Is There a Direct Effect Between the Plication of the Myoaponeurotic Layer and the Force of Inspiratory and Expiratory Muscles After Abdominoplasty?

OBJECTIVE: Abdominoplasty may generate an increase in the intra-abdominal pressure (IAP) and consequently an alteration in the pulmonary ventilation. The purpose of this study was to evaluate the potential alterations in the maximal static inspiratory pressure (MIP) and maximal static expiratory pressure (MEP) after abdominoplasty. METHODS: Thirty-three female patients, aged between 18 and 60, with type III/B Nahas abdominal deformity that underwent abdominoplasty with plication of the anterior rectus and external oblique aponeurosis were selected. The MIP and MEP were measured using a mouthpiece. This is a simple way to indirectly gauge inspiratory and expiratory muscle strength. Measurements were performed before surgery and on the 2nd, 7th, 15th, and 180th postoperative day. In addition, IAP was measured before abdominoplasty and after the placement of compression garment. The MIP and MEP were compared using analysis of variance, followed by the Bonferroni multiple comparison test pairing the different points in time. Paired Student's t test was used for comparing IAP measurements. Pearson's correlation test was used to compare MIP and MEP variations with IAP variation. Results were considered statistically significant when P ≤ 0.05. RESULTS: A decrease was observed in MEP on the 2nd day, with a return close to normal values on the 15th day. In opposition MIP had a surprisingly increase on the 15th postoperative day (129 cmH2O), normalizing 180 days after the operation. A leap in IAP values was revealed at the end of the surgical procedure. It was not possible to establish a positive correlation between the increase of IAP and the alterations of MIP and MEP. CONCLUSIONS: There is a decrease in maximum expiratory pressure on the very early postoperative day (2nd postoperative day) and an increase in maximum inspiratory pressure on the 15th postoperative day in patients who underwent abdominoplasty. There was no correlation between the IAP and maximum respiratory pressure variations, both inspiratory and expiratory.

Effectiveness of 5-Fluorouracil and Hypertonic Glucose in the Prevention of Post-mastectomy Seroma in an Experimental Animal Model.

INTRODUCTION: Seroma is a frequent complication that can affect the final result of reconstructive and cosmetic surgeries. METHODOLOGY: This study evaluated the effectiveness of 5-Fluorouracil and 75% hypertonic glucose in preventing seroma in a mastectomy rat model, as well as cellular and vascular events in adjacent tissues. A left mastectomy with lymphadenectomy was performed in 60 Wistar-Albino female rats. Animals randomly allocated to the control group (Group I; n = 20) were sutured right after mastectomy. The intervention groups received 1.0 mL of 75% hypertonic glucose (Group II; n = 20) or 1.0 mL of 5-Fluorouracil (Group III; n = 20) at the surgical site before suturing. The assessment of the presence of seroma was performed in all animals at 24, 48, and 72 h and on the 7th and 12th postoperative day. After the 12th day, a tissue sample was taken from the surgical site and sent for histological analysis. The occurrence of seroma was assessed using GEE. A significance level of 5% was adopted. RESULTS: Differences in seroma formation over time were observed for both Control Group I (p=0.041) and Intervention Group II (p<0.001). In Intervention Group III, there was no difference in the percentage and volume of seroma across the assessment points (p=0.627). When both the Control and Intervention Group II were compared to Intervention Group III, we found a reduction in seroma formation in the last group. The reduction in the inflammatory process was more regular to Intervention Group III. CONCLUSION: In this animal model, 5-Fluorouracil was more effective in preventing seroma formation than 75% Hypertonic Glucose. No Level Assigned This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Effect of Compression Garments on the Ventilatory Function After Abdominoplasty.

BACKGROUND: The use of compression garments in the postoperative period of abdominoplasty seems to be a consensus, but the incidents of complications arising from this have been described, related to an increase in intraabdominal pressure and reduction of the femoral vein blood flow that may facilitate thromboembolic events. There are no studies that have evaluated the isolated effect of postoperative compression garments on respiratory function. OBJECTIVES: The purpose of this study was to evaluate the effect of compression garments on respiratory function after abdominoplasty. METHODS: Thirty-four female patients who underwent standard abdominoplasty were divided into 2 groups, the garment group (n = 18) and the no garment group (n = 16). Respiratory function assessment (with spirometry and manovacuometry) was performed in the preoperative and postoperative periods. RESULTS: Forced vital capacity assessment revealed a greater ventilatory restriction in the garment group. Forced expiratory volume in 1 second (FEV1) showed differences between the evaluation time points in the garment group; the intergroup comparisons showed that the no garment group had a lower FEV1. Slow vital capacity was evaluated with no significant differences found on both intergroup comparisons. The inspiratory capacity was reduced in the garment group, representing ventilatory restriction. Measurements of the maximum inspiratory pressure showed no significant differences between the groups. The maximum expiratory pressure showed significantly lower values on postoperative day 7 in the garment group. CONCLUSIONS: The use of compression garments after abdominoplasty impairs ventilatory function. Not wearing this type of garment can improve ventilation, decreasing the risk of pulmonary complications.

