Rev. Bras. Cir. Plást. Volume 38 - Issue 1 - January/March 2023
Revista Brasileira de Cirurgia Plástica | Brazilian Journal of Plastic Surgery | Volume 38 • Issue 1 • January/March 2023
ISSN Print: 1983-5175
ISSN Online: 2177-1235
.
Jan/Feb/Mar - 2023 - Volume 38, Issue 1
REVISTA BRASILEIRA DE CIRURGIA PLÁSTICA
BRAZILIAN JOURNAL OF PLASTIC SURGERY
SOCIEDADE BRASILEIRA DE
CIRURGIA PLÁSTICA
ISSN Online: 2177-1235
ISSN Impresso: 1983-5175
EDITOR-IN-CHIEF
Dov Charles Goldenberg - Universidade de São
Paulo, Faculdade de Medicina, Hospital das Clínicas,
São Paulo, SP Brazil.
COEDITOR
Hugo Alberto Nakamoto - Universidade de São
Paulo, Faculdade de Medicina, Hospital das Clínicas,
São Paulo, SP Brazil.
ASSOCIATE EDITORS
Daniela Francescato Veiga - Universidade Federal
de São Paulo, Programa de Pós-graduação em
Cirurgia Translacional, São Paulo, SP, Brazil.
Lydia Masako Ferreira - Universidade Federal de
São Paulo, Departamento de Cirurgia, Disciplina
Cirurgia Plástica, São Paulo, SP, Brazil.
Nivaldo Alonso - Universidade de São Paulo,
Faculdade de Medicina, São Paulo, SP, Brazil.
Rolf Gemperli - Universidade de São Paulo,
Faculdade de Medicina, Departamento de
Cirurgia, São Paulo, SP, Brazil.
NATIONAL EDITORIAL BOARD
Alfredo Gragnani Filho - Universidade Federal de São
Paulo, Departamento de Cirurgia, São Paulo, SP, Brazil.
Anne Karoline Groth - Hospital Erasto Gaertner,
Curitiba, PR, Brazil.
Antonio Roberto Bozola - Faculdade de Medicina
de São José do Rio Preto, Disciplina de Cirurgia,
Departamento de Cirurgia Plástica, São José do Rio
Preto, SP Brazil.
Carlos Lacerda de Andrade Almeida - Hospital
Agamenon Magalhães, Recife, PE, Brazil.
Cristina Pires Camargo - Universidade de São Paulo,
Faculdade de Medicina, Hospital das Clínicas, São
Paulo, SP Brazil.
Dimas André Milcheski - Universidade de São Paulo,
Faculdade de Medicina, Hospital das Clínicas, São
Paulo, SP, Brazil.
Diogo Franco Vieira de Oliveira - Universidade
Federal do Rio de Janeiro, Hospital Universitário
Clementino Fraga Filho, Rio de Janeiro, RJ, Brazil.
Eduardo Montag - Universidade de São Paulo,
Faculdade de Medicina, Hospital das Clínicas, São
Paulo, SP, Brazil.
Elvio Bueno Garcia - Universidade Federal de São
Paulo, Escola Paulista de Medicina, Disciplina de
Cirurgia Plástica, São Paulo, SP, Brazil.
Fabiel Spani Vendramin - Universidade Federal do
Pará, Conselho Superior de Ensino e Pesquisa, Belém,
PA, Brazil.
Fábio de Freitas Busnardo - Universidade de São
Paulo, Faculdade de Medicina, São Paulo, SP, Brazil.
Fábio Xerfan Nahas - Universidade Federal de São
Paulo, Departamento de Cirurgia, Disciplina Cirurgia
Plástica, São Paulo, SP, Brazil.
Fausto Viterbo de Oliveira Neto - Universidade
Estadual Paulista Júlio de Mesquita Filho, Faculdade
de Medicina de Botucatu, Botucatu, SP, Brazil.
Fernando Antônio Gomes de Andrade - Universidade
Federal de Alagoas, Centro de Ciências da Saúde,
Departamento de Clínica Cirúrgica, Maceió, AL,
Brazil.
Fernando Serra Guimarães - Universidade do Estado
do Rio de Janeiro, Hospital Universitário Pedro
Ernesto, Rio de Janeiro, RJ, Brazil.
Francisco Claro de Oliveira Junior - Universidade
Estadual de Campinas, Centro de Assistência Integral
a Saúde da Mulher, Campinas, SP, Brazil.
Henri Friedhofer - Universidade de São Paulo,
Faculdade de Medicina, Hospital das Clinicas, Divisão
de Cirurgia Plástica e Queimaduras, São Paulo, SP,
Brazil.
Humberto Campos - Escola Baiana de Medicina e
Saúde Pública, Salvador, BA, Brazil. - E-mail: hc@
humbertocampos.med.br)
Jayme Adriano Farina Junior - Universidade de
São Paulo, Faculdade de Medicina de Ribeirão Preto,
Hospital das Clinicas, Departamento de Cirurgia e
Anatomia, Ribeirão Preto, SP, Brazil.
Joel Veiga Filho - Universidade do Vale do Sapucaí,
Pouso Alegre, MG, Brazil.)
José Horácio Costa Aboudib Junior - Universidade
do Estado do Rio de Janeiro, Centro Biomédico,
Departamento de Especialidades Cirúrgicas, Rio de
Janeiro, RJ, Brazil.
Juan Carlos Montano Pedroso - Universidade
Federal de São Paulo, Departamento de Cirurgia, São
Paulo, SP, Brazil.
Kátia Torres Batista - Rede Sarah de Hospitais de
Reabilitação, Brasília, DF, Brazil.
Luiz Carlos Ishida - Universidade de São Paulo,
Faculdade de Medicina, Hospital das Clínicas, São
Paulo, SP, Brazil.
Marcelo Sacramento Cunha - Universidade Federal
da Bahia, Faculdade de Medicina, Departamento de
Cirurgia, Salvador, BA, Brazil.
Marco Tulio Junqueira Amarante - Santa Casa de
Misericórdia de Poços de Caldas, Poços de Caldas,
MG, Brazil.,
Marcus Vinicius Jardini Barbosa - Universidade
de Franca, Curso de Medicina, Laboratório
Morfofuncional e de Práticas Integradas, Franca,
SP, Brazil.
Marcus Vinícius Martins Collares - Universidade
Federal do Rio Grande do Sul, Faculdade de Medicina,
Porto Alegre, RS, Brazil.
Max Domingues Pereira - Universidade Federal
de São Paulo, Departamento de Cirurgia, Disciplina
Cirurgia Plástica, São Paulo, SP, Brazil.)
Miguel Sabino Neto - Universidade Federal de
São Paulo, Departamento de Cirurgia, São Paulo,
SP, Brazil.
Níveo Steffen - Universidade Federal de Ciências da
Saúde de Porto Alegre, Santa Casa de Porto Alegre,
Departamento de Microcirurgia Reconstrutiva e
Cirurgia Plástica, Porto Alegre, RS, Brazil.
Osvaldo Ribeiro Saldanha - Santa Casa de Santos,
Departamento de Cirurgia Plástica, Santos, SP,
Brazil.
Paulo Kharmandayan - Universidade Estadual
de Campinas, Faculdade de Ciências Médicas,
Campinas, SP, Brazil.
Renato da Silva Freitas - Universidade Federal do
Paraná, Setor de Ciências da Saúde, Hospital das
Clínicas, Curitiba, PR, Brazil.
Rodrigo Itocazo Rocha - Universidade de São
Paulo, Faculdade de Medicina, Hospital das Clínicas,
Divisão de Cirurgia Plástica e Queimaduras, São
Paulo, SP, Brazil.
Rui Manuel Rodrigues Pereira - Instituto Materno
Infantil de Pernambuco, Centro de Atenção aos
Defeitos da Face, Recife, PE, Brazil.
Salustiano Gomes de Pinho Pessoa - Universidade
Federal do Ceará, Faculdade de Medicina, Fortaleza,
CE, Brazil.
Sérgio da Cunha Falcão - Universidade Federal da
Paraíba, Centro de Ciências Médicas, João Pessoa,
PB, Brazil.
Sérgio da Fonseca Lessa - Santa Casa da
Misericórdia do Rio de Janeiro, Rio de Janeiro,
RJ, Brazil.
Wilson Cintra Junior - Universidade de São Paulo,
Faculdade de Medicina, São Paulo, SP, Brazil.
INTERNATIONAL
EDITORIAL BOARD
Horácio F. Mayer - Instituto Universitário Hospital
Italiano de Buenos Aires (IUHIBA), CABA,
Argentina.
Jesse A. Taylor - University of Pennsylvania,
Philadelphia, Pennsylvania, USA.
John A. Persing - Yale University, New Heaven,
New York, USA.
Laurence Boon - Cliniques universitaires Saint-Luc
(UCLouvain), Brussels, Belgium.
Paolo Persichetti - University of Rome - Rome, Italy
Renata Souza Maricevich - Texas Children’s
Hospital, Houston, Texas, USA.
Richard Hopper - Burn and Plastic Surgery Clinic,
Seattle, Washington, USA.
Rogério Izar Neves - Neves (Institute Pennsylvania
State University, Hershey, Pennsylvania, USA.
iv
INSTRUCTIONS FOR AUTHORS
REVISTA BRAZILEIRA DE CIRURGIA PLÁSTICA
BRAZILIAN JOURNAL OF PLASTIC SURGERY
The Brazilian Journal of Plastic Surgery (Revista Brasileira
de Cirurgia Plástica–RBCP) is the official scientific journal
of the Brazilian Society of Plastic Surgery (Sociedade
Brasileira de Cirurgia Plástica–SBCP) (ISSN 1983-5175,
ISSN online 2177-1235). It is a quarterly publication with
uninterrupted service since 1986 and from 2021 onwards,
articles are also published in the form of advanced article
publication - Ahead of Print (AOP). The RBCP is indexed
in the Latin American and Caribbean Health Sciences
Literature (LILACS) and Scopus databases.
The Brazilian Journal of Plastic Surgery aims to record the
scientific production in Plastic Surgery, foster the study,
improvement and updating of professionals in the specialty.
The articles submitted to the RBCP should address
topics on plastic surgery and related subjects. The RBCP
publishes articles in the following categories: Editorial,
Original Article, Review Article, Case Report, Ideas and
Innovations, Special Article, and Letter to the Editor.
RBCP is an open access journal and does not charge any fees
for article submission, review, translation and publication.
All processes are carried out electronically.
Authors must declare that they are aware of the copyright
licenses that will come into force if the manuscript is
accepted and published in the RBCP.
The journal and its contents are licensed under a Creative
Commons Attribution 4.0 International License (https://
creativecommons.org/licenses/by/4.0/deed.pt).
HOW TO CONTACT THE JOURNAL
Revista Brasileira de Cirurgia Plástica (Brazilian Journal
of Plastic Surgery)
Funchal Street, 129, 2nd floor - Vila Olímpia
São Paulo - SP - Brazil – Zip Code 04551-060
Phone: 55 11 3044-0000 - Cell Phone: 55 11 99661-4366
E-mail: [email protected]
Website: www.rbcp.org.br
ARTICLE CATEGORIES
Editorial - Articles selected for publication based on
scientific relevance. These articles are written by the
Editorial Board or assigned to renowned experts from
different research fields. The Editorial Board may consider
publishing editorials submitted spontaneously.
Original Article - Includes controlled and randomized
studies, observational studies, and basic research with
experimental animals. These articles should contain the
following sections: Introduction, Objective, Methods,
Results, Discussion, Conclusion, References, and Abstract
in Portuguese and English. The main text should have
no more than 3000 words (excluding tables, references,
and abstracts), 30 references, 20 images (presented either
individually or in groups), and four tables.
Review Article - Critical and organized reviews of the
literature, systematic reviews, and meta-analyses on a
specific topic of clinical importance. The text should not
exceed 3000 words (excluding references and tables) and
six images presented individually or in groups. References
should be current, preferably published in the last five
years, and contain up to 40 citations.
Case Report - Description of patients or unique cases,
especially rare diseases, and innovative forms of diagnosis
and treatment. The text should contain the following
sections: Introduction, which describes the importance of
the subject matter and presents the objectives of presenting
the case(s) in question; Case Report; Discussion, wherein
relevant aspects are discussed and compared with the
literature; Conclusion; and References. The main text
should not exceed 1000 words (excluding references and
tables), ten references, and eight figures presented either
individually or in groups.
Ideas and Innovations - Original and innovative studies.
The text should not exceed 1000 words, ten references,
and eight figures presented either individually or in
groups; moreover, it should contain the following sections:
Introduction, Methods, Results, Discussion, Conclusion,
and References.
Letter to the Editor - Comment, discussion, or article
appraisals published in the RBCP. However, this category
may contain other topics of general interest. The text
should have up to 250 words and five references. Whenever
possible, a list of the authors of the study will be published
together with the letter.
Special Article - Articles not classified in the above
categories and the Editorial Board deems to be of particular
relevance to the field. The review of these articles follows
unique criteria, and there are no limits on word count or
the number of references.
v
EDITORIAL POLICY
Peer review
Before the publication, all articles sent to the Brazilian
Journal of Plastic Surgery go through a review and
arbitration process to guarantee their quality standard
and the exemption in selecting works to be published.
Initially, the secretariat evaluates the article to verify that
it is complete and following the publication rules.
All papers are submitted to peer review by at least two
reviewers. Acceptance is based on originality, significance
and scientific contribution. The reviewers fill out a form
in which they make a rigorous assessment of all the items
that make up the work. In the end, they make general
comments about the work and give their opinion on
whether it should be published or corrected according to
the recommendations. With this data, the Editor makes
the final decision. In case of discrepancies between the
evaluators, a new opinion may be requested for a better
judgment. When the reviewers suggest changes, they are
sent to the main author and the new version is sent back to
the reviewers to verify that the suggestions/requirements
have been met. The sending of a study may or may not
be sent back to the original reviewer at the Editors’
discretion. In exceptional cases, when the manuscript’s
subject so requires, the Editor may request the
collaboration of a professional who is not on the Editorial
Board’s list to make the assessment (ad hoc reviewers).
This entire process is carried out through the electronic
submission system. The evaluation system is doubleblind, ensuring anonymity throughout the evaluation
process. Regardless of the result, authors have access to
all assessments and questionnaires that are available in
the electronic submission system. The dates of receipt and
approval of the article for publication are informed in the
published article to respect the authors’ priority interests.
The RBCP suggests to its editors and reviewers that they
become familiar with and act according to the relevant
best practice guidelines on peer review and follow the
guidelines proposed by the COPE Ethical Guidelines
for Peer Review https://publicationethics.org/resources/
guidelines-new/cope-ethical-guidelines-peer-reviewers.
Openness in peer review
The RBCP, following the recommendations of good
practices in open science and transparency in evaluations,
supports open peer review, making it possible to include
in the approved article: the name of the editor responsible
for evaluating the manuscript; to offer the referees and
the corresponding author the opening of their respective
identities; offer reviewers the option of publishing the
review in the journal as a communication identified
with DOI and capable of being indexed and cited with or
without identifying the reviewer as the author.
Research with Humans and Animals
Research involving humans or animals must be approved
by relevant Research Ethics Committees (CEP) and must
comply with international ethical and legal standards for
research. Authors must respect the human participants’
right to privacy and obtain the necessary consent to
publish before submission. Research projects in human
beings must comply with the Declaration of Helsinki as
revised in 2013 (https://www.wma.net/policies-post/wmadeclaration-of-helsinki-ethical-principles-for-medicalresearch-involving-human-subjects/) and studies carried
out in Brazil must follow Resolutions 466/2012 (http://
conselho.saude.gov.br/resolucoes/2012/Reso466.pdf)
and Resolution 510/2016 (http://conselho.saude.gov.br/
resolucoes/2016/ Reso510.pdf), in addition to Circular
Letter No. 166/2018 (http://conselho.saude.gov.br/images/
comissoes/conep/documentos/CARTAS/CartaCircular166.
pdf) by the National Health Council. It is linked to the
approval of the study by the Research Ethics Committee.
Investigations on animal models must comply with the
rules applicable to these procedures, as specified in
the Basel Declaration (www.basel-declaration.org), in
the ARRIVE guidelines - Animal Research: Reporting
of In Vivo Experiments (https://arriveguidelines.org/
arrive-guidelines) and the Guide for the Care and Use
of Laboratory Animals (Institute of Laboratory Animal
Resources, National Academy of Sciences, Washington,
USA). The Editorial Board of the Journal may refuse
articles that do not strictly comply with the ethical
precepts of the research, whether in humans or animals.
Authors must identify precisely all drugs and chemicals
used, including the names of the active ingredient,
dosages and forms of administration. They should also
avoid commercial or company names.
Clinical trial registration
The RBCP supports the World Health Organization (WHO)
and International Committee of Medical Journal Editors
(ICMJE) clinical trial registration policies and recognizes
the importance of these initiatives for the international
registration and dissemination of information on open
access clinical trials. Therefore, to qualify for publication,
clinical trials should be registered at www.clinicaltrials.
gov or an equivalent international repository before the
beginning of data collection, and the identification number
should be added to the end of the Abstract.
Within this context, the RBCP adopts the definition of
clinical trial recommended by the WHO, which can be
summarized as follows: “any research that prospectively
designates humans for one or more interventions to assess
their effects on health-related outcomes. Interventions
include drugs, cells and other biological products, surgical,
radiological procedures, devices, behavioral therapies,
changes in care processes, preventive care, etc.“
vi
Authorship and Contribution Criteria
The criteria for authoring the articles should follow
the recommendations of the International Committee
of Medical Journal Editors (http://www.icmje.org/
recommendations/browse/roles-and-responsibilities/
defining-the-role-of-authors-and- contributors.html). Only
those people who contributed directly to the intellectual
content of the work should be listed as authors. Authors
must satisfy all of the following criteria to be able to have
public responsibility for the content of the work:
1. Have conceived and planned the activities that led
to the work or interpreted the results to which they
arrived, or both;
2. Have written the work or revised the successive
versions and participated in the review process;
3. Have approved the final version;
4. Agree to be responsible for all aspects of the work and
ensure that issues related to the accuracy or integrity
of any part of the work are properly investigated and
resolved.
We consider the corresponding author to be the person
who handles the manuscript and correspondence during
the publication process. We request that the corresponding
author confirm that he has the authority to act on behalf
of all co-authors in all matters relating to the publication
of the manuscript, including supplementary material. The
corresponding author is responsible for obtaining such
agreements and informing co-authors of the manuscript’s
status during the submission, review and publication
process. In addition, the corresponding author is the main
contact for any questions (including those related to the
work’s integrity) after the publication of the article.
It is mandatory to include the ORCID ID for all authors
(https://orcid.org/signin), and a letter must be attached
to the system with the ORCID ID of all authors to the
electronic submission system.
The Committee on Publication Ethics (Cope) also provides
comprehensive resources on authorship and authorship
disputes, and we recommend everyone involved in
editorial decisions become familiar with these resources.
We have adopted initiatives that allow transparency
in authorship and contribution, such as the CRediT
taxonomy.
People who do not fulfill the requirements above and who
had purely technical or general support participation can
be cited in the Acknowledgments section.
Preprints
RBCP accepts the submission of manuscripts previously
deposited in preprint servers recognized by the journal.
Preprints are manuscripts ready for submission to a journal
and are deposited on an open access web server prior to
or in parallel with journal submission for evaluation for
formal publication as a peer-reviewed article.
Plagiarism and Duplicity
Plagiarism
Plagiarism is defined as “using ideas, words, data or other
material produced by another person without recognition”.
Plagiarism can occur concerning all types of sources and
means of communication, including:
• text, illustrations, musical quotes, extended
mathematical derivations, computer code, etc .;
• material downloaded from websites or taken from
manuscripts or other media;
• published and unpublished material, including
lectures, presentations and gray literature.
We do not tolerate plagiarism in any of our publications,
and we reserve the right to verify all submissions through
Similarity Check/iThenticate (http://www.ithenticate.
com) to ensure originality. Submissions containing
suspected plagiarism, in whole or in part, will be rejected.
If plagiarism is discovered after publication, we will
adopt retraction following COPE’s Retraction Guidelines
(https://publicationethics.org/retraction-guidelines). We
hope that our readers, reviewers and editors will mention
any suspicions of plagiarism by sending an e-mail to
Duplicate and redundant publishing
Duplicate or redundant publication, or “self-plagiarism”,
occurs when work, or substantial parts of a work, is
published more than once by the author (s) of the work
without good cross-reference or justification for the
overlap. It can be in the same language or a different
language. We do not support substantial overlaps between
publications unless:
• it is considered that, editorially, this will strengthen the
academic discourse;
• have the explicit approval of the original publication;
• Include a quote from the original source.
We advise our readers, reviewers and editors to mention
any suspicions of duplicate or redundant publication by
sending an e-mail to [email protected].
When authors submit their studies to the RBCP, these
manuscripts should not be considered, accepted for
publication or in press in a different journal, book or
similar entity.
Conflicts of Interest and Financing
We guarantee that any publication on the Brazilian
Journal of Plastic Surgery is free from undue influence.
Authors who submit an article must declare any potential
vii
conflicts of interest that may interfere with the objectivity
or integrity of a publication, stating whether the authors’
institution at any time received payment or third-party
service of any kind for the submitted work (including,
but not limited to, funds, data monitoring committee,
study type, manuscript preparation, statistical analysis,
financial support for travel to meetings relevant to the
study or other reasons, consulting fee, payment for writing
or reviewing the manuscript, etc.). Conflicts of interest
are situations that may have an undue influence on the
presentation, review or publication of a work. They may
be of a financial, non-financial, professional, contractual
or personal nature. We also hope that anyone who
suspects an undisclosed conflict of interest concerning a
work published in the RBCP will inform us by sending an
e-mail to [email protected].
Language
Articles should be written in English and Portuguese.
Authors should follow current spelling guidelines and use
simple, technical, and precise language; informal language
should be avoided. The English version, when available,
should be submitted to expedite publication. The printed
version of the articles is published in Portuguese, whereas
the electronic version of the articles is published in
Portuguese and English, both in XML and PDF.
Retractions and Errata
The journal’s editors will consider retractions and
errata following COPE’s Retraction Guidelines (https://
publicationethics.org/retraction-guidelines). If it is found
that the author or RBCP made an error, the magazine
will issue an errata. Retractions are generally reserved
for articles with flaws so serious that their findings or
conclusions should not be trusted. Manuscripts Accepted
by the RBCP may make minor changes, such as those
likely to occur during composition or review. Still, any
substantive corrections will be made following the COPE
Disclaimer.
Image Manipulation, Counterfeiting and Fabrication
When survey data is collected or presented as images,
modifying these images can sometimes misrepresent the
results obtained or their meaning. We recognize that there
may be legitimate reasons for modifying images. Still, we
hope that authors will avoid modifying images when this
leads to falsification, fabrication or misrepresentation of
their results.
Fraudulent Research and Misconduct in Research
When we are informed about fraudulent research or
research misconduct by an author of the Brazilian Journal
of Plastic Surgery, our first concern is the integrity of the
published content. The Editor, co-editors, and associate
editors will open an investigation to ascertain the
facts. Any publication that contains fraudulent results
will be withdrawn, or an errata will be issued. See the
Disclaimers and Errata section of these guidelines for
more information.
Versions and Adaptations
The RBCP does not modify existing published content,
nor does it originate new materials to meet political or
ideological requirements when we believe that these
compromise the quality, effectiveness or accuracy of the
materials or conflict with our Code of Ethics. We grant
volume licenses and subsidiary rights to third parties that
allow the reproduction, reuse or adaptation of our content
in different contexts, languages and territories. When we
license volume rights, our authors and we retain the right
to refuse approval for publication if we doubt the integrity
and accuracy of the licensed edition.
Slander, Defamation and Freedom of Speech
Freedom of expression is fundamental to us as academic
editors, but we do not support the publication of false
statements that damage the reputation of individuals,
groups or organizations. Our legal team can advise on
defamation reviews before publication and deal with any
defamation allegations eventually published in the RBCP.
Transparency
We strive to follow COPE’s Principles of Transparency
and Best Practices in Academic Publications (https://
publicationethics.org/resources/guidelines-new/
principles-transparency-and-best-practice-scholarlypublishing) and encourage our publication partners to
defend these same principles.
Authors are encouraged to make available all content
(data, program codes and other materials) underlying
the manuscript text before or at the time of publication
through a Data Availability Declaration that must be
entered into the RBCP submission system. The Data
Availability Statement should signal where the data
associated with a document is available and under what
conditions (licenses) the data can be accessed, including
links (where applicable) to the dataset. Exceptions are
allowed in cases of legal and ethical issues. The objective
is to facilitate the evaluation of the manuscript and, if
approved, to contribute to the preservation and reuse of
the contents and the reproducibility of the research. The
initiative increases transparency, enables compliance
with data policies, encourages good scientific practice and
trusts in published studies.
viii
Registry Integrity
We keep a record of the existence of everything we
publish with information (metadata) that describes each
publication. Whenever we have to change the publication
record, as in the case of research misconduct leading to
retraction of a publication, we preserve the academic
record as far as possible.
We apply these same principles to our marketing and do
not modify or manipulate publications in our marketing
activities.
When an article is accessed on our portal (www.rbcp.org.
br), we provide it only in its entirety, which does not have
the right to change its content in a way that is inconsistent
with the licensing terms under which it was published.
Marketing Communication
Social media and e-mail communication are powerful
tools to disseminate and interact with our publications,
reach new readers, and keep content alive. However, such
communication should not be made at the expense of
the integrity of the content. We reserve the right to reject
or remove any ad when we doubt that it violates these
Research Publication Ethics Guidelines. We also advertise
our products and services to customers. We do this
following our Privacy Policy, data protection regulations,
the Advertising Standards Authority Guidance on
Publication Marketing and our internal compliance
procedures.
Final considerations
Other decisions regarding the ethics, misconduct, and
integrity of scientific research are based on the Code of
Conduct guidelines for Journal Editors (COPE), available
at http://publicationethics.org/files/Code_of_conduct_for_
journal_editors_Mar11.pdf, and the World Association of
Medical Editors (WAME), available at http://www.wame.org.
MANUSCRIPT PREPARATION
The journal adopts the Vancouver style - Uniform
Requirements for Manuscripts Submitted to Biomedical
Journals, organized by the ICMJE - “Vancouver Group”
(http://www.icmje.org/recommendations/browse/manuscriptpreparation). Compliance with these instructions is
mandatory for the study to qualify for analysis.
Title page
Write the title of the article concisely in Portuguese
and English. Write the authors’ full names with their
affiliations (Institution, Faculty and Department,
City, State and Country), the ORCID and e-mail. Also
inform the name, address and telephone number of the
corresponding author. Potential conflicts of interest and
funding sources must be declared. Declare potential
conflicts of interest and sources of funding. Please list up
to eight authors and specify their contribution to the study.
Authors are researchers who contributed substantially
to the conception and design and/or data analysis and
interpretation, drafted the manuscript or reviewed it
critically for intellectual content, and approved the final
manuscript.
Abstract in English and Portuguese (only for Original
Article, Special Article, Review Article, and Case Report)
The abstracts of Original Articles should contain
Introduction, Method, Results, and Conclusions. The
abstracts should explain the study’s main findings without
the need to resort to the main text. Write an abstract in
English containing the following sections: Introduction,
Methods, Results, and Conclusions. This abstract should
be a faithful translation of the Portuguese abstract. For
Review Articles and Case Reports, write unstructured
abstracts in English and Portuguese. Abstracts should not
exceed 250 words.
Keywords
Include five to ten keywords, in Portuguese and English.
The descriptors should be based on the Health Sciences
Descriptors (Descritores em Ciências da Saúde–DeCS)
published by Bireme, which are translations of the Medical
Subject Headings from the National Library of Medicine
(NLM), https://www.nlm.nih.gov/mesh/meshhome.html.
Main text
The text must be typed in double space, font Arial, size 12,
margin 2.5cm on each side. The number of sections depends
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ix
detail. Indicate the study period and study site(s) and the
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References
References must be updated, and we recommend using
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Different types of bibliographic references are shown
below; other examples are available at the NLM website
(http://www.ncbi.nlm.nih.gov/nlmcatalog/journals).
Article
Quintas RC, Coutinho AL. Risk factors for the impairment
of surgical margins in resections of basal cell carcinomas.
Rev Bras Cir Plást. 2008;23(2):116-9.
Book Chapter
D’Assumpção EA. Problems and solutions in
rhytidoplasties. In: Melega JM, Baroudi R, eds. Plastic
surgery fundamentals and art: cosmetic surgery. Rio de
Janeiro:Medsi;2003. p.147-65.
Book
Saldanha O. Lipoabdominoplasty. Rio de Janeiro:Di Livros;
2004.
Thesis
Freitas RS. Jawbone elongation using an internal device:
quantitative analysis of the results [doctoral thesis]. São
Paulo: University of São Paulo Medical School; 2003. 97p.
Events
Carreirão S. Reduction mammoplasty. In: XXXVI Brazilian
Congress of Plastic Surgery; November 11-16, 2001; Rio de
Janeiro, Brazil.
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Include up to four tables and number them sequentially, in
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Add tables only when necessary to understand the research
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• Image 1: Di Lamartine J, Cintra Junior R, Daher JC, Cammarota MC, Galdino J, Pedroso DB, et al. Reconstruction of the nipple-areola complex
with double opposing flap. Rev Bras Cir Plást. 2013;28(2):233-40.
