Inservice Exam - 2005
Cosmetic Liposuction, Abdomen and Thigh

A healthy 60-year-old woman undergoes suction lipectomy of the lateral thighs during which a total volume of 2 L is aspirated. During the procedure, 1.5 L of infiltrate and 1.5 L of crystalloid are administered intravenously. Which of the following is the most appropriate additional intervention for fluid management?

(A) Administer a 1-L bolus of crystalloid
(B) Administer a 3-L bolus of crystalloid
(C) Administer a diuretic
(D) No further hydration


The correct response is Option A.

Hydration during suction lipectomy is very important to prevent complications. Too little fluid causes hypotension and too much fluid can cause pulmonary edema. As larger amounts of infiltrate are used with the tumescent technique, it is difficult to know how much intravenous fluid to give to the patient.

One study concludes that the combination of infiltrate and intravenous fluids (1.5 L and 1.5 L in this case) should add up to twice the aspirate removed (2 _ 2 L). Therefore, this patient should receive 1 L of fluid in the recovery area. Careful monitoring of blood pressure, tissue turgor, and urine output will confirm that the patient is euvolemic.

Patients should not be discharged before adequate fluids are given to maintain normal urine output. Large-volume liposuctions may require overnight monitoring. Administration of a diuretic is inappropriate because the patient is not overloaded with fluid. A 3-L bolus may overhydrate the patient and lead to pulmonary edema.

References:
1. Pitman G. Liposuctioning and body contouring. In: Aston SJ, Thorne CHM, Beasley RW, eds. Grabb and Smith’s Plastic Surgery. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 1997:669-690
2. Pitman GH. Discussion on “The Role of Subcutaneous Infiltration in Suction Assisted Lipoplasty: A Review.” Plast Reconstr Surg. 1997;99(2):523-526.




The incidence of complications is highest following abdominoplasty when the procedure is combined with suction lipectomy of which of the following areas?

(A) Central infraumbilical
(B) Epigastric
(C) Flank
(D) Lateral thigh
(E) Medial thigh

The correct response is Option A.

Suction lipectomy of the central portion of the abdominoplasty flap can lead to loss of skin in the central and inferior portions of the flap and should be avoided. A critical step in avoiding skin loss is leaving intact the subcutaneous layer of fat between the skin and the fascia of Scarpa. Only very limited, cautious suction lipectomy should be attempted in the central portion of the abdominoplasty flap and should be limited to globular fat deep to the fascia of Scarpa. The lateral portions of the abdominoplasty flap can be suctioned deep to the fascia of Scarpa. The epigastrium may also be suctioned carefully without complications. The hips and thighs can be suctioned aggressively or defatted directly without concern for skin loss in the abdominoplasty flap.

References:
1. Matarasso A. Liposuction as an adjunct to a full abdominoplasty. Plast Reconstr Surg. 1995;95:829.
2. Mladick RA. Body contouring of the abdomen, thighs, hips and buttocks. In: Georgiade GS, Riefkohl R, Levin LS, eds. Georgiade Plastic, Maxillofacial, and Reconstructive Surgery. 3rd ed. Baltimore: Williams & Wilkins; 1997:674.




A healthy 30-year-old man is scheduled to undergo suction lipectomy of the trunk using the superwet technique. When injected into subcutaneous fat with solutions containing epinephrine, which of the following is the maximum recommended dose of lidocaine?

(A) 7 mg/kg
(B) 14 mg/kg
(C) 21 mg/kg
(D) 28 mg/kg
(E) 35 mg/kg

The correct response is Option E.

The maximum recommended dose of lidocaine is 35 mg/kg when injected into subcutaneous fat with solutions containing epinephrine. Doses of up to 50 mg/kg have been used, but are not generally recommended because of toxicity concerns.