Do Compression Garments Prevent Subcutaneous Edema After Abdominoplasty?

BACKGROUND: The main disadvantages of wearing a compression garment following abdominoplasty are the increase in intra-abdominal pressure and risk of venous stasis. On the one hand, the wearing of garments may increase the risk of venous thromboembolism. On the other hand, it may be beneficial in decreasing edema formation after surgery. OBJECTIVES: The authors sought to evaluate the effectiveness of compression garments in reducing subcutaneous edema after abdominoplasty. METHODS: Thirty-two women aged 19 to 50 years were selected and randomly allocated to either the garment (n = 16) or no-garment (n = 16) group. All patients underwent abdominoplasty and received 10 sessions of manual lymphatic drainage during the postoperative period. Postoperative edema formation was assessed by perimetry and bioimpedance, and seroma formation was assessed by ultrasound. Statistical tests included t test, mixed linear models, analysis of variance with repeated measures, and the Kolmogorov-Smirnov test, which were performed at a significance level α of .05 (P ≤ .05). RESULTS: The no-garment group showed a trend toward lower mean waist circumference at 29 days following abdominoplasty and significantly lower waist circumference after postoperative day 35 compared with the garment group (P < .001). The mean total body water was slightly lower in the no-garment group than in the garment group 7 days after surgery (P = .05). CONCLUSIONS: Patients who did not wear a compression garment after abdominoplasty showed less subcutaneous edema formation after 24 days of surgery than those who wore the garment.

The Effect of Quilting Sutures on the Tension Required to Advance the Abdominal Flap in Abdominoplasty.

BACKGROUND: Quilting sutures attaching the abdominal flap to the aponeurosis contribute to the prevention of seroma formation following abdominoplasty. The sutures distribute the tension over the subcutaneous tissue along the flap length, theoretically decreasing tension at the distal (cutaneous) end of the flap. This is expected to reduce the risks of necrosis, dehiscence, and enlarged or hypertrophic scars. OBJECTIVES: This study sought to verify whether quilting sutures decrease the tension required to advance the dermal-fat flap in abdominoplasty. METHODS: Thirty-four women undergoing abdominoplasty with quilting sutures participated in the study. The tensile force required for flap advancement was measured with a digital force gauge before and after placement of quilting sutures and then compared. Differences in tensile force were tested for correlations with BMI, age, weight of flap tissue removed, number of previous pregnancies, and postoperative complications, including seroma formation, hematoma, necrosis, dehiscence, and enlarged or hypertrophic scars. RESULTS: A mean reduction in tension of 27.7% was observed at the skin suture after the placement of quilting sutures (P < 0.001). No significant correlation was found between reduced flap tension and BMI, age, weight of tissue removed, or number of births. One case of seroma formation and 2 cases of enlarged scars were observed, but no case of hematoma, necrosis, or wound dehiscence was detected. CONCLUSIONS: The use of quilting sutures to attach the abdominal flap to the aponeurosis of the anterior abdominal wall reduced tension at the advancing edge of the flap in abdominoplasty.

Do Abdominal Binders Prevent Seroma Formation and Recurrent Diastasis Following Abdominoplasty?