• Image 2: Alves JC, Fonseca RP, Silva Filho AF, Andrade Filho JS, Araujo IC, Almeida AC, et al. Extended resection in the treatment of
dermatofibrosarcoma protuberans. Rev Bras Cir Plást. 2014;29(3):395-403.
• Image 3: Alves JC, Fonseca RP, Silva Filho AF, Andrade Filho JS, Araujo IC, Almeida AC, et al. Extended resection in the treatment of
dermatofibrosarcoma protuberans. Rev Bras Cir Plást. 2014;29(3):395-403.
Font: Adapted from http://www.ncbi.nlm.nih.gov/pmc/pub/filespec-images/#fig-format
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xi
Dov Charles Goldenberg
Editor-in-Chief
Hugo Alberto Nakamoto
Coeditor
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xii
SOCIEDADE BRAZILEIRA DE CIRURGIA PLÁSTICA
BRAZILIAN SOCIETY OF PLASTIC SURGERY
Revista Brazileira de Cirurgia Plástica / Sociedade Brazileira
de Cirurgia Plástica. — v.1, (jun. 1986)—.— São Paulo: Fundo
Educacional da SBCP, 1986.
v.l: il
Trimestral
ISSN Online 2177-1235
ISSN Impresso 1983-5175
1. Cirurgia Plástica - Publicações periódicas.
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Address
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Telefone: 55 11 3044-0000 - Fax: 55 11 3846-8813
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Revista Brazileira de Cirurgia Plástica (Brazilian Journal of Plastic Surgery)
Is indexed in LILACS - Latin-American and Caribbean Literature on Health Scienses
Desktop Publishing and Editorial Consulting: GN1 Sistemas e Publicações Ltda.
Fone: (19) 3633-1624 Site: www.gn1.com.br E-mail: [email protected]
SBCP NATIONAL BOARD OF DIRECTORS
Lydia Masako Ferreira
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President
xiii
O pós-operátorio
para um corpo
perfeito exige Oxy!
Saiba mais em
oxycamaras.com.br
xiv
Jan/Feb/Mar - 2023 - Volume 38, Issue 1
EDITORIAL / EDITORIAL
RBCP in Continuous Publishing mode
RBCP em modo Publicação Contínua
DOV GOLDENBERG; JOÃO EGIDIO DE ALVARENGA .................................................................................. e03801
ORIGINAL ARTICLES / ARTIGOS ORIGINAIS
Use of negative pressure therapy in closed surgical incisions of post-bariatric dermolipectomy
Uso da terapia de pressão negativa em incisões cirúrgicas fechadas de dermolipectomia pós-bariátrica
LARA GOMES FAISTEL; DILMAR FRANCISCO LEONARDI ......................................................................... e0443
Analysis of post-bariatric plastic surgeries performed in the Brazilian Unified Health System
Análise das cirurgias plásticas pós-bariátricas realizadas no Sistema Único de Saúde
ALEXANDRE CARDOSO DE CARVALHO FREITAS; AMANDA QUEIROZ LEMOS; CLARA ANDRADE
GUIMARÃES ESPÍNDOLA CAVALCANTE; CLARISSA HENRIQUE PALMEIRA; EMILANE ALMEIDA
SANTOS BEZERRA; GIOVANNA CEDRAZ PRINZ; PAULA KALINE SANTOS JATOBÁ ........................... e0655
Application of data mining to extract knowledge about the occurrence of fistulas after palatoplasty
Aplicação de mineração de dados para extração de conhecimento sobre ocorrência de fístulas após palatoplastia
PATRICK PEDREIRA SILVA; ELVIO GILBERTO DA SILVA; VINICIUS SANTOS ANDRADE; TELMA
VIDOTTO DE SOUSA BROSCO; GABRIELA APARECIDA PREARO; MARIA INÊS PEGORARO-KROOK;
JENIFFER DE CASSIA RILLO DUTKA ................................................................................................................. e0666
ORIENTA COVID-19 app
Aplicativo ORIENTA COVID-19
JOSÉ RONALDO ALVES; GERALDO MAGELA SALOMÉ ................................................................................ e0677
Increase in the volume of the breast implant by passing organic material into it
Aumento do volume do implante mamário por passagem de material orgânico para seu interior
MILTON JAIME BORTOLUZZI DANIEL; LEANDRO ALVES GARCIA BORTOLUZZI DANIEL; VITOR
ALVES GARCIA BORTOLUZZI DANIEL; LINCOLN GRAÇA .......................................................................... e0185
Immediate bilateral breast reconstruction after skin-sparing mastectomy: cross-sectional incision and
implants in mixed plane
Reconstrução bilateral imediata de mamas pósmastectomia preservadora de pele: incisão transversal e implantes
em plano misto
ANTONIO ROBERTO BOZOLA; ALEXANDRE CARONI BOZOLA; ITALO BOZOLA ............................... e0463
xv
Brazilian Portuguese version of the Patient Scar Assessment Questionnaire
Validação da versão em português do Patient Scar Assessment Questionnaire
ANA SAYURI OTA; FABIANNE MAGALHÃES GIRARDIN PIMENTEL FURTADO; ELVIO BUENO GARCIA;
LYDIA MASAKO FERREIRA .................................................................................................................................... e0631
Non-melanoma skin cancer: an analysis of compromised margins in excisions
Câncer de pele não melanoma: uma análise do comprometimento de margens em excisões
CAROLINE PAGUNG; EMANUELE DE SANTIAGO; JESSICA NOBRE ANDRADE; LUCAS PISSOLATO;
CIPRIANO FERREIRA DA SILVA; RODOLFO LUÍS KORTE ......................................................................... e0666
HIV-associated lipodystrophy: epidemiological analysis of a Plastic Surgery Service in Brazil
Lipodistrofia associada ao HIV: análise epidemiológica de um Serviço de Cirurgia Plástica no Brasil
MURILO SGARBI SECANHO; BALDUINO FERREIRA DE MENEZES; LAÍSA BRANDÃO CARVALHO;
WEBER RIBOLLI MORAGAS; OONA TOMIÊ DARONCH; RENATA FERNANDA RAMOS MARCANTE;
ARISTIDES AUGUSTO PALHARES ...................................................................................................................... e0674
Frailty syndrome, feelings of impotence and functional capacity in elderly patients with venous ulcers
Síndrome de fragilidade, sentimento de impotência e capacidade funcional em idosos portadores de úlcera venosa
ELIANA GONÇALVES AGUIAR; GERALDO MAGELA SALOMÉ; LYDIA MASAKO FERREIRA ............ e0681
REVIEW ARTICLE / ARTIGO DE REVISÃO
Double transposition flap for lower eyelid reconstruction: case report of a new surgical approach
Retalho de dupla transposição para reconstrução de pálpebra inferior: relato de caso de uma nova abordagem
cirúrgica
LISSIÊ LUNARDI SBROGLIO BASTIAN; MARCELA DUARTE BENEZ MILLER; MARINA ARAÚJO FONTE
BOA; GUILHERMO LODA ............................................................................................................................................ e0680
IDEAS AND INNOVATIONS / IDEIAS E INOVAÇÕES
The main abdominoplasty techniques used in post-bariatric patients after massive weight loss: systematic
review
As principais técnicas utilizadas de abdominoplastia em pacientes pós-bariátricos após massiva perda de peso:
Revisão sistemática
EURICO ARTEAGA SANTIAGO; THAIS CONTE DIAS BENCINI ANDRIGHETTI; MATHEUS LUCENA
MIRANDA MERONI; THAYS FAVARO FERNANDES NOLASCO; RODRIGO CONTENTE; CAROLINA
LACERDA SOUZA ...................................................................................................................................................... e0610
Complications in liposuction: systematic review
Complicações em lipoaspiração: revisão sistemática
LUIZ FERNANDO LIMA BARROS; VINÍCIUS FIALHO TEIXEIRA; JOSÉ AUGUSTO PÚPIO REIS; REBECA
ANDRADE FERRAZ; DINÉIA DA CONCEIÇÃO ARAÚJO; FABIEL SPANI VENDRAMIN ........................ e0641
Body Dysmorphic Disorder and the influence of the media in demand for plastic surgery: the importance
of proper evaluation
O Transtorno Dismórfico Corporal e a influência da mídia na procura por cirurgia plástica: a importância da
avaliação adequada
ALEXANDRE KATAOKA; RENATO ROCHA LAGE; CAMILA CRISTINA SILVA MENDES; NIKOLE
GUIMARÃES SOARES .............................................................................................................................................. e0645
xvi
Preoperative clinical management of patients who are candidates for facial transplantation
Manejo clínico pré-operatório de pacientes candidatos ao transplante facial
MARTIN IGLESIAS MORALES; MATEUS DE SOUSA BORGES; MARIO ROBERTO TAVARES CARDOSO
DE ALBUQUERQUE; RODOLFO COSTA LOBATO ............................................................................................ e0709
Augmentation mammoplasty and autologous fat transplantation: an alternative for the treatment of
hypomastia and mild pectus excavatum - Case report
Mamoplastia de aumento e transplante de gordura autóloga: uma alternativa para o tratamento da hipomastia e
pectus excavatum leve - Relato de caso
MARCUS VINICIUS JARDINI BARBOSA; BARBARA RODRIGUES BATISTA; FABIO XERFAN NAHAS;
LYDIA MASAKO FERREIRA ................................................................................................................................... e0693
Galactorrhea after breast augmentation: case report and literature review
Galactorreia após mamoplastia de aumento: relato de caso e revisão da literatura
RAPHAELA SILVEIRA DO AMARAL; ERICK SAMUEL SANTOS-DEMELLO; RODRIGO PINTO GIMENEZ;
FERNANDO GIOVANETTI MORANO; SORAYA TERESA TEIXEIRA CASSITAS GONÇALVES; TATIANI
CERIONI TOTH ........................................................................................................................................................... e0736
Method of closing fasciotomies by progressive tissue traction
Método de fechamento de fasciotomias por tração tecidual progressiva
ANTONINHO JOSÉ TONATTO; JORGE LUÍS DE MORAES; CAIO MUNARETTO GIACOMAZZO; BRUNA
VALDUGA DUTRA; JOSÉ PAULO TAPIE BARBOSA; RENATO DA SILVA FREITAS .............................. e0487
Diagnosis, evolution and treatment of a patient with pyomyositis
Diagnóstico, evolução e tratamento de paciente com piomiosite
LARISSA FIGUEIREDO VIEIRA; GUSTAVO OLIVIERI BARCELLOS; CHRISTIAN TALES ELIAS; MARCO
TULIO RODRIGUES DA CUNHA; ISABELLA DA SILVA IDELFONSO; PEDRO AUGUSTO FÁVARO
AMARAL ....................................................................................................................................................................... e0659
CASE REPORTS / RELATOS DE CASO
SPECIAL ARTICLE / ARTIGO ESPECIAL
Ear shut and Dentistry: ethical and legal approach
Ear shut e Odontologia: abordagem ética e legal
PAULO HENRIQUE VIANA PINTO; JULIANE BUSTAMANTE SÁ DOS SANTOS; ANTÔNIO CASTELOBRANCO; CINDY MAKI SATO; MARCONI DELMIRO NEVES DA SILVA; RICARDO HENRIQUE ALVES
DA SILVA ..................................................................................................................................................................... e0642
LETTER TO THE EDITOR / CARTA AO EDITOR
Complications of orofacial harmonization
Complicações da harmonização orofacial
IRINEU GREGNANIN PEDRON; RAFAELA RODRIGUES CAVALCANTI .................................................... e0753
1 Rev. Bras. Cir. Plást. 2023;38(1):e03801
RBCP in Continuous Publishing mode
DOI: 10.5935/2177-1235.2023RBCP.edit.v38n1-EN
RBCP em modo Publicação Contínua
Aligned with advances in scientific diffusion, RBCP informs readers about changing its publication policy
to the Continuous Publication model.
The basis of this decision, in favor of the RBCP, are the new guidelines needed to maintain the current
indexation. However, this change will favor obtaining imminent future indexing in databases and requests to
obtain impact factors provided by different systems.
Continuous publishing mode, also known as “publish-as-you-go”, is a publishing model in which articles
are published online as soon as they are ready, rather than waiting for an entire issue to be compiled. The
continuous publication of articles eliminates the need to wait for the complete composition of fascicles or serial
issues. It streamlines disclosure and reduces the need for “article in press” or “preprint” qualifications. Once
approved, the publication process occur in continuity1,2. The publication in the continuous flow modality is
essentially electronic and the organization of the articles, in addition to respecting the sections, are organized
in an electronic summary. Articles now have an electronic identifier called “elocation-id”, eliminating the need
for sequential continuous pagination.
By making research available more quickly and improving the peer review process, this approach can help
advance scientific knowledge and promote greater collaboration within the scientific community. This means
that research can spread more quickly, which is particularly important for rapidly evolving fields. It promotes, in
this way, speed in the communication process and availability of research with numerous advantages for users
of scientific information.
Continuous publication mode allows for more frequent updates of scientific journals, making them more
accessible to a wider audience. This can be particularly interesting for journals that publish their content
preferably in electronic format and for open access journals, as it ensures greater agility so that a greater number
of readers have access to new publications3,4.
Another advantage is the greater chance of studies being cited more frequently, as they will be available
to the scientific community more quickly.
In conclusion, the continuous publication mode can offer significant benefits for scientific journals, authors,
and readers.
Dov Goldenberg,
Editor Chefe.
Universidade de São Paulo, Faculdade de Medicina,
Hospital das Clínicas, São Paulo, SP, Brazil.
João Egidio de Alvarenga Jr.,
Sociedade Brasileira de Cirurgia Plástica, São Paulo, SP, Brazil.
REFERENCES
1. Pérez Andrés C. La publicación continua frente a la publicación periódica: otra vuelta de tuerca en la edición de las revistas científicas
en Internet [Continuous publication against periodical: another twist in scientific journals edition online]. Rev Esp Salud Publica.
2015;89(6):533-6. Spanish. DOI: 10.4321/S1135-57272015000600001. PMID: 26786301.
2. Anderton S, Harvey L. Continuous publication: ready, set, cite! Br J Radiol. 2013;86(1026):20130252. DOI: 10.1259/bjr.20130252. Epub
2013 May 9. PMID: 23659924; PMCID: PMC3664984.
3. Sukhov A, Burrall B, Maverakis E. The history of open access medical publishing: a comprehensive review. Dermatol Online J.
2016;22(9):13030/qt6578w9f8. PMID: 28329604.
4. McManus CM, Neves AAB, Maranhão AQ. Brazilian Publication Profiles: Where and How Brazilian authors publish. An Acad Bras
Cienc. 2020;92(2):e20200328. doi: 10.1590/0001-3765202020200328. Epub 2020 Aug 7. PMID: 32785445.
Editorial
1 Rev. Bras. Cir. Plást. 2023;38(1):e0443
Use of negative pressure therapy in closed surgical
incisions of post-bariatric dermolipectomy
Uso da terapia de pressão negativa em incisões cirúrgicas fechadas de
dermolipectomia pós-bariátrica
Introduction: Negative pressure therapy gains ground in surgical practice as an
intervention to improve healing. Post-bariatric patients undergoing abdominal
dermolipectomy are at increased risk of local complications. There is a notable
dearth of current Brazilian studies on this. This study aims to analyze the presence
of complications in patients undergoing post-bariatric dermolipectomy surgery with
negative pressure dressing in closed surgical incisions. Method: Descriptive study
that evaluated complications of surgical incisions in 20 patients undergoing postbariatric dermolipectomy surgery with negative pressure therapy. Data tabulated
in Windows Excel software and analyzed in the Statistical Package for the Social
Sciences 18.0 program. Qualitative variables were presented in simple frequency
and quantitative as mean, standard deviation, and amplitude. CEP-UNISUL
approved the study. Results: 20 patients undergoing negative pressure therapy,
80% (n=16) female, mean age 39.55 years (±9.08). Anchor incision was chosen in
70% (n=14) of the surgeries, with an average tissue removal of 1940 grams (±710.37)
and hospitalization time of 40.20 hours (±19.18), corresponding to 1,66 daily. Only
15% (n=3) of patients had complications (dehiscence, seroma, and hematoma,
which occurred in the same proportion). There was no case of necrosis. Conclusion:
The use of negative pressure therapy in closed surgical incisions of post-bariatric
dermolipectomy seems to contribute to reducing postoperative complications.
Keywords: Negative-pressure wound therapy; Reconstructive surgical procedures;
Body contouring; Obesity; Wound Healing; Seroma; Bruise; Necrosis.
Introdução: Terapia de pressão negativa ganha espaço na prática cirúrgica como
intervenção para melhorar cicatrização. Pacientes pós-bariátricos submetidos a
dermolipectomia abdominal apresentam maior risco de complicações locais. Há
uma notável escassez de estudos brasileiros atuais acerca disso. O objetivo desse
estudo é analisar a presença de complicações em pacientes submetidos a cirurgia de
dermolipectomia pós-bariátrica com curativo de pressão negativa em incisões cirúrgicas
fechadas. Método: Estudo descritivo que avaliou complicações de incisões cirúrgicas
de 20 pacientes submetidos a cirurgia de dermolipectomia pós-bariátrica com terapia
de pressão negativa. Dados tabulados no software Windows Excel e analisados no
programa Statistical Package for the Social Sciences 18.0. Variáveis qualitativas foram
apresentadas em frequência simples e quantitativas através de média, desvio padrão
e amplitude. O estudo foi aprovado pelo CEP-UNISUL. Resultados: 20 pacientes
submetidos a terapia de pressão negativa, sendo 80% (n=16) do sexo feminino, com
idade média de 39,55 anos (±9,08). Incisão em âncora foi escolha em 70% (n=14)
■ RESUMO
■ ABSTRACT
Original Article
DOI: 10.5935/2177-1235.2023RBCP0443-EN
Conflicts of interest: none.
Institution: Universidade do Sul
de Santa Catarina, Campus Pedra
Branca, Palhoça, SC, Brazil.
Article received: July 20, 2020.
Article accepted: September 13, 2022.
1
Universidade do Sul de Santa Catarina Campus Pedra Branca, Curso de Medicina, Palhoça, Santa Catarina, Brazil.
LARA GOMES FAISTEL1
*
DILMAR FRANCISCO
LEONARDI1
Negative pressure therapy in post-bariatric dermolipectomy
Rev. Bras. Cir. Plást. 2023;38(1):e0443 2
das cirurgias, com retirada média de tecido de 1940 gramas (±710,37) e tempo de
hospitalização de 40,20 horas (±19,18), correspondendo a 1,66 diárias. Apenas 15%
(n=3) dos pacientes apresentaram complicações (deiscência, seroma e hematoma,
que aconteceram na mesma proporção). Não houve caso de necrose. Conclusão: Uso
da terapia de pressão negativa em incisões cirúrgicas fechadas de dermolipectomia
pós-bariátrica parece contribuir na redução das complicações pós-operatórias.
Descritores: Tratamento de ferimentos com pressão negativa; Procedimentos
cirúrgicos reconstrutivos; Contorno corporal; Obesidade; Cicatrização; Seroma;
Hematoma; Necrose.
INTRODUCTION
Obesity is defined as an abnormal or excessive
accumulation of body fat that can affect health1
.
Currently, about a third of the world’s population is
obese or overweight2
. In Brazil, 18.9% of Brazilians are
obese, and over half of the population is overweight3
.
The high prevalence rate of obesity makes
Brazil the second country where most bariatric and
metabolic surgery is performed, the most effective
treatment for the disease, which increased by 46.7%
between 2012 and 2017, 76% of which in men and
female4
. Surgical success is considered when there are
losses greater than 20% of the total body weight in 6
months5
; however, the loss of excess weight in 5 years
can vary between 59.1% and 69.3% when undergoing
laparoscopic sleeve gastrectomy Roux-en-Y gastric
bypass, respectively6
.
After significant weight loss, skin flaccidity
associated with ptosis in different anatomical
compartments are direct consequences 7, and
about half of the patients feel dissatisfied with
this result8
. Plastic surgery receives them after
weight stabilization and performs abdominal
dermolipectomy, mammoplasty, brachioplasty, and
cruroplasty, among others9
. Such procedures are
desired by 65% of male patients and 85% of female
patients10, mainly in the abdominal region11.
Every surgery is subject to complications,
whether major complications such as hemorrhage,
deep vein thrombosis (DVT), and pulmonary
thromboembolism (PTE); or smaller such as
hematoma, surgical dehiscence, seroma, and surgical
wound infection12. Preoperative evaluation and
postoperative care are relevant to avoid them and
obtain better functional and aesthetic results for
the patient13, especially in post-bariatric patients,
who have a significantly higher risk of complications
(48%) compared to non-bariatric patients undergoing
surgery to reduce weight (29%)14. However, even
with all care taken, 68% of cases present seroma,
dehiscence, or hematoma, and 32% may present
abscess, seroma infection, pathological scarring,
DVT, and PE15. Seroma is the most frequent minor
complication16.
Postoperative dressings are essential for
reducing minor complications and are basically
divided into two types: the common ones, which
include micropore, bandage, adhesive tapes, and
modern dressings such as negative pressure therapy17.
The latter is a modality gaining ground in surgical
practice as an intervention method to improve the
healing process, in risky closed incisions, by keeping
the wound edges together, stimulating blood perfusion,
reducing tension and edema, and protecting the
wound against infections18.
Current international literature recognizes the
many benefits of using negative pressure therapy
in closed surgical incisions, identifying its value in
treatment19-23. In our midst, however, there is a notable
lack of studies on the subject; that said, verifying the
impact of negative pressure therapy in closed surgical
incisions of dermolipectomy in post-bariatric patients
becomes of great value to be studied.
OBJECTIVE
To analyze the presence of complications in
patients undergoing post-bariatric dermolipectomy
with negative pressure dressing in closed surgical
incisions.
METHOD
Observational, descriptive study carried out
from August to November 2019 with collection through
the physical records of a clinic in Florianópolis, Santa
Catarina, Brazil. Twenty patients who underwent
post-bariatric dermolipectomy surgery comprised the
study population. The sample is non-probabilistic for
convenience. Clinical and surgical data of patients who
underwent the procedure with a negative pressure
dressing were included, including sex, age, type of
bariatric surgery, body mass index (BMI) pre-bariatric
surgery, total weight loss, time since bariatric surgery,
pre-abdominal dermolipectomy BMI, smoking, type
3 Rev. Bras. Cir. Plást. 2023;38(1):e0443
Faistel LG et al. www.rbcp.org.br
of abdominal incision, tissue removed, length of stay
and complications.
Data were tabulated in Windows Excel software
and then analyzed using the Statistical Package for the
Social Sciences 18.0 program. Qualitative variables
were presented in simple and relative frequencies, and
quantitative variables as mean standard deviation and
amplitude. The study was submitted and approved by
the Research Ethics Committee of Unisul under CAAE
16295519.0.0000.5369.
Surgical technique
Dermolipectomy surgery with extensive
tissue removal without additional procedures,
such as liposuction, was the surgical procedure all
patients underwent. The surgically removed tissue
was weighed and recorded in the medical record.
Surgical wound closure was performed in all patients
adequately to avoid dead space formation, after
which negative pressure therapy was established
continuously at 125mmHg. The procedure in this study
can be seen in the figures below (Figures 1A, 1B, 1C,
2A, 2B, and 2C).
A Portovac-type continuous suction drain
was used in the suprafascial space as a routine. All
participants used negative pressure therapy for 7 days
and then migrated to a simple dressing with micropore
until the surgical stitches were completely removed
on the 14th day.
Patients had follow-up appointments on the
seventh, fourteenth, and thirtieth postoperative days
for clinical evaluation of the surgical incision, with the
results recorded in the physical record.
RESULTS
Twenty patients underwent negative pressure
therapy in a closed surgical incision of postbariatric dermolipectomy. The clinical and surgical
characteristics identified in each patient are described
in Table 1. 80% of the participants were female (n=16),
and the mean age was 39.55 years (±9.08), with an age
range of 29 and 59 years old.
Roux-en-Y gastric bypass was the most prevalent
bariatric and metabolic surgery technique in 90% (n=18),
with a mean pre-surgical BMI of 43.85 kg/m2 (±5.31) and
weight loss average weight of 39.41% (±8.72). The mean
time to perform the post-bariatric dermolipectomy surgery
was 32.45 months (±18.31). A pre-dermolipectomy BMI of
26.55 kg/m2 (±2.18) was demonstrated, with a minimum
and maximum value of 23 and 30 kg/m2, respectively.
Smoking was absent in 85% (n=17).
The anchor incision was chosen in 70% (n=14) of
the procedures. There was an average tissue resection
of 1940 grams (±710.37), corresponding to an average
excision of 2.75% (±1.04) concerning weight before
dermolipectomy. Post-dermolipectomy hospitalization
was 40.20 hours (±19.18), equivalent to 1.66 days.
Only 15% (n=3) of the patients had complications,
namely dehiscence, seroma, and hematoma, which
occurred in the same proportion. No case of necrosis
of any extent was identified (Table 2).
Figure 1. A. Preoperative plastic surgery of post-bariatric dermolipectomy (right profile); B. Preoperative plastic surgery of post-bariatric dermolipectomy
(front); C. Preoperative plastic surgery of post-bariatric dermolipectomy (left profile).
Negative pressure therapy in post-bariatric dermolipectomy
Rev. Bras. Cir. Plást. 2023;38(1):e0443 4
Figure 2. A. Immediate postoperative; B. Surgical specimens removed in the transoperative period of post-bariatric dermolipectomy surgery using the anchor
technique; C. Installation of negative pressure therapy and Portovac drain.
Table 1. Clinical and surgical characteristics and outcome of each patient.
#Case
Sex
Age years)
Type of bariatric surgery (pre-OP BMI)
Total weight loss (%)
Time since surgery (months)
Pre-dermolipectomy BMI (kg/m2
)
Smoking
Type of incision
Tissue removed (grams)
Tissue removed (%)
Hospitalization time (hours)
Complications
#1
♀
33 years old
Roux-en-Y gastric bypass (40.27 kg/m2
)
46.72%
48 months
26.34 kg/m2
In anchor
1900.00g
2.71%
24 hours
-
#2
♀
45 years
BypassRoux-en-Y gastric (45.72 kg/m2
)
41.66%
36 months
26.67 kg/m2
In anchor
2100.00g
3%
72 hours
-
#3
♀
36 years old
Roux-en-Y gastric bypass (39.54 kg/m2
)
34.18%
60 months
25.68 kg/m2
Classic
1900.00g
2.50%
36 hours
-
#4
♀
37 years
Roux-en-Y gastric bypass (49.47 kg/m2
)
42.10%
26 months
30.04 kg/m2
In anchor
2000.00g
2.66%
72 hours
-
#5
♀
59 years old
Sleeve gastrectomy (32.84 kg/m2
)
14.63%
36 months
28.04 kg/m2
Smoker
In anchor
2000.00g
2.85%
72 hours
-
#6
♀
31 years
Sleeve gastrectomy (53.23 kg/m2
)
43.47%
78 months
30.47 kg/m2
In anchor
2000.00g
2.53%
72 hours
-
#7
♀
34 years
Roux-en-Y gastric bypass (36.57 kg/m2
)
31.37%
17 months
26.89 kg/m2
at anchor
2900.00g
3.86%
24 hours
-
#8
♂
31 years
Roux-en-Y gastric bypass (53.62 kg/m2
)
47.48%
15 months
24.3 kg/m2
Classic 600.00g
0.95%
24 hours
Bruise
continue...
5 Rev. Bras. Cir. Plást. 2023;38(1):e0443
Faistel LG et al. www.rbcp.org.br
#Case
Sex
Age years)
Type of bariatric surgery (pre-OP BMI)
Total weight loss (%)
Time since surgery (months)
Pre-dermolipectomy BMI (kg/m2
)
Smoking
Type of incision
Tissue removed (grams)
Tissue removed (%)
Hospitalization time (hours)
Complications
#9
♀
32 years old
Roux-en-Y gastric bypass (48.47 kg/m2
)
44.64%
26 months
28.99 kg/m2
At anchor 3600.00g
5.37%
24 hours
-
#10
♀
29 years old
Roux-en-Y gastric bypass (40.27 kg/m2
)
38.31%
14 months
24.84 kg/m2
Smoker
In anchor 2000.00g
3.03%
24 hours
Dehiscence
#11
♀
57 years old
Roux-en-Y gastric bypass (40.26 kg/m2
)
43.87%
22 months
22.6 kg/m2
In anchor 1800.00g
3.27%
24 hours
-
#12
♀
38 years
Roux-en-Y gastric bypass (48 kg/m2
)
42.59%
30 months
26.22 kg/m2
Classic 1200.00g
2.03%
24 hours
-
#13
♀
31 years
Roux-en-Y gastric bypass
(39.51 kg/m2
)
47.61%
36 months
22.58 kg/m2
Smoker
Eat anchor
3000.00g
5.00%
24 hours
-
#14
♀
51 years
Roux-en-Y gastric bypass (47.25 kg/m2
)
45.21%
32 months
25.88 kg/m2
In anchor 1000.00g
1.58%
48 hours
-
#15
♀
36 years olds
Roux-en-Y gastric bypass (40.61 kg/m2
)
37.93%
16 months
25.9 kg/m2
Classic 1500.00g
2.02%
24 hours
-
#16
♂
40 years
Roux-en-Y gastric bypass (45.63 kg/m2
) 29.62%
48 months
30.42 kg/m2
In anchor 2500.00g
2.77%
48 hours
-
#17
♂
34 years
Roux-en-Y gastric bypass (41.09 kg/m2
)
24.39%
17 months
29.4 kg/m2
Classic 2200.00g
2.50%
48 hours
-
#18
♂
46 years
Roux-en-Y gastric bypass (45.16 kg/m2
)
43.33%
8 months
25.21 kg/m2
In anchor 1800.00g
2.68%
24 hours
-
#19
♀
39 years old
Roux-en-Y gastric bypass (46.84 kg/m2
)
49.12%
60 months
24.65 kg/m2
Classic
1800.00g
3.00%
48 hours
-
#20
♀
52 years
Roux-en-Y gastric bypass (41.62 kg/m2
)
40%
24 months
26.22 kg/m2
26,22 kg/m2
In anchor 1000.00g
1.58%
48 hours
Seroma
♀ Women; ♂ Male gender; BMI: body mass index; - Absence of complications
...continuation.
