Lateral Thigh Reference Line in Body Contouring.

Background: We present a novel vertical axillary line protocol that offers several benefits to high-definition (HD) liposuction and body contouring procedures. High-definition liposuction and body contouring are predicated on addressing the body circumferentially in a 360-degree manner. The vertical axillary line protocol utilizes a vertical line drawn from the armpit or axilla down to the mid-lateral thigh. The benefits of this vertical axillary line to HD body contouring are derived from its ability to delineate the junction between the front and back halves of the body. Objective: The vertical axillary line provides safety measures and superior outcomes for HD body contouring cases. By gauging the halfway point when performing liposuction around the waist, the vertical axillary line avoids theoretical point burns from the tip of the ultrasound probe, promotes preservation of perforators during abdominoplasty, and even avoids inadvertent injury to breast implants. In addition, it helps clarify gender-specific contouring guidelines. Finally, it provides anatomical landmarks to guide preoperative surgical markings in excisional body lifting procedures, thereby ensuring symmetry of incision lines. Method: The HD vertical axillary lines are defined by the axillary folds located along the anterior and posterior aspects of the armpit. The apex of the axilla is used to set the mid-HD vertical axillary line. The anterior and posterior axillary folds define the anterior HD vertical axillary line and posterior HD vertical axillary line, respectively. These 3 points (anterior, mid, posterior) define the start point of the HD vertical axillary lines, which are then extended down through the mid-point of the lateral thigh. Results: We present 8 cases to demonstrate how the HD vertical axillary line protocol may improve safety measures and aesthetic outcomes. Conclusion: In summary, we present a novel HD vertical axillary line protocol that may help improve both safety and aesthetic outcomes in HD liposuction and body contouring surgeries. Level of Evidence: Level V, clinical experience

Massive weight loss results in skin excess, leading to an unsatisfying body contour. Various thigh lift procedures can correct flabby skin in the lower leg. We present a lower body contouring technique with a report on two patients. The procedure is determined by the body contour of the patient. As the skin excess in the thigh area tended to appear mostly on the medial side, a vertical medial thigh lift was considered. Moreover, for patients with a pear/guitar-shaped body contour, we added the spiral thigh lift for skin excess in the buttocks and the lateral thigh area. The extent of tissue to excise was determined by pinching the patient in a standing position. The inferior skin flap was fixed to non-movable tissue, which was helpful for lifting the tissue and preventing the widening of the scar. After the operation, a drain was kept for 3 to 4 days. A compressive garment was used after removing the drain. There were no complications. The patients were discharged 6 to 8 days after the operation. In conclusion, skin excess, especially in the lower body, can be corrected by a thigh lift combining several procedures, varying from person to person.

Background: Ex vivo liposuction is a novel technique wherein tissues that are preoperatively planned for excision can be liposuctioned in a sterile manner after removal from the patient. Excised tissues are routinely obtained during a tummy tuck or variant, lateral thigh tuck, buttock tuck, brachioplasty, upper body tuck, and medial thigh tuck. These tucking procedures are performed when moderate to severe skin redundancy is present in patients undergoing body contouring. Traditionally, these tissues were first liposuctioned prior to being excised, termed in vivo liposuction. However, we have developed ex vivo liposuction protocols wherein the tissues are liposuctioned after they have been excised off the patient. Routine processing of harvested fat focuses on minimizing blood products in the aspirate prior to injection. This is because blood products are felt to contain pro-inflammatory products that negatively affect fat graft take. We hypothesized that fat collected by ex vivo technique provides a less bloody harvest than fat collected by in vivo technique. Materials and Methods: We quantitated blood concentrate of ex vivo versus in vivo fat aspirate by comparing the hemolysis index in 14 consecutive patients undergoing high-definition liposuction and body contouring. Results: Comparison of hemolysis index demonstrated significant reduction in blood concentrate in ex vivo versus in vivo fat aspirate. In vivo hemolysis index demonstrated a larger median than ex vivo hemolysis index. These results confirm our clinical observation that fat harvested by ex vivo liposuction is cleaner and less blood-tinged than fat harvested by in vivo liposuction. Conclusion: No patients experienced complications related to fat graft infection nor fat emboli. Ex vivo liposuction has proven a safe and less blood-tinged technique for harvesting fat in patients who require excisional procedures.

Augmentation buttock-pexy using autologous tissue following massive weight loss

There is an increased demand for the reduction of localized adipose tissue by noninvasive methods. The objective of this study was to determine the safety and efficacy of noninvasive lipolysis of excess adiposities overlying the lateral thigh region using acoustic wave therapy (AWT). This study incorporates 2 mechanical waves with varying properties in the same session: radial and planar AWT. The treatment was performed using AWT on the lateral thigh areas of 15 female patients. The study was performed using the planar and radial pulse handpieces, with 8 sessions performed within 4 weeks. Follow-up visits were performed 1, 4, and 12 weeks after the last treatment. Reduction in both thigh circumference and subcutaneous fat layer thickness, measured through ultrasound, was observed. This study demonstrates that AWT is safe and efficacious for the treatment of localized adiposities in the saddlebag area. However, the results obtained were not statistically significant. Larger studies will be needed to further access the effects of AWT on thigh circumference reduction. Furthermore, the authors also found an improvement in the appearance of both cellulite and skin firmness after the treatments.

