(A) Dry
(B) Superwet
(C) Tumescent
(D) Wet

The correct response is Option B.

The superwet technique was first used for subcutaneous infiltration in the late 1980s. This technique involves the injection of a diluted solution of anesthesia and vasopressors that is of equal volume to the estimated volume of fat removed, or an infiltrate-to-aspirate ratio of 1:1. Blood loss in this technique has been shown to vary from 1% to 4% of the aspirate.

In the dry technique, local anesthetics and epinephrine are not injected.

The tumescent technique involves the injection of 2 to 3 mL of wetting solution for every 1 mL of aspirate. One study of 112 patients who had undergone suction lipectomy reported injection, on average, of 4,600 mL of anesthetic solution and an average removal of 2,657 mL of aspirate. Pumps were used to infiltrate the solution at a rate of 50 to 200 mL/min, depending on the affected region of the body and tolerance of the patient. Blood loss of less 1% was noted in these patients, and virtually all procedures were performed using local anesthesia.

With the wet technique, 100 to 300 mL of fluid is injected into each treatment area regardless of the amount of aspirate removed. However, this technique has been shown to result in extensive bruising when performed using general anesthesia, and blood loss has been shown to be as high as 25%.

References
1. Klein JA. Tumescent technique for local anesthesia improves safely in large-volume liposuction. Plast Reconstr Surg. 1993;92:1085-1100.
2. Trott SA, Beran SJ, Rohrich RJ, et al. Safety considerations and fluid resuscitation in liposuction: an analysis of 53 consecutive patients. Plast Reconstr Surg. 1998;102:2220-2229.

A 58-year-old woman who recently lost 100 lb desires correction of excess skin and fat in the upper arm but does not want unsightly scars. Which of the following is the most appropriate management?

(A) Circumferential excision lipectomy of the upper arm
(B) Excision lipectomy using a medial approach
(C) Excision lipectomy using a posterolateral approach
(D) Suction-assisted lipectomy

The correct response is Option B.

In this patient who desires correction of excess skin and fat in the upper arms, the most appropriate management is excision lipectomy using a medial approach. This procedure effectively removes the skin and fat, leaves only a medial scar, and is appropriate for patients who have lost an excessive amount of weight. Most surgeons recommend an elliptical excision, which results in a scar that extends from the medial epicondyle to the axillary dome. The scar is not visible with the arms in adduction.

Circumferential excision lipectomy provides only limited contour correction and results in unsightly scars. Excision lipectomy via a posterolateral approach leaves a visible scar. Suction-assisted lipectomy is preferred in younger patients who have excess fat without excess skin.

References
1. Grazer FM. Body contouring. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co, 1990;6:3964.
2. Pittman GH. Liposuction and Aesthetic Surgery. Saint Louis, Mo: Quality Medical Publishing, Inc; 1993:169.

A 36-year-old woman has numbness of the anterolateral right thigh one month after undergoing abdominoplasty. The most likely cause is injury to which of the following nerves?

(A) Genitofemoral
(B) Lateral cutaneous
(C) Iliohypogastric
(D) Ilioinguinal
(E) Obturator

The correct response is Option B.

In this 36-year-old woman who has numbness of the anterolateral right thigh one month after undergoing blepharoplasty, the lateral cutaneous nerve of the thigh is most likely injured. This nerve arises from L2-3 and passes through the inguinal ligament approximately 1 cm medial to the anterosuperior iliac spine. It then passes superficially to the sartorius muscle and divides into anterior and posterior branches in the thigh. The anterior branch becomes superficial about 10 cm below the anterosuperior iliac spine, supplying sensation to the skin of the anterior and lateral thigh. Injury is likely to result in numbness and dysesthesia in this region.

According to the results of a recent study of 101 abdominoplasty patients, 10% had symptoms consistent with injury to the lateral cutaneous nerve. Other studies have reported rates of lateral cutaneous nerve injury following abdominoplasty ranging from 10% to 32%. It is important that the surgeon use extreme caution when performing lateral dissection during this procedure.

The genitofemoral nerve originates from L1-2 and inserts into the abdomen at a variable distance above the inguinal ligament. This nerve divides into genital and femoral branches; the genital branch supplies sensation to the skin of the scrotum, mons pubis, or labia; the femoral branch supplies sensation to the skin over the upper part of the femoral triangle.

The iliohypogastric nerve arises from L1 and divides into lateral and anterior branches. The lateral branch provides sensation to the skin of the lateral part of the buttocks, and the anterior branch supplies sensation to the skin of the abdomen above the pubis.

The ilioinguinal nerve originates from L1 and passes through the superficial inguinal ring to supply sensation to the skin of the superomedial portion of the thigh and the scrotum or mons pubis.

The obturator nerve arises from L2-4 and courses through the lower pelvis with the obturator vessels. It then enters the thigh to provide sensation to the skin of the medial and lower thigh.

References
1. Floros C, Davis PK. Complications and long-term results following abdominoplasty: a retrospective study. Br J Plast Surg. 1991;44:190-194.
2. Van Uchelen J, Werker P, Kon M. Complications of abdominoplasty in 86 patients. Plast Reconstr Surg. 2001;107:1869-1873.
3. Warwick R, Williams P, eds. Gray's Anatomy. Philadelphia, Pa: WB Saunders Co; 1993:1050.

A 42-year-old woman who has excess skin and subcutaneous tissue of the lower buttocks is scheduled to undergo excisional lipectomy with the incisions parallel to the gluteal fold. Which of the following is the most likely adverse effect?

(A) Dimpling of the buttocks
(B) Fat necrosis
(C) Flattening of the gluteal fold
(D) Painful scarring
(E) Widening of the gluteal cleft

The correct response is Option C.

Adverse effects reported with transverse excision lipectomy include flattening and asymmetry of the buttocks and hypertrophic scarring. Dimpling of the buttocks is more commonly associated with suction lipectomy in the region overlying the gluteal muscles because of the large amount of fibrous septa between the fascia and skin. Widening of the gluteal cleft is uncommon because the incision is made parallel to the gluteal fold.

Fat necrosis does not generally occur in the buttocks because of the good vascularity in this region. Long-term painful scarring is also rare.

References
1. 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. Baltimore, Md: Williams & Wilkins; 1997:674.
2. Pittman GH. Liposuction and Aesthetic Surgery. Saint Louis, Mo: Quality Medical Publishing, Inc; 1993:169.