Table 1. Clinical and surgical characteristics and outcome of each patient.
Negative pressure therapy in post-bariatric dermolipectomy
Rev. Bras. Cir. Plást. 2023;38(1):e0443 6
Table 2. Complications related to the use of negative pressure therapy in closed surgical incisions in patients undergoing
post-bariatric dermolipectomy surgery (n=20).
Outcomes n (%)
Total complications 3 15
Dehiscence 1 5
Seroma 1 5
Bruise 1 5
Necrosis - -
DISCUSSION
It is known that massive weight loss, such as
that in patients undergoing metabolic and bariatric
surgery, is directly related to aesthetic deformities
that often make the individual not have a good
perception of himself8
. Body contouring plastic surgery,
dermolipectomy, becomes relevant for improving
self-image acceptance9. However, post-bariatric
patients have higher rates of surgical complications
when compared to those who did not undergo weight
reduction surgery14.
It is indisputable that the greatest demand for
post-bariatric abdominal dermolipectomy surgery is
female. In the present study, 80% corresponded to
this group, in line with several studies published both
nationally and internationally16,24-27. The mean age was
39.50 years, similar to that found in the literature24,26,27,
but with a discrepancy of 4 years compared to a
Colombian study by García Botero et al.25.
The surgical technique of Roux-en-Y gastric
bypass deserves to be highlighted as a surgical
method for weight reduction in 90% of the patients
analyzed. The pre-surgical BMI ranged, according
to the formal indication of the Brazilian Society of
Bariatric and Metabolic Surgery (SBCBM)4
, between
33 and 54 kg/m2
, with a mean value of 43.85 kg/m2
,
which also corresponds to the value found in studies
by Donnabella et al.24 and Staalesen et al.14.
The mean post-bariatric weight loss was
39.41% of the total body weight, which means that
these patients achieved the efficacy goal proposed
by the SBCBM with the procedure5
. This shows how
considerable the weight reduction is, to the point that
the surgeon in charge foresees the likely need for
post-bariatric reconstructive surgery as a method to
improve the patient’s quality of life. It is reiterated
that the indication is not only aesthetic but also a
hygienic-prophylactic method, as there are risks of
eczema formation due to the accumulation of sweat and
fetid odor, in addition to the proliferation of fungi and
bacteria in regions with greater skin ptosis9
.
The average time between the bariatric surgery
and the abdominal dermolipectomy was 32.45 months,
a lower value than that found in the literature since
the study by Donnabella et al.24 showed 47 months.
Notably, the procedure is indicated from when weight
loss is stable, with no ideal minimum limit, but it has
already become routine to indicate it from 6 months9
.
In that study, the mean pre-dermolipectomy BMI
was 26.55 kg/m2
, and three patients were in the grade I
obesity group (30.42; 30.47 and 30.04 kg/m2
), while the
remaining were eutrophic or overweight, which is in
line with several published articles14,24,25,27. It is essential
to highlight that post-bariatric dermolipectomy surgery
does not have weight loss as its main function; therefore,
the plastic surgeon should consider it for those with a
BMI below 30 kg/m2
or with specific indications for
those over 30 kg/m2 9
.
Smoking was present in only 15% (n=3) of the
participants in this study, and only one had partial
dehiscence of the surgical incision, even with negative
pressure therapy. It is already established both in
the literature and in clinical practice that nicotine,
a product present in cigarettes, hinders the healing
process since the collagen fibers become disorganized
and the granulation tissue deficiency prevents adequate
cell proliferation for proper wound closure operative28;
therefore, if the patient is an active smoker, a monthlong cessation prior to the surgical act is requested.
The type of dermolipectomy surgical incision
choice depends on clinical and surgical factors. In
that study, there was a predominance of the proposed
anchor incision in 70% of the patients, converging with
the study by Donnabella et al.24, however diverging
from the article by Rosa et al.27, in which it was only
indicated in 19.42%. This difference can be attributed
to the specific characteristics of the patients in this
study, for example, time after bariatric surgery, skin
flaccidity, and total weight loss. The average tissue
resection was 1940 grams, with an average excision of
2.75% concerning the total body weight, confirming
data obtained in the literature14,26. It is reiterated that
the main objective of post-bariatric surgery is to correct
flaccidity and not to reduce weight.
In this study, patients who had the installation
of negative pressure therapy in the surgical incision
of post-bariatric dermolipectomy had an average
7 Rev. Bras. Cir. Plást. 2023;38(1):e0443
Faistel LG et al. www.rbcp.org.br
hospital stay of 40.2 hours, equivalent to only 1.66
days, while in several studies, which did not have the
use of negative pressure therapy as an intervention,
hospital stays varied between 2 and 5 days16,27. This
reduction can be associated with the immobilization
of the surgical wound maintained by the dressing;
this results in less local pain stimulation, greater
comfort, and early return of the patient to his daily
activities.
There are several risk factors for complications
in patients with significant weight loss due to bariatric
surgery compared to those who lost weight through diet
and physical activity, 48% vs. 29%14. In the cohort study
by García Botero et al.25, the rate of minor complications
in wide abdominal dermolipectomy surgery was 53.7%,
mainly seroma, and dehiscence. These data remain
high in the literature, following the pattern of rates
greater than 20%14,16,26,27.
Only 15% of the participants in this study
had minor complications, in equal proportions, in
the case of dehiscence, seroma, and hematoma.
No case of necrosis of any extent was found in all
patients who underwent the post-bariatric abdominal
dermolipectomy procedure using negative pressure
therapy. These results seem to indicate that negative
pressure can improve the healing process by
stabilizing the wound edges close to the suture line,
increasing local blood perfusion, and decreasing
tension and edema18.
associated with this procedure. New studies are
needed to confirm this outcome.
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COLLABORATIONS
LGF Analysis and/or data interpretation, Conception
and design study, Conceptualization, Data
Curation, Methodology, Project Administration,
Visualization, Writing - Original Draft Preparation.
DFL Conception and design study, Final manuscript
approval, Supervision.
CONCLUSION
The present study is not exempt from design,
population, and sample size limitations. However, the
scarcity of national studies demonstrating a causal
relationship between the use or not of negative pressure
therapy in the surgical incision of post-bariatric
abdominal dermolipectomy and its complications
demonstrates its importance.
The use of negative pressure therapy in
closed surgical incisions of post-bariatric abdominal
dermolipectomy seems to indicate that it contributes
to the reduction of postoperative complications,
suggesting a significant decrease in the complications
Negative pressure therapy in post-bariatric dermolipectomy
Rev. Bras. Cir. Plást. 2023;38(1):e0443 8
Lara Gomes Faistel
Rua José Durieux, 90, casa 2, Florianópolis, SC, Brazil.
Zip Code: 88037-406
E-mail: [email protected]
*Corresponding author:
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25. García Botero A, García Wenninger M, Fernández Loaiza D.
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DR, Basso RCF, et al. Análise retrospectiva de pacientes
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1 Rev. Bras. Cir. Plást. 2023;38(1):e0655
Analysis of post-bariatric plastic surgeries performed
in the Brazilian Unified Health System
Análise das cirurgias plásticas pós-bariátricas realizadas no Sistema Único
de Saúde
Introduction: Obesity and overweight have been increasing in Brazil and in the world,
in an expressive way, as well as the demand for bariatric surgeries. As a result, postbariatric plastic surgery has also grown, especially abdominal dermolipectomy. The
objective is to describe the frequency of post-bariatric plastic surgeries performed
by the Unified Health System (SUS - Sistema Único em Saúde, in portuguese) from
January 1, 2015 to October 21, 2020. Methods: Ecological study, where individuals
who underwent post-bariatric surgeries were selected. bariatric tests by SUS obtained
by the Hospital Information System of Department of Informatics of the Unified
Health System (DATASUS - Departamento de Informática do Sistema Único de Saúde,
in portuguese). Data from the 27 states of the national territory were analyzed and
the following variables were used: gender, age group, procedure performed, level of
education. Results: The southeastern region of the country had the highest number
of post-bariatric surgeries. White individuals, on the other hand, had higher numbers
than other races (60.9%), abdominal dermolipectomy was the most frequent (53.7%)
followed by mammoplasty (22.3%). Conclusion: Plastic surgeries have increased
significantly in the last five years, and are more frequent among white women,
aged between 35 and 44 years, living in the southeastern region of the country.
Descritores: Obesidade; Cirurgia bariátrica; Abdominoplastia; Redução de peso;
Procedimentos cirúrgicos reconstrutivos; Sistema Único de Saúde.
Introdução: A obesidade e o sobrepeso vêm aumentando no Brasil e no mundo,
de uma forma expressiva, assim como a procura por cirurgias bariátricas. Em
consequência, a cirurgia plástica pós-bariátrica também cresceu, com destaque
para a dermolipectomia abdominal. O objetivo é descrever a frequência das
cirurgias plásticas pós-bariátricas feitas pelo Sistema Único de Saúde (SUS) no
período de 1 de janeiro de 2015 a 21 de outubro de 2020. Método: Estudo ecológico,
no qual foram selecionados indivíduos que realizaram cirurgias pós-bariátricas
pelo SUS obtidos pelo Sistema de Informações Hospitalares do Departamento
de Informática do Sistema Único de Saúde (DATASUS). Foram analisados
dados dos 27 estados do território nacional e utilizaram-se as variáveis: sexo,
faixa etária, procedimento realizado, grau de instrução. Resultados: A Região
Sudeste do país apresentou maiores números de cirurgias pós-bariátricas. Já
indivíduos da cor branca apresentaram números maiores do que outras raças
(60,9%); a dermolipectomia abdominal foi a mais frequente (53,7%), em seguida,
a mamoplastia (22,3%). Conclusão: As cirurgias plásticas tiveram aumento
expressivo nos últimos cinco anos e são mais frequentes entre mulheres,
brancas, com faixa etária de 35 a 44 anos, residentes na Região Sudeste do país.
■ ABSTRACT
■ RESUMO
Original Article
ALEXANDRE CARDOSO DE
CARVALHO FREITAS1
AMANDA QUEIROZ LEMOS1
*
CLARA ANDRADE
GUIMARÃES ESPÍNDOLA
CAVALCANTE1
CLARISSA HENRIQUE
PALMEIRA1
EMILANE ALMEIDA SANTOS
BEZERRA1
GIOVANNA CEDRAZ PRINZ1
PAULA KALINE SANTOS
JATOBÁ1
1
União Metropolitana para o Desenvolvimento da Educação e Cultura, Lauro de Freitas, BA, Brasil.
DOI: 10.5935/2177-1235.2023RBCP0655-EN
Institution: União Metropolitana
para o Desenvolvimento da
Educação e Cultura, Lauro de
Freitas, BA, Brazil.
Article received: October 28, 2021.
Article accepted: September 13, 2022.
Conflicts of interest: none.
Keywords: Obesity; Bariatric surgery; Abdominoplasty; Weight loss; Reconstructive
surgical procedures; Unified Health System.
Post-bariatric plastic surgeries performed at SUS
Rev. Bras. Cir. Plást. 2023;38(1):e0655 2
Data were obtained by the Hospital Information System
(SIH) of Department of Informatics of the Unified Health
System (DATASUS - Departamento de Informática do
Sistema Único de Saúde, in portuguese).
The collection was carried out on 10/22/2020 through
TABWIN, a program for local analysis of the Sinan Net
database, which allows the import of tabulations made
on the Internet (generated by the TABNET application,
developed by DATASUS and used on the Information page
of Health of this site), using the abdominal, brachial and
crural dermolipectomy procedures after bariatric surgery
and mammoplasty after bariatric surgery, from 2015 to
2020, analyzing the compulsory notifications through
the variables of race, sex, suicide attempt, age detailed,
occupation, medications, and municipality.
Data analysis will be presented by tables and graphs
organized using the Microsoft Excel 2019 software. In
this study, data from the 27 states of the national territory
were analyzed, and the following variables were used:
gender, age group, the procedure performed, and level of
education. Pearson’s correlation analysis was performed
using the Statistical Package for the Social Sciences
software (SPSS inc., Chicago, IL, USA) version 14 for
Windows. For statistical inferences, p<0.05 was adopted.
RESULTS
Within the analyzed period, a total of 6307 procedures
were performed by the SUS. Figure 1 demonstrates an
increase in procedures until 2019; in 2015, there were 1088
surgeries, and in 2019 there was an increase of 25.09%,
totaling 1361 procedures. There was a positive linear
correlation (r 0.894), significant (p=0.041) when comparing
the years 2015 to 2019 (Figure 1).
In Table 1, the white race had the highest prevalence
in all years analyzed, followed by brown and black races.
However, there was a large number of people who did not
know how to inform about their race during this study
period. Abdominal dermolipectomy is the most frequent
procedure (53.7%), followed by mammoplasty (22.3%).
Table 2 presents the frequency of plastic surgeries
according to the region among the studied age groups.
The country’s Southeast Region had the highest number
of post-bariatric surgeries in adults between 40 and 59
years old, as well as a higher frequency of surgeries in the
general population (Figure 2).
In 2020, data available by TabWin up to October 22
were analyzed. Until the writing of this article, there was
no update of this data in the system, with a partial total of
355 procedures performed.
Figure 3 shows the frequency of abdominal
dermolipectomy by sex according to the processing
year; 5941 were women, and 366 were men. In all the
years analyzed in the present study, the procedure was
performed more among females.
INTRODUCTION
Obesity and overweight have been increasing
in Brazil and worldwide. These comorbidities are
considered by the World Health Organization (WHO)
to be a global epidemic caused mainly by inadequate
diet and sedentary lifestyle1
. In Brazil, in 2018, about
55.7% of the adult population was overweight, and
19.8% was obese2
. In this context, the demand for
bariatric surgeries has increased, which was even more
expressive within the Unified Health System (SUS -
Sistema Único em Saúde, in portuguese).
Between 2001 and 2014, 49,425 bariatric surgeries
were performed by SUS. Bariatric surgery is considered
the most effective long-term treatment to control obesity,
resulting in significant weight loss. About a year after
bariatric surgery, patients can lose about 45% of their
initial weight, which leads to the remnant of considerable
excess skin, which results in marked sagging3
.
The abdomen is one of the places most affected
by post-bariatric weight loss and can cause discomfort
to patients, such as difficulties with personal hygiene,
social interaction, or even damage to intimate life,
reduced self-esteem, and distortions in body contour.
These impacts can be corrected or minimized through
plastic surgeries that, in addition to the aesthetic
advantage, significantly improve the quality of life of
patients4
.
In recent years, demand for post-bariatric plastic
surgery has grown, with an emphasis on abdominal
dermolipectomy – also known as abdominoplasty. A study
indicates a frequency of 76.97% of abdominoplasties and
42.46% of mammoplasties in a public hospital in the
Federal District5
. Moreover, the average time between
bariatric surgery and plastic surgery was 42 months.
Such surgeries aim to minimize the consequences
secondary to bariatric surgery and demonstrate a
positive impact on the patient’s quality of life. Because
of the high prevalence of obesity and the demand for
post-bariatric plastic surgery, the importance of this
topic for the medical field and its impact on the SUS is
highlighted.
OBJECTIVE
Therefore, the present study aims to describe the
frequency of post-bariatric plastic surgeries performed
by SUS from January 1, 2015, to October 21, 2020.
METHOD
This is an ecological time-series, observational
and descriptive study, with individuals who underwent
post-bariatric surgeries by the SUS from January 1,
2015, to October 21, 2020, carried out in the city of Lauro
de Freitas, Bahia, following the principles of Helsinki.
3 Rev. Bras. Cir. Plást. 2023;38(1):e0655
Freitas ACC et al. www.rbcp.org.br
DISCUSSION
The present study showed an increase in the
frequency of plastic surgeries after bariatric surgeries
performed by the Unified Health System. When
evaluating the five regions of Brazil, a large numerical
difference in the number of surgeries performed between
the South and Southeast compared to the other regions
Figure 1. Correlation between the variables number of procedures and year, in patients undergoing dermolipectomy and
mammoplasty after bariatric surgery between 2015 and 2019.
Pearson correlation. Number of procedures
p=0.041
r=0.894
Year
Pearson correlation
1400
1300
1200
1100
2015 2016 2017 2018 2019
Figure 2. Absolute number of procedures according to the region of Brazil between the years 2015 and 2019.
Source: Hospital Information System (SIH)/DATASUS.
Midwest
South
Southeast
North East
North
MAMMOPLASTY
BRACHIAL DERMOLIPECTOMY
CRURAL DERMOLIPECTOMY
ABDOMINAL DERMOLIPECTOMY
Post-bariatric plastic surgeries performed at SUS
Rev. Bras. Cir. Plást. 2023;38(1):e0655 4
is notable. This is due both to factors of population size
and also because these regions are great centers of
technological reference, specialists from different areas
of health and hospitals. The states representing the
Southeast and South regions have a higher concentration
of plastic surgery specialists registered with the Brazilian
Society of Plastic Surgery (SBCP), with 60.4% of the
surgeons registered in the Southeast Region and 16.8%
in the South Region in 20146
.
Analyzing these data, we noticed that the
Caucasian race has a greater aesthetic and functional
concern concerning other races after bariatric surgery.
This hypothesis arises from the higher frequency of
white individuals undergoing surgery after bariatric
surgery, corroborating other studies3,7. With surgical
intervention, these individuals can acquire a higher
level of satisfaction and improve their quality of life
since removing excess skin and flaccid skin reduces
the psychosocial repercussions that affect the lifestyle
of these patients5
. The present study shows that, out
of every ten plastic surgeries, seven are performed on
Table 1. Characteristics of patients undergoing dermolipectomy
and mammoplasty after bariatric surgery between 2015 and
2020.
Variables Absolute number (%)
Color/race
White 3842 (60.9%)
Brown 1637 (21.6%)
Black 206 (3.2%)
Yellow 54 (0.8%)
Indigenous 1 (0.01%)
No information 567 (8.9%)
Total 6307 (100%)
Procedures performed
Abdominal dermolipectomy 3391 (53.7%)
Brachial dermolipectomy 735 (11.6%)
Crural dermolipectomy 771 (12.2%)
Mammaplasty 1410 (22.3%)
Source: Hospital Information System (SIH)/DATASUS.
Source: Hospital Information System (SIH)/DATASUS.
Table 2. Absolute number and percentage of procedures according to the region of Brazil and the age group between 2015
and 2019.
Region 10-14 years 20 -39 years 40 - 59 years old Over 60
North Region 1 (20%) 35 (1.5%) 33 (0.9%) 2 (0.4%)
Northeast Region 1 (20%) 334 (15.1%) 381 (10.6%) 46 (9.0%)
Southeast Region 3 (60%) 1088 (49.2%) 1851 (51.7%) 300 (58.7%)
South Region 0 (0%) 626 (28.3%) 1087 (30.3%) 146 (28.5%)
Midwest region 0 (0%) 128 (5.7%) 227 (6.3%) 17 (3.3%)
Total 5 (100%) 2211 (100%) 3579 (100%) 511 (100%)
Source: Hospital Information System (SIH)/DATASUS.
Figure 3. Frequency by sex according to the processing year in patients undergoing dermolipectomy and mammoplasty after
bariatric surgery between 2015 and 2020.
Men Women
5 Rev. Bras. Cir. Plást. 2023;38(1):e0655
Freitas ACC et al. www.rbcp.org.br
patients of color or white race (70%). Only 20% of brown
people, 7% of black people, and 3% of yellow people.
Mentions of indigenous people did not reach 1%.
According to the analysis performed on the
frequency of dermolipectomy by age group, it is
observed that there is a higher frequency of the
procedure in the adult population (40-59 years),
followed by young adults aged between 20 and 39
years, corroborating a previous study5
. Concerning
bariatric surgeries, on average, patients are 41.4 years
old, have a body mass index of 48.6kg/m2
, 21% are men,
61% are hypertensive, 22% are diabetic, and 31% have
sleep apnea3
. It is data of important correlation with
our study.
However, when we analyze the frequency of
plastic surgery according to the gender variable, a higher
prevalence of females can be seen, corroborating the
literature4,7,8. This fact can probably be theorized due to
men’s prejudice towards acceptance of plastic surgery, in
addition to abdominal flaccidity being more pronounced
in some women, making them seek this intervention, in
addition to the beauty standard imposed by society being
more targeted for women9
.
In patients after bariatric surgery, the consequence
of great weight loss is skin sagging, which can be
present in different body regions, frequently in the
abdomen and breasts10,11. The study by Fernandez et al.9
demonstrated a high mean of abdominal circumference
and waist measurement in obese patients (waist
circumference value above 80 cm), which can generate
a large accumulation of skin after bariatric surgery9
.
The accumulation of skin and flaccidity in these
regions may explain the higher frequency of abdominal
dermolipectomy and mammoplasty observed in the
present study.
In this way, the importance of the present study is
demonstrated to describe the scenario of post-bariatric
plastic surgery in the Unified Health System. Because
it is a descriptive ecological study, it has limitations
regarding data collection and underreporting in
the sources of data records. Therefore, multicentric
cross-sectional studies are encouraged to obtain more
information about the population profile that seeks this
procedure and determine the impacts on public health.
CONCLUSION
Post-bariatric plastic surgeries are more frequent
among white women between 35 and 44. As Brazil’s
center of technology and urbanism, the Southeast
consequently had the highest numbers of post-bariatric
surgeries, probably due to the pace of life, technology,
available human resources, and ease of access to health
services in this region.
REFERENCES
1. World Health Organization (WHO). Obesity: Preventing and
managing the global epidemic. Report of a WHO Consultation
on Obesity Geneva: World Health Organization; 1998.
2. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde.
Departamento de Análise em Saúde e Vigilância de Doenças
não Transmissíveis. Vigitel Brasil: 2018. Brasília: Ministério da
Saúde; 2019.
3. Kelles SMB, Diniz MFHS, Machado CJ, Barreto SM. Perfil
de pacientes submetidos à cirurgia bariátrica, assistidos pelo
Sistema Único de Saúde do Brasil: revisão sistemática. Cad
Saúde Pública. 2015;31(8):1587-601.
4. Holanda EF, Pessoa SGP. Cirurgia plástica de contorno corporal
pós-bariátrica: revisão de literatura. Rev Bras Cir Plást.
2018;33(Suppl 2):16-8.
COLLABORATIONS
ACCF Analysis and/or data interpretation, Conception
and design study, Conceptualization, Data
Curation, Final manuscript approval, Formal
Analysis, Methodology, Project Administration,
Software, Writing - Original Draft Preparation,
Writing - Review & Editing.
AQL Analysis and/or data interpretation,
Conceptualization, Validation.
CAGEC Analysis and/or data interpretation, Conception
and design study, Conceptualization, Formal
Analysis, Investigation, Methodology, Project
Administration, Software, Visualization, Writing -
Original Draft Preparation.
CHP Analysis and/or data interpretation, Conception
and design study, Conceptualization, Data
Curation, Formal Analysis, Investigation,
Methodology, Project Administration, Software,
Visualization, Writing - Original Draft Preparation.
EASB Analysis and/or data interpretation, Conception
and design study, Conceptualization, Final
manuscript approval, Formal Analysis,
Investigation, Methodology, Project
Administration, Software, Visualization, Writing -
Original Draft Preparation.
GCP Analysis and/or data interpretation, Conception
and design study, Conceptualization, Final
manuscript approval, Formal Analysis,
Investigation, Methodology, Software, Validation,
Visualization, Writing - Original Draft Preparation.
PKSJ Analysis and/or data interpretation, Conception
and design study, Conceptualization, Final
manuscript approval, Formal Analysis,
Investigation, Methodology, Software,
Validation, Visualization, Writing - Original
Draft Preparation.
Post-bariatric plastic surgeries performed at SUS
Rev. Bras. Cir. Plást. 2023;38(1):e0655 6
5. Rosa SC, Macedo JLS, Casulari LA, Canedo LR, Marques JVA.
Perfil antropométrico e clínico de pacientes pós-bariátricos
submetidos a procedimentos em cirurgia plástica. Rev Col Bras
Cir. 2018;45(2):e1613.
6. Sociedade Brasileira de Cirurgia Plástica (SBCP). Censo
2018: análise comparativa das pesquisas 2014, 2016 e 2018.
2018, 25 slides. [acesso 2021 Nov 21]. Disponível em: http://
www2.cirurgiaplastica.org.br/wp- content/uploads/2019/08/
Apresentac%CC%A7a%CC%83o-Censo-2018_V3.pdf
7. Barazzetti DO, Cavalheiro LT, Barazzetti PHO, Garcia CP,
Mattiello CM, Ely JB. Dermolipectomia após cirurgia bariátrica:
sistematização da técnica e complicações em um serviço público.
Rev Bras Cir Plást. 2019;34(Suppl 1):139-41.
Amanda Queiroz Lemos
União Metropolitana para o Desenvolvimento da Educação e Cultura (UNIME). Av. Luis Tarquínio Pontes,
600, Lauro de Freitas, BA, Brazil.
Zip code: 42700-000
E-mail: [email protected]
*Corresponding author:
8. Lage RR, Amado BN, Sizenando RP, Heitor BS, Ferreira BM.
Dermolipectomia abdominal pós-gastroplastia: avaliação de 100
casos operados pela técnica do “peixinho”. Rev Bras Cir Plást.
2011;26(4):675-9.
9. Fernandez M, Toimil RF, Rasslan Z, Ilias EJ, Gradinar ALT,
Malheiros CA. Avaliação da gordura corporal em pacientes
obesas no pré-operatório de cirurgia bariátrica. Arq Bras Cir
Dig. 2016;29(Supl. 1):59-61.
10. Akbas H, Guneren E, Eroglu L, Demir A, Uysal A. The combined
use of classic and reverse abdominoplasty on the same patient.
Plast Reconstr Surg. 2002;109(7):2595-6.
11. Baroudi R. Body sculpturing. Clin Plast Surg. 1984;11(3):419-43.
1 Rev. Bras. Cir. Plást. 2023;38(1):e0657
Application of data mining to extract knowledge
about the occurrence of fistulas after palatoplasty
Aplicação de mineração de dados para extração de conhecimento sobre
ocorrência de fístulas após palatoplastia
Introduction: Data mining techniques expand access to important information
for the decision-making process during health care. The objective the study
proposes using data mining techniques to identify variables (surgical treatment
protocols, patient characteristics, post-surgical complications) associated with
fistulas after primary palatoplasty in patients with unilateral transforamen incisor
cleft (UTIC). Method: A data set of 222 patients with UTIC without syndromes,
operated by four surgeons with Furlow’s or von Langenbeck’s primary palatoplasty
techniques, was analyzed for this study. Two models for detecting the outcome of
surgery were induced using data mining techniques (Decision Tree and Apriori).
Results: Five rules were selected from a decision tree pointing to some variables
as predictors of fistulas associated with primary palatoplasty: infection, cough,
hypernasality, and surgeon. Analysis of the model indicates that it correctly
classifies 95.9% of occurrences between the absence and presence of fistulas. The
second model indicates that the absence of post-surgical complications (infection
and fever) and normal speech results (absent hypernasality, without suggestive
of velopharyngeal dysfunction) are related to the absence of fistulas. Regarding
surgical procedures, the Furlow technique and the Vomer flap were more frequent
in patients with fistulas. Conclusion: Data mining techniques, as applied in the
present study, pointed to infection and cough, hypernasality, and surgeon and
surgical techniques as predictors of fistulas related to primary palatoplasty.
DOI: 10.5935/2177-1235.2023RBCP657-EN
Conflicts of interest: none.
Introdução: As técnicas de mineração de dados ampliam o acesso a informações
importantes para o processo de tomada de decisão durante os cuidados com a saúde. O
objetivo do estudo propõe a utilização de técnicas de mineração de dados para identificar
variáveis (protocolos de tratamento cirúrgico, características do paciente, intercorrências
pós-cirúrgicas) associadas à ocorrência de fístulas após palatoplastia primária em
pacientes com fissura transforame incisivo unilateral (FTIU). Método: Um conjunto de
dados de 222 pacientes com FTIU sem síndromes, operados por quatro cirurgiões com
as técnicas de palatoplastia primária de Furlow ou von Langenbeck, foi analisado para
este estudo. Dois modelos para detecção do resultado da cirurgia foram induzidos usando
técnicas de mineração de dados (Árvore de Decisão e Apriori). Resultados: Cinco regras
■ ABSTRACT
■ RESUMO
Original Article
Keywords: Data mining; Health; Cleft palate; Oral fistula; Algorithms.
