Rivaroxabana para profilaxia de tromboembolismo venoso em abdominoplastia após grande perda ponderal: 396 casos / Rivaroxaban for venous thromboembolism prophylaxis in abdominoplasty after massive weight loss: 396 cases

Introdução: Abdominoplastia consiste em um dos procedimentos estéticos mais populares realizados no Brasil. Pacientes pósbariátricos representam um desafio peculiar ao cirurgião plástico, uma vez que não só requerem reconstruções complexas, mas também apresentam comorbidades residuais e deficiências nutricionais. O tromboembolismo venoso (TEV) constitui uma complicação grave e potencialmente fatal da abdominoplastia. Apesar da pequena frequência desta complicação, os métodos aceitos como padrões para prevenção de TEV em pacientes após abdominoplastia, incluindo quimioprofilaxia, permanecem controversos. Objetivo: Avaliar a experiência do autor com rivaroxabana para profilaxia de TEV em pacientes submetidos a abdominoplastia após grande perda ponderal. Métodos: Uma série de 396 casos foi conduzida retrospectivamente. Todos os pacientes submetidos à abdominoplastia após cirurgia bariátrica que receberam rivaroxabana foram incluídos. A dose profilática foi de 10mg por dia. Dados demográficos, comorbidades, tipo de cirurgia e complicações foram registrados. Resultados: 396 casos de pacientes pós-bariátricos (356 mulheres e 40 homens) foram submetidos à abdominoplastia e receberam rivaroxabana no pós-operatório, de julho de 2015 a julho de 2018. A média de idade dos pacientes foi de 39,1 anos. O índice de massa corporal médio no momento da abdominoplastia foi de 27,2kg/m². Houve apenas um caso de tromboembolismo venoso (0,25%). Treze pacientes apresentaram hematoma com necessidade de drenagem. Conclusões: A quimioprofilaxia de rotina com rivaroxabana para pacientes submetidos à abdominoplastia após grande perda ponderal revela uma baixa incidência de TEV. Esta medicação oral é bem tolerada e apresenta um perfil de complicação aceitável.

Introduction: Abdominoplasty is one of the most popular aesthetic procedures performed in Brazil. Postbariatric patients present a challenge to the plastic surgeon as not only do they have complex reconstructive challenges but also they have residual medical comorbidities and nutritional deficiencies. A serious and potentially fatal complication of abdominoplasty is venous thromboembolism (VTE). Despite the frequency of this serious complication, the accepted standard methods to prevent VTE in abdominoplasty patients, including chemoprophylaxis, remain controversy. Objective: To evaluate the author experience with rivaroxaban, for VTE prophylaxis in abdominoplasty patients after massive weight loss. Methods: A retrospective 396 cases series were conducted. All patients who underwent abdominoplasty after bariatric surgery and received rivaroxaban were included. The prophylactic dose was 10 mg daily for 30 days, beginning 24 hours postoperatively. Patient demographics, comorbidities, type of surgery and complications were recorded. Results: From July 2015 until July 2018, 396 post bariatric patients (356 women and 40 men) underwent abdominoplasty and received rivaroxaban postoperatively. The mean body mass index prior to their weight loss procedure was 43.8kg/m2 (range, 37.3- 61.9kg/m2) and mean BMI was 27.2kg/m² at the time of the abdominoplasty. Mean patient age was 39.1 years. Only one patient had a symptomatic PTE event. Thirteen patients had a hematoma requiring operative evacuation, and all went on to heal without sequel. Conclusions: Routine chemoprophylaxis with rivaroxaban for abdominoplasty patients after massive weight loss has a low rate of VTE events. This oral medication is well tolerated and has an acceptable complication profile.

Gigantomastia gestacional: como abordar essa situação clínica / Gestational gigantomastia: how to address this clinical situation

A gigantomastia gestacional é uma desordem rara, na qual ocorre o crescimento excessivo e rápido das mamas, culminando com edema e congestão venosa das mesmas, além de ocasionar dor, ulceração da pele e infecção local. Estas complicações, em alguns casos, levam à necessidade de mastectomia de emergência ou abortamento induzido. A hipótese etiológica mais aceita é a de que exista uma estimulação anormal do tecido mamário, que pode ser desencadeada por níveis excessivos de hormônios ou por uma hipersensibilidade deste tecido a níveis hormonais normais. Apesar de a mama regredir após a gestação, raramente volta ao estado original; portanto, a redução da mama através de mastectomia ou mamoplastia geralmente é necessária. Além disso, é grande o risco de recorrências em gestações futuras. Os autores relatam o caso de gigantomastia em uma primigesta, com necessidade de interrupção da gravidez, devido ao risco de morte materna, e posterior intervenção cirúrgica com mamoplastia redutora.

Gestational gigantomastia is a rare disorder characterized by an excessive and rapid enlargement of the breasts, resulting in edema and venous congestion of breast tissue. It is a painful condition that causes skin ulceration and local infection. In some cases, these complications lead to an emergency mastectomy or induced abortion. The most probable etiology is an abnormal stimulation of breast tissue that is probably triggered by an abnormally elevated level of hormones or by the hypersensitivity of breast tissue to normal hormone levels. Although the breast volume decreases after pregnancy, it rarely returns to its original state; therefore, breast reduction through mastectomy or mammaplasty is usually necessary. Moreover, there is a high likelihood of recurrence in subsequent pregnancies. The authors report a case of gigantomastia in a primigravida that required pregnancy termination, because of the risk of maternal death, and a subsequent breast reduction surgery.

