(A) 1%
(B) 10%
(C) 20%
(D) 30%
(E) 50%

The correct response is Option A.

The tumescent technique of suction lipectomy uses a dilute solution of lidocaine and epinephrine as infiltrate in the area that is to be suctioned. With this technique, 2 to 3 mL of infiltrate are used for every 1 mL of fluid that is to be aspirated. Blood loss is significantly decreased with this technique; many studies have shown blood loss of only 1% with tumescent anesthesia.

The dry technique of anesthesia is associated with the greatest blood loss, as 20% to 45% of the aspirate consists of blood. The wet technique infiltrates 300 mL of fluid per region and results in aspirate that is comprised of 25% blood.

The superwet technique has a blood-to-aspirate ratio of 3 to 10% and uses an injected volume of 1 mL for every 1 mL of aspirate.

References
1. Commons GW, Halperin B, Chang CC. Large-volume liposuction: a review of 631 consecutive cases over 12 years. Plast Reconstr Surg. 2001;108:1753-1763.
2. Karmo FR, Milan MF, Silbergleit A. Blood loss in major liposuction procedures: a comparison study using suction-assisted versus ultrasonically assisted lipoplasty. Plast Reconstr Surg 2001;108:241-247.

A 32-year-old woman who smokes two packs of cigarettes daily wishes to undergo full abdominoplasty to correct excess skin and fat in the lower abdomen resulting from two pregnancies. The risk for development of complications in this patient is closest to

(A) 10%
(B) 30%
(C) 50%
(D) 70%
(E) 90%

The correct response is Option C.

Because conventional abdominoplasty procedures involve significant undermining, there is increased potential for complications, such as skin necrosis, infection, wound dehiscence, seroma, and hematoma. In addition, plastic surgery procedures are associated with a high incidence of adverse effects when performed in patients who smoke. These complications are related to the release of nicotine and carbon monoxide during smoking, which decrease blood flow and oxygen delivery and induces thrombogenesis. There is dysfunction of leukocytes, macrophages, and fibroblasts, leading to impaired wound healing.

One recent study of 132 patients who underwent abdominoplasty reported a complication rate of 48% in smokers, compared with a complication rate of 15% in those patients who did not smoke. Another study of 199 abdominoplasty patients reported a complication rate of 52% in smokers and 24% in nonsmokers.

Patients should be advised to discontinue smoking four to eight weeks before the surgical procedure and for an additional four weeks after surgery. Serum levels of nicotine have been shown to return to normal when patients abstain from smoking for eight weeks. In addition, studies of patients who underwent flap reconstruction showed that complications were decreased significantly when smoking was discontinued a minimum of four weeks before surgery.

References
1. Hensel JM, Lehman JA Jr, Tantri MP, et al. An outcomes analysis and satisfaction survey of 199 consecutive abdominoplasties. Ann Plast Surg. 2001;46:357-363.
2. Krueger JK, Rohrich RJ. Clearing the smoke: the scientific rationale for tobacco abstention with plastic surgery. Plast Reconstr Surg. 2001;108:1063-1073.
3. Manassa EH, Hertl CH, Olbrisch RR. Wound healing problems in smokers and nonsmokers after 132 abdominoplasties. Plast Reconstr Surg. 2003;111:2082-2087.

Compared with traditional suction lipectomy, which of the following is more likely to occur with ultrasonic-assisted suction lipectomy?

(A) Contour irregularity
(B) Major blood loss
(C) Nerve injury
(D) Pulmonary edema
(E) Thermal burns

The correct response is Option E.

Ultrasonic-assisted suction lipectomy (UAL) is currently performed as a complement to, not a replacement for, traditional suction lipectomy. This technique involves the transmission of ultrasonic energy via a transducer to cavitate adipocytes and emulsify the liquefied fat, making aspiration of fat easier. UAL is advantageous in removing fat from difficult or fibrous body areas, such as the epigastrium and upper abdomen. It is also purported to stimulate skin retraction after superficial treatment.

Many complications that occur with UAL are similar to those seen with traditional lipectomy procedures, including contour irregularities, perforations, paresthesia and hypoesthesia resulting from nerve injury, seroma formation, and adverse cardiopulmonary effects. In addition, UAL has been shown to elicit greater tissue damage and bleeding than traditional techniques; however, the decrease in hemoglobin level postoperatively is similar with either technique.
UAL is associated with an increased incidence of internal and external cutaneous burns resulting from the intense heat generated by sound waves; this complication does not occur with traditional suction lipectomy. In addition, there are concerns regarding the unknown long-term effects of sound waves and exposure to high temperatures, bond dissociation within molecules, production of free radicals within the body, and other factors.

References
1. Baker JL. A practical guide to ultrasound-assisted lipoplasty. Clin Plast Surg. 1999;26:363-368.
2. Cardenas-Camarena L, Andino-Ulloa R, Mora RC, et al. Laboratory and histopathologic comparative study of internal ultrasound-assisted lipoplasty and tumescent lipoplasty. Plast Reconstr Surg. 2002;110:1158-1164.
3. Grazer FM, Grazer JM, Sorensen CL. Suction-assisted lipectomy. In: Achauer BM, Erikkson E, Guyuron B, et al, eds. Plastic Surgery: Indications, Operations, and Outcomes. Saint Louis, Mo: Mosby Year - Book Inc; 2000:2859-2887.
4. Howard BK, Beran SJ, Kenkel JM, et al. The effects of ultrasonic energy on peripheral nerves: implications for ultrasound-assisted liposuction. Plast Reconstr Surg. 1999;103:984-989.
5. Karmo FR, Milan MF, Silbergleit A. Blood loss in major liposuction procedures: a comparison study using suction-assisted versus ultrasonically assisted lipoplasty. Plast Reconstr Surg. 2001;108:241-247.