1
Hospital de Reabilitação de Anomalias Craniofaciais, Universidade de São Paulo, Programa de Pós-Graduação em Ciências da Reabilitação,
Bauru, SP, Brazil.
2
Hospital de Reabilitação de Anomalias Craniofaciais, Universidade de São Paulo, Programa de Pós-Doutorado, Bauru, SP, Brazil.
3
Hospital de Reabilitação de Anomalias Craniofaciais, Universidade de São Paulo, Departamento de Cirurgia Plástica, Bauru, SP, Brazil.
4
Faculdade de Odontologia de Bauru, Universidade de São Paulo, Programa de Pós-Graduação em Fonoaudiologia, Bauru, SP, Brazil.
PATRICK PEDREIRA SILVA1
*
ELVIO GILBERTO DA SILVA2
VINICIUS SANTOS
ANDRADE1
TELMA VIDOTTO DE SOUSA
BROSCO3
GABRIELA APARECIDA
PREARO4
MARIA INÊS
PEGORARO-KROOK1, 4
JENIFFER DE CASSIA
RILLO DUTKA1, 4
Institution: Hospital de
Reabilitação de Anomalias
Craniofaciais da Universidade de
São Paulo, Bauru, SP, Brazil.
Article received: November 3, 2021.
Article accepted: September 13, 2022.
Data mining of fistulas after palatoplasty
Rev. Bras. Cir. Plást. 2023;38(1):e0657 2
In data mining, hypotheses are induced from a set
of observed data, such as, for example, data on patients.
Each patient is called an object, and different attributes
are stored on each object (name, identification, gender,
age, symptoms, etc.), which correspond to the different
data of that patient. In one of the typical mining tasks,
one seeks to learn ways to predict one of the attributes
(this specific attribute of which one wants to make the
prediction is called class or, simply, target attribute or
output attribute). The other attributes that predict the
target attribute are called predictors or input attributes.
From a set of data, we seek to create a model or
hypothesis (represented by an algorithm or set of rules)
capable of relating one or more attributes (predictors)
to the target attribute (class). Through an inductive
bias, each model identified from data mining uses a
representation to describe the hypothesis induced from
the data set.
OBJECTIVE
This work aims to use data mining techniques to
automatically extract knowledge about variables (surgical
treatment protocols, postoperative complications,
speech results after surgery, and patient characteristics)
associated with the occurrence of oronasal fistulas
in patients with unilateral transforamen incisor cleft
(UTIC).
METHOD
The investigation deals with descriptive,
quantitative, experimental, and applied research,
approved by the Research Ethics Committee of the
Hospital for Rehabilitation of Craniofacial Anomalies of
the University of São Paulo (opinion 1,753,467), carried
out at that institution in September 2021. sample refers
to a subset of medical records of patients with cleft lip
and palate participating in a randomized clinical trial
(RCT) with UTIC13.
INTRODUCTION
One of the main objectives of primary surgery of
the palate in cleft lip and palate (CLP) is the successful
reconstruction of the levator muscle belt to provide a
functional velopharyngeal mechanism for adequate
speech production1
. The presence of an oronasal fistula
is one of the most significant complications after surgical
repair of the palate since its implications can interfere
with the individual’s quality of life. The incidence of
residual oronasal fistulas is one factor that indicates the
success of primary surgical repair of the palate2-4.
A fistula, as reported by Brosco4,5, is a failure
in healing or rupture of the primary surgical palate
repair that can occur anywhere along the cleft closure
line. The literature presents conflicting data regarding
the occurrence of fistula6-9; for example, Salimi et al.10
reported an incidence ranging between 0 and 78%. It
is important to understand which variables (surgical
treatment protocols, postoperative complications,
speech results after surgery, and patient characteristics)
are associated with fistulas to prevent and minimize
these surgical complications.
The so-called “information age” is characterized
by the growing expansion in the volume of data
generated and stored, a phenomenon also reflected
in the health area, which increases the possibility
of obtaining important information supporting the
decision-making process11. The patients’ data and the
surgery results are available in their medical records
and can be used for clinical studies.
However, many times, the volume of data generated
is so large that its use and manual analysis are difficult,
demanding more sophisticated processes, such as, for
example, automated processes, for the manipulation
of such data. In this context of the overabundance of
data, data mining emerged as a systematic, interactive,
and iterative process of preparing and automatically
extracting knowledge from databases11,12.
foram selecionadas de uma árvore de decisão apontando para algumas variáveis
como preditivas de fístulas associadas à palatoplastia primária: infecção, tosse,
hipernasalidade, cirurgião. A análise do modelo indica que ele classifica corretamente
95,9% das ocorrências entre ausência e presença de fístulas. O segundo modelo indica
que a ausência de intercorrências pós-cirúrgicas (infecção e febre) e resultado de fala
normal (hipernasalidade ausente, sem sugestivo de disfunção velofaríngea) estão
relacionados à ausência de fístulas. Em relação aos procedimentos cirúrgicos, o uso
da técnica de Furlow e retalho de Vomer foram mais frequentes nos pacientes com
fístulas. Conclusão: Técnicas de mineração de dados, conforme aplicadas no presente
estudo, apontaram para infecção e tosse, presença de hipernasalidade, cirurgião e
técnica cirúrgica como preditores de fístulas relacionadas à palatoplastia primária.
Descritores: Mineração de dados; Saúde; Fissura palatina; Fístula bucal; Algoritmos.
3 Rev. Bras. Cir. Plást. 2023;38(1):e0657
Silva PP et al. www.rbcp.org.br
Data on the occurrence of fistulas were obtained
for a total of 466 patients (infants). These patients
were randomized (using a script–code written in a
programming language developed at the University
of Florida) to receive different surgical treatment
protocols, including 1) primary cheiloplasty between 3
and 6 months of age with the Millard technique ( M) or
Spina (S); 2) early (9 to 12 months) or late (>12 months)
palatoplasty; 3) primary palatoplasty with the von
Langenbeck (VL) or Furlow (F) technique; and 4) to one
of four possible surgeons (C1, C2, C3, C4).
Information about the occurrence of fistula after
primary palatoplasty was of interest to the present
study. To determine classes in data mining, Spina’s14
classification was used, grouping patients into two
groups: SUCCESS (patients without fistula or with
fistula in the pre-incisive foramen region); FAILURE
(patients with fistulas in the post-incisive foramen region
or transforamen fistulas). The incisive foramen marks
the limits of the primary palate (central part of the upper
lip and premaxilla) and secondary palate (hard and soft
palate).
Table 1 presents the information identified in the
patient’s records for this study. The definition of the
variables of interest is directly related to some factors,
including 1) Surgical treatment protocols (a surgical
technique in cheiloplasty and palatoplasty, surgeon,
use of surgery modifications such as relaxing incision
and vomer flap, duration of palatoplasty in minutes );
2) Patient characteristics (age at palatoplasty, duration
of palatoplasty); 3) Post-surgical complications (whether
there was an infection in the palatoplasty - at the site -
or elsewhere after the primary palatoplasty; whether
there was vomiting or coughing in the postoperative
period of the palatoplasty); 4) Speech results after
surgery (whether there was a symptomatic diagnosis of
velopharyngeal dysfunction, presence of hypernasality
- recorded in spontaneous or directed conversation);
results of nasal air emission, hypernasality, and
hyponasality tests (observed during the repetition of 10
words); 5) Result of the surgery regarding the occurrence
of fistula (SUCCESS or FAILURE). The variables of
interest are listed in the “attribute name” column.
Variables associated with surgical treatment
protocols and patient characteristics can help indicate
whether there is a greater propensity to develop fistulas
(even before the surgical procedure). In contrast,
variables related to post-surgical complications and
speech results can be indicative of clinically relevant
fistulas after surgery.
In the management of CLP, the SUCCESS of
the treatment occurs in the absence of a fistula and
absence of speech disorders. For the present study, a
fistula in the region posterior to the incisive foramen
and the presence of velopharyngeal dysfunction were
interpreted as indicative of treatment FAILURE. The
guiding question for data mining involved checking
which factors (surgical treatment protocols, patient
characteristics, post-surgical complications, and speech
results after surgery) would be associated with the
occurrence or not of fistulas. Therefore, this study aimed
to identify whether some of the analyzed variables could
be used as predictors of the occurrence of fistulas on
the palate or as indicators of clinically relevant fistulas
after palatoplasty.
To compute the results of the experiment, the
algorithm C4.5 (J48) was used, which generates decision
trees to find the relationship between the characteristics
considered and the results of the surgeries, as well
as the “Apriori algorithm” (association) for the rule
generation. Decision trees allow variables or attributes
to be categorical (qualitative) or numerical (quantitative).
It can be used simultaneously by the model (which
proved adequate considering the different types of
Table 1. Definition of variables (attributes) of interest for
this study.
Variables (Attribute Name) Categories (Values)
Surgical technique in
cheiloplasty Millard, Spina
Palatoplasty time Early (9-12m), Late
(>12m)
Age at palatoplasty months (m)
Surgical technique in
palatoplasty Furlow, von Langenbeck
Surgeon C1, C2, C3, C4
Relaxing incision No incision, unilateral,
bilateral
Vomer flap yes, no
Duration of palatoplasty Minutes
Infection in palatoplasty surgery,
at another location
There was not; at the
site of
Postoperative vomiting
Palatoplasty yes, no
Cough after surgery of
palatoplasty yes, no
Fever yes, no
Suggestive of velopharyngeal
dysfunction yes, no
Hypernasality yes, no
Air emission test [1-10]
Hypernasality test [1-10]
Hyponasality test [1-10]
*Occurrence of fistula SUCCESS, FAILURE
m=months; C=surgeon; *target attribute (class)
Data mining of fistulas after palatoplasty
Rev. Bras. Cir. Plást. 2023;38(1):e0657 4
variables in the database used in the investigation ). The
Apriori algorithm deals only with qualitative variables.
Both models induce a hypothesis through a model
represented by rules (“if...then”).
In this analysis, the variables of interest were
treated as attributes in the WEKA software. Considering
a typical mining task, the experiment was divided into
four stages: data pre-processing, feature extraction,
classification, and description of results. The procedure
was performed considering the occurrence of a fistula
after palatoplasty as the primary result. Pre-processing
was carried out semi-automatically. Data from the
medical records made available in the “.XLS” file format
(Excel® spreadsheet) were converted to the “.ARFF”
format (used by WEKA) using the Excel2ArffConverter
software. Before conversion, the attributes were
identified as described in Table 1.
RESULTS
Only patients with complete data were selected
for analysis, considering the parameters described in
Table 1. After discarding patients with incomplete data
for any variables, 222 patients were selected for analysis.
Due to the possibility of bias in the base, it was decided
not to estimate the missing values7
. Information on the
occurrence of some type of fistula was identified in the
medical records of 222 (47.6%) of the 466 patients studied,
and data from these patients were mined for this article.
Of the 222 patients considered for this study, 98
(44.1%) were female, and 124 (55.9%) were male. The
mean age at primary palatoplasty was 12.8 months
(σ=3.2). In this group, 114 (51.3%) received the Millard
procedure in primary cheiloplasty, while 108 (48.7%)
received the Spina procedure. One hundred twelve
patients (50.4%) received the Furlow technique in
primary palatoplasty, while 110 (49.6%) received von
Langenbeck. Of the patient sample, 182 (81.9%) belonged
to the SUCCESS group and 40 (18.1%) to the FAILURE
group.
Through constructing a decision tree, 37 rules
were generated from the complete patient data set.
However, in this article, we chose to display only the 5
rules with the highest value for the coverage metric of
each final result of the surgery (SUCCESS or FAILURE).
The coverage metric is the ratio of correctly classified
data to the total sample data for that class. Information
about the rule’s accuracy metric (probability of the final
result conditional on the attributes, i.e., the model’s
ability to avoid false positives) was also considered.
The mean accuracy of the rules associated with
surgical SUCCESS is 97.26% (σ=4.59). The five rules
together present coverage of about 77.5%; that is, if
applied to the data, they manage to detect 77.5% of the
cases of SUCCESS. As for the FAULT class, the average
accuracy of the associated rules is 84.32% (σ=9.40). The
coverage of the five rules is 62.5%, that is, the number
of FAILURE cases that the rules can detect if applied
to the database.
The rule with greater coverage and accuracy for
predicting a good result indicates that the main factors
involved are: infection (“absence”), hypernasality
tests (“≤6”) and hyponasality (“>9”), and the surgical
technique (“von Langenbeck”). The interpretation of
this rule indicates, therefore, that patients submitted to
the “von Langenbeck” procedure, without infection and
with hyponasality test results with values greater than
or equal to 9 and hypernasality test with values less than
or equal to 6 are more likely to have obtained SUCCESS
as the final result of the surgery. As for FAILURE,
according to the two rules with greater precision and
coverage, the factors involved are related to post-surgical
complications and speech results and include infection
(“absence or elsewhere”), hypernasality tests (“greater
than 6”), air emission (“greater than 9”) and fever (“yes”).
The rules are shown in Table 2.
When analyzing the global performance of the
model (generated decision tree) concerning its predictive
capacity, it is observed that it correctly classifies 95.9% of
the patients and incorrectly only 4.1%. Considering each
category individually, the model manages to hit 90.0%
of the cases in which a FAILURE result occurs. As for
the other class, the model manages to hit 97.3% of the
cases in which a SUCCESS result occurs.
The correlations found using the Apriori algorithm
were obtained using the support (minimum of 60%) and
confidence (minimum of 90%) metrics. The objective
was to find frequent (high support value) rules in the
database with a high degree of confidence (directly
related to rule validity). Four rules were found with an
average confidence of 90.75% (σ=0.5) and an average
support of 69.45% (σ=0.49), which meet the requirements
above, as shown in Table 3.
Considering only the 40 patients in the FAILURE
group, the results show the six rules found with a
minimum support of 67.5% and a minimum confidence
of 100% (Table 3). The rules have average support of
72.08% for this group. In the SUCESSO group, the model
indicates the absence of post-surgical intercurrences
(cough and infection) and speech results with absent
hypernasality. Patients in the FAILURE group also had
no cough and no infection.
Table 4 summarizes the relationship between the
duration of the palatoplasty and the result regarding the
occurrence of fistulas. It is observed that surgery times
vary from 25 to 140 minutes.
The algorithms allow data-based exploration
of non-linear relationships and interactions between
5 Rev. Bras. Cir. Plást. 2023;38(1):e0657
Silva PP et al. www.rbcp.org.br
Table 3. Rules with high support and confidence values.
Characteristics Result Support Confidence
Absence of cough and infection without suggestive of dysfunction velopharyngeal SUCCESS 69.8% 91.0%
Absence of cough and infection with absent hypernasality SUCCESS 69.8% 91.0%
Absence of cough and infection without suggestive of dysfunction velopharyngeal
with absent hypernasality SUCCESS 69.8% 91.0%
Absence of cough and infection and no fever SUCCESS 68.4% 90.0%
absence of cough FAILURE 77.5% 100.0%
absence of infection FAILURE 77.5% 100.0%
Furlow’s surgical technique FAILURE 72.5% 100.0%
Use of vomer flap FAILURE 70.0% 100.0%
absence of vomiting FAILURE 67.5% 100.0%
Absence of cough and infection FAILURE 67.5% 100.0%
Table 2.Surgery result.
Number Rule Result (class) Coverage Precision
1
If “infection=none” and “hypernasality test≤6” and
“cough=no” and “surgical technique=von Langenbeck” and
“hyponasality test>9”
SUCCESS 77 100%
2
If “infection=none” and “test hypernasality≤6” and
“cough=no” and “surgical technique=Furlow” and “fissure
width=regular”
SUCCESS 33 96.9%
3
If “infection=none” and “test in hypernasality≤6” and
“cough=no” and “surgical technique=Furlow” and “cleft
width=wide” and “surgeon=C3”
SUCCESS 19 89.4%
4
If “infection=none” and “test in hypernasality≤6” and
“cough=no” and “surgical technique=Furlow” and “fissure
width=wide” and “surgeon=C2”
SUCCESS 7 100%
5
If “infection=none” and “test in hypernasality≤6” and
“cough=no” and “surgical technique=Furlow” and “fissure
width=wide” and “surgeon=C1” and “relaxing incision=no”
SUCCESS 5 100%
6 If “infection=none” and “hypernasality test>6” and “air
emission test>9” and “fever=yes” FAILURE 6 83.3%
7 If “infection=occurred elsewhere” FAILURE 6 83.3%
8
If “infection=none” and “hypernasality test>6” and
“air emission test>9” and “fever=no” and “relaxing
incision=bilateral” and “vomit=no” and “surgeon=C3”
FAILURE 5 80.0%
9
If “infection=none” and “test hypernasality≤6” and
“cough=no” and “surgical technique=Furlow” and “fissure
width=wide” and “surgeon=C4” and “air emission test>2”
FAILURE 4 100%
10 If “infection=none” and “test in hypernasality>6” and “air
emission test>9” and “fever=no” and “relaxing incision=no” FAILURE 4 75.0%
Table 4. Relationship between duration of palatoplasty and classes (SUCCESS and FAILURE).
Duration: Minutes No Average Standard deviation Minimum Maximum
Duration of palatoplasty – All groups 222 65.62 24.43 25 140
Duration of palatoplasty (group SUCCESS) 182 62.57 22.89 25 125
Duration of palatoplasty (group FAILURE) 40 79.5 26.62 25 140
Data mining of fistulas after palatoplasty
Rev. Bras. Cir. Plást. 2023;38(1):e0657 6
many variables, generating easy interpretation models.
However, as a weakness of the method, the unbalance
between the two groups (SUCCESS and FAILURE)
and the full use of the sample for the induction of the
models can be pointed out, which can cause overfitting
of the data, impairing the extrapolation of the findings
( rules) to other databases.
DISCUSSION
Specifically, concerning fistulas, the rules found
with a high degree of precision and coverage can show
useful standards on which variables, among surgical
treatment protocols, patient characteristics, speech
results after surgery, and post-surgical intercurrences,
are determinant for the success or failure of the
palatoplasty. The opportunity to adopt data mining on
patients undergoing palatoplasty can provide a better
understanding of the specificities that may occur with
the group of patients, thus expanding the professional’s
knowledge in identifying the conduct to be adopted.
In this specific study, the visibility given to
some factors (Table 1) allows health professionals to
identify patterns of association of variables, with the
proper analysis of this set of discoveries, which can
give meaning to diagnostic and therapeutic actions.
In the same way, as in other previous studies, this
investigation opted for combining different types
of data mining tasks to carry out the experiment or
identify patterns15-19.
Despite the initial availability of data referring
to 466 patients, we chose to use 222 (considering only
the complete ones). This may have limited the rules
obtained and not have evidenced other associations of
the factors related to the final results of the palatoplasty.
This decision follows the guidelines of other works20.
The entire database can be used for future studies, as
some algorithms can deal with missing data11.
Another limitation related to the base is the
fact that the two classes considered are unbalanced;
however, as they reflect the real situation in which
SUCCESS results are more common than FAILURES,
it was decided to maintain the natural proportion
of the data. This presence of majority classes much
more frequently than other minority classes makes
algorithms respond well to majority classes to the
detriment of minority ones. In future works, the
experiment can be repeated using random resampling
techniques of the data in order to generate balanced
sets21.
The fact that the entire database was used for
induction and testing of the model may generate a
bias to fit the data. Any mining method is subject
to generating a model that overfits itself to the data
on which it was induced (overfitting) but cannot
generalize the learned knowledge, not obtaining a
good performance when confronted with data from
another base. However, this approach was chosen as
the purpose of this experiment is not to induce a model
to automate the classification process of surgeries but
rather to extract rules that can be evaluated by humans,
evidencing useful patterns.
The analysis of Table 2 indicates that the
SUCCESS results are associated with post-surgical
complications such as the absence of infection
and cough; in addition, the patients presented a
hypernasality test below or equal to 6 (on a scale that
goes up to 10). In the case of large fissures associated
with the Furlow surgical technique, in addition to
the complications highlighted, the surgeon’s factor
influences the final result.
In the case of the FAILURE results, the presence
of infection seems to be an important factor; however,
it is not decisive. Due to the similarity between rules
9, 3, and 4 (Table 2), the decisive factor for obtaining
a FAILURE result is linked to the surgeon. Under
the same conditions, surgeons C2 and C3 obtained
SUCCESSFUL results; however, surgeon C4 obtained
SUCCESS in only 50% of the surgeries, which may
indicate the influence of the surgeon factor. In the case
of speech results, values of hypernasality tests greater
than 6 are indicative of a possible FAILURE.
In the same way as the rules of the decision
tree, the rules presented by the model induced by the
Apriori algorithm must be evaluated by a professional
to validate them against reality. The Apriori algorithm
does not deal with quantitative attributes, only with
categorical ones, which requires excluding some
attributes or even their transformation to nonnumerical data (discretization process); this strategy
was used in some processing carried out in this
work. Thus, to avoid this limitation in future work,
other algorithms may be experimented with, such as
AprioriTid, SETM, and AprioriHybrid22.
The analysis of Table 3 indicates that, in
general, the absence of post-surgical complications
(infection and fever) and speech results with absent
hypernasality, as well as patients without suggestive of
velopharyngeal dysfunction, present SUCCESS after
primary palatoplasty. Concerning surgical procedures,
there are indications that the Furlow technique and
the Vomer flap are frequent in the FAILURE group.
Observations such as the absence of cough, vomiting,
or infection alone cannot be used as parameters to rule
out a possible FAILURE.
7 Rev. Bras. Cir. Plást. 2023;38(1):e0657
Silva PP et al. www.rbcp.org.br
The analysis of Table 4 shows that a palatoplasty
in the group of patients who had a result of FAILURE
lasts an average of 79.5 minutes; for the group of
patients with SUCCESS results, the average drops to
62.57 minutes. There are indications, therefore, that
longer surgeries tend to cause worse results.
Finally, it is recognized that this study offers only
a punctual perspective of reality through the analysis
of models induced by data mining techniques in the
considered database since it reveals only a few factors
associated with the results of palatoplasty from the
point of view of the mining algorithms, with the need
for validation by health professionals.
CONCLUSION
Data analysis revealed that the absence of some
post-surgical complications (fever, cough, infection)
together with speech results after surgery (hypernasality,
suggestive of velopharyngeal dysfunction) and with
characteristics associated with surgical treatment
protocols (technique, the flap of the vomer, surgeon)
could help to predict the success or failure of the
palatoplasty.
COLLABORATIONS
PPS Analysis and/or data interpretation, Data
Curation, Formal Analysis, Investigation, Writing -
Original Draft Preparation.
EGS Analysis and/or data interpretation, Data
Curation, Methodology, Writing - Original Draft
Preparation.
VSA Data Curation, Final manuscript approval,
Writing - Original Draft Preparation, Writing -
Review & Editing.
TVSB Final manuscript approval, Visualization, Writing -
Original Draft Preparation, Writing - Review &
Editing.
GAP Resources, Writing - Original Draft Preparation,
Writing - Review & Editing.
MIPK Visualization, Writing - Original Draft Preparation,
Writing - Review & Editing.
JCRD Final manuscript approval, Project
Administration, Supervision, Writing - Review
& Editing.
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Patrick Pedreira Silva
R. Silvio Marchione, 3-20, Vila Nova, Cidade Universitaria, Bauru, SP, Brazil.
Zip code: 17012-900
E-mail: [email protected]
*Corresponding author:
1 Rev. Bras. Cir. Plást. 2023;38(1):e0677
ORIENTA COVID-19 app
Aplicativo ORIENTA COVID-19
Objective: Develop an application to guide health professionals during home
care in coping with the COVID-19 pandemic. Method: The structure of the
application was developed in four stages: Analysis - an integrative literature
review was carried out with the Health Sciences databases, such as MEDLINE,
SciELO, and LILACS. Design - this step involved planning and producing didactic
content, defining topics and writing subjects, selecting media, and designing
the interface (layout). Development - definition of the navigation structure and
planning of the configuration of environments. Implementation - construction
of an environment for downloading the application on the Internet. Results:
The ORIENTA COVID-19 application has 40 screens and 130 images describing
gowning, and undressing of PPE, including using a homemade mask, guidelines for
care to prevent COVID-19, and social etiquette. After registration at the National
Institute of Industrial Property, it will be available on the Google Play Store under
ORIENTA COVID-19. Conclusion: After an integrative review of the literature
obtained from the main databases, the ORIENTA COVID-19 application was
developed to support health professionals during home care related to COVID-19.
Descritores: COVID-19; SARS-CoV-2; Aplicativos móveis; Equipamento de
proteção individual; Estratégia saúde da família; Cuidados de enfermagem;
Atenção terciária à saúde.
Objetivo: Desenvolver um aplicativo para orientar os profissionais de saúde durante
o atendimento domiciliar, no enfrentamento da pandemia da COVID-19. Método: A
estrutura do aplicativo foi desenvolvida em quatro etapas: Análise - foi realizada uma
revisão integrativa da literatura junto às bases de dados das Ciências da Saúde, como:
MEDLINE, SciELO e LILACS. Design - esta etapa envolveu o planejamento e a produção
do conteúdo didático, a definição dos tópicos e a redação dos assuntos, a seleção das
mídias e o desenho da interface (layout). Desenvolvimento - definição da estrutura
de navegação e o planejamento da configuração de ambientes. Implementação -
construção de um ambiente para download da aplicação na Internet. Resultados: O
aplicativo ORIENTA COVID-19 tem 40 telas e 130 imagens descrevendo a paramentação,
desparamentação dos EPIs incluindo a técnica do uso da máscara caseira, orientações
dos cuidados para prevenir a COVID-19 e a etiqueta social. Após seu registro no Instituto
Nacional da Propriedade Industrial, estará disponível no Google Play Store sob o nome
ORIENTA COVID-19. Conclusão: Após revisão integrativa da literatura obtida nas
principais bases de dados, desenvolveu-se o aplicativo ORIENTA COVID-19, para apoio
aos profissionais da saúde durante o atendimento domiciliar relacionado à COVID-19.
■ ABSTRACT
■ RESUMO
Original Article
Keywords: COVID-19; SARS-CoV-2; Mobile applications; Personal protective
equipment; Family health strategy; Nursing care; Tertiary healthcare.
JOSÉ RONALDO ALVES1
GERALDO MAGELA
SALOMÉ1
*
1
Universidade do Vale do Sapucaí. Mestrado Profissional em Ciências aplicadas à Saúde, Pouso Alegre, MG, Brazil.
DOI: 10.5935/2177-1235.2023RBCP0677-EN
Institution: Universidade do
Vale do Sapucaí, Pouso Alegre,
MG, Brazil.
Article received: December 11, 2021.
Article accepted: April 7, 2022.
Conflicts of interest: none.
ORIENTA COVID-19 Application
Rev. Bras. Cir. Plást. 2023;38(1):e0677 2
information about the techniques for using PPE and
the guidelines that must be provided to patients,
family members, and caregivers to prevent the spread
of COVID-19 for family members, caregivers, and the
community. Thus, when using this technology, the
professional who provides care at home will provide
harm-free, safe, and risk-free care for the patient, family
members, caregivers, and the community.
OBJECTIVE
Develop an application to guide health professionals
during home care in the fight against the COVID-19
pandemic.
METHOD
The study applied the modality of technological
production based on software engineering of the
methodological development research type. The study
was developed at the University of Vale do Sapucaí from
February to March 2020.
The study was approved by the Research Ethics
Committee of the Faculdade de Ciências da Saúde Dr.
José Antônio Garcia Coutinho (Opinion No. 4,472,241).
For the construction of the ORIENTA COVID-19
application, the methodology relevant to Contextualized
Instructional Design was used, which involves a
constructivist proposal and consists of the intentional
action of planning, developing, and applying specific
didactic situations, incorporating mechanisms that favor
contextualization11,12. The construction of the ORIENTA
COVID-19 application followed the following steps:
First step: Analysis
An integrative literature review was performed.
The following steps were delimited for the development
of the research: identification of the theme and selection
of the research question; the establishment of criteria
for the inclusion and exclusion of studies; defining
the information to be extracted from the selected
studies and categorizing the studies; the evaluation
of the studies included in the integrative review; the
interpretation of the results, presentation of the review;
and the synthesis of knowledge12.
The theme was “Application to guide health
professionals in coping with the COVID-19 pandemic
during home care”.
The objective was to answer the following
guiding question: What are the personal protective
equipment and the correct techniques to use during
home care of patients with COVID-19?
What should preventive measures available in
the literature be provided to patients, family members,
INTRODUCTION
Respiratory secretions and saliva transmit
COVID-19. Some precautions are indicated to avoid
contamination and transmission to other individuals,
such as: covering your mouth when coughing or
sneezing, washing your hands regularly, and avoiding
touching your face, especially in the area of eyes, nose,
and mouth1,2.
The performance of health professionals who
provide home care goes beyond hospital environments.
Many work in the patients’ homes and, in this health
context, home patients are generally those with acute,
chronic, re-aggravated conditions, in palliative care,
with respiratory syndromes, neurological disorders,
hypertension, and diabetes more susceptible to the
COVID-19 virus.3,4
Professionals who provide home care must have
technical-scientific knowledge that goes beyond those
learned during professional training, as entering the
home and developing care actions requires much more
than knowing and acting. This is because the care is
performed in a space controlled by the patient and his
family, and the health professional is a mere guest3,4.