BACKGROUND: For decades, the postoperative wearing of abdominal binders has been suggested to reduce dead space and prevent mobilization of the musculoaponeurotic layer in an attempt to decrease the risk of seroma formation and recurrent diastasis. OBJECTIVES: This study sought to evaluate whether the postoperative wearing of an abdominal binder provides any additional contribution to the reduction of either seroma formation or recurrent diastasis recti when abdominoplasty is performed with quilting sutures. METHODS: Thirty-four women undergoing abdominoplasty were randomized into 2 groups: the binder group (n = 16) wore abdominal binders during the postoperative period, whereas the control group (n = 18) did not. Ultrasound examination was performed on postoperative days 7 and 14 to assess seroma formation and at 6 months postoperatively to assess recurrence of diastasis recti. A t test for independent samples was applied to compare means between 2 numeric variables. Generalized estimation equation models were used to evaluate seroma volume at different time points for the 2 groups. RESULTS: No significant differences in seroma volume were found between groups on postoperative days 7 (P = 0.830) and 14 (P = 0.882). Seven cases of subclinical recurrent diastasis were observed by ultrasound examination in the supraumbilical (4 cases) and infraumbilical regions (3 cases), but without significant differences (P = 1.000) between the 2 groups. Recurrent diastasis was not detected during physical examinations. CONCLUSIONS: The postoperative wearing of abdominal binders was not effective in preventing either seroma formation or recurrent diastasis following abdominoplasty with quilting sutures.

A Variation of the Components' Separation Technique that Preserves the Semilunaris for Treatment of Abdominal Wall Deformities.

The variation of the components' separation technique, which uses the anterior rectus sheath and the release of the oblique muscles, proved to be effective in tension reduction. This paper aimed to present the initial experience using a variation that preserves semilunaris through the incision of the lateral aspect of the rectus sheath. All of the 12 patients presented an abdominal wall defect that included incisional hernia, peritoneostomy, lateral implantation of the rectus muscle, and defect secondary to TRAM flap. The separation was done in the following stages: stage 1-anterior rectus sheath and stage 2-external oblique muscles. From the 12 patients, three presented early complications: seroma ( n = 2) and epitheliolysis ( n = 1). There were no recurrences or other late complications (48 months follow-up period). The separation of the anterior rectus sheath, and incision in the lateral recess to undermine the oblique muscles, allowed the treatment of abdominal wall defects, without late complications.

The "Shirt Pocket" Technique-An Alternative for Augmentation-Mastopexy.

Augmentation-mastopexy is a frequent procedure with high rates of early recurrence of breast ptosis, mainly after subglandular approach. The dual-plane techniques, based on the cranial dissection of the pectoralis, is the most used, but this plane does not cover the inferior pole of the breast. Then, the possibility of a downward dissection of the muscle seems to be more reasonable to retain the implant and improve postoperative results. This study aimed to review the anatomy of the pectoralis in cadavers and the use of its downward dissection to create a pocket for breast implant as a "shirt pocket." This maneuver was associated with a superior-based dermoglandular flap to overprotect the inferior pole. No complications were related in the postoperative period. The anatomic review showed that the "shirt pocket" is a safe option if done carefully. The technique demonstrated to be feasible and seemed to be effective, being another alternative to prevent early recurrence of breast ptosis in these procedures.

Invited Response on: Body Dysmorphic Disorder: There is an "Ideal" Strategy?

Body dysmorphic disorder (BDD) has been considered the most relevant neuropsychiatric condition to cosmetic treatments. Patients' ideal expectations often exceed what is expected to be achieved in reality by plastic surgery, signaling the presence of BDD. It is fundamental to detect BDD symptoms during screening for cosmetic surgery. A secondary concern with physical appearance may be one of the most important parameters to be detected during patient assessment, as it may interfere with overall patient satisfaction following treatment. A good doctor-patient relationship is essential for detecting this psychopathology. Mild-to-moderate BDD is not an exclusion criterion for cosmetic surgery, but specific treatment planning and a multidisciplinary approach are required. Recent studies have presented preliminary evidence for the effectiveness of cosmetic procedures in reducing BDD symptoms and providing patient satisfaction with treatment results. The use of validated instruments at pre- and postoperative assessments to systematically evaluate the patient's level of distress with the physical appearance and patient satisfaction with treatment results will provide important information for the development of more sensitive validated tools for detection of severe levels of BDD symptoms to help plastic surgeons in the selection of patients in a more effective and practical manner.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Abdominal Wall Plication and Correction of Deformities of the Myoaponeurotic Layer: Focusing on Materials and Techniques Used for Synthesis.