Changes in body habitus and age-related soft tissue descent can alter the body’s centre of mass, thus centre of gravity and loading patterns, contributing to postural maladaptations and myofascial dysfunction. Previous studies have demonstrated postural improvement and reduction in back pain after abdominoplasty and rectus plication; however, to our knowledge, no reports have described comprehensive body contouring as a functional intervention to reat Gluteus Medius Syndrome. A 61-year-old female with a history of L4 fracture managed conservatively presented with progressive buttock pain and ambulatory limitation consistent with Gluteus Medius Syndrome. She underwent a combined single-session procedure: abdominoplasty with rectus plication (preserving infra-umbilical Scarpa’s fascia), 360° waist liposuction, liposuction of the lateral thighs, buttock lift with autologous adipo-dermal pedicled auto-augmentation cranial adipo-dermal paddle rotation). Total aspirate/excised volumes were 6 L of fat and 4.3 kg of skin flaps. The postoperative course was uncomplicated. By 8 months post-op, the patient reported complete resolution of buttock pain and returned to habitual ambulation, now walking ~5 km daily beyond routine activities. Photographs at 8 months show improved trunk posture. Comprehensive body contouring that includes abdominal wall tightening and circumferential lift procedures may alter the body’s centre of gravity and spinal loading sufficiently to produce clinically meaningful improvements in posture and function. This single case suggests a potential functional role for plastic surgical body contouring beyond aesthetic benefit. Prospective studies using objective postural and gait metrics are needed to conclusively recommend this approach broadly.

Unlike traditional plastic surgery patients who present with a specific anatomical complaint, massive weight loss patients often have multiple regions of concern. No single procedure can address the whole-body deformities associated with massive weight loss. The authors sought to quantify their clinical experience to provide evidence-based analysis of procedural combination in body contouring. Patients were enrolled in an institutional review board-approved prospective clinical database over a 5-year period. Procedure categories included breast, medial thigh lift, buttock and lateral thigh lift, upper back lift, brachioplasty, and abdomen. Analysis of variance was used to analyze differences between procedure combinations. Six hundred nine massive weight loss patients underwent 661 cases involving 1070 procedures. Length of hospital stay increased with the number of procedures performed (p < 0.001). Second-stage cases (n = 60) had similar complication rates and length of hospital stay. Seroma and dehiscence were strongly correlated with the number of procedures (p < 0.001), as were tissue necrosis and infection (p = 0.02), whereas hematoma was unrelated (p = 0.25). Major complications did not increase in multiple-procedure cases. In a large experience at a high-volume center, concomitant procedures were performed safely in carefully selected patients with low major complication rates. Although aggregate minor complication rates were predictably higher than in single-procedure cases, there was no significant increase on a per-procedure basis. Multiple procedures can be combined safely in the body contouring patient, with surgical staging offering a viable alternative for patients who are unable to undergo combined procedures.

Patients with massive weight loss following bariatric surgery are now presenting in large numbers for body contouring. To achieve optimum cosmetic results in these patients, a comprehensive circumferential approach is usually required that includes the lateral thighs and buttocks. For a number of reasons, many patients are not candidates for these comprehensive procedures. Some patients view the circumferential procedures as too extensive or aggressive. Others have large hernias or other medical conditions that necessitate a more limited approach. Still others do not have sufficient resources to treat multiple areas. A 2-year review of patients presenting with a chief complaint of anterior lower abdominal tissue excess as a consequence of massive weight loss following bariatric procedures was conducted. In 64 cases, patients opted for anterior-only treatment of the lower trunk. Average operative time in patients undergoing modified abdominoplasty alone was 2.5 hours. The mean mass of the excised panniculectomy specimens was 3.8 kg (range, 1.1 to 10.0 kg). The most common complication was wound dehiscence at the T-junction (27 percent), which was treated successfully with local wound care in all cases and did not require reoperation to achieve wound closure. There were no known thromboembolic events. Not all massive weight loss patients are suitable candidates for comprehensive circumferential body contouring procedures, and many patients desire a limited anterior approach to the frontal abdomen. The modified vertical abdominoplasty should be considered as an option in these patients.