Autologous Fat Grafting for Treatment of Breast Implant Capsular Contracture: A Study in Pigs.

BACKGROUND: Capsular contracture (CC) is a common complication after breast augmentation. Autologous fat grafting may be effective for restoring tissue vascularization and function. OBJECTIVE: The authors evaluated the efficacy of autologous fat grafting in a porcine model as a treatment for CC after breast augmentation. METHODS: This prospective study was performed in 20 female 30-day-old pigs. Each animal was implanted with three 30-cc textured silicone implants (stage 1 of the experiment). Group A served as the untreated control group. To induce CC, 2 mL of autologous fibrin glue was applied to the pericapsular space in group B and C animals at implantation. Three months after implantation (stage 2), the CCs of all groups were assessed by Baker classification and applanation tonometry (AT). Liposuction was performed in group B to harvest fat for these animals. Three months after group B underwent fat grafting, all 3 groups were reevaluated. Reassessments included Baker classification, AT, histologic analysis, and tensiometry (stage 3). RESULTS: The deposition of mature and immature collagen was similar for the 3 groups. The amount of fat remaining around the implanted capsules did not differ significantly between the groups. At stage 3, group B exhibited significantly larger tonometry areas than did group C. The CCs in groups B and C were significantly thicker than those of group A, but the difference between groups B and C was not significant. Capsule rupture forces did not differ significantly between groups A and B but were significantly higher in group C compared with the other groups. CONCLUSIONS: Results in this animal model indicate that pericapsular lipoinjection may be a promising treatment for CC in humans.

Evaluation of maxillary growth: is there any difference using relief incision during palatoplasty?

INTRODUCTION: Scar retraction due to exposed bone in palatoplasty is the leading cause of constricted maxilla. Modern techniques have focused on minimizing the effects of scarring by reducing the exposure of the bone area. OBJECTIVE: The objective of the study was to compare the palatal mucoperiosteal detachment with minimal lateral incision, followed by their synthesis, with the maintenance of lateral areas for relaxation (similar to the von Langenbeck technique) and evaluate the transversal development of the maxilla. METHODS: A prospective, randomized study was conducted, in which the molding of the dental arch of 14 pigs in 2 stages (at 1 month and 5 months) was performed. The pigs were divided into 3 groups: group 1 underwent lateral incision of the palate for mucoperiosteal detachment and maintenance of bone exposure; group 2 underwent mucoperiosteal palatal detachment with lateral access and no bone exposure; and group 3, the control animals, did not undergo any surgical procedures. Measurements of the dental arches were compared between the groups to assess differences in the development of the maxillary transverse diameter. RESULTS: There were no animals lost during the study. Group 1 showed greater growth restriction of the transverse diameter of the maxilla (36%) when compared with groups 2 (56%) and 3 (59%). Groups 2 and 3 showed similar transverse maxillary development, with no statistical difference. CONCLUSIONS: The technique of mucoperiosteal detachment without lateral relief incision has the advantage of reducing future morbidity of a constricted maxilla. This study demonstrated that the technique described can reduce rates of maxillary underdevelopment, a significant complication inherent in the procedure for palatoplasty. The lateral incisions reduce maxillary growth by approximately 20% as compared with this technique. Level II of evidence.

Comparison of orbital volume obtained by tomography and rapid prototyping.

PURPOSE: This study aims to compare orbital volume obtained by helical tomography and rapid prototyping. METHODS: The study sample was composed of 6 helical tomography scans. Eleven healthy orbits were identified to have their volumes measured. The volumetric analysis with the helical tomography utilized the same protocol developed by the Plastic Surgery Unit of the Federal University of Paraná. From the CT images, 11 prototypes were created, and their respective volumes were analyzed in 2 ways: using software by SolidWorks and by direct analysis, when the prototype was filled with saline solution. For statistical analysis, the results of the volumes of the 11 orbits were considered independent. RESULTS: The average orbital volume measurements obtained by the method of Ono et al was 20.51 cm, the average obtained by the SolidWorks program was 20.64 cm, and the average measured using the prototype method was 21.81 cm. The 3 methods demonstrated a strong correlation between the measurements. The right and left orbits of each patient had similar volumes. CONCLUSIONS: The tomographic method for the analysis of orbital volume using the Ono protocol yielded consistent values, and by combining this method with rapid prototyping, both reliability validations of results were enhanced.

Neurofibroma plexiforme gigante de dorso: relato de caso / Giant plexiform neurofibroma of the back: case report

O neurofibroma plexiforme é uma das principais apresentações da neurofibromatose, com incidência maior no segmento cefálico e menos frequente no tronco. A sua ressecção torna-se um desafio em decorrência da rica vascularização e da infiltração aos planos profundos. Descrevemos o caso de um neurofibroma gigante acometendo todo o dorso de uma paciente jovem, com crescimento progressivo, associado a manchas “café com leite” e déficit cognitivo. A investigação clínico-radiológica mostrou se tratar de neurofibromatose tipo I e a abordagem cirúrgica foi realizada em dois tempos, por meio de enxertia de pele parcial em toda a área ressecada.

Plexiform neurofibroma is one of the major presentations of neurofibromatosis, with a higher incidence in cephalic segment and less common in the trunk. It's resection becomes a challenge due to its rich vascularization and infiltration to deep plans. We present the case of a giant neurofibroma embodying the whole back of a young patient, with progressive growth associated with “café-au-lait” spots and cognitive deficit. Clinical and radiologic inquiry indicated type 1 neurofibromatosis. Surgical resection was achieved in two steps, covering the naked area with split-thickness skin grafts.