The different types of sutures utilized in plications and for correction of diastasis during abdominoplasty are reviewed and discussed. Because correction of abdominal deformities also involves fascia and muscle advancement, this review also covers the suture materials used in muscle advancement. The selection of specific techniques to treat different types of abdominal wall deformity is also considered. This is important, because the outcome when correcting these deformities depends not only on suture materials but also on employing the optimum technique. A PubMed/Medline search was performed with the following search terms: rectus diastasis, diastasis recti, diastasis recti abdominis, correction of rectus diastasis, abdominoplasty. Relevant articles identifying the type of suture (rapidly absorbable, slowly absorbable, nonabsorbable), monofilament or multifilament sutures, antibiotic-coated sutures, and barbed sutures were evaluated. In addition, articles about surgical technique comparing continuous and interrupted sutures, in both the anterior and posterior aponeurosis, to correct rectus diastasis are discussed. Efficacy of suture materials was evaluated based on the long-term results and recurrence rates reported in these articles. The current literature provides sufficient data to recommend a single-layer continuous suture, with slowly absorbable sutures of 0 polydioxanone or 2-0 nylon, for correction of abdominal diastasis. An interrupted triangular suture is a good alternative to correct the vertical elongation of the myoaponeurotic layer that occurs after pregnancy.

Impact of Fractional Ablative Carbon Dioxide Laser on the Treatment of Rhinophyma.

BACKGROUND: Rhinophyma results in nasal deformity, which may lead to significant distress, embarrassment, social isolation, and low self-esteem. Fractional carbon dioxide (CO2) laser treatment is a simple, noninvasive, outpatient procedure with a low complication rate that has proved useful in rhinophyma treatment. OBJECTIVES: The aim of this study was to assess the impact of fractional ablative CO2 laser treatment on self-esteem in patients with rhinophyma. METHODS: Twelve patients with rhinophyma, between 50 and 80 years of age, received 4 monthly treatment sessions with a fractional ablative CO2 laser. The laser parameters were chosen based on the severity of the condition of each patient. Patient satisfaction was assessed through a study-specific questionnaire administered 1 month after treatment. Self-esteem was assessed by the Rosenberg Self-Esteem (RSE) Scale, which was administered before treatment, and at 1, 6, and 12 months after treatment. RESULTS: A decrease in RSE scores was observed in the post-treatment period, indicating an improvement in self-esteem among patients. All patients were satisfied with the aesthetic results and would recommend the treatment to a friend. CONCLUSIONS: Fractional ablative CO2 laser treatment is associated with high levels of rhinophyma patient satisfaction, and significant improvements in self-esteem.

Endocrine-Metabolic Response in Patients Undergoing Multiple Body Contouring Surgeries After Massive Weight Loss.

BACKGROUND: The endocrine-metabolic response to trauma is directly related to its magnitude, but little is known about the adverse effects of combined surgical procedures on morbidity. OBJECTIVES: The authors sought to evaluate risk factors by measuring the endocrine-metabolic response in patients who underwent multiple body-contouring surgeries after massive weight loss. METHODS: This prospective, randomized, interventional study included 46 massive weight loss patients who experienced a weight loss >30% of their body mass index (BMI) and were referred for body contouring surgery. Patients were randomly allocated to the control group (n = 10) or intervention group (n = 36), which in turn was divided into 3 subgroups (n = 12, each) according to BMI, surgical time, and scar length values. Blood samples were collected from all patients at different time points to assess biological stress markers. RESULTS: Levels of IL-6 in patients in the higher ranges of BMI and operating time and with more extensive scar length were significantly higher in the immediate postoperative period compared with baseline. Concentrations of noradrenaline were significantly higher 24 hours after surgery compared with baseline only in patients in the higher range of operating time. A higher level of IL-6 at 72 hours after surgery compared with baseline was associated with more extensive scar length. Levels of other biological stress markers did not significantly differ. CONCLUSIONS: The combination of surgical procedures did not significantly affect the concentrations of most biological stress markers. The variable of operating time most influenced increase in plasma concentrations of stress markers.

Evidence-Based Medicine in Plastic Surgery: Are We There Yet?

BACKGROUND: The practice of evidence-based medicine in plastic surgery is no longer a trend but a reality, with a growing number of studies published in recent years using evidence-based medicine as an assessment tool. OBJECTIVE: The aim of this study was to verify whether the number of citations to articles with a high level of evidence is greater than articles with low level of evidence. METHODS: A search was conducted in the 4 main international journals of plastic surgery. All original articles published in 2011 were analyzed, selected, and classified based on the study design. The articles were then divided into 2 groups: group 1, high level of evidence; and group 2, low level of evidence. Next, Scopus was searched for the number of citations of each article in the 2 subsequent years. The proportion of the number of citations received by articles in groups 1 and 2 was statistically compared. RESULTS: The articles with the highest level of evidence were the most cited among original articles, with 48.6% of them being cited more than 10 times over 2 years, whereas only 18.4% of articles in group 2 were cited with the same frequency. The mean number of citations was 12.6 citations per article in group 1 and 6.56 citations in group 2, with a significant difference between groups (P < 0.0001). CONCLUSIONS: The articles with a higher level of evidence are, on average, cited more often than those with low levels of evidence in the leading journals of plastic surgery.