There is a need for health professionals to
strictly observe the precautions standardized by the
Ministry of Health in order to minimize transmission.
It is recommended that the use of personal protective
equipment (PPE) be adopted by all health professionals
involved in home care and that all patients, family
members, and caregivers are advised on the measures
to be used to prevent infection COVID-195,6.
In this sense, it is important to build and validate
applications that provide professionals with appropriate
information on the use of PPE and measures to prevent
the spread of COVID-19 infection for patients, family
members, caregivers, and communities. Thus, when
using this technology, the professional will safely
provide damage-free care with minimal risk to the
patient, avoiding contamination.
An application is a software with a specific function
capable of assisting in a given task. Smartphones are
important tools, as most of the population has them,
and they are almost always available due to their
portability7
.
The use of computational tools in the health
area is expanding, as this type of support can provide
professionals with greater precision and agility in
their work. Concerning assistance in the health area
in Brazil, the adoption of technological resources has
been a growing factor since the 1960s, with the scientific
foundation of the profession8-10.
This research is part of a project to develop a
mobile application for health professionals, providing
3 Rev. Bras. Cir. Plást. 2023;38(1):e0677
Alves JR et al. www.rbcp.org.br
and caregivers to prevent the spread of COVID-19 to
family members, caregivers, and the community?
For the construction of an adequate question for
the resolution of the researched clinical question, the
PICO13 strategy was used, with “P” corresponding
to the population (a health professional who attends
at home); “I” to intervention (technique of PPE and
undressing and preventive measures that professionals
should use during home care related to the transmission
of COVID-19); “C” for comparison (does not apply, as
this is not a comparative study) and “O” for an outcome
(application protocol).
An integrative literature review was carried
out with the Health Sciences databases: (MEDLINE),
Scientific Electronic Library Online (SciELO), and
Latin American and Caribbean Literature in Health
Sciences (LILACS).
The descriptors controlled in Health Sciences were
COVID-19, personal protective equipment, family health
strategy, and home care. Depending on the searched
base, the search strategy occurred from its different
combinations, adopting the Boolean AND operator in
Portuguese, Spanish, and English.
The following inclusion criteria were adopted
for the selection of publications: only primary studies
directly connected with the theme; be available in full,
original articles published between 2015 and 2020.
As exclusion criteria: theses, dissertations,
monographs, technical reports, and articles that, after
reading the abstract, are not related to the proposed
object of study, and publications that are repeated in
the databases.
The titles and abstracts were read independently
by two authors of the study in question to ensure that
the texts contemplated the guiding question of the
review and met the established inclusion criteria. In
case of doubt regarding the selection, it was decided
to initially include the publication and decide on its
selection only after reading its entire content.
To classify the level of evidence of the selected
studies, the categories of the Agency for Healthcare
Research and Quality were used, which cover six levels:
Level 1: evidence resulting from the meta-analysis of
multiple controlled and randomized clinical trials;
Level 2: evidence obtained from individual studies
with an experimental design; Level 3: evidence from
quasi-experimental studies; Level 4: evidence from
descriptive studies (non-experimental) or qualitative
approach; Level 5: evidence from case reports or
experience; Level 6: evidence based on expert opinion.
Chart 1 presents the articles selected during the
integrative literature review to develop the ORIENTA
COVID-19 application, which were classified according
to the level of evidence.
Second step: Design
This step involved planning and producing
didactic content, defining topics and writing subjects,
selecting media, and designing the interface (layout).
We opted for using texts, drawings, photos, and videos
structured in topics. The didactic contents addressed in
the application were distributed in the following phases:
Phase 1 - COVID-19 infection
Information was provided on the definition,
type, signs, and symptoms of COVID-19 and preventive
measures recommended by the World Health
Organization.
Phase 2 - Use of Personal Protective Equipment by
health professionals during the COVID-19 pandemic
At this stage, the definition of PPE was provided;
thus, the types of PPE recommended by the World
Health Organization should be used when providing
care to patients with COVID-19.
We will also seek well-defined instructions on the
correct techniques for donning and undressing PPE during
home care, which must be carried out systematically to
prevent the professional from contracting the infection.
Phase 3
The second phase will consist of preventive
measures that professionals should guide patients,
family members, caregivers, and the community during
home care to avoid contamination and transmission of
the COVID-19 infection.
Third stage: Development
Understood the selection of the application’s
tools, the definition of the navigation structure, and
the planning of the configuration of environments. A
decision tree was built to guide the professional system
analyst regarding the construction of the application.
Fourth step: Implementation
The configuration of tools and educational and
technological resources was prepared, as well as the
construction of an environment for downloading an
application on the Internet and installing it on a mobile
device, which will be available for free on the Play Store.
RESULTS
During the integrative literature review, 9,982 articles
were identified in the LILACS, PUBMED, and SciELO
ORIENTA COVID-19 Application
Rev. Bras. Cir. Plást. 2023;38(1):e0677 4
databases. After exclusion, 19 articles were selected to
develop the ORIENTA COVID-19 application (Figure 1).
The application has 40 screens and 130 images
describing clothing and undressing of PPE, including
the technique for using a homemade mask, care
guidelines to prevent the transmission of COVID-19,
and social etiquette. Examples of application screens
are shown in Figure 2.
DISCUSSION
Many applications are available online, including
everything from fitness systems to monitoring and
controlling the most diverse diseases. When well
designed, they are didactic and educational tools that
can benefit patients and health professionals10,31,32.
The application developed in this study sought
to meet the needs and clarify doubts of health
professionals who are at the forefront of home care,
offering information about the types and correct
techniques for using PPE and measures to prevent and
avoid contamination and transmission of the infection
caused by COVID-19 among professionals, patients,
families, caregivers, and communities.
The use of applications as a tool for therapeutic,
preventive, and diagnostic procedures is quite
innovative and capable of generating interest and
motivation for learning since the mobile devices that
host these applications are used by 45% to 85% of health
professionals or caregivers, being consulted more than
books and magazines10,29-32.
An application developed by health professionals
should be built to manage care, indicate preventive
measures and assist in formulating the diagnosis,
and provide subsidies for a clinical assessment of risk
factors for developing a disease or complication10,31,32 .
The ORIENTA COVID-19 application was
developed after an integrative literature review. It can
be considered a technological innovation in health as
it is the first mobile application produced in Brazil
to support health professionals during home care,
bringing benefits to health professionals, caregivers,
and patients assisted, and providing guidance that
should be provided during the COVID-19 home visit,
Figure 1. Flowchart of the studies’ identification, selection, and inclusion process, prepared based on the PRISMA recommendation. Pouso Alegre, MG, Brazil, 2021.
Articles identified through database searches (n=9,982)
Records after eliminating
duplicate studies
(n=5,459)
Studies excluded
(n=4,523)
Studies selected after
reading the title (n=468)
Studies excluded
(n=4,991)
Studies excluded
(n=399)
Studies selected after
reading the abstract (n=69)
Studies selected after
reading the articles in full
(n=20)
Studies excluded
(n=49)
Studies selected for
the construction of the
ORIENTA COVID-19
application (n=19)
Studies excluded
(n=01)
LILACS
(n=3,421)
PUBMED
(n=6,076) SciELO (n=485)
IDENTIFICATION
ELIGIBILITY
INCLUSION
5 Rev. Bras. Cir. Plást. 2023;38(1):e0677
Alves JR et al. www.rbcp.org.br
thus avoiding the transmission of the infection to the
relatives of the patients assisted and to the community.
Applications must be built scientifically, so the
application favors the execution of the correct technique
and general care, systematic and individualized care
recording, enabling safe assistance30-32.
The ORIENTA COVID-19 application allows
quick access to information on the main national and
international guidelines during home visits through
smartphones and tablets. It assists the professional
in data collection, guidance related to signs and
symptoms, and preventive measures to avoid the
transmission of COVID-19. It also offers which PPE
should be used by professionals during home visits
and the technique of gowning and undressing. It also
contributes to the professional’s routine, increasing their
scientific knowledge, as it puts an up-to-date tool in the
professional’s pocket that helps clinical practice develop
actions to prevent complications, damages, and risks.
CONCLUSION
After an integrative review of the literature obtained
from the main databases, a multimedia application
was developed on a mobile platform called ORIENTA
COVID-19 to support health professionals during home
care related to signs and symptoms, preventive measures
to prevent the spread of COVID-19 among professionals,
family members, caregivers, the community and guide
the use of personal protective equipment.
The application developed in this study can
potentially reduce adverse events, assisting with
minimal risk, damage, and greater safety and quality, but
its update will be carried out according to new evidence.
Figure 2. Screen examples of the ORIENTA COVID-19 application. (A) Summary with hyperlinks to the subjects addressed; (B) Recommendations for home
care; (C) Screen related to the choice of personal protective equipment and gowning and undressing techniques; and (D) Mask care during use and after
removing it. Pouso Alegre, MG, Brazil, 2021.
COLLABORATIONS
JRA Analysis and/or data interpretation, Conception
and design study, Data Curation, Final manuscript
approval, Formal Analysis, Funding Acquisition,
Methodology, Project Administration, Realization
of operations and/or trials, Software, Validation,
Writing - Original Draft Preparation.
GMS Analysis and/or data interpretation, Final
manuscript approval, Methodology, Supervision,
Validation, Visualization, Writing - Original Draft
Preparation, Writing - Review & Editing.
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Geraldo Magela Salomé
Av. Prefeito Tuany Toledo, 470, Pouso Alegre, MG, Brazil.
Zip code: 37550-000
E-mail: [email protected]
*Corresponding author:
1 Rev. Bras. Cir. Plást. 2023;38(1):e0185
Increase in the volume of the breast implant by
passing organic material into it
Aumento do volume do implante mamário por passagem de material
orgânico para seu interior
Introduction: The search for an anatomical substitute for the breast, for the purpose of
correcting aesthetic problems has a long history of failure until the arrival of silicone. Since
the beginning of its use, in the 1960s, many complications have appeared, such as infection,
rejection, rupture, in addition to silicone leakage. We did not find in the literature, however,
any report on the passage of materials from the human organism to the interior of implants.
The objective is to identification by infrared spectrophotometry (FTIR) and clinical
analysis, reporting the passage of organic substances into breast implants without any
violation of their capsule. Methods: 1500 pairs of breast implants were analyzed, surgically
removed from 1998 to 2018. Of which six were included in the study. Results: Three
materials were analyzed showing macroscopic changes in their interior, without violating
the capsule. A second sample was performed on a similar implant, but without use. The
third material was a sample of fatty breast tissue removed from the patient during the
surgery. Materials compatible with fat, animal protein and hemoglobin were found inside
the implant. Conclusions: The change evidenced in the material inside the two implants
indicates the occurrence of the passage of organic materials through an intact capsule.
Keywords: Breast; breast implants; Implant capsular contracture; Reconstructive
surgical procedures; Lipids.
1
Clínica Dr. Milton Daniel, Cirurgia Plástica, Curitiba, PR, Brazil.
2
Faculdade Evangélica Mackenzie do Paraná, Medicina, Curitiba, PR, Brazil.
3
Hospital do Trabalhador, Cirurgia Geral, Curitiba, PR, Brazil.
DOI: 10.5935/2177-1235.2023RBCP0185-EN
Conflicts of interest: none.
Introdução: A busca de um substituto anatômico para a mama, para fins de correção
de problemas estéticos, tem longa história de insucessos até a chegada do silicone.
Desde o início de seu uso, na década de 1960, muitas complicações surgiram, como
infecção, rejeição, rotura, além do extravasamento de silicone. Não encontramos na
literatura, porém, relato algum sobre a passagem de materiais do organismo humano
para o interior de implantes. O objetivo é a identificação por espectrofotometria
de infravermelho (FTIR) e análise clínica, relatando a passagem de substâncias
orgânicas para o interior de implantes mamários sem que os mesmos apresentem
violação qualquer de sua cápsula. Método: Foram analisados 1500 pares de
implantes mamários, removidos cirurgicamente no período de 1998 a 2018. Destes,
seis foram encaminhados incluídos no estudo. Resultados: Foram analisados três
materiais apresentando alterações macroscópicas em seu interior, sem que houvesse
violação da cápsula. Uma segunda amostra foi realizada em implante semelhante,
porém sem uso. O terceiro material foi uma amostra de tecido gorduroso mamário
removido da própria paciente durante o ato cirúrgico. Foram encontrados materiais
■ RESUMO
■ABSTRACT
Original Article
MILTON JAIME BORTOLUZZI
DANIEL1
LEANDRO ALVES GARCIA
BORTOLUZZI DANIEL2
VITOR ALVES GARCIA
BORTOLUZZI DANIEL3
LINCOLN GRAÇA NETO2
*
Institution: Clínica Privada,
Curitiba, PR, Brazil.
Article received: February 26, 2019.
Article accepted: September 13, 2022.
Breast implant volume augmentation by organic material
Rev. Bras. Cir. Plást. 2023;38(1):e0185 2
INTRODUCTION
The search for an anatomical substitute for
the breast to correct aesthetic problems, hypoplasia
or hypotrophy, has a long history of failures until the
arrival of silicone. Since the beginning of its use in the
1960s, many complications have arisen and have always
been the nightmare of any surgeon, such as capsular
contracture, capsule rupture, and calcification, in
addition to silicone leakage into the surrounding
structures, generating local manifestations1
.
Several alterations were attempted in the
capsule and the silicone to avoid such complications,
such as the thickness and texture of the capsule, the
polyurethane cover in the 1970s2
, and the cohesive
gel, in the 1990s3
. Since then, silicone implants have
increased applicability in breast augmentation and
reduction surgeries, as well as correction of ptosis4-6,
corroborated by the exponential increase in the number
of studies on the subject7
.
We did not find a report on the passage of materials
from the body into implants in the current literature.
OBJECTIVE
The present study seeks, through identification
by infrared spectrophotometry (FTIR), combined
with observation and careful clinical analysis, carried
out over more than 20 years, of 1500 pairs of breast
implants surgically removed, to report the passage of
organic substances to the interior of breast implants
without showing damage, cracks or violation of any of
their capsules.
METHOD
The present work clinically analyzed a sample of
1500 pairs of breast implants surgically removed from
1998 to 2018, showing changes in volume, shape, and
color between units of the same pair (Figures 1, 2, 3,
4, 5, 6, 7, 8, 9 and 10). Six pairs were sent for analysis
by comparative qualitative chemical identification by
infrared spectrophotometry (FTIR) before and after
sample preparation by acetone solvent extraction.
Three materials were analyzed, one of which
was an implant surgically explanted after years of
compatíveis com gordura, proteína animal e hemoglobina no interior do implante.
Conclusões: A alteração evidenciada no material do interior dos dois implantes nos
indica a ocorrência de passagem de materiais orgânicos através de cápsula intacta.
Descritores: Mama; Implantes de mama; Contratura capsular em implantes; Procedimentos cirúrgicos reconstrutivos; Lipídeos.
Figure 1. First implant found more than 20 years ago with a substance inside.
Figure 2. Patient with enlargement of the left breast after 3 years of
implantation.
use, showing macroscopic changes inside, without
capsule violation. A second sample was performed on
a similar but unused implant. The third material was
a breast fat tissue sample removed from the patient
during surgery. Comparative analysis was performed
between all materials and the reference, and all samples
were compared. There was also an evaluation of other
materials found inside, different from silicone.
3 Rev. Bras. Cir. Plást. 2023;38(1):e0185
Graça Neto L et al. www.rbcp.org.br
Figure 3. Pair of textured submuscular implants, explanted after 3 years of
use. It can be seen on the left showing a yellowish color and an increase of
30ml. Whenever the implant changes its original color, there is fat inside it.
Figure 4. A: Original prosthesis 255cc polyurethane and 300cc with volume
increase by substances inside. B: Same inverted prostheses. C: Transoperative
explantation.
Figure 5. Patient with increased volume in the left breast after 8 years of
implantation. Two pregnancies in the period.
RESULTS
Materials compatible with fat (fatty acid ester),
animal protein (hydrolyzed animal protein), and
hemoglobin (protein of hemoglobin) were found inside
the implant, altered after years of use, with no cracks or
leaks in the external capsule. The breast fat sample was
compatible with the material found inside the altered
implant and the laboratory reference. Meanwhile,
the only material found in the unused implant was
Figure 6. Silimed® implant 215cc polyurethane. By transillumination, the
substance is observed inside the prosthesis.
Figure 7. Silimed® implant 215cc polyurethane. Increased to 300cc after 8
years of use.
polydimethylsiloxane, evidenced inside both samples,
regardless of use, as expected.
DISCUSSION
Despite the evolution of breast implants, with
changes in the gel of their content and the elastomer
(wrap), complications such as capsular contracture,
rupture, and microleakage persist7
. The literature
presents many studies of silicone migration to
contiguous breast tissue and adjacent lymphatic tissue,
but no publication is found on the migration of organic
tissue from the patient’s body to the interior of the
silicone breast prosthesis2,3.
In daily clinical practice (private clinic) dedicated
to many breast surgeries, approximately 1500 cases
Breast implant volume augmentation by organic material
Rev. Bras. Cir. Plást. 2023;38(1):e0185 4
Figure 8. Menthor 225cc implant, 5 years old, in transillumination.
Figure 9. 280cc Pherthese implant showing heterogeneity inside.
of pair exchanges of silicone breast implants were
performed, the vast majority due to capsular contracture
and the silicone prosthesis rupture and aesthetic
dissatisfaction of the patients.
In this 20-year series (1998 to 2018), some samples
were noted that were above normal in size and weight
(observation with the naked eye) and also with changes
in the color of their contents, predominantly yellowish
tones, but without signs of damage, cracks or violation
of any of the implant casing.
In this way, without many resources at that
time, the observation was carried out through
transillumination, which did not bring technical
analysis or veracity, but sharpened curiosity even more.
The study continued with the six pairs sent for analysis
by comparative qualitative chemical identification by
infrared spectrophotometry (FTIR).
Materials compatible with fat (fatty acid ester),
animal protein (hydrolyzed animal protein), and
hemoglobin (protein of hemoglobin) were found inside
the implants. In order to corroborate that the fat
tissue found inside the implant could even be human
and from the same patient, a small breast fat sample
was resected, which served as a parameter and was Figure 10. Silimed® 355cc implant, removed after 4 years of use.
5 Rev. Bras. Cir. Plást. 2023;38(1):e0185
Graça Neto L et al. www.rbcp.org.br
compatible with the material found inside the altered
implant, as well as with the laboratory reference.
This demonstrates the migration of organic
components into the silicone prosthesis, proving that
the possible microcracks allow the passage of content
from the inside to the outside and in the opposite
direction, from the outside to the inside.
CONCLUSION
The breast implant presents interaction with the
organism, with the passage of substances, mainly lipids
(fatty acid), animal proteins, and hemoglobin, into the
interior of the implant, without damage or violation in
the capsule surrounding it. This process can cause harm
to the patient as it leads to inflammatory responses and
increase in breast volume, often unilaterally, generating
breast asymmetry, clinically confused with breast
pseudo-contracture, and a possible increase in the
incidence of capsular contracture, showing no difference
between submuscular and subglandular implantation.
Changes are usually clinically noticeable after the fourth
year of surgery, appearing to be progressive.
The alteration evidenced in the material inside the
two implants, which differ only in terms of use, indicates
the occurrence of the passage of organic materials through
the intact capsule, in a flow not yet reported in the
literature, from the human body to the inorganic implant.
REFERENCES
1. Berson M. Derma-fat transplant used in building up the breasts.
Surgery. 1945;15:451-6.
2. Miró AL. Próteses mamárias revestidas com poliuretano:
avaliação de 14 anos de experiência. Rev Bras Cir Plást.
2009;24(3):296-303.
3. Wagenführ Júnior J. Análise histopatológica comparativa das
cápsulas dos implantes de espumas de silicone e poliuretano
em ratos. Rev Bras Cir Plást. 2007;22(1):19-23.
4. Daniel MJB. Inclusão de Prótese de Mama em Duplo Espaço -
Prêmio Georges Arié 2004. Rev Bras Cir Plást. 2005;20(2):82-7.
5. Saldanha OR, Maloof RG, Dutra RT, Luz OAL, Saldanha Filho O,
Saldanha CB. Mamaplastia redutora com implante de silicone.
Rev Bras Cir Plást. 2010;25(2):317-24.
6. Almeida ARH, Araújo GKM, Mafra AVC, Pimenta PS, Fabrini
HS. Mastoplastia de aumento com inclusão de implante
de silicone associado a mastopexia com abordagem inicial
periareolar (safety pocket). Rev Bras Cir Plást. 2012;27(4):569-75.
7. Roncatti C, Batista KT, Roncatti Filho C. Escolha da técnica
de mastoplastia de aumento: uma ferramenta na prevenção de
litígio médico. Rev Bras Cir Plást. 2013;28(2):253-9.
Lincoln Graça Neto
Av. Visconde de Guarapuava, 4742, Batel, Curitiba, PR, Brazil.
Zip Code: 80240-010
E-mail: [email protected]
*Corresponding author:
COLLABORATIONS
MJBD Analysis and/or data interpretation, Conception
and design study, Conceptualization, Data
Curation, Final manuscript approval,
Funding Acquisition, Methodology, Project
Administration, Resources, Supervision,
Visualization
LAGBD Analysis and/or data interpretation,
Conceptualization, Data Curation, Final
manuscript approval, Formal Analysis,
Investigation, Methodology, Project
Administration, Resources, Supervision,
Validation, Visualization, Writing - Original Draft
Preparation, Writing - Review & Editing.
VAGBD Analysis and/or data interpretation, Final
manuscript approval, Formal Analysis,
Supervision, Visualization, Writing - Review
& Editing.
LGN Writing - Review & Editing.
1 Rev. Bras. Cir. Plást. 2023;38(1):e0463
ANTONIO ROBERTO
BOZOLA1
*
ALEXANDRE CARONI
BOZOLA1
ITALO BOZOLA FILHO1
Introduction: Complications in immediate breast reconstruction after skinpreserving mastectomies are recurrent. The authors describe conduct to reduce
them and improve the anatomical/esthetic result using implants. The objective
is to reduce the incidence of areolar necrosis, improve breast projection in
reconstructions with submuscular implants, recover partial or total sensitivity, and
facilitate symmetrization. Method: The mastectomy involves a lateral transverse
incision from the areolar border to the armpit. Repair with implants included in
a mixed plane by divulsion of the pectoral muscle, dividing it into two portions in
the direction of its fibers, the association of the serratus muscle fascia and inferior/
lateral subcutaneous tissue, and/or pectoralis minor muscle in the superolateral
area. The incision is sutured when there is no breast ptosis or superimposed
by de-epidermization of one of the borders, which may include a reduction in
diameter and relocation of the areola. Or fusiform de-epidermization of the
periareolar skin and medially to it. The contralateral risk-reducing mastectomy
had a similar procedure, improving symmetry. Results: 106 patients (212 breasts)
were operated on with satisfactory results and complications due to infection,
positioning of the implants on the learning curve, and surface irregularities.
Conclusion: Immediate breast reconstruction after skin-preserving mastectomy
by the proposed method is a possible option, obtaining good breast symmetrization
and projection, return of sensitivity, and absence of total necrosis of the areola.
Keywords: Breast; Prostheses and implants; Mammaplasty; Breast Neoplasms.
Reconstructive surgical procedures.
1
Faculdade Estadual de Medicina de São José do Rio Preto, Divisão de Cirurgia Plástica, São José do Rio Preto, SP, Brazil.
DOI: 10.5935/2177-1235.2023RBCP0463-EN
Institution: Faculdade de
Medicina de São José do Rio
Preto, Disciplina de Cirurgia,
Departamento de Cirurgia Plástica,
São José do Rio Preto, SP, Brazil.
Article received: August 27, 2020.
Article accepted: September 13, 2022.
Conflicts of interest: none.
Introdução: Complicações nas reconstruções imediatas de mamas pós-mastectomias
preservadoras de pele são recorrentes. Os autores descrevem conduta para
redução delas e melhoria do resultado anatômico/estético utilizando implantes.
O objetivo é reduzir a incidência de necroses areolares, melhorar a projeção das
mamas nas reconstruções com implantes submusculares, recuperar a sensibilidade
parcial ou total e facilitar a simetrização. Método: A mastectomia é realizada com
incisão transversal lateral, do bordo areolar à axila. A reparação com implantes
incluídos em plano misto por divulsão do músculo peitoral, dividindo-o em duas
porções na direção de suas fibras, associação da fáscia do músculo serrátil e
tecido celular subcutâneo inferior/lateral, e/ou músculo peitoral menor na área
superolateral. A incisão é suturada quando não há ptose mamária, ou superposta
por desepidermização de um dos bordos, podendo incluir redução do diâmetro
e relocação da aréola. Ou desepidermização fusiforme da pele periareolar e
medialmente a ela. A mastectomia contralateral redutora de riscos teve procedimento
semelhante, melhorando a simetria. Resultados: Foram operadas 106 pacientes (212
■ RESUMO
■ ABSTRACT
Immediate bilateral breast reconstruction after skinsparing mastectomy: cross-sectional incision and
implants in mixed plane
Reconstrução bilateral imediata de mamas pós-mastectomia preservadora
de pele: incisão transversal e implantes em plano misto
Original Article
Immediate bilateral breast reconstruction after skin-sparing mastectomy
Rev. Bras. Cir. Plást. 2023;38(1):e0463 2
Moreover, breast emptying causes reduced
sensitivity.
OBJECTIVE
The objective is to describe tactics as an attempt to
reduce the incidence of areolar necrosis, improve breast
projection with submuscular implants, subjectively
analyze the recovery of tactile breast sensitivity and
objectively the painful one, and facilitate symmetrization.
METHOD
This is a retrospective study of cases with an
analysis of medical records.
Those referring to unilateral mastectomy were
excluded, including expanders and subsequent repair,
late reconstructions, immediate or late reconstructions
with flaps, secondary repairs, and hygienic mastectomies.
With the patient standing, mark the breast lines
that form the quadrilateral where the implant’s base will
be located (Figure 1A)11. The mastectomy is performed
with a transverse incision from the lateral border of
the areola to the axillary region, taking advantage of
it to detect and remove the sentinel node or axillary
dissection (Figure 1B).
In the detachment of the glandular tissue, the
thickness of the skin and subcutaneous tissue must
be homogeneous and decreasing, from the base of the
breast to the papilla, without prejudice to the oncological
treatment. If there is breast ptosis, the incision is curved
with caudal concavity.
After oncological procedures, with no lymph
node emptying, the pectoralis major muscle is divulsed
obliquely in the direction of the fibers in half its width
(Figure 1C), gently detaching it with the index finger.
In the inferior caudal and medial direction, an electric
scalpel is used, going beyond the submammary fold
(HLBL) by 2 centimeters, elevating along the anterior
aponeurosis of the rectus abdominis muscle, making
three vertical incisions in it, loosening its constriction.
Upwards, it is shifted up to 1.5cm below the
superior horizontal mammary line and paramedially
to the medial vertical mammary line 1.5cm from the
INTRODUCTION
The first description of the attempt to repair the
mastectomy area with a latissimus dorsi myocutaneous
flap dates back to the end of the 19th century, carried out
by Tanzini in 19061
. After 19812
, the aggressiveness of
the treatment of breast tumors was reduced, preserving
muscles, skin, sometimes the nipple-areolar complex
(NAC), and part of the gland. It was reconstructed after
quadrantectomy and radiotherapy intraoperatively or
later.
After 1991, skin-sparing mastectomies, and
sometimes NAC, in cases without lymph node metastasis
that did not require radiotherapy, received immediate
repair and incision changes3
. With the improvement of
implants, they became an option in the arsenal of tactics.
They allow for less surgical time, quick recovery, lower
hospital costs, and patient acceptance.
The symmetry is not adequate in a breast receiving
an implant, and the contralateral breast corrected with
its own tissues. Moreover, there is a description of an
incidence of 7.3% of occult ductal carcinoma and 4.6%
of lobular carcinoma “in situ” in this breast4
and a
cumulative risk of appearance of 0.5 to 1% each year of
life5
. In the presence of BRCA1/2 and a family history of
breast cancer6
, contralateral subcutaneous mastectomy
(risk reduction) may be indicated, repairing it with an
implant. The permanence of this breast, risk reduction7,
and better symmetry and aesthetics are the patient’s
decision8,9.
Post-mastectomy repair has intercurrences,
under any approach, occurring even in experienced
hands (34.64%)10. Removing tissues close to the NAC,
either by necessity or prevention, reduces periareolar
vascularization, with eventual necrosis.
If the skin and subcutaneous coverage are less
than 1.5/2.0cm thick, inserting the implant in the
supramuscular plane is not ideal. It is recommended
to place it under the pectoral muscle and serratus
anterior, but the projection of the reconstructed breast
is reduced by muscle pressure. Furthermore, implant
displacement in the cranial direction may occur, causing
discomfort during muscle contraction or lateral-inferior
displacement.
mamas) com resultados satisfatórios e complicações por infecção, posicionamento
dos implantes na curva de aprendizado, e irregularidades de superfície. Conclusão:
Reconstrução imediata das mamas pós-mastectomia preservadora de pele
pelo método proposto é opção possível, obtendo boa simetrização e projeção
das mamas, retorno da sensibilidade e ausência de necrose total de aréola.