Various individual anesthetic agents and anesthetic combinations are appropriate for suction lipectomy, depending on the patient=s health, the estimated volume of aspirate to be removed, and the postoperative discharge plan. For suction lipectomy, anesthetic agents are added to the wetting solution to provide preemptive and prolonged postoperative local analgesia. In smaller-volume suction lipectomy cases, anesthetic infiltration solutions alone may provide adequate pain relief. In larger-volume suction lipectomy cases, the superwet and tumescent solutions are often used for sedation, general, or epidural anesthesia to ensure adequate patient comfort.

Lidocaine with epinephrine is used most often as the anesthetic agent in the wetting solution. Historically, the recommended dose of lidocaine was less than 7 mg/kg. However, this dose did not take into consideration the slow absorption of lidocaine from fat, the persistent vasoconstriction caused by epinephrine, and the lidocaine removed in the suction lipectomy aspirate. All these factors decrease the risk of systemic toxicity from lidocaine and allow higher doses to be used safely.

References:
1. Iverson RE, Lynch DJ, and the ASPS Committee on Patient Safety. Practice advisory on liposuction. Plast Reconstr Surg. 2004;113(5):1478-1490.
2. Grazer FM, Grazer JM, Sorenson CL. Suction-assisted lipectomy. In: Achauer BM, Eriksson E, Vander Kolk C, et al, eds. Plastic Surgery: Indications, Operations, and Outcomes. Vol 5. St. Louis, MO: Mosby; 2000:2859-2887.






A 45-year-old man who has achieved substantial weight loss from massive obesity is scheduled to undergo belt lipectomy for circumferential truncal excess. Which of the following is the most likely postoperative complication?

(A) Deep venous thrombosis
(B) Dehiscence
(C) Infection
(D) Seroma
(E) Skin necrosis

The correct response is Option D.

Compared with traditional abdominoplasty, belt lipectomy (which combines abdominoplasty with circumferential excision of skin and fat) can provide more optimal contouring for patients with circumferential truncal excess because it addresses the trunk as a unit. Patients who have had a substantial weight loss commonly are candidates for this procedure. After belt lipectomy, care must be undertaken to monitor for and treat complications. Seroma management is a significant part of postoperative care for up to one third of patients who undergo belt lipectomy, and patients should be made aware of the significant morbidity associated with the procedure.

The other complications listed affect less than 10% of patients. Procedures that increase intraabdominal pressure, such as hernia repair, increase the risk of deep venous thrombosis and pulmonary emboli. Deep venous thrombosis and pulmonary emboli are always possible with long-term anesthesia and immobilization, but these are fortunately rare. Wound dehiscence is a concern in belt lipectomy; when the patient flexes at the waist to relieve anterior tension, the back incision is strained and vice versa. Infection rates are less than 5%. Factors that may increase the risk of skin necrosis involve interruption of the lateral intercostal blood supply by lateral skin resection, lack of vascularization across the midline of the anterior abdominal flap, and excess tension on the abdominal flap.

References:
1. Aly AS, Cram AE, Chao M, et al. Belt lipectomy for circumferential truncal excess: the University of Iowa experience. Plast Reconstr Surg. 2003;111:398-413.
2. Lockwood T. Contouring of the arms, trunk, and thighs. In: Achauer BM, Eriksson E, Vander Kolk C, et al, eds. Plastic Surgery: Indications, Operations, and Outcomes. Vol 5. St. Louis, MO: Mosby; 2000:2839-2858.




During a medial thigh lift procedure, the incision over the femoral triangle is dissected more superficially to avoid injury to which of the following?

(A) Femoral artery
(B) Femoral nerve
(C) Femoral vein
(D) Inguinal ligament
(E) Lymphatic plexus

The correct response is Option E.