Suction lipectomy is a viable means of breast reduction because the percentage of the female breast that is comprised of fat is closest to

(A) 10%
(B) 25%
(C) 50%
(D) 75%
(E) 90%

The correct response is Option C.

Suction lipectomy can be performed to remove fatty tissue in the breast without disturbing parenchymal tissue. It is an attractive option for breast reduction in women who would like to avoid the scarring associated with traditional surgical techniques. According to the results of one recent study that involved a significant population of overweight women, the mean percentage of fat in the breast was 61%. Another study of women predominantly of normal body weight showed a mean percentage of fat of 48%. In addition, these studies showed that younger patients have significant amounts of fat in the breast, even though the percentage of fat was shown to increase with age. Body mass index had more influence on the percentage of breast fat than age, and the amount of fat in the breast could not be accurately assessed on physical examination.

One clinical study reported that breast reduction via suction lipectomy alone produced the best results in women who had well-located or slightly ptotic nipples. Benefits of this technique include the avoidance of scarring and compromise to the blood supply and nerves to the nipple. However, many surgeons remained concerned about the effectiveness of suction lipectomy alone in patients with very large breasts, as well as the lack of skin excision, the potential for induction of microcalcifications, and the viability of pathologic examination of removed fat.

References
1. Cruz-Korchin N, Korchin L, Gonzalez-Keelan C, et al. Macromastia: how much of it is fat? Plast Reconstr Surg. 2002;109:64-68.
2. Lejour M. Evaluation of fat in breast tissue removed by vertical mammaplasty. Plast Reconstr Surg. 1997;99:386-393.
3. Matarasso A. Suction mammaplasty: the use of suction lipectomy to reduce large breasts. Plast Reconstr Surg. 2000;105:2604-2607.

A 35-year-old woman who weighs 80 kg (176 lb) is undergoing large volume suction lipectomy with expected removal of 5 L of aspirate. In this patient, the total dose of lidocaine should NOT exceed how many milligrams?

(A) 300
(B) 400
(C) 1600
(D) 2800
(E) 4800

The correct response is Option E.

The maximum safe dose of lidocaine is controversial. Some standard anesthesia texts list a maximum safe dose of 300 mg. In contrast, other texts report of maximum dose of 5 mg/kg or 7 mg/kg with the addition of epinephrine. However, more recent studies, from patients undergoing suction lipectomy with tumescent anesthesia, have reported the use of higher doses of lidocaine without complication. Several large studies have reported a maximum safe dose of lidocaine of 35 mg/kg, and some published dermatologic studies have cited the maximum safe dose to be as high as 55 mg/kg.

Although recent articles on fatalities related to suction lipectomy have attributed most patient deaths to pulmonary emboli, there has been speculation regarding the role of lidocaine toxicity, because lidocaine levels are typically not obtained at autopsy. Other recent articles suggest that a portion of the infused lidocaine is subsequently suctioned out, and that the use of general anesthesia versus local anesthesia may affect patient mortality rates.

Of the levels listed, 4800 mg is 60 mg/kg in an 80-kg patient, and is higher than the reported safety standards.

References
1. Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol. 1990;16:248-263.
2. Ostad A, Kageyama N, Moy RL. Tumescent anesthesia with a lidocaine dose of 55 mg/kg is safe. Dermatol Surg. 1996;22:921-927.
3. Rao RB, Ely SF, Hoffman RS. Deaths related to liposuction. N Engl J Med. 1999:340:1471-1475.
4. Rohrich RJ, Kenkel JK, Janis JE, et al. An update on the role of subcutaneous infiltration in suction-assisted lipoplasty. Plast Reconstr Surg. 2003;111:926-927.

Suction lipectomy is an effective procedure for management for each of the following conditions EXCEPT

(A) axillary hyperhidrosis
(B) HIV-associated lipodystrophy
(C) liposarcoma
(D) lymphedema
(E) Madelung’s disease

The correct response is Option C.

Suction lipectomy is recommended for many conditions because it effectively removes tissue while limiting incisions. Indications for suction lipectomy include axillary hyperhidrosis, in which apocrine and eccrine glands are removed from the axilla using a superficial technique. This results in reduced sweating with a minimal amount of scarring. Although repeat procedures are necessary in approximately 30% of patients, suction lipectomy produces longer lasting effects than treatment with botulinum toxin (Botox).

In patients with HIV infection, administration of protease inhibitor agents may cause abnormal redistribution of fat. Affected patients may develop adiposity in the abdominal and mandibular regions and atrophy in other areas, such as the nasolabial fold. Suction lipectomy is appropriate to remove the excess fat.

Madelung’s disease, or benign symmetric lipomatosis, is a disorder of unknown cause that is characterized by diffuse growth of nonencapsulated lipomas, especially in the neck, shoulders, and posterior trunk. Suction lipectomy can increase range of motion and provide good cosmesis.

Patients with both congenital and acquired lymphedema can benefit from suction lipectomy to decrease tissue thickness. Although its effects are temporary, it provides significant relief and increases function. Other measures, such as massage and use of compressive garments, can be performed in combination with the lipectomy procedure.

Suction lipectomy is not recommended for removal of malignant tumors, such as liposarcoma, because this method of resection is often incomplete. In addition, such tumors may be seeded and histopathologic examination of the tumor specimen may be compromised.

References
1. Tung TC. Endoscopic shaver with liposuction for treatment of axillary osmidrosis. Ann Plast Surg. 2001;46:400-404.
2. Wolfort FG, Cetrulo CL Jr, Nevarre DR. Suction-assisted lipectomy for lipodystrophy syndromes attributed to HIV-protease inhibitor use. Plast Reconstr Surg. 1999;104:1814-1820.