Descritores: Mama; Próteses e implantes; Mamoplastia; Neoplasias da mama;
Procedimentos cirúrgicos reconstrutivos.
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Bozola AR et al. www.rbcp.org.br
Figure 1. A: Marking the quadrilateral where the implant will be located
between the vertical and horizontal mammary lines HHBL-HLBL-VMBLVLBL, the meridian, and point A. B: Lateral incision for exploration of the
sentinel node and skin-sparing mastectomy completed.
A
B
C
mid-external line11, similarly to what is used in breast
augmentation by some authors12-14. Laterally, the entire
pectoral muscle is detached until the aponeurosis of the
serratus anterior muscle is found. Ahead, it is detached,
including muscle fibers, added to the loose subcutaneous
tissue over the delicate aponeurosis, together up to
the vertical lateral breast line (VLBL)11, sufficient to
obtain the lateral and inferior contour of the pocket and
accommodate the implant (Figure 2A).
This is lodged between the two strands of the
pectoral muscle. In its outline, the implant is covered
Figure 2. A: Store where the implant will be placed with the lateral region
composed of subcutaneous cellular tissue and some serratus muscle fibers
seen by transillumination. B: Implant positioned and smooth closure of the
pectoralis major muscle at the lateral/superior pole. C: Scheme provided by
Leandro Debs12, slightly modified, of the implant positioned in his pocket.
A
B
C
Immediate bilateral breast reconstruction after skin-sparing mastectomy
Rev. Bras. Cir. Plást. 2023;38(1):e0463 4
by the muscle, and in the center, it is free to protrude
and obtain a better base/height ratio15 (Figure 2B). To
prevent their retraction during healing, gentle traction
stitches with absorbable sutures are placed between
the divulsed strands in the superolateral half over the
implant (Figures 2B and 2C).
If the pectoralis minor muscle has good extension
and volume, the pectoralis major is moved medially
from its lateral border, and the minor one laterally to
the vertical lateral breast line (VLBL), reinforcing the
superolateral part of the pocket (Figures 3A and 3B).
circulation, allowing areolar and periareolar irrigation.
The dermis that folds under itself protects the implant
and gives the breast greater projection. The skin is
sutured with separate non-absorbable stitches, gentle
traction, and constriction.
Vacuum drainage of the subcutaneous pocket is
necessary until the daily volume drained is less than
30 ml/24 hours. The end of the drain is placed in the
axillary region and extruded in the inferior medial
pole (Figure 4D). The same procedure is performed on
the contralateral breast for symmetrization and risk
reduction.
The initial bandage covers the incisions with
insulating ointment, and the breast is covered with a
microporous tape bra, which remains and is retouched
until the stitches are removed, around 12 days (Figure 5A).
From the first day onwards, a delicate, seamless,
slightly compresswive bra is applied over it, plus a
bandage that slightly compresses the implants in
the caudal direction, preventing their displacement
upwards, until the formation of the fibrous capsule in 2
months (Figure 5B).
RESULTS
One hundred six patients (212 breasts) were
operated on in the same surgery as the skin-preserving
and contralateral risk-reducing mastectomy, using
the tactics described, from June 2009 to July 2019.
The patients are from a private clinic and signed an
Informative Consent and Enlightening.
Figure 3. A: Possibility of making the pocket by moving the pectoralis major
muscle medially. B: And the small pectoral to the side.
A B
After introducing the implant, the lateral edge of the
pectoralis major is sutured to the medial edge of the
pectoralis major.
The skin and subcutaneous tissue on the side
of the thorax, detached from the breast during the
mastectomy, are fixed to it with separate absorbable
sutures16,17.
Three options for final skin closure will be
determined by the excess amount preoperatively.
First: A subdermal and skin suture is performed
without initial ptosis (AM from 0 to 2cm). If the ptosis
is small (AM of 3/4cm)11, the lower part of the flap is
de-epithelialized and sutured to the lateral edge of the
pectoral muscle, reinforcing the superolateral coverage
of the implant.
Second: With medium ptosis (AM of 4/5cm) and
need to relocate or reduce the areolar diameter, in
addition to the procedure described in the first option,
the excess in the periareolar region is marked, the areola
is de-epidermized and repositioned.
Third: With large ptosis (MA greater than 5cm)11,
a transverse spindle is marked using a bidigital grip
around and medially to the areola. Its diameter is
demarcated, and the de-epidermized area is the new
areolar site (Figures 4A, 4B, 4C and 4D).
The closure of de-epidermized areas should
be performed with a few simple sutures separated
subdermal with absorbable threads, not strangling the
Figure 4. A: Marking of the periareolar de-epidermization spindle using a
bidigital grip. B: De-epidermization of the area, keeping the nipple-areolar
complex (NAC) vascularized. C: Marking of the new areolar site. D: Completed
sutures.
A B
C D
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Figure 5. A: Dressing and drainage in the 24-hour postoperative period. B:
Bra plus a slightly compressive band used for 60 days.
A B
Figure 6. Pre- and postoperative of a patient without breast flaccidity or need
to relocate the nipple-areolar complex (NAC).
Figure 7. Pre and postoperative with slight relocation of the nipple-areolar
complex (NAC).
Figures 6A, 6B, 6C, 6D, 6E and 6F; 7A, 7B, 7C, 7D,
7E and 7F; 8A, 8B, 8C, 8D, 8E and 8F; 9A, 9B, 9C, 9D, 9E
and 9F are from patients who underwent surgery with
good results.
Figure 8. Pre and postoperative with medium flaccidity and relocation of the
nipple-areolar complex (NAC) and correction of ptosis stretching medially
to the scar.
Figure 9. Pre and postoperatively with great flaccidity corrected and relocation
of the nipple-areolar complex (NAC).
Three patients had inflammatory signs and
seroma after one month (Table 1). In two, the drained
liquid was subjected to three cultures. Of these, the first
two were negative, and the third, in a different laboratory,
detected S. epidermidis. The third patient had a positive
result in the first culture. The implant was removed and
reoperated after four months in all three cases. The fibrotic
tissue was removed, and a new implant was inserted
(Figures 10A, 10B, 10C, 10D, 10E, and 10F). All of them
presented late moderate capsular contracture.
One patient presented late seroma after three
months due to trauma, drained for one week, without
vacuum, and use of anti-inflammatory drugs. The
resolution was satisfactory. One case of hematoma was
treated clinically. Only one patient had marginal, partial
areolar necrosis in the lower half, with spontaneous
healing. In this case, the lateral incision contoured the
areola inferiorly to the medial pole.
Two patients had skin suture dehiscence. In one, the
de-epidermized area protected the implant, and healing
was spontaneous. On the other, the muscle was exposed and
was solved with an elastic bandage18,19 (Figures 11A, 11B,
and 11C and Figures 12A, 12B, 12C, 12D, 12E, and 12F).
Immediate bilateral breast reconstruction after skin-sparing mastectomy
Rev. Bras. Cir. Plást. 2023;38(1):e0463 6
Figure 10. A and B: Patient with S. epidermidis infection. C and D: Implant
removed. E and F: After 5 months, reimplant without prior expansion.
A B C
D E F
Table 1. Complications and inadequate results after procedures.
106 Patients - 212 Breasts
Surface irregularity 25 - 23.58%
Seromas 3 - 2.83%
Post-trauma seroma 1 - 0.94%
S. Epidermidis infection 3 - 2.83%
Bruises 1 - 0.94%
Areolar necrosis 1 - 0.94%
Dehiscence of sutures 2 - 1.88%
Tall implants 2 - 1.88%
Contralateral breast tumor 5 - 4.71%
Complications and inadequate
results
35.82% of patients and
17.91% of breasts
Figure 11. A: Area of necrosis at the edges of the suture. B: Debridement and
elastic bandage. C: Resultant scarring.
A
B
C
The implant was positioned high 2 months
postoperatively in two initial cases.
Surface irregularity was the most frequent bad
result (25 cases).
The projection obtained was always similar to
breasts in good shape.
Perfect symmetry depended on regularity in the
“post-mastectomy flap” thickness, which was more easily
obtained when it was homogeneous bilaterally.
Tactile sensitivity was analyzed at 2/6 months, with
the examiner and the patient lightly sliding fingers over the
breast. The painful one with the tip/cannon of the needle
pressing against the skin in the quadrants determines it
hurts/does not hurt without the patient’s vision. The partial
or total return was constant and variable, smaller and later
the thinner the mastectomy skin remnant20.
DISCUSSION
Before puberty, the subcutaneous tissue over
the breast buds is thickly homogeneous. The hormonal
stimulus depends on the serum level, the elastic quality
of the skin, and the number of buds. The breasts, as
they grow, more or less distend the skin and reduce the
thickness of the subcutaneous tissue from its periphery in
the thorax to the NAC. This is the main cause of various
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Figure 12. Pre and postoperative of the case in Figure 11. The mastology team
removed the nipple-areolar complex (NAC).
procedure or tattoo. Alternatively, if there were excesses,
immediately redone with a graft from the contralateral
areola; this breast always had a flatter apex than the
contralateral one, requiring posterior fat grafting.
It is convenient to carry different volumes of
implants to decide which one will be used during the
reconstruction. Contralateral subcutaneous mastectomy,
in general, was more tissue conservative, and the volume
used was often smaller.
The tactic described made it possible to eliminate
total necrosis of the areola, even if the periareolar region
had minimal subcutaneous tissue after the mastectomy.
The transverse incisions provide good scars, and
together with the preserved thickness of the subcutaneous
tissue, they recover partial or total breast sensitivity
between two months and two years20.
All 106 patients operated on using this technique
received the procedure on the contralateral side, aiming
at symmetrization. This is not easy to obtain. Five patients
had an undiagnosed tumor in the contralateral breast.
In the postoperative period, the fear of mutilation
due to the loss of the breast is replaced by a feeling of
relief and enthusiasm when obtaining breasts that are
many times more adequate than those before the surgery.
This fact facilitates the acceptance of chemotherapy with
possible hair loss. Removal of the contralateral breast also
caused a feeling of relief.
Patient satisfaction with having performed the
contralateral mastectomy ranges from 84 to 96%7,8, but
it depends on the quality of the result obtained. These
were better in patients with small tumors and without the
involvement of axillary nodes. It is then possible to preserve
the thicker and more homogeneous subcutaneous fatty
tissue without removing the areolas.
When there was a positive sentinel node, predicting
possible radiotherapy, a skin expander was included for
breast repair and contralateral mastectomy after the end
of treatment. Nevertheless, the symmetrization results did
not reach the same quality.
In the surface irregularities caused by the
mastectomy, a second procedure was necessary to
perform correction with a fat graft, improving the results.
Discussing the need for a second surgical procedure in
advance is convenient.
The tactic of leaving the pectoralis major muscle
open, in addition to providing greater projection of the
breast, eliminates the discomfort of pressure due to
muscle contraction. And, in the long term, possible costal
alterations.
Immediate reconstruction with implants became the
authors’ best option. However, late reconstructions with
donor areas of adequate volume are the ones they prefer.
Considering 212 breasts operated on in 106 patients,
the total incidence of complications or unsatisfactory
breast shapes and volumes based on the extent of the base
and projection of the breast. Preserving it with decreasing
thickness is convenient, remaining vessels and nerves that
form the superficial vascular and nervous network up to
the papilla essential to reduce circulatory deficiency and
return sensitivity.
The removed breast volume is measured and placed
in a 2000ml graduated bottle containing 1000ml water.
The added tissue collaborates with the choice of implant
volume, disregarding the axillaries removed in association
with the mammary.
Based on the existing breast, the patient discusses
the convenience and possible volume in the preoperative
period. The remaining skin, the thorax’s lateral and
vertical extension, and the major pectoralis muscle must
be considered.
Ptosis measurement is not the only parameter
that determines the extent of scarring; the volume of the
implant also.
After three cases of late infection by S. epidermidis,
the skin was routinely re-sterilized, the pocket was washed
with saline solution after the mastectomy, and no further
cases occurred.
Two patients, 2 months after the operation, had high
implants, despite being well positioned in the surgical act
at the beginning of the use of the tactic. The approach was
modified using a transverse band on the upper mammary
poles and relaxing incisions on the aponeurosis of the
rectus muscle.
In tumors close to the skin in quadrants other than
the lateral ones, requiring resection, the spindle was
performed in the direction from the base of the breast
to the areola. In the axilla, a transverse incision was
made in the same direction, obtaining the sentinel node.
Depending on the ptosis, the procedure joins the two
incisions or not, with de-epidermization.
When the areola was removed, the procedure was
similar, and its repair was postponed to another surgical
Immediate bilateral breast reconstruction after skin-sparing mastectomy
Rev. Bras. Cir. Plást. 2023;38(1):e0463 8
results was 17.91% of the breasts or 35.82% of the patients,
the most prevalent being surface irregularities.
CONCLUSION
Immediate breast reconstruction with transverse
incision and implants in a mixed plane after skinpreserving mastectomy and contralateral risk-reducing
mastectomy is another possible option. It allows good
projection, reduction of areolar necrosis, and partial
or total return of tactile/painful sensitivity, facilitating
symmetrization.
unilateral breast cancer: a cancer research network project. J
Clin Oncol. 2005;23(19):4275-86.
7. Crosby MA, Garvey PB, Selber JC, Adelman DM, Sacks JM,
Villa MT, et al. Reconstructive outcomes in patients undergoing
contralateral prophylactic mastectomy. Plast Reconstr Surg.
2011;128(5):1025-33.
8. Chagpar AB. Contralateral Prophylactic Mastectomy: Pro and
Cons. Am J Hematol Oncol. 2016;12(4):21-4.
9. Buchanan PJ, Abdulghani M, Waljee JF, Kozlow JH, Sabel
MS, Newman LA, et al. An Analysis of the Decisions Made
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Damasio AA. Reconstruções mamárias: estudo retrospectivo de
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11. Bozola AR, Bozola AC. Indicações e Limites da Mamoplastia
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technique” for breast augmentation. Aesthetic Plast Surg.
2011;35(5):859-65. DOI: 10.1007/s00266-011-9668-1
13. Rigo MH, Piccinini PS, Sartori LDP, de Carvalho LAR, Uebel
CO. SMS-Split Muscle Support: A Reproducible Approach
for Breast Implant Stabilization. Aesthetic Plast Surg.
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14. Procópio LD, Silva DDP, Rosique R. Implante submuscular em
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15. Bozola AR, Longato FM, Bozola AP. Análise geométrica da forma
da beleza da mama e da forma de prótese baseado na proporção
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16. Baroudi R, Ferreira CA. Seroma: how to avoid it and how to treat
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Antonio Roberto Bozola
Avenida Brigadeiro Faria Lima, 5544, Vila São José, São José do Rio Preto, SP, Brazil.
Zip Code: 15090-000
E-mail: [email protected]
*Corresponding author:
COLLABORATIONS
ARB Final manuscript approval
ACB Final manuscript approval
IBF Final manuscript approval
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Reconstruction. Plast Reconstr Surg. 2019;144(1):1-9.
5. Yi M, Hunt KK, Arun BK, Bedrosian I, Barrera AG, Do KA, et al.
Factors affecting the decision of breast cancer patients to undergo
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1 Rev. Bras. Cir. Plást. 2023;38(1):e0631
Brazilian Portuguese version of the Patient Scar
Assessment Questionnaire
Validação da versão em português do Patient Scar Assessment Questionnaire
Introduction: Scars and their associated signs and symptoms have the potential
to impact many aspects of health. Given the growing number of individuals with
new scars, it is essential to have reliable, sensitive, and specific assessment tools
that analyze the influence that scars can have on the quality of life. The objective is
translate the Patient Scar Assessment Questionnaire (PSAQ) into Portuguese, adapt
it to the Brazilian cultural context, and test its reproducibility, reliability, and validity.
Methods: The questionnaire was applied to 121 individuals with post-surgical scars
consecutively selected at a plastic surgery clinic from January 2015 to June 2016. The
PSAQ consists of 39 questions divided into five subscales: appearance, symptoms,
perception, satisfaction with appearance, and symptoms. Then its reproducibility, face,
content, and construct validity were analyzed. Internal consistency was tested using
Cronbach’s alpha coefficient, and construct validation was performed by correlating the
translated instrument with the QualiFibro and Patient and Observer Scar Assessment
Scale (POSAS) questionnaires. Results: Analysis of the internal consistency of
the PSAQ subscales obtained values >0.70 in all domains, showing good internal
consistency. Reproducibility was demonstrated using Pearson’s correlation and the
Bland-Altman method, and the outcomes showed good reproducibility. In construct
validation, a significant correlation was observed in all PSAQ domains with POSAS
and QualiFibro. Conclusion: The PSAQ was translated into Portuguese and adapted
to Brazilian culture, reproducible and presenting face, content, and construct validity.
Introdução: Cicatrizes e seus sinais e sintomas associados têm potencial para
impactar vários aspectos da saúde. Dado o número crescente de indivíduos que
adquirem novas cicatrizes, é importante ter ferramentas de avaliação confiáveis,
sensíveis e específicas que analisem a influência que as cicatrizes podem exercer sobre
a qualidade de vida. O objetivo é traduzir o Patient Scar Assessment Questionnaire
(PSAQ) para a língua portuguesa, adaptá-lo ao contexto cultural brasileiro e
testar sua reprodutibilidade, confiabilidade e validade. Método: O questionário foi
aplicado em 121 indivíduos portadores de cicatrizes pós-cirúrgicas selecionados
consecutivamente em ambulatório de cirurgia plástica no período de janeiro de 2015
a junho de 2016. O PSAQ é constituído por 39 questões divididas em cinco subescalas:
aparência, sintomas, percepção, satisfação com a aparência e com os sintomas.
Foram analisados a reprodutibilidade, validade de face, conteúdo e construto. A
consistência interna foi testada pelo alfa de Cronbach e a validação de construto foi
realizada correlacionando o instrumento traduzido com os questionários QualiFibro
e Patient and Observer Scar Assessment Scale (POSAS). Resultados: A análise da
consistência interna das subescalas do PSAQ obteve valores maiores que 0,70 em
■ ABSTRACT
■ RESUMO
Original Article
ANA SAYURI OTA1
*
FABIANNE MAGALHÃES
GIRARDIN PIMENTEL
FURTADO1
ELVIO BUENO GARCIA1
LYDIA MASAKO FERREIRA1
1
Universidade Federal de São Paulo, São Paulo, SP, Brazil.
DOI: 10.5935/2177-1235.2023RBCP0631-EN
Institution: Universidade Federal
de São Paulo, São Paulo, SP, Brazil.
Article received: September 14, 2021.
Article accepted: September 13, 2022.
Conflicts of interest: none.
Keywords: Cicatrix; Surveys and questionnaires; Quality of life; Cross-cultural
comparison; Psychometrics.
Validation of the Patient Scar Assessment Questionnaire in Portuguese
Rev. Bras. Cir. Plást. 2023;38(1):e0631 2
appearance, symptoms, perception, satisfaction with
appearance, and satisfaction with symptoms. The PSAQ
can be self-applied and completed in approximately 10
minutes.
Considering the scarcity of studies in Brazil on
the impact of postoperative scars, it is important to use
a scar assessment instrument that incorporates aspects
related not only to the physical characteristics of the
scar but also to its influence on the patient’s QoL.
OBJECTIVE
In light of these considerations, the objective
of this study was to validate the PSAQ in Brazilian
Portuguese through the stages of translation, synthesis,
review by the multidisciplinary group, back-translation,
and cultural adaptation and test the measurement,
reproducibility, and validity properties of this adaptation.
METHOD
The author previously authorized the translation
into Portuguese, cultural adaptation, and validating
of the PSAQ in Brazil. This study was characterized
as a clinical, analytical, observational, cross-sectional,
uncontrolled, and single-center study and was
approved by the Research Ethics Committee of the
Federal University of São Paulo (UNIFESP) through
Plataforma Brasil (471.728/2013).
The sample consisted of individuals selected
consecutively at the Plastic Surgery Outpatient Clinic
of the Federal University of São Paulo (UNIFESP) from
January 2015 to June 2016. The participants were of
both sexes, aged 18–65 years, and had had post-surgical
scars for more than 1 year and less than 5 years. The
questionnaire was applied to 121 individuals: 65 in
the cultural adaptation phase and 56 in the validation
phase. All study participants were duly informed about
the nature, justification, and objective of the project and
were then invited to participate by signing an informed
consent form.
The methodology used in the study was based
on the proposal of Beaton et al.9
, divided into the
following steps: translation, synthesis, review by the
INTRODUCTION
Scarring is the last stage of the tissue repair
process. Unlike lower vertebrates, humans do not heal
through a process of regeneration that replaces injured
tissues with the same type of tissue, identical to the
original one1
. The ideal endpoint would be complete
regeneration, with the new tissue retaining the same
structural, aesthetic, and functional attributes as
the original tissue. However, there are considerable
quantitative and qualitative variations in healing
potential between individuals and within the same
individual2,3.
Scars are often considered trivial, but they can be
disfiguring and aesthetically unpleasant, causing loss
of function, restriction of movement and growth, pain,
sleep disorders, anxiety, depression, and disruption of
daily activities, with physical, psychological, social, and
functional sequelae4,5.
Scar evaluation can be performed objectively
or subjectively. Objective evaluation quantitatively
measures the scar using instruments to asses its
physical attributes. Subjective assessment is observerdependent and provides a qualitative measure of
scarring by the patient and physician. Scar assessment
methods using scales have been developed to make
them more objective6
.
Scales to assess scars have been developed
since 19907
. However, those early scales focused on the
physician’s opinion and the physical properties of the
scar6 and did not capture unobservable concepts and
the extent of the impact, which are known only by the
patient. Most data collection instruments for assessing
scars were formulated in English and targeted their
respective populations. Thus, there was a need to
translate and culturally adapt these instruments
before they were applied to populations with different
languages and cultures.
One of the instruments designed to assess scars,
the Patient Scar Assessment Questionnaire (PSAQ) —
validated and published by Piyush Durani et al.8 — was
initially developed in English to assess the quality of
life (QoL) in patients with postoperative linear scars.
It consists of 39 questions divided into 5 subscales:
todos os domínios, evidenciando uma boa consistência interna. A reprodutibilidade
foi demonstrada através da correlação de Pearson e método de Bland-Altman,
sendo observada boa reprodutibilidade. Na validação de construto observou-se
correlação significativa entre todos os domínios do PSAQ com a POSAS e QualiFibro.
Conclusão: O PSAQ foi traduzido para o português e adaptado à cultura brasileira,
mostrando-se reprodutível e apresentando validade de face, conteúdo e construto.
Descritores: Cicatriz; Inquéritos e questionários; Qualidade de vida; Comparação
transcultural; Psicometria.
3 Rev. Bras. Cir. Plást. 2023;38(1):e0631
Ota AS et al. www.rbcp.org.br
multidisciplinary group, back-translation (back to the
original language), and pre-test (or cultural adaptation).
The first step in the process was the initial
translation. Two direct translations of the original
questionnaire were made by two independent bilingual
translators, fluent in English and native to the language
(Brazilian Portuguese) into which the instrument was
being translated.
The next step was the synthesis of the translations.
In this step, the two translated versions were evaluated
and compared by a multidisciplinary group, and a single
version of the questionnaire was created by consensus.
This group consisted of bilingual individuals who were
specialists in the studied disease and knowledgeable
about the intention of the measures and the concepts
to be explored.
After this translation was obtained, two other
translators unfamiliar with the original version of
the instrument performed a new translation into
the original language. The back-translations were
produced by two translators fluent in Portuguese but
were native English speakers.
The expert committee met again to discuss
the differences and discrepancies arising from the
translation process. This analysis generated the first
version of the questionnaire in Portuguese, preserving
the idiomatic, semantic, conceptual, and cultural
equivalences.
The first version was applied to a group of 28
individuals belonging to the target population. Items
not understood by a percentage of ≥20% of patients
were reviewed by the same multidisciplinary group,
which formulated a second version of the questionnaire.
This second version was applied to another group of
38 patients with the same characteristics, obtaining an
understanding greater than 80% in the entire series for
all questions. After this evaluation, the questionnaire
was considered to be translated into Portuguese and
adapted to Brazilian culture.
The instrument’s psychometric properties were
evaluated after the cross-cultural adaptation process.
The instrument’s reliability (reproducibility and
internal consistency) and face, content, and construct
validity were tested.
The final version’s reproducibility (test/retest)
was evaluated in another 56 patients. The final version
of the questionnaire was applied on an initial date and
reapplied with the same interviewer after 15–30 days,
without any surgical or therapeutic intervention on the
scar. The statistical analysis to assess reproducibility
was performed using the intraclass correlation
coefficient and Pearson’s linear correlation coefficient
(r) between the individual values obtained in the first
and second interviews, and a Bland–Altman analysis
for the mean of the two evaluations and the difference
between the observations.
Internal consistency per subscale was analyzed
using Cronbach’s alpha coefficient, which varies
between “0” and “1”. The closer to 1, the greater the
consistency between items on a scale or subscale.
Values of α above 0.7 were considered satisfactory.
The validity of an instrument is defined as the
ability to measure what it proposes to measure, and
it can be classified into face, content, and construct
validity. Face validity checks whether the instrument
appears to measure what it was designed for.
Content validity corresponds to the relevance
of each item in the instrument for measuring the
topic addressed and examines the extent to which a
questionnaire represents the universe of the concept or
domains. In this study, face and content validity were
determined by consensus by the multidisciplinary team
that participated in elaborating the consensus version
of the questionnaire in Portuguese.
Construct validity is present if the measurement
is coherently related to other measures considered part
of the same phenomenon. When testing constructs
validity, hypotheses are worded according to the
direction and power of expected relationships based
on theory and literature. Validity is confirmed when
the association confirms the hypothesis.
Construct validity was tested by correlating the
measure obtained by the PSAQ with measures from
instruments that assess constructs correlated with
the sense of coherence that are reliable and valid. The
instruments used for correlation were the Quality of
Life of Patients with Keloid and Hypertrophic Scarring
(QualiFibro)10,11 and the Patient and Observer Scar
Assessment Scale (POSAS)12,13.
Pearson’s linear correlation tests were applied
between the measures of the domains of the adapted
version of the PSAQ and the instruments listed above.
For the analysis of the values, correlation values between
0.50 and 0.75 (or −0.50 and −0.75) were considered
moderate, those between 0.75 and 1.00 (or −0.75 and −1)
were considered strong, and perfect if equal to 1 or −1).
For all statistical tests, a significance level of
5% was adopted. The analyses were performed using
the SPSS 20.0 and Stata 12.0 (Structural Equation
Modeling/SEM) statistical packages.
RESULTS
The first version of the questionnaire was
applied to a group of 28 individuals (pre-test group 1),
consisting of 24 women and 4 men, with a mean age of
51.89 years (range 32–65 years). Nine items presented
a comprehension index of less than 80%, and the
Validation of the Patient Scar Assessment Questionnaire in Portuguese
Rev. Bras. Cir. Plást. 2023;38(1):e0631 4
multidisciplinary committee reviewed the instrument.
The second version of the questionnaire was applied to a
group of 37 individuals (pre-test group 2), consisting of 35
women and 2 men, with a mean age of 47.21 years (range
21–65 years). All questions reached a comprehension
rate of >89%, and no further modifications were needed.
Cultural equivalence was considered complete (Chart 1).
Next, the reproducibility and validity of the
questionnaire were evaluated. A new group of 56
patients participated in this phase, with a predominance
of females (94.6%) and a mean age of 41.4 years. The
same evaluator conducted two interviews at an interval
of 15–30 days. The total score of the questionnaire was
obtained by adding the scores for each question. Good
reproducibility was observed, with values above 0.70 in
all domains (Tables 1 e 2).
Reliability analysis was performed using the
same questionnaires from the first reproducibility
phase. Reliability was demonstrated using Cronbach’s
alpha, as shown in Table 3.
The PSAQ was also evaluated regarding face,
content, and construct validity. To estimate the content
validity, the conceptual framework of the impact of scars
on the patient’s quality of life was defined by conducting a
literature review and seeking expert opinion. To determine
the PSAQ’s face validity, text clarity, probability of the target
audience being able to answer the questions, questionnaire
formatting, and style were evaluated. The multidisciplinary
team evaluated the items and concluded that the Brazilian
version of the PSAQ has face and content validity.
In assessing the construct validity, the PSAQ
was correlated with POSAS and the Quality of Life
of Patients with Keloid and Hypertrophic Scarring
(QualiFibro). Strong positive correlations were observed
between satisfaction with appearance and the score of
psychological damage — QualiFibro (r=0.711, p<0.001)
and POSAS (r=0.811, p<0.001), indicating that the
greater the dissatisfaction with appearance, the greater
the psychological damage (QualiFibro) or, the greater the
problems caused by the scar (POSAS) (Table 4).
Chart 1. Translation into Portuguese of the Patient Scar Assessment Questionnaire (PSAQ).
1 How well does your scar’s color match the skin surrounding
it? A cor da sua cicatriz combina com a pele ao seu redor?
2 Is your scar darker or lighter compared to the surrounding
skin?
A sua cicatriz é mais escura ou mais clara do que a pele ao
seu redor?
3 Do you think your scar is red at all? Você acha que sua cicatriz é avermelhada?
4 In terms of length, my scar is: Quanto ao comprimento, sua cicatriz é:
5 In terms of width, my scar is: Quando à largura, sua cicatriz é:
6 How flat do you think your scar is, compared to the
surrounding skin?