The lymphatics of the lower extremity travel to the superficial inguinal nodes and deep inguinal nodes. The deep inguinal nodes are situated just medial to the femoral vein and receive lymphatics that accompany the femoral vessels, lymph vessels from the genitalia, and efferents from the superficial nodes. The superficial nodes receive vessels from the gluteal region, infraumbilical abdominal wall, perianal region, and external genitalia as well as most of the superficial lymph vessels of the lower limb. Because superficial lymph vessels are small, they are prone to injury, which can lead to wound-healing problems such as lymphoceles and seromas as well as problems associated with recurrent peripheral edema. The femoral vein, artery, and nerve run deeper, beneath the inguinal ligament at the level of the incision, significantly deeper than the fragile lymphatics of the superficial inguinal nodes.

References:
1. Lockwood TE. Body contouring, trunk and thigh lifts. In: Cohen M, ed. Mastery of Plastic and Reconstructive Surgery. Vol 3. Philadelphia: Lippincott Williams & Wilkins; 1994:2201-2218.
2. Pitman G. Liposuctioning and body contouring. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith’s Plastic Surgery. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 1997:669-690.
3. Williams PL, Warwick R, Dyson M, et al, eds. Gray’s Anatomy. 37th ed. New York: Churchill Livingstone, 1989:812-813, 848-849.




When performing suction lipectomy using the superwet technique, the amount of blood loss in the suction aspirate is closest to which of the following?

(A) 0%
(B) 10%
(C) 20%
(D) 30%
(E) 40%


The correct response is Option A.

With the superwet technique, blood loss is approximately 1% of the suction aspirate. This technique uses a 1:1 ratio of subcutaneous infiltrate to aspirate. The infiltrate consists of saline or Ringer’s lactate solution, epinephrine, and in some cases lidocaine.

The first method of suction lipectomy, the dry technique, was associated with blood loss of 20% to 45% in the suction aspirate as well as substantial swelling and discoloration. It was performed under general anesthesia without infiltration of subcutaneous solutions before insertion of the suction lipectomy cannula. Except in limited applications, this approach has been abandoned.

The wet technique is associated with blood loss of 4% to 30% of the aspirate. In this technique, 200 to 300 mL of infiltrate or wetting solution, with or without additives, is injected into the operative field before insertion of the suction lipectomy cannula. Small doses of the vasoconstrictor epinephrine are added to the infiltrate.

Like the superwet technique, tumescent suction lipectomy is associated with blood loss of approximately 1% in the suction aspirate. However, it uses more infiltrate, up to 3 or 4 mL of infiltrate for each planned milliliter of aspirate.


References:
1. Iverson RE, Lynch DJ, and the APSP Committee on Patient Safety. Practice advisory on liposuction. Plast Reconstr Surg. 2004;113(5):1478-1490.
2. Grazer FM, Grazer JM, Sorenson CL. Suction-assisted lipectomy. In: Achauer BM, Eriksson E, Vander Kolk C, et al, eds. Plastic Surgery: Indications, Operations, and Outcomes. Vol 5. St. Louis, MO: Mosby; 2000:2859-2887.




Which of the following structures is LEAST likely to be injured during brachioplasty?

(A) Basilic vein
(B) Cephalic vein
(C) Intercostobrachial nerve
(D) Medial cutaneous nerve of the forearm


The correct response is Option B.


Because the cephalic vein runs anterior and superior to the dissection planes used in brachioplasty, it is not likely to be injured during this procedure. The basilic vein, intercostobrachial nerve, and medial cutaneous nerve of the forearm are aligned slightly medially and posteriorly along the arm in the area of dissection for a standard brachioplasty. Therefore, they are susceptible to injury during the procedure.


References:
1. Vogt P, Baroudi R. Brachioplasty and brachial suction assisted lipectomy. In: Cohen M, ed. Mastery of Plastic and Reconstructive Surgery. Vol 3. Philadelphia: Lippincott Williams & Wilkins; 1994:2224-2228.
2. Netter FH. Atlas of Human Anatomy. 2nd ed. East Hanover, NJ: Novartis, 1997:410.
3. Williams PL, Warwick R, Dyson M, et al, eds. Gray’s Anatomy. 37th ed. New York: Churchill Livingstone, 1989:806, 1132.