Previous studies reported the ligament attachments with regard to anatomic landmarks. However, these absolute distances may differ in size and anatomic variability. To develop radiologic methods for assessing the tunnel placements of anatomic lateral ankle ligament reconstruction with a single common fibular tunnel and provide quantitative data on radiography and 3-dimensional computed tomography (3D CT). Sixteen ankle specimens were used to identify the attachment centers of the anterior talofibular ligament and calcaneofibular ligament. Subsequently, bone tunnels were created at these sites, with their positions evaluated via lateral radiographs and CT scans. Reference lines such as the anterior distal fibular line from the inferior tip of the fibula to the anterior tubercle on the fibula and the anterior lateral malleolar line from the apex of the lateral talar process to the anterolateral corner of the trochlea on the talus were employed for accurate tunnel positioning. For the calcaneal tunnel, the posterior subtalar line and its orthogonal line form the basis for a structured square measurement frame. The tunnel entries were orthogonally projected onto these references, enabling a percentage-based description of their locations. The interobserver and intraobserver reliability of the radiographic measurements were assessed using intraclass correlation coefficients (ICCs). The fibular tunnel was projected at 35.9% on lateral radiography and 35.0% via 3D CT along the anterior distal fibular line. The talar tunnel was recorded at 62.4% on radiography and 63.5% on 3D CT along the anterior lateral malleolar line. There were no significant differences in the length of the posterior subtalar line (34.6 vs 31.4 mm, P = .140), distance a to the calcaneal tunnel (16.1 vs 14.7 mm, P = .100), and distance b to the calcaneal tunnel (27.9 vs 25.1 mm, P = .233) between the lateral roentgenogram and 3D CT. The calcaneal tunnel was observed at 80.6% on lateral radiography and 79.7% on 3D CT along the posterior subtalar line and at 46.4% on radiography and 46.3% on 3D CT along the orthogonal line. No significant differences were observed in the locations of the fibular, talar, and calcaneal tunnels between lateral radiography and 3D CT. Good interobserver agreement and intraobserver reproducibility were achieved, as indicated by ICCs. This study describes reproducible radiographic measuring techniques and provides quantitative data for intraoperative positioning and postoperative assessment of tunnel locations for anatomic lateral ankle ligament reconstruction. Both lateral radiography and 3D CT were effective modalities for evaluating the bone tunnels. By offering reproducible measurement strategies and critical quantitative data on tunnel positioning for anatomic lateral ankle ligament reconstruction, this research significantly aids in optimizing intraoperative tunnel placement and postoperative evaluation, particularly for procedures involving a single common fibular tunnel and limited exposure methodologies.

An advanced technique for multiple breath-hold volumetric modulated arc therapy (VMAT) has been proposed under fluoroscopic image guidance with a fiducial marker implanted close to a tumor. The marker coordinates on a digitally reconstructed radiography image at a gantry start angle, under a planned breath-hold condition, were transferred to the fluoroscopic image window. Then, a reference lateral line passing through the planned breath-hold marker position was drawn on the fluoroscopic image. Additional lateral lines were further added on both sides of the reference line with a distance of 3 mm as a tolerance limit for the breath-hold beam delivery. Subsequently, the patient was asked to breathe in slowly under fluoroscopy. Immediately after the marker position on the fluoroscopic image moved inside the tolerance range, the patient was asked to hold the breath and the VMAT beam was delivered. During the beam delivery, the breath-hold status was continuously monitored by checking if the deviation of the marker position exceeded the tolerance limit. As long as the marker stayed within the tolerance range, a segmented VMAT delivery continued for a preset period of 15 to 30 seconds depending on the breath-hold capability of each patient. As soon as each segmented delivery was completed, the beam interrupt button was pushed; subsequently, the patient was asked for free breathing. This procedure was repeated until all the segmented VMAT beams were delivered. A lung tumor case is reported here as an initial study. The proposed technique may be clinically advantageous for treating respiratory moving tumors including lung tumor, liver cancer, and other abdominal cancers.

Reliability evaluation of inter-eminence line, Akagi and Dalury lines for intraoperative tibial rotation: An osteology-based study

Foot Deformity Correction Planning in the Sagittal Plane Based on the Vitruvian Foot First Metatarsal Anatomic Axis

There is increasing evidence associating "atypical" femoral fractures with prolonged exposure to bisphosphonate therapy. The cause of these fractures is unknown and likely multifactorial. This study evaluated the hypothesis that patients with primary osteoporosis who sustain atypical femoral fracture(s) while on chronic bisphosphonate therapy have a more varus proximal femoral geometry than patients who use bisphosphonates for primary osteoporosis but do not sustain a femoral fracture. The femoral neck-shaft angle was measured on the radiographs of 111 patients with atypical femoral shaft fracture(s) and thirty-three asymptomatic patients; both groups were on chronic bisphosphonate therapy. Patients with characteristic lateral cortical thickening, stress lines, and thigh pain were included in the fracture group. The mean neck-shaft angle of the patients who sustained atypical femoral fracture(s) while taking bisphosphonates (case group) differed significantly from that of the patients on bisphosphonate therapy without a fracture (129.5° versus 133.8°; p < 0.001). Fifty-three (48%) of the patients in the case group had a neck-shaft angle that was lower than the lowest angle in the control group (128°). Side-to-side comparison in patients with a unilateral pathologic involvement and an asymptomatic contralateral lower limb did not demonstrate any significant difference between the neck-shaft angles in the two limbs. Patients on chronic bisphosphonate therapy who presented with atypical femoral fracture(s) had more varus proximal femoral geometry than those who took bisphosphonates without sustaining a fracture. Although no causative effect can be determined, a finding of varus geometry may help to better identify patients at risk for fracture after long-term bisphosphonate use.

25.3 - Circumferential approaches to truncal contouring: The lower lipo-bodylift

Circumferential Body Contouring: The Lower Body Lift