Você acha que a sua cicatriz é plana em comparação à pele
ao redor dela?
7 Does your scar look shiny to you? Você acha sua cicatriz brilhante?
8 Does your scar feel ‘lumpy’ at all? Sua cicatriz está ‘encaroçada’?
9 In terms of texture, my scar feels: Quanto à textura, sua cicatriz é:
10 Overall what do you think of the appearance of your scar No geral, o que você acha da aparência de sua cicatriz?
11 Does your scar ever itch at all? Sua cicatriz coça?
12 Does your scar cause you pain at all? Sua cicatriz dói?
13 Is your scar ever uncomfortable at all? Sua cicatriz causa desconforto?
14 Does your scar ever feel numb at all? Sua cicatriz fica dormente?
15 Do you ever get odd sensations in your scar, e.g.,
tightening’, ‘pulling, or pins and needles?
Você tem alguma sensação estranha em sua cicatriz, como
“enrijecimento”, “repuxão” ou “alfinetadas e agulhadas”?
16 Does your scar ever catch on things, e.g., clothes? Sua cicatriz enrosca nas coisas, por exemplo, nas roupas?
17 Overall, how troublesome are the symptoms of your scar? Em geral, sua cicatriz causa algum incômodo?
18 How noticeable is your scar to you? Para você, o quanto a sua cicatriz é visível?
19 How noticeable do you think your scar is to others? Sua cicatriz é visível para os outros?
20 Do you think people ever stare at your scar? Você acha que as pessoas olham para a sua cicatriz?
21 Do you make an effort to try and hide your scar? Você se esforça para esconder a sua cicatriz?
22 How often do you think about your scar? Com que frequência você pensa em sua cicatriz?
23 How often do you look at your scar? Com que frequência você olha para sua cicatriz?
continued...
5 Rev. Bras. Cir. Plást. 2023;38(1):e0631
Ota AS et al. www.rbcp.org.br
Table 1. Summary measures of PSAQ subscale scores
PSAQ (first interview) Mean Std Dev Min. Max. First
quartile Median Third
quartile N
Appearance (9 items) 18,1 4,1 12,0 29,0 15,0 17,0 21,0 56
Symptoms (6 items) 7,9 2,8 6,0 17,0 6,0 7,0 9,0 56
Perception of the scar (6 items) 12,3 4,7 6,0 24,0 9,0 11,0 16,0 56
Satisfaction with the appearance (8 items) 16,3 5,3 8,0 32,0 13,3 16,0 19,0 56
Satisfaction with the symptoms (5 items) 8,5 4,1 5,0 20,0 5,0 7,0 10,0 56
PSAQ (second interview) Mean Std Dev Min. Max. First
quartile Median Third
quartile N
Appearance (9 items) 17,5 3,8 11,0 26,0 14,3 16,5 20,0 56
Symptoms (6 items) 7,7 2,3 6,0 16,0 6,0 6,5 8,8 56
Perception of the scar (6 items) 12,3 4,9 6,0 24,0 9,0 10,5 16,0 56
Satisfaction with the appearance (8 items) 15,6 4,7 8,0 26,0 13,0 15,0 17,8 56
Satisfaction with the symptoms (5 items) 7,6 3,9 5,0 20,0 5,0 5,0 8,0 56
DISCUSSION
A scar assessment instrument must capture the
extent of scar impact on a patient. The evaluation of
results has usually focused on the physician’s opinion
and the physical properties of the scar6
. However, such
measures do not capture unobservable concepts such
as pain or QoL, which are known only to the patient.
One way to measure the severity and evolution
of physical and psychological repercussions on
individuals’ daily lives is by using questionnaires
that assess QoL. QoL is a multidimensional concept
24 Overall, how self-conscious are you of your scar? No geral, você se sente envergonhado(a) da sua cicatriz?
25 How satisfied are you with how the color of your scar
matches the surrounding skin?
Você está satisfeito com a cor de sua cicatriz comparada à
pele ao redor dela?
26 How satisfied are you with the redness of your scar? Você está satisfeito com a vermelhidão de sua cicatriz?
27 How satisfied are you with the length of your scar? Você está satisfeito com o comprimento de sua cicatriz?
28 How satisfied are you with the width of your scar? Você está satisfeito com a largura de sua cicatriz?
29 How satisfied are you with the height of your scar
compared to the surrounding skin?
Você está satisfeito com a altura de sua cicatriz comparada
com à pele ao redor dela?
30 How satisfied are you with the texture of your scar (the way
it feels to touch)?
Você está satisfeito com a textura de sua cicatriz (sensação
ao toque)?
31 How satisfied are you with the ‘lumpiness’ of your scar? Você está satisfeito com os ‘caroços’ de sua cicatriz?
32 How satisfied are you with the ‘shininess’ of your scar? Você está satisfeito com o ‘brilho’ de sua cicatriz?
33 Overall, how satisfied are you with the appearance of your
scar?
No geral, você está satisfeito com a aparência de sua
cicatriz?
34 How satisfied are you with the itchiness from your scar? Você está satisfeito com a coceira causada pela cicatriz?
35 How satisfied are you with the amount of pain from your
scar? Você está satisfeito com a dor causada pela cicatriz?
36 How satisfied are you with the amount of discomfort from
your scar?
Você está satisfeito com o desconforto causada
pela cicatriz?
37 How satisfied are you with the amount of numbness from
your scar? Você está satisfeito com a dormência causada pela cicatriz?
38 How satisfied are you with the amount of odd sensations
you get from your scar?
Você está satisfeito com as sensações estranhas
causadas pela sua cicatriz?
39 Overall, how satisfied are you with the amount of trouble
you get from the symptoms of your scar?
No geral, você está satisfeito com os problemas causados
pela sua cicatriz?
Chart 1. Translation into Portuguese of the Patient Scar Assessment Questionnaire (PSAQ).
...continuation
Validation of the Patient Scar Assessment Questionnaire in Portuguese
Rev. Bras. Cir. Plást. 2023;38(1):e0631 6
(b) promote the development of a new instrument that
is simultaneously adapted to different cultural contexts;
(c) use a measure unrelated to QoL questionnaires that
allows the individual to define the important domains
for his or her own assessment; and (d) translate and
adapt a preexisting instrument for their own language16.
The first three options demand considerable
time and personal and financial commitment. The most
feasible alternative, capable of generating instruments
that allow comparison between cultures, has been
the translation and cultural adaptation of existing
instruments whose measurement properties have been
demonstrated in their original language9,16.
In this first study with the PSAQ, we carried out
the translation and cultural adaptation and tested the
properties: of face, content, and construct validity, as
well as reproducibility and internal consistency. The
processes adopted to translate and culturally adapt
the PSAQ were the ones suggested by Beaton et al.9
,
which recommend the initial translation, the synthesis
of translations, the back translation, the review by a
committee of specialists, and the pre-test (cultural
adaptation).
In the pre-test, the patients were selected
consecutively, and the researcher read the questionnaire
(administered application). When the respondent did not
understand the meaning of a question, the researcher
reread the question slowly. To avoid changing its original
meaning, no synonyms or explanations of the question
were given in other words. In the end, the subjects were
asked to suggest changes in the wording of the questions
or the choice of words if they felt that these suggestions
could make the questions more understandable. At
the end of the second pre-test, all terms reached a
comprehension index of more than 80%, and no further
changes were needed. The cultural equivalence was
considered complete, and the second version became
the final version of the questionnaire.
The reproducibility and validity of the questionnaire
were then evaluated with a new group of 56 patients.
The definition of reproducibility of a scale refers to
Intraclass
correlation (CI95%) p
Appearance 0.865 (0.781–0.919) <0.001
Symptoms 0.905 (0.844–0.943) <0.001
Perception of the scar 0.940 (0.900–0.964) <0.001
Satisfaction with the
appearance
0.825 (0.719–0.893) <0.001
Satisfaction with the
symptoms 0.742 (0.597–0.840) <0.001
Table 2. Intraclass correlations for the subscales and their
95% confidence intervals.
Table 3. Overall Cronbach Alpha.
Subscales
Overall
Cronbach’s
Alpha
Appearance (9 items) 0.770
Symptoms (6 items) 0.799
Perception of the scar (6 items) 0.832
Satisfaction with the appearance (8 items) 0.919
Satisfaction with the symptoms (5 items) 0.938
Table 4. Pearson’s correlation (rp) between PSAQ, QualiFibro, and POSAS scores.
QualiFibro POSAS
Psychological damages Physical damages
rP p rP p rP p
Appearance 0.560 <0.001 0.364 0.006 0.628 <0.001
Symptoms 0.473 <0.001 0.515 <0.001 0.487 <0.001
Perception of the scar 0.628 <0.001 0.294 0.028 0.668 <0.001
Satisfaction with the appearance 0.711 <0.001 0.527 <0.001 0.811 <0.001
Satisfaction with the symptoms 0.558 <0.001 0.663 <0.001 0.664 <0.001
N=56
involving propositions beyond symptom control,
reducing mortality, and increasing life expectancy. QoL
is related to the individual’s subjective perception of
their position in life in the context of the culture and
value system in which they live and concerning their
goals, expectations, standards, and concerns. It is a
broad concept that encompasses the complexity of the
construct and interrelates the environment with physical
and psychological aspects, level of independence, social
relationships, and personal beliefs14.
Instruments with patient-reported outcomes
are growing in importance in research. They can be
used as primary outcomes or complement traditional
surgical outcomes15.
Researchers who do not have an appropriate
instrument in their own language should choose to (a)
develop an instrument for their own cultural context;
7 Rev. Bras. Cir. Plást. 2023;38(1):e0631
Ota AS et al. www.rbcp.org.br
obtaining equal or very similar results in two or more
administrations for the same individual, as long as there
is no change in his/her clinical status17. Reproducibility
aims to analyze random fluctuations in the same group
of respondents on two or more occasions, quantifying the
overall agreement of responses at the individual level.
Good reproducibility was observed with values higher
than 0.70 in all domains. The minimum acceptable value
of 0.70 is in the original description of the questionnaire8
.
The same interviews from the first reproducibility
phase were used to evaluate the instrument’s internal
consistency, and the verification used Cronbach’s
alpha coefficient. Values below 0.5 were considered
insufficient; values between 0.5 and 0.7 were moderate;
and values above 0.7 were adequate. In the item-total
correlation, values higher than 0.20 suggest that the
items measure the same construct and are therefore
considered adequate2,8.
Internal consistency was considered satisfactory
for all subscales. The one for “Appearance” obtained
the lowest Cronbach’s alpha value (0.770). We also
noticed that the lower item-total correlation values
suggest that these items probably measure more than
one construct.
As for validity, the PSAQ was evaluated for face,
content, and construct validity. Valid questionnaires
have the following attributes: (i) have simplicity and
feasibility, (ii) exhibit word reliability and accuracy,
(iii) are appropriate for the problem intended to be
measured, (iv) reflect the underlying theory or concept
to be measured, and (v) can measure change18.
To estimate the content validity of the PSAQ,
the researcher defined the conceptual framework of
the impact of scars on patients’ QoL by conducting
a literature review and seeking expert opinion.
Once the conceptual framework was created, the
multidisciplinary group examined the items to ensure
they were consistent and endorsed content validity.
Table 5. Spearman’s correlation between general self-perception items of each subscale with their respective score.
rS p
Appearance and Q10
“Overall, what do you think your scar looks like?” 0.756 <0.001
Symptoms and Q17
“In general, does your scar cause any discomfort?” 0.612 <0.001
Perception of the scar and Q24
“In general, are you ashamed of your scar?” 0.828 <0.001
Satisfaction with the appearance and Q33
“Overall, are you satisfied with the appearance of your scar?” 0.866 <0.001
Satisfaction with the symptoms and Q39
“Overall, how satisfied are you with the problems caused by your scar?” 0.875 <0.001
N=56
Face validity is the easiest validation process to
undertake but is the weakest form of validity as it assesses
the appearance of the questionnaire in terms of feasibility,
readability, consistency of style, formatting, and clarity of
the language used. The multidisciplinary team evaluated
the items and concluded that the Brazilian version of the
PSAQ presents face and content validity.
The assessment of construct validity refers to the
degree to which a measure correlates (converges) with
other measures to which it is similar and is typically
examined, using associations with other validated
instruments that measure the same construct in a group
of at least 50 patients19-21.
We observed strong positive correlations between
satisfaction with appearance and psychological distress
scores - QualiFibro (r=0.711, p<0.001) and POSAS
(r=0.811, p<0.001), indicating that the greater the
dissatisfaction with appearance, the greater the
psychological distress (QualiFibro) or, the greater
the problems due to scarring (POSAS). The other
correlations presented variations between 0.294 and
0.668. Very high correlations may indicate that the
measures evaluate the same thing and are redundant.
To assess the correlation between each of the
general self-perception items of each subscale with
their respective score, Spearman’s correlation was
used. According to Table 5, moderate/strong positive
correlations are observed between the score of each
subscale and the respective self-perception item. The
correlations ranged from 0.612 to 0.875, indicating good
internal validity. The data coincide with those obtained
in the validation of the original instrument, which was
moderate/high in all domains, ranging from 0.63 to 0.91.
The PSAQ was explicitly designed to evaluate
linear scars and is planned to be self-administered,
with all the necessary written information to avoid
administrator bias. It has internal consistency and
acceptable reproducibility for all subscales. The
Validation of the Patient Scar Assessment Questionnaire in Portuguese
Rev. Bras. Cir. Plást. 2023;38(1):e0631 8
subscales can thoroughly discriminate between groups
with known differences in scar appearance, and the
appearance subscale can detect change over time8
.
One of the PSAQ’s main strengths is the fact
that its subscales can be used in isolation when only
a certain aspect needs to be evaluated. Since each
subscale addresses a specific domain, researchers can
use the most relevant subscale in isolation without
affecting reliability or validity.
CONCLUSION
The PSAQ was translated into Brazilian Portuguese,
culturally adapted, and reproducible, presenting global
face, content, and construct validity. This adaptation was
called PSAQ-BR (Annex 1).
This instrument can help multidisciplinary
teams to determine the impact of scars on the QoL
from the patients’ perspective, thus providing a more
comprehensive assessment of severity, in addition
to providing high-quality evidence for use in clinical
trials, in confronting treatment modalities and their
impact, and in comparing results with international
multicenter studies.
COLLABORATIONS
ASO Analysis and/or data interpretation, Conception
and design study, Conceptualization, Formal
Analysis, Investigation, Methodology, Project
Administration, Resources, Validation, Writing -
Original Draft Preparation, Writing - Review &
Editing.
FMGPF Analysis and/or data interpretation,
Conceptualization, Supervision, Writing -
Review & Editing.
EBG Analysis and/or data interpretation, Final
manuscript approval, Formal Analysis,
Supervision, Writing - Review & Editing.
LMF Final manuscript approval, Formal Analysis,
Supervision.
Ana Sayuri Ota
Rua Pedro de Toledo, 650, 2° andar, Vila Clementino, São Paulo, SP, Brazil.
Zip code: 04039-002
E-mail: [email protected]
*Corresponding author:
4. Ferguson MW, O’Kane S. Scar-free healing: from embryonic
mechanisms to adult therapeutic intervention. Philos Trans
R Soc Lond B Biol Sci. 2004;359(1445):839-50. DOI: 10.1098/
rstb.2004.1475
5. Durani P, McGrouther DA, Ferguson MW. Current scales for
assessing human scarring: a review. J Plast Reconstr Aesthet
Surg. 2009;62(6):713-20. DOI: 10.1016/j.bjps.2009.01.080
6. Fearmonti R, Bond J, Erdmann D, Levinson H. A review of scar
scales and scar measuring devices. EPlasty. 2010;10:e43.
7. Sullivan T, Smith J, Kermode J, McIver E, Courtemanche DJ.
Rating the burn scar. J Burn Care Rehabil. 1990;11(3):256-60.
DOI: 10.1097/00004630-199005000- 00014
8. Durani P, McGrouther DA, Ferguson MW. The Patient Scar
Assessment Questionnaire: a reliable and valid patient-reported
outcomes measure for linear scars. Plast Reconstr Surg.
2009;123(5):1481-9. DOI: 10.1097/PRS.0b013e3181a205de
9. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines
for the process of cross-cultural adaptation of self-report
measures. Spine (Phila Pa 1976). 2000;25(24):3186-91. DOI:
10.1097/00007632-200012150-00014
10. Bock O, Schmid-Ott G, Malewski P, Mrowietz U. Quality of life of
patients with keloid and hypertrophic scarring. Arch Dermatol
Res. 2006;297(10):433-8. DOI: 10.1007/s00403-006-0651-7
11. Furtado F, Hochman B, Ferrara SF, Dini GM, Nunes JM, Juliano
Y, et al. What factors affect the quality of life of patients with
keloids? Rev Assoc Med Bras (1992). 2009;55(6):700-4. DOI:
10.1590/s0104-42302009000600014
12. Draaijers LJ, Tempelman FR, Botman YA, Tuinebreijer WE,
Middelkoop E, Kreis RW, et al. The patient and observer scar
assessment scale: a reliable and feasible tool for scar evaluation.
Plast Reconstr Surg. 2004;113(7):1960-5; discussion 1966-7. DOI:
10.1097/01.prs.0000122207.28773.56
13. Linhares CB, Viaro MSS, Collares MVM. Tradução para o
Português da Patient and Observer Scar Assessment Scale
(POSAS). Rev Bras Cir Plást. 2016;31(1):95-100.
14. The World Health Organization Quality of Life assessment
(WHOQOL): position paper from the World Health Organization.
Soc Sci Med. 1995;41(10):1403-9. DOI: 10.1016/0277-9536(95)00112-k
15. Mundy LR, Miller HC, Klassen AF, Cano SJ, Pusic AL. PatientReported Outcome Instruments for surgical and traumatic
scars: A systematic review of their development, content, and
psychometric validation. Aesthet Plast Surg. 2016;40(5):792- 800.
DOI: 10.1007/s00266-016-0642-9
16. da Mota Falcão D, Ciconelli RM, Ferraz MB. Translation
and cultural adaptation of quality of life questionnaires: an
evaluation of methodology. J Rheumatol. 2003;30(2):379-85.
17. Jenkinson C, Peto V, Fitzpatrick R, Greenhall R, Hyman N. Selfreported functioning and well-being in patients with Parkinson’s
disease: comparison of the short-form health survey (SF-36) and
the Parkinson’s Disease Questionnaire (PDQ-39). Age Ageing.
1995;24(6):505-9.
18. García de Yébenes Prous MA, Rodríguez Salvanés F, Carmona
Ortells L. Validation of questionnaires. Reumatol Clin.
2009;5(4):171-7.
19. DeVon HA, Block ME, Moyle-Wright P, Ernst DM, Hayden SJ,
Lazzara DJ, et al. A psychometric toolbox for testing validity
and reliability. J Nurs Scholarsh. 2007;39(2):155-64.
20. Frost MH, Reeve BB, Liepa AM, Stauffer JW, Hays RD; Mayo/FDA
Patient-Reported Outcomes Consensus Meeting Group. What is
sufficient evidence for the reliability and validity of patient-reported
outcome measures? Value Health. 2007;10 Suppl 2:S94-S105.
21. Terwee CB, Bot SD, de Boer MR, van der Windt DA, Knol DL,
Dekker J, et al. Quality criteria were proposed for measurement
properties of health status questionnaires. J Clin Epidemiol.
2007;60(1):34-42.
REFERENCES
1. Brockes JP, Kumar A, Velloso CP. Regeneration as an evolutionary
variable. J Anat. 2001;199(1-2):3-11. DOI: 10.1046/j.1469-
7580.2001.19910003.x
2. Bayat A, McGrouther DA, Ferguson MW. Skin scarring. BMJ.
2003;326(7380):88-92. DOI: 10.1136/bmj.326.7380.88
3. Brown BC, McKenna SP, Siddhi K, McGrouther DA, Bayat A.
The hidden cost of skin scars: quality of life after skin scarring. J
Plast Reconstr Aesthet Surg. 2008;61(9):1049-58. DOI: 10.1016/j.
bjps.2008.03.020
9 Rev. Bras. Cir. Plást. 2023;38(1):e0631
Ota AS et al. www.rbcp.org.br
Annex 1. PSAQ-BR Questionnaire and Scoring System.
The PSAQ consists of 5 subscales: Appearance, Symptoms, Consciousness, Satisfaction with Appearance
and Satisfaction with Symptoms. The Symptoms subscale has been omitted from analysis due to reliability issues
related to format and application in scar groups with minimal symptom prevalence.
Scoring System:
Each subscale consists of a set of items with 4-point categorical responses, scoring 1 to 4 points (with 1 point
assigned to the most favourable category and 4 assigned to the least favourable). Each subscale also contains
a single global assessment item that is not included in the summary subscale score, but is used to provide a
clinically meaningful descriptor for the summary score generated, and also used for internal validation analysis.
In items with double response scales e.g. item 2 in the Appearance subscale, ’Is your scar darker or lighter
compared to surrounding skin?’: ‘No’ is assigned 1 point, but if the subject does decide the scar is darker or
lighter, the remaining categories are assigned 2 (slightly darker OR slightly lighter), 3 (fairly darker OR fairly
lighter) or 4 points (much darker OR much lighter).
Therefore the following range of scores is possible for each subscale, with higher scores reflecting a poorer
perception of the scar related to the domain being evaluated:
Number of Scored Items Minimum Score Maximum Score
Appearance 9 9 36
Consciousness 6 6 24
Satisfaction with Appearance 8 8 32
Satisfaction with Symptoms 5 5 20
Patient Scar Assessment Questionnaire (PSAQ)
Part I: Attribute Rating
I. APPEARANCE
1. How well does the colour of your scar match with your skin surrounding it?
Very well matched Well matched A little matched Poorly matched
□ □ □ □
2. s your scar darker or lighter compared to surrounding skin?
No □
Yes, it looks DARKER Slightly Darker □ Fairly Darker □ Much Darker □
Yes, it looks LIGHTER Slightly Lighter □ Fairly Lighter □ Much Lighter □
3. Do you think your scar is red at all?
No □
Yes, it looks RED Slightly Red □ Fairly Red □ Very Red □
Patient Id. Date of completion Month:
Validation of the Patient Scar Assessment Questionnaire in Portuguese
Rev. Bras. Cir. Plást. 2023;38(1):e0631 10
4. In terms of length, my scar is:
Very short Short Long Very long
□ □ □ □
5. In terms of width, my scar is:
Very thin Thin Wide Very wide
□ □ □ □
6. How flat do you think your scar is, compared to your surrounding skin?
It is FLAT and LEVEL □
It is RAISED Slightly Raised □ Fairly Raised □ Very Raised □
It is SUNKEN Slightly Sunken □ Fairly Sunken □ Very Sunken □
7. Does your scar look shiny to you?
No □
Yes, it looks SHINY Slightly Shiny □ Fairly Shiny □ Very Shiny □
8. Does your scar feel ‘lumpy’ at all?
No □
Yes, it feels LUMPY Slightly Lumpy □ Fairly Lumpy □ Very Lumpy □
9. In terms of texture, my scar feels:
Very smooth Smooth Rough Very rough
□ □ □ □
10. Overall what do you think of the appearance of your scar?
Excellent Good Okay Poor Very Poor
□ □ □ □ □
II. SYMPTOMS
11. Does your scar ever itch at all?
No □
Yes, it is ITCHY Sometimes □ Often □ Always □
AND when it is itchy, it is:
Slightly Itchy □ Fairly Itchy □ Very Itchy □
12. Does your scar cause you pain at all?
No □
Yes, it is PAINFUL Sometimes □ Often □ Always □
AND when it hurts, it is:
Slightly Painful □ Fairly Painful □ Very Painful □
Patient Id. Date of completion Month:
11 Rev. Bras. Cir. Plást. 2023;38(1):e0631
Ota AS et al. www.rbcp.org.br
13. Is your scar ever uncomfortable at all?
No □
Yes, it is UNCOMFORTABLE Sometimes □ Often □ Always □
AND when it is uncomfortable, it is:
Slightly Uncomfortable □ Fairly Uncomfortable □ Very Uncomfortable □
14. Does your scar ever feel numb at all?
No □
Yes, it feels NUMB Sometimes □ Often □ Always □
AND when it feels numb, it is:
Slightly Numb □ Fairly Numb □ Very Numb □
15. Do you ever get odd sensations in your scar e.g. ‘tightening’, ‘pulling’ or ‘pins and needles’?
No □
Yes, I get ODD sensations Sometimes □ Often □ Always □
16. Does your scar ever catch on things, e.g. clothes?
No □
Yes, it does CATCH on things Sometimes □ Often □ Always □
17. Overall, how troublesome are the symptoms from your scar?
Not at all troublesome A little troublesome Fairly troublesome Very troublesome Unbearable
□ □ □ □ □
III. SCAR CONSCIOUSNESS
18. How noticeable is your scar to you?
Not at all noticeable Slightly noticeable Fairly noticeable Very noticeable
□ □ □ □
19. How noticeable do you think your scar is to others?
Not at all noticeable Slightly noticeable Fairly noticeable Very noticeable
□ □ □ □
20. Do you think people ever stare at your scar?
No, never □
Yes, people stare Sometimes □ Often □ Always □
21. Do you make an effort to try and hide your scar?
No, never □
Yes, I try and hide the scar Sometimes □ Often □ Always □
Patient Id. Date of completion Month:
Validation of the Patient Scar Assessment Questionnaire in Portuguese
Rev. Bras. Cir. Plást. 2023;38(1):e0631 12
22. How often do you think about your scar?
Never Sometimes Often Always
□ □ □ □
23. How often do you look at your scar?
Never Sometimes Often Always
□ □ □ □
24. Overall, how self-conscious are you of your scar?
Not at all Self-conscious Slightly Self-conscious Fairly Self-conscious Very Self-conscious
□ □ □ □
Patient Scar Assessment Questionnaire (PSAQ)
Part II: Satisfaction Rating
I. SATISFACTION WITH APPEARANCE
25. How satisfied are you with the way the colour of your scar matches with surrounding skin?
Very satisfied Satisfied Dissatisfied Very Dissatisfied
□ □ □ □
26. How satisfied are you with the redness of your scar?
Very satisfied Satisfied Dissatisfied Very Dissatisfied
□ □ □ □
27. How satisfied are you with the length of your scar?
Very satisfied Satisfied Dissatisfied Very Dissatisfied
□ □ □ □
28. How satisfied are you with the width of your scar?
Very satisfied Satisfied Dissatisfied Very Dissatisfied
□ □ □ □
29. How satisfied are you with the height of your scar compared to surrounding skin?
Very satisfied Satisfied Dissatisfied Very Dissatisfied
□ □ □ □
30. How satisfied are you with the texture of your scar (the way it feels to touch)?
Very satisfied Satisfied Dissatisfied Very Dissatisfied
□ □ □ □
31. How satisfied are you with the ‘lumpiness’ of your scar?
Very satisfied Satisfied Dissatisfied Very Dissatisfied
□ □ □ □
Patient Id. Date of completion Month:
13 Rev. Bras. Cir. Plást. 2023;38(1):e0631
Ota AS et al. www.rbcp.org.br
32. How satisfied are you with the ‘shininess’ of your scar?
Very satisfied Satisfied Dissatisfied Very Dissatisfied
□ □ □ □
33. Overall, how satisfied are you with the appearance of your scar?
Very satisfied Satisfied Dissatisfied Very Dissatisfied
□ □ □ □
II. SATISFACTION WITH SYMPTOMS
34. How satisfied are you with the itchiness from your scar?
Very satisfied Satisfied Dissatisfied Very Dissatisfied
□ □ □ □
35. How satisfied are you with the amount of pain from your scar?
Very satisfied Satisfied Dissatisfied Very Dissatisfied
□ □ □ □
36. How satisfied are you with the amount of discomfort from your scar?
Very satisfied Satisfied Dissatisfied Very Dissatisfied
□ □ □ □
37. How satisfied are you with the amount of numbness from your scar?
Very satisfied Satisfied Dissatisfied Very Dissatisfied
□ □ □ □
38. How satisfied are you with the amount of odd sensations you get from your scar?
Very satisfied Satisfied Dissatisfied Very Dissatisfied
□ □ □ □
39. Overall, how satisfied are you with the amount of trouble you get from the symptoms from your scar?
Very satisfied Satisfied Dissatisfied Very Dissatisfied
□ □ □ □
Patient Id. Date of completion Month:
1 Rev. Bras. Cir. Plást. 2023;38(1):e0666
Non-melanoma skin cancer: an analysis of
compromised margins in excisions
Câncer de pele não melanoma: uma análise do comprometimento de
margens em excisões
Introduction: Non-melanoma skin cancer is the most frequent neoplasm in Brazil,
with an estimated 176,930 new cases during the 2020-2022 period, with basal cell
carcinoma (BCC) and squamous cell carcinoma (SCC) as the most common subtypes.