Preoperative Respiratory Physiotherapy in Abdominoplasty Patients.

BACKGROUND: After abdominoplasty, patients experience decreased ventilatory function and increased intra-abdominal pressure (IAP). Breathing exercises are used during the pre- and postoperative periods of several abdominal surgeries to prevent or minimize postoperative complications. OBJECTIVES: The aim of this study was to assess the effect of preoperative respiratory physiotherapy on the outcome of abdominoplasty patients. METHODS: Thirty-three patients were divided into 2 groups. The control group (n = 18) received no preoperative intervention. The intervention group (n = 15) performed breathing exercises during the preoperative period, including incentive spirometry, diaphragmatic breathing, shortened expiration, and sustained maximal inspiration. Respiratory physiotherapy started one week before surgery. Breathing exercises were performed daily. They were performed 3 times weekly in the presence of a physiotherapist and patients were instructed to carry on the exercises at home on days without physiotherapy sessions for three sets of 20 repetitions each. Patients were assessed by spirometry and IAP measurements. RESULTS: No significant difference in spirometry was found between groups. However, patients in the intervention group had lower IAP at the start of surgery and at all time points (P = 0.010) compared with controls. CONCLUSIONS: Preoperative respiratory physiotherapy had no impact on spirometry, but may have contributed to reduce IAP intraoperatively.

Single-Layer Plication for Repair of Diastasis Recti: The Most Rapid and Efficient Technique.

Background: Plication of the anterior rectus sheath is the most commonly used technique for repair of diastasis recti, but is also a time-consuming procedure. Objectives: The aim of this study was to compare the efficacy and time required to repair diastasis recti using different plication techniques. Methods: Thirty women with similar abdominal deformities, who had had at least one pregnancy, were randomized into three groups to undergo abdominoplasty. Plication of the anterior rectus sheath was performed in two layers with 2-0 monofilament nylon suture (control group) or in a single layer with either a continuous 2-0 monofilament nylon suture (group I) or using a continuous barbed suture (group II). Operative time was recorded. All patients underwent ultrasound examination preoperatively and at 3 weeks and 6 months postoperatively to monitor for diastasis recurrence. The force required to bring the anterior rectus sheath to the midline was measured at the supraumbilical and infraumbilical levels. Results: Patient age ranged from 26 to 50 years and body mass index from 20.56 to 29.17 kg/m2. A significant difference in mean operative time was found between the control and study groups (control group, 35 min:22 s; group I, 14 min:22 s; group II, 15 min:23 s; P < 0.001). Three patients in group II had recurrence of diastasis. There were no significant within- and between-group differences in tensile force on the aponeurosis. Conclusions: Plication of the anterior rectus sheath in a single-layer with a continuous suture showed to be an efficient and rapid technique for repair of diastasis recti.

Functional and Volumetric Analysis of the Pectoralis Major Muscle After Submuscular Breast Augmentation.

BACKGROUND: Dual plane breast augmentation is a technical variation of the submuscular plane described as a technique that reduces contour deformities due to contraction of the pectoralis major muscle and lower risk of double-bubble deformity associated with breast ptosis. Despite improvement in the aesthetic aspect, there is still no consensus whether this technique affects the function of the pectoralis major muscle. OBJECTIVES: The aim of this study was to correlate functional with volumetric changes associated with dissection of the muscle origin in submuscular breast augmentation. METHODS: Thirty women who desired to undergo breast augmentation were selected prospectively and randomly allocated to 2 groups: 10 patients in the control group and 20 patients in the interventional group, who underwent submuscular breast augmentation. Magnetic resonance imaging and volumetric software were used to assess muscle volume and isokinetic dynamometry was used to assess function of the pectoralis major muscle. Preoperative measurements were compared with those at 3, 6, and 12 months after surgery. RESULTS: Magnetic resonance imaging revealed significant decrease in muscle volume at 6 and 12 months follow-up. The isokinetic test conducted during adduction showed a significant difference in muscle strength between groups from baseline to the 12-month follow-up, and between the 3- and 12-month follow-up. No significant differences in muscle strength during abduction were observed from baseline to the 3-, 6-, and 12-month follow-up. CONCLUSIONS: Submuscular breast augmentation reduced muscle strength during adduction 12 months after surgery, but without a significant correlation with volumetric muscle loss.