult. Nerve grafting and muscle transfers for facial reanimation are not indicated because the deficit will most likely resolve spontaneously. These procedures are typically reserved for correction of a significant facial nerve defect.

References
1. Dellon AL. Peripheral nerve injuries. In: Georgiade GS, Riefkohl R, Levin LS, eds. Textbook of Plastic, Maxillofacial and Reconstructive Surgery. Baltimore, Md: Williams & Wilkins; 1997:1011-1013.
2. Dillerud E. Suction lipoplasty: a report on complications, undesired results, and patient satisfaction based on 3511 procedures. Plast Reconstr Surg. 1991;88:239-246.
3. Dingman RO, Grabb WO. Surgical anatomy of the mandibular ramus of the facial nerve based on the dissection of 100 facial halves. Plast Reconstr Surg. 1962;29:266-272.

Which of the following is the most common cause of death following suction lipectomy?

(A) Abdominal perforation
(B) Anesthetic complications
(C) Fat embolism
(D) Infection
(E) Thromboembolism

The correct response is Option E.

The incidence of fatalities associated with suction lipectomy performed in the outpatient setting is one in every 5000 procedures. According to a recent study of deaths associated with suction lipectomy procedures, in those patients in whom a cause of death was definitively established, 23% of the fatalities were shown to have resulted from thromboembolism. In contrast, 15% of fatalities resulted from abdominal wall perforation (with or without organ perforation), 10% involved anesthetic complications, 8% involved fat embolism, and only 5% were due to infection. Because lidocaine screening is rarely performed, any potential link between lidocaine toxicity and the development of the complications listed above was undetermined. Many of the reported deaths occurred during the first 24 hours following patient discharge. Other risk factors associated with suction lipectomy include aspiration of large amounts of tissue, increased volume of tumescent injection, and concomitantly performed procedures.

References
1. Gorney M. Sucking fat: an 18-year statistical and personal retrospective. Plast Reconstr Surg. 2001;107:608-613.
2. Grazer FM, de Jong RH. Fatal outcomes from liposuction: census survey of cosmetic surgeons. Plast Reconstr Surg. 2000;105:436.
3. Rao RB, Ely SF, Hoffman RS. Deaths related to liposuction. N Engl J Med. 1999;340:1471.
4. Teimourian B, Adham MN. A national survey of complications associated with suction lipectomy: what we did then and what we do now. Plast Reconstr Surg. 2000;105:1881.

In patients undergoing brachioplasty, which of the following is the most common long-term unfavorable result?

(A) Intermittent sharp pain in the arm
(B) Lymphedema of the hand and forearm
(C) Numbness of the medial arm
(D) Seroma of the upper arm
(E) Widening of the scar

The correct response is Option E.

Widened scars are the most common long-term complication following brachioplasty. These scars, which are typically located on the posteromedial upper arms, are red and visible for a minimum of one year and in fact may never completely fade. Patients should be informed of the potential for widened, visible scars prior to undergoing the procedure.

Intermittent sharp pain, lymphedema, numbness, and seromas can be complications of brachioplasty but are most likely to be temporary and to resolve within one to four weeks.

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;102:545-551.

Which of the following nerves is NOT at risk for injury during abdominoplasty?

(A) Genitofemoral
(B) Iliohypogastric
(C) Ilioinguinal
(D) Intercostal

The correct response is Option A.

During abdominoplasty, there is an increased risk for nerve entrapment or injury to the iliohypogastric and ilioinguinal nerves because of their anatomic location. Although the intercostal nerves are less prone to injury, they still lie in the region of the abdominoplasty. Because of the potential for injury, patients who have localized pain, paresthesias, and/or tenderness in the distribution of any of these nerves should undergo complete evaluation.

The genitofemoral nerve originates from L1-2 and courses deep in the abdominal wall. It pierces the fascia below the inguinal ligament and supplies sensation to the skin of the femoral triangle and pubis. Because this nerve lies inferior and deep to the abdominoplasty incision, it is not at risk for injury during an abdominoplasty procedure.