Surgical treatment of the lesions is effective, with a recurrence rate varying between
3 and 23%, with compromised margins being an important prognostic factor for this
recurrence, increasing the importance of complete excision of the tumor. Method:
To prepare this work, 1127 lesions treated at the Hospital de Amor Amazônia were
analyzed, seeking to quantify cases and analyze surgically compromised margins
through a retrospective analytical descriptive study. For this, histopathological
reports of the operated patients were reviewed, dividing them according to sex,
age, lesion topography, date of excision, lesion diameter, lesion depth, presence
of ulceration, compromised margins, and histological type. Results: Among the
lesions treated, 65% were BCC and 35% SCC, both histological types presenting a
low incidence of compromised margins. In cases of CPB impairment, treatment via
exeresis was chosen in 100% of cases. Concerning BCC impairment, the majority
opted for clinical follow-up, with reapproach in only 9% of cases. Conclusion: This
study demonstrates that the cases treated at the Hospital de Amor Amazônia align
with the epidemiological data in the main literature, except for finding a higher
incidence of non-melanoma skin cancer in men. In addition, this work demonstrates
good results in the clinical approach of compromised margins in BCC lesions.
Introdução: O câncer de pele não melanoma é a neoplasia mais frequente no Brasil,
com uma estimativa de 176.930 novos casos durante o triênio 2020-2022, tendo o
carcinoma basocelular (CBC) e o carcinoma espinocelular (CEC) como subtipos mais
presentes. O tratamento cirúrgico das lesões é efetivo, apresentando taxa de recorrência
variando entre 3 e 23%, sendo o comprometimento de margens importante fator
prognóstico para essa recorrência, aumentando a importância da excisão completa
do tumor. Método: Para a elaboração deste trabalho, foram analisadas 1127 lesões
abordadas no Hospital de Amor Amazônia, buscando quantificar casos e analisar
margens cirurgicamente comprometidas por meio de um estudo descritivo analítico
retrospectivo. Para isso, foram revisados laudos histopatológicos dos pacientes
operados, dividindo-os de acordo com sexo, idade, topografia da lesão, data de excisão,
diâmetro da lesão, profundidade da lesão, presença de ulceração, comprometimento
de margens e tipo histológico. Resultados: Dentre as lesões abordadas, 65% eram
■ ABSTRACT
■ RESUMO
Original Article
Keywords: Skin neoplasms; Carcinoma, basal cell; Carcinoma, squamous cell;
Margins of excision; Reoperation.
CAROLINE PAGUNG1
EMANUELE DE SANTIAGO1
JESSICA NOBRE ANDRADE1
LUCAS PISSOLATO1
CIPRIANO FERREIRA DA
SILVA JÚNIOR1
RODOLFO LUÍS KORTE1
*
1
Universidade Federal de Rondônia, Medicina, Porto Velho, Rondônia, Brazil.
DOI: 10.5935/2177-1235.2023RBCP0666-EN
Institution: Hospital de Amor
Amazônia, Porto Velho, RO, Brazil.
Article received: November 21, 2021.
Article accepted: September 13, 2022.
Conflicts of interest: none.
Non-melanoma skin cancer: analysis of compromised margins
Rev. Bras. Cir. Plást. 2023;38(1):e0666 2
METHOD
This is a retrospective analytical descriptive
study based on a review of the histopathological reports
of patients operated on for basal cell carcinoma and/
or squamous cell carcinoma at the Hospital de Amor
Amazônia in Porto Velho between January 2016 and
December 2019. The variables analyzed were gender,
age, the topography of the lesion, date of excision,
histological type, largest diameter, depth of invasion,
presence of ulceration, number of excised lesions, and
position of the excision margins. Incisional biopsies
and non-BCC and non-SCC skin cancer cases were
excluded, totaling 1127 lesions in 487 patients.
The histological types were divided into BCC and
SCC for statistical analysis and evaluated separately.
Statistical analysis was performed using the
STATA9.2 software, and Pearson’s chi-square test was
used to study the association between compromised
surgical margins and the anatomopathological
examination and the presence of positive lesions in
surgical reapproach. The significance level adopted
was 5% (p<0.05).
The study was approved by the Human Research
Ethics Committee, under number 67100417.3.0000.543,
of the Hospital de Câncer de Barretos.
RESULTS
During the study, 487 patients were analyzed,
totaling 1127 BCC and/or SCC lesions. Among these
patients, 236 (48%) were women, and 251 (52%) were
men. Those studied ranged between 29 and 102 years,
averaging 66 years. Among the 487 individuals, 321 (66%)
had only BCC, 92 (19%) only SCC, and 74 (15%) had both
BCC and SCC. Concerning lesions, among the 1127 total,
738 (65%) were BCC, and 389 (35%) were SCC.
Regarding the margins in the 389 SCC lesions,
the deep margins were compromised in 32 (8%), narrow
in 13 (3%), free in 327 (84%), and unknown in 17 (4%).
On the lateral margins, 34 (9%) were involved, 7 (2%)
INTRODUCTION
Non-melanoma skin cancer is the most common
neoplasm in Brazil, with an estimate of new cases for
the three years 2020-2022 of 83,770 in men and 93,160 in
women, with an estimated risk in the North Region of
21.28/100,000 male inhabitants and 39.24/100 thousand
inhabitants women1
. Basal Cell Carcinoma (BCC) and
Squamous Cell Carcinoma (SCC) are the two most
common subtypes.
Treatment by surgical excision is highly effective
for non-melanoma skin neoplasms, and the recurrence
rate varies in the literature - between 5 and 14% after
excision of BCC2
and between 3 and 23% for primary
SCC3
. Complete excision of the tumor, macroscopically
and microscopically, is an important prognostic factor
since compromised margins are associated with a
greater chance of recurrence4
.
In the surgical treatment of BCC, the rate of
anatomopathological results showing compromised
margins varies between 5.5 and 12.5%2
. However, a
discrepancy in the rate of tumor recurrence in positive
margins is observed in the literature, which varies
from 10 to 67%2
; therefore, the need for a new surgical
intervention may not be mandatory, and clinical followup may be chosen.
The SCC presents a pattern of greater
aggressiveness when compared to the CBC. About
5% of cases evolve into locally advanced or metastatic
conditions, with uncontrollable growth and substantial
disfigurement5. In excisional surgical treatment, the
cure rate is around 92% and drops to 77% in the case
of recurrent tumors6
.
OBJECTIVE
To evaluate the incidence of BCC and SCC
at the Hospital de Amor Amazônia, in Porto Velho/
RO, as well as to quantify the cases, the presence of
positive margins in excised lesions, rates of surgical
reapproaches in these cases and their results.
CBC e 35% CEC, ambos os tipos histológicos apresentando baixa incidência de
margens comprometidas. Nos casos de comprometimento em CEC, optou-se pelo
tratamento via exérese em 100% dos casos. Já em relação ao comprometimento em
CBC, optou-se majoritariamente pelo acompanhamento clínico, com reabordagem
em apenas 9% dos casos. Conclusão: Este estudo demonstra que os casos abordados
no Hospital de Amor Amazônia vão ao encontro dos dados epidemiológicos presentes
nas principais literaturas, com ressalva, apenas, ao encontrar uma maior incidência
de câncer de pele não melanoma em homens. Além disso, esse trabalho demonstra
bons resultados na abordagem clínica de margens comprometidas em lesões de CBC.
Descritores: Neoplasias cutâneas; Carcinoma basocelular; Carcinoma de células
escamosas; Margens de excisão; Reoperação.
3 Rev. Bras. Cir. Plást. 2023;38(1):e0666
Pagung C et al. www.rbcp.org.br
were exiguous, 331 (85%) were free, and 17 (4%) were
unknown. All cases of compromised or narrow SCC
margins were treated again via excision.
The histological types and histopathological
grade found in work can be seen in Charts 1 and 2.
As for the BCC, of the 738 lesions, the deep
margins were involved in 77 (10%), exiguous in 19
(3%), free in 631 (86%), and unknown in 11 (1%). On
the lateral margins, 115 (16%) were involved, 34 (5%)
were exiguous, 578 (78%) were free, and 11 (1%) were
unknown.
DISCUSSION
In our study, cases were predominant in males
(52%), unlike the casuistic estimate of INCA1
, which
stipulated approximately 53% of cases in women in the
three years 2020-2022. Concerning age, the average was
66 years, which aligns with the information provided by
INCA1
, which shows a higher incidence from 40 years
of age. There was a predominance, in BCC, of cases
with mixed presentation (51%), that is, with more than
one histological subtype. However, separately, among
the histological subtypes, the most frequent was the
nodular histological subtype (25%), as well as the one
found in the study by Rossato et al.7
. As for the SCC,
47% had a pattern of moderate differentiation.
There is no consensus in the literature regarding
the best therapy to be adopted in cases of compromised
margins in BCC. However, it is known that the BCC has
an intimate relationship with the peritumoral stroma,
and Pinkus saw its development in the constitution and
interaction with basal cell carcinomas in 1962 and 19678
.
The recurrent tumor has a worse prognosis than
the primary one because the relationship between the
tumor and its stroma can be altered due to the treatment
initially instituted, facilitating its dissemination9
. In
addition, it may present exulcerations, more evident cell
dysplasia, loosening of tumor cell cords, stromal fibrosis,
and decreased peritumoral inflammatory reaction,
increasing the spread of neoplastic cells10. Therefore,
one might want to opt for a more invasive approach.
However, according to Rodrigues et al.11, only onethird of the patients will present residual disease in the
enlargements performed. In our study, we obtained 64%
of the reapproached cases with residual disease in the
margin enlargement; however, we believe there is a bias
SCC: Squamous Cell Carcinoma
Source: Authors
Table 2. Histopathological grading of SCC.
Histopathological grading of the SCC Total injuries
Well-differentiated 115
Moderately differentiated 184
Little differentiated 18
Uninformed 72
Considering the BCC’s narrow and/or compromised
margins, without differentiating them into deep or
lateral, 177 lesions were obtained. Of these, 17 (9%)
were reapproached, with 11 (64%) compromised and 6
(35%) free of neoplasia. The time interval between the
first excision and the reapproach of the margins was
variable, with 9 (52%) immediate approach, 2 (12%) with
an interval of fewer than 30 days postoperatively, 1 (6%)
in an interval from 30 to 60 days, and 5 (29%) with an
interval greater than 60 days.
The histological types found are illustrated in
Chart 3.
In cases of BCC with compromised margins,
longitudinal clinical follow-up was preferred. In the
minority, a surgical reapproach of the positive margins
was performed (9%).
SCC: Squamous Cell Carcinoma
Source: Authors
Histological patterns of SCC total injuries
acantholytic 4
Basaloid 1
Keratoacanthoma 18
Conventional 4
Crateriform 1
In situ 57
Infiltrative 59
Superficially invasive 19
Verrucous 3
Nodular 1
Chart 1. SCC patterns found on histopathological examination.
BCC: Basal Cell Carcinoma
Source: Authors
BCC Histological Subtypes Total injuries
Infiltrative 1
Sclerodermiform 24
Superficial 22
Nodular 187
Micronodular 30
Adenoid 8
Mixed 383
Areas of squamous differentiation 2
Basosquamous 3
Multicentric 1
Solid 13
Uninformed 64
Chart 3. BCC histopathological subtypes found in the sample.
Non-melanoma skin cancer: analysis of compromised margins
Rev. Bras. Cir. Plást. 2023;38(1):e0666 4
due to the low sample size (17 reapproached patients) or
the surgical technique used in the first excision. When
we compare the number of compromised margins, we
have 177 cases, with reapproach of approximately 9% of
the cases, and if we compare it with the total number of
lesions with compromised margins, we have only 6.3% of
lesions with the presence of tumor in the excised lesions,
the which is below the existing indicators in the literature.
In a study on surgical margins for skin cancer
in nonagenarians in England, carried out by Rollett
et al.12, rates of incomplete excision in BCC of 24%
were found, with rates of reoperation required in only
21.7% of cases. According to the British Association
of Dermatology, watchful waiting is appropriate for
BCCs with compromised margins when only one lateral
margin is compromised, of a non-aggressive histological
type, non-recurring, and involving low-risk anatomical
sites11. We opted for the clinical follow-up of BCCs with
compromised margins in 90% of the cases, obtaining a
good prognosis. In the lesions in which it was decided
to widen the margins, 35% were free of the neoplasm;
that is, surgical reintervention would not be necessary,
which brings us to a minority of cases.
Another study that recommends larger margins
depending on the location and size of the lesion presented
results of 5% of cases with compromised margins in
1669 excisions performed; however, it does not specify
how many of these were surgically reapproached. What
we can absorb from this study is that, even with wider
margins, compromised margins still exist, and the
removal or not follows the protocol of each service13.
CONCLUSION
Given the data presented and discussed, we
observed an epidemiological agreement between our
study and the numbers presented by INCA1
; however,
there is a contrast in the incidence of non-melanoma
skin cancer, which is higher among men in our
sample. This makes us raise hypotheses about possible
predisposing factors to this condition, mainly related to
sun exposure and the lifestyle of the state of Rondônia.
Concerning BCC therapy, our results corroborate
a less invasive approach, showing good results for the
clinical follow-up of the lesions. Even in surgically
enlarged lesions, the benefit of the intervention is not
clear; sometimes, it is performed unnecessarily, as
occurred in our research scope, with 94% of unnecessary
reapproaches.
It is necessary to emphasize that patient monitoring
is fundamental to identifying the recurrence of lesions,
which is the preponderant factor in the early diagnosis.
REFERENCES
1. Brasil. Ministério da Saúde. Instituto Nacional de Câncer José
Alencar Gomes da Silva (INCA). Estimativa 2020: incidência de
câncer no Brasil. Rio de Janeiro: INCA; 2019.
2. Lara F, Santamaría JR, Garbers LE. Recurrence rate of basal cell
carcinoma with positive histopathological margins and related
risk factors. An Bras Dermatol. 2017;92(1):58-62.
3. Ribero S, Osella Abate S, Di Capua C, Dika E, Balagna E,
Senetta R, et al. Squamocellular Carcinoma of the Skin:
Clinicopathological Features Predicting the Involvement of the
Surgical Margins and Review of the Literature. Dermatology.
2016;232(3):279-84.
4. Bueno Filho R, Fantini BC, Santos CA, Melo RVG, Rosan I,
Chahud F, et al. Attributes and risk factors of positive margins
on 864 excisions of basal cell carcinomas: a single-center
retrospective study. J Dermatolog Treat. 2020;31(6):589-96.
5. Weber MB, Ferreira IG, Ferreira LO, Silva AB, Cernea
SS. Carcinoma espinocelular avançado e imunoterápicos:
novas perspectivas terapêuticas. Surg Cosmet Dermatol.
2021;13:e20210023.
6. Robins P, Kopf AW, Wheeland RG. Carcinoma de células
escamosas. The Skin Cancer Foundation. O segundo tipo de
câncer de pele mais comum [Internet]; 2010 [acesso 2021 Mar
14]. Disponível em: https://www.skincancer.org/international/
carcinoma-celulas-escamosas/
7. Rossato LA, Carneiro RC, Macedo EMS, Lima PP, Miyazaki
AA, Matayoshi S. Diagnosis of aggressive subtypes of eyelid
basal cell carcinoma by 2-mm punch biopsy: prospective and
comparative study. Rev Col Bras Cir. 2016;43(4):262-9. DOI:
10.1590/0100-69912016004008
8. Bandeira AM, Bandeira V, Silva JF, Mazza E. Carcinomas
basocelulares: estudo clínico e anatomopatológico de 704
tumores. An Bras Dermatol. 2003;78(1):23-34.
COLLABORATIONS
CP Conceptualization, Data Curation, Formal
Analysis, Writing - Original Draft Preparation.
ES Conceptualization, Data Curation, Formal
Analysis, Writing - Original Draft Preparation.
JNA Conception and design study, Data Curation,
Formal Analysis, Writing - Original Draft
Preparation.
LP Analysis and/or data interpretation, Conception
and design study, Conceptualization, Writing -
Original Draft Preparation.
CFSJ Analysis and/or data interpretation, Conception
and design study, Formal Analysis, Validation,
Writing - Review & Editing.
RLK Analysis and/or data interpretation, Conception
and design study, Conceptualization, Final
manuscript approval, Formal Analysis,
Methodology, Realization of operations and/or
trials, Supervision, Validation, Writing - Review
& Editing.
5 Rev. Bras. Cir. Plást. 2023;38(1):e0666
Pagung C et al. www.rbcp.org.br
Rodolfo Luís Korte
Departamento de Medicina da Universidade Federal de Rondônia. Rodovia BR 364, Km 9,5, Campus
Universitário José Ribeiro Filho, Bloco 3A, 2º Andar, Sala 301, Porto Velho, RO, Brazil.
Zip code: 76859-001
E-mail: [email protected]
*Corresponding author:
9. Bøgelund FS, Philipsen PA, Gniadecki R. Factors affecting the
recurrence rate of basal cell carcinoma. Acta Derm Venereol.
2007;87(4):330-4.
10. Chinem VP, Miot HA. Epidemiologia do carcinoma basocelular.
An Bras Dermatol. 2011;86(2):292-305.
11. Rodrigues EW, Moreira MR, Menegazzo PB. Análise do
Tratamento do Carcinoma Basocelular. Rev Bras Cir Plást.
2014;29(4):504-10.
12. Rollett R, Fennell N, Deodhar A, Agarwal R. Analysis of the
surgical management of skin cancer in the nonagenarian
population: Twenty-five year data analysis from a single centre.
JPRAS Open. 2020;26:28-36.
13. Marchetti Cautela J, Mannocci A, Reggiani C, Persechino F,
Ferrari F, Rossi E, et al. Identifying the factors that influence
surgeon’s compliance with excisional margins of non-melanoma
skin cancer. PLoS One. 2018;13(9):e0204330.
1 Rev. Bras. Cir. Plást. 2023;38(1):e0674
HIV-associated lipodystrophy: epidemiological
analysis of a Plastic Surgery Service in Brazil
Lipodistrofia associada ao HIV: análise epidemiológica de um Serviço de
Cirurgia Plástica no Brasil
Introduction: Lipodystrophy is an important complication of HIV and has different
clinical manifestations, such as lipoatrophy of the face, buttocks, and limbs and
accumulation of fat in the abdominal and cervical regions. Lipodystrophy has
aesthetic and psychosocial consequences, stigmatizing and affecting patients’ quality
of life. The objective is to evaluate the epidemiology and treatments performed in
patients treated at the HIV-related Lipodystrophy Outpatient Clinic at Hospital das
Clínicas da Faculdade de Medicina de Botucatu. Method: The study was conducted
retrospectively, with port analysis of patients treated between June 2012 and
December 2019, at Hospital das Clínicas da Faculdade de Medicina de Botucatu, in
Botucatu, SP, Brazil. Results: The medical records of 153 individuals were analyzed,
79 male and 74 female patients. The mean age was 45.6 years. The referrals came from
48 cities in four states. Caucasian patients accounted for 74.5% of the consultations.
The complaint of facial lipodystrophy was reported by 52.9% of the patients. The
most common invasive procedure was facial filling with polymethylmethacrylate
(PMMA) in 62 patients. Gluteal implants were the most common surgery on six
occasions. Conclusion: The data found show a higher proportion of female patients
with complaints of lipodystrophy when compared to general data of patients with
HIV. The white race was predominant, and the main complaint of lipodystrophy
was facial atrophy. Facial filling with PMMA was the most common procedure.
Introdução: A lipodistrofia é uma importante complicação do HIV e apresenta
diferentes manifestações clínicas, como lipoatrofia de face, glúteos e membros,
e acúmulo de gordura em região abdominal e cervical. A lipodistrofia apresenta
consequências estéticas e psicossociais, que são estigmatizantes e afetam a qualidade
de vida dos pacientes. O objetivo é avaliar a epidemiologia e os tratamentos realizados
nos pacientes atendidos no Ambulatório de Lipodistrofia relacionada ao HIV do
Hospital das Clínicas da Faculdade de Medicina de Botucatu. Método: O estudo foi
realizado de maneira retrospectiva, com análise de portuário dos pacientes atendidos
entre junho de 2012 e dezembro de 2019, no Hospital das Clínicas da Faculdade
de Medicina de Botucatu, em Botucatu, SP, Brasil. Resultados: Os prontuários
de 153 indivíduos foram analisados, sendo 79 pacientes do sexo masculino e 74
do sexo feminino. A média de idade foi 45,6 anos. Os encaminhamentos tiveram
origem de 48 cidades, de quatro estados. Pacientes da raça branca totalizaram
74,5% dos atendimentos. A queixa de lipodistrofia de face foi referida por 52,9%
■ ABSTRACT
■ RESUMO
Original Article
MURILO SGARBI SECANHO1
*
BALDUINO FERREIRA DE
MENEZES NETO1
LAÍSA BRANDÃO CARVALHO1
WEBER RIBOLLI MORAGAS1
OONA TOMIÊ DARONCH1
RENATA FERNANDA RAMOS
MARCANTE1
ARISTIDES AUGUSTO
PALHARES NETO1
1
Universidade Estadual Paulista, Faculdade de Medicina de Botucatu, Departamento de Cirurgia e Ortopedia, Divisão de Cirurgia
Plástica, Botucatu, São Paulo, Brazil.
DOI: 10.5935/2177-1235.2023RBCP0674-EN
Institution: Universidade Estadual
Paulista, Faculdade de Medicina de
Botucatu, Botucatu, SP, Brazil.
Article received: December 4, 2021.
Article accepted: September 13, 2022.
Conflicts of interest: none.
Keywords: HIV; HIV Seroprevalence; Epidemiology; HIV-associated lipodystrophy
syndrome; Reconstructive surgical procedures; Brazil.
Lipodystrophy associated with HIV: epidemiological analysis
Rev. Bras. Cir. Plást. 2023;38(1):e0674 2
The inclusion criteria were described in an
ordinance of the following year, 2005. Diagnosis of HIV/
AIDS and use of antiretroviral drugs for at least 12
months; patients who did not respond to switching or
cannot be switched to antiretrovirals; clinically stable;
CD4 greater than 200; viral load (VL) less than 10,000
copies were included15.
In our service, Department of Plastic Surgery of
Faculdade de Medicina de Botucatu (FMB) – Universidade
Estadual Paulista (UNESP), we are accredited to this type
of service, respecting all regulations and ordinances in
force.
OBJECTIVE
To evaluate the epidemiology of patients treated
at the HIV-related Lipodystrophy Outpatient Clinic at
the Hospital das Clínicas (HC) of the FMB and the most
common treatments.
METHOD
The study was conducted retrospectively, with
port analysis of patients treated at the Lipodystrophy
Outpatient Clinic, between June 2012 and December
2019, at HC da UNESP in Botucatu, São Paulo, Brazil.
Data were collected in an Excel table and
analyzed descriptively.
All patients undergoing invasive procedures
were within the criteria established by the Ministry of
Health15 and the Plastic Surgery team at HC UNESP,
with a Body Mass Index (BMI) limit of less than or
equal to 25 kg/m2
.
Patients who did not return 12 months after the
last consultation were considered lost to follow-up.
All procedures performed in this study followed
the 1964 Declaration of Helsinki and its subsequent
amendments. The local Ethics Committee approved
this study (protocol number: 38919020.6.0000.5411).
RESULTS
During the analyzed period, 172 patients received
care. Of these, 19 patients were excluded from the study
INTRODUCTION
In 2020 begins the fifth decade of facing the
epidemic caused by the Human Immunodeficiency
Virus (HIV) in the world; Brazil is one of the bestorganized countries, with its policy of access to
universal and integral health as a highlight, with a
reduction in the lethality and increased survival1-3.
In 1985, the Ministry of Health began structuring
the direct fight against the disease by creating the
Acquired Immunodeficiency Syndrome Control
Program (AIDS)4
. In 1991, zidovudine (AZT) was
incorporated into the medicines of the Unified Health
System (SUS), and in 1996, antiretroviral therapy was
introduced and distributed universally and free of
charge to people with HIV5
.
With the advent and incorporation of this therapeutic
arsenal, there was an increase in patient survival;
however, not free of side effects and complications, such
as cardio and cerebrovascular diseases, insulin resistance,
and lipodystrophy6,7.
Primarily related to the class of protease inhibitors,
lipodystrophy may be associated with different
antiretroviral drugs and other factors, such as the
inflammatory state of the infection, the phenomenon
associated with immune reconstitution, and aspects of
the host, such as age and sex8,9.
The prevalence of this complication varies in
the literature, between 6 and 80%10,11, and has different
manifestations, such as lipoatrophy of the face, buttocks,
and limbs, and accumulation of fat in the abdominal and
cervical regions12,13.
Lipodystrophy, in addition to presenting aesthetic
consequences, also involves psychosocial aspects,
as it is stigmatizing and affects patients’ quality of
life, which may lead to interruption and therapeutic
discontinuation in some cases12,14.
In 2004, the Ministry of Health launched an
ordinance to offer these patients access to plastic surgery
to offer free treatment for HIV-related lipodystrophy.
There was the inclusion in the SUS of surgical
procedures, such as liposuction, gluteal implants,
reduction mammoplasty, and ancillaries, such as the
application of polymethylmethacrylate (PMMA)15.
dos pacientes. O procedimento invasivo mais realizado foi o preenchimento facial
com polimetilmetacrilato (PMMA), em 62 pacientes. A inclusão de implantes
glúteos foi a cirurgia mais realizada, em seis ocasiões. Conclusão: Os dados
encontrados mostram maior proporção de pacientes do sexo feminino com queixa
de lipodistrofia, quando comparados a dados gerais de pacientes com HIV. A
raça branca foi predominante e a principal queixa de lipodistrofia foi a atrofia
facial. O preenchimento facial com PMMA foi o procedimento mais realizado.
Descritores: HIV; Soroprevalência de HIV; Epidemiologia; Síndrome de
lipodistrofia associada ao HIV; Procedimentos cirúrgicos reconstrutivos; Brasil.
3 Rev. Bras. Cir. Plást. 2023;38(1):e0674
Secanho MS et al. www.rbcp.org.br
due to the absence of HIV-related lipodystrophy, thus
leaving 153 individuals.
The mean age was 45.6 years (between 19 and
68 years). There were 79 male and 74 female patients.
Referrals came from 48 cities in four states (São
Paulo, Paraná, Mato Grosso do Sul, and Ceará).
White patients totaled 116 (74.5%) attendances,
18 brown (10.4%), 10 black (5.9%), and nine without
information (5.2%).
The complaint of facial lipodystrophy was
reported by 81 (52.9%) patients, with a predominance of
this condition in males, being the reason for seeking care
in 74.3% of individuals of this gender. Despite a lower
prevalence than men, 25.8% of women sought care due
to facial complaints, thus constituting the most frequent
complaint of females in our outpatient clinic (Table 1).
In females, lipodystrophy of the abdomen
(24.7%), breasts (17.9%), and buttocks (24.6%) were
highly frequent.
The most common invasive procedure was
facial filling with PMMA in 62 patients (50 men and
12 women).
Another 20 patients underwent surgical
procedures, 27 performed in an inpatient setting and
three on an outpatient basis. Including gluteal implants
was the most common procedure on six occasions,
followed by GIBA liposuction, with four procedures,
and lipoabdominoplasty, with three (Table 2). In the
queue, awaiting surgery, we counted 26 patients, but
11 had a BMI above 25 kg/m2
, six needed comorbidity
control, such as HCV, SAH, and smoking, and two were
awaiting current CD4 and viral load tests. With that, we
have seven patients ready for the surgical procedure.
Forty-five patients lost outpatient follow-up. Of
these, 11 needed weight loss, four needed better control
of underlying pathologies, two were serving time in a
closed regime, and they moved to another city when
released. The remaining 24 contained no information.
DISCUSSION
The numbers presented in this article are unique
in the literature, as we present general data from our
series; thus, we included all patients with complaints of
lipodystrophy without selecting patients by anatomical
areas or procedures performed16-22.
There is a slight predominance of males. The
difference found in our sample, the M: F ratio of 1.06,
differs from AIDS epidemiology data in Brazil, with a
more marked prevalence and incidence in men, where
this ratio is currently at 2.623. This can be explained by
the fact that women tend to develop more lipodystrophy
and complain more about the aesthetic alterations
caused by antiretrovirals22.
Caucasian patients had the largest share of
consultations in our outpatient clinic, 74.5%. Although,
as of 2014, the prevalence of HIV-positive patients in
the national territory is of the brown race, with over
40% of those infected, only 10.4% of our casuistry were
brown and 5.9% black. Studies in the literature indicate
greater difficulty for black and brown people to access
HIV treatment, even with the universality and equity of
the SUS, which could explain the low demand for these
groups. The factors pointed out were socioeconomic
reasons, social marginalization, structured racism, and
difficulty understanding the disease and therapy24-26.
Attending patients from different states indicates
the difficulty of access to this specific type of care. Despite
the recognized quality of HIV treatment in Brazil, there
are still geographic discrepancies regarding the location
and access to specialized health services for this disease,
with patients requiring long journeys. This accessibility
difficulty can hurt these patients’ care, leading to low
adherence and discontinuity27.
Table 1. Main complaints of patients in consultations performed
at the Lipodystrophy outpatient clinic.
Complaint Men Women Total
Lipodystrophy of the face 58 23 81
Abdominal lipodystrophy 5 22 27
Breast lipodystrophy 0 16 16
Gluteal atrophy 1 13 14
Hump 4 6 10
Gynecomastia 9 0 9
Anterior cervical lipodystrophy 1 5 6
Arm lipodystrophy 0 2 2
Back lipodystrophy 0 2 2
Table 2.Main surgical procedures performed.
Surgical Procedures Performed Under General Anesthesia