References
1. Choi PD, Nath R, Mackinnon SE. Iatrogenic injury to the ilioinguinal and iliohypogastric nerves in the groin: a case report, diagnosis, and management. Ann Plast Surg. 1996;37:60-65.
2. Liszka TG, Dellon AL, Manson PN. Iliohypogastric nerve entrapment following abdominoplasty. Plast Reconstr Surg. 1994;93:181.
3. Matarasso A. Abdominoplasty. In: Achauer BM, Eriksson E, Guyuron B, et al, eds. Plastic Surgery: Indications, Operations, and Outcomes. Saint Louis, Mo: Mosby Ð Year Book, Inc; 2000;5:2783-2821.

DIAGRAM

A 39-year-old woman is scheduled to undergo full abdominoplasty with adjunctive suction lipectomy for management of laxity and fat deposition of the abdomen and flanks. Which of the following areas labeled in the above diagram should undergo the LEAST amount of suction lipectomy?

(A) A
(B) B
(C) C
(D) D
(E) E

The vascularity of the abdominal flap used in the full abdominoplasty procedure is derived from the lateral intercostal perforators through the remaining subcutaneous vessels. The central inferior area, illustrated by point A in the above diagram, lies in the most distal location of the flap and has the least vascular supply. Applied tension is also greatest in this region following abdominoplasty. Suction lipectomy is often performed in patients undergoing abdominoplasty to remove adipose tissue, blend the area of resection, and provide an additional means of sculpting. However, the risk for infection and subsequent necrosis is increased when these procedures are combined. Therefore, a combined abdominoplasty/suction lipectomy procedure is only recommended as long as the suction procedure is limited centrally (ie, in the area of point A) and the central inferior region is not defatted sharply. Other systemic factors such as a history of smoking, diabetes mellitus, or obesity would warrant a limited suction lipectomy.

References
1. Cardenas-Camarena L, Gonzalez LE. Large-volume liposuction and extensive abdominoplasty: a feasible alternative for improving body shape. Plast Reconstr Surg. 1998;102:1698.
2. Matarasso A. Liposuction as an adjunct to a full abdominoplasty revisited. Plast Reconstr Surg. 2000;106:1197.

For each patient, select the most appropriate management (A-E).

(A) Suction lipectomy
(B) Mini-abdominoplasty
(C) Full abdominoplasty
(D) Lower body lift
(E) Panniculectomy

1) A 35-year-old woman who has lost 150 lb following a gastric bypass procedure

2) A 45-year-old woman who weighs 400 lb and has a large, overhanging area of skin in the lower abdomen with ulceration

The correct response for Item 1 is Option D and for Item 2 is Option E.

In each of these patients who desires improved abdominal contour, the optimal procedure can be determined by evaluating the patient's skin tone, abdominal wall musculature, and fat distribution.

The 35-year-old woman who had a massive reduction in weight following gastric bypass should undergo a lower body lift procedure. This will remove the excess skin and fat in the lower abdomen and thighs typically seen in patients who have lost an extensive amount of weight.

The obese 45-year-old woman who has a large, overhanging area of skin and fat (pannus) with ulceration should undergo panniculectomy. In this patient, gastric bypass may be performed either simultaneously or prior to the panniculectomy procedure.
Suction lipectomy alone is most appropriate for correction of localized abdominal protuberance in patients who have good skin tone and firm musculature in the abdominal wall. Mini-abdominoplasty is useful for removal of mild amounts of lower abdominal skin and fat. The length of the scar is limited with this procedure and the umbilicus is not altered. Full abdominoplasty removes the excess skin and fat in the lower abdomen but relocates the umbilicus and results in an elongated scar. This procedure does not correct excess skin in the flanks and upper thighs.

References
1. Grazer FM. Abdominoplasty. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;6:3929-3963.
2. Lockwood T. Contouring of the arms, trunk, and thighs. In: Achauer BM, Eriksson E, Guyuron B, et al, eds. Plastic Surgery: Indications, Operations, and Outcomes. Saint Louis, Mo: Mosby Ð Year Book, Inc; 2000;5:2839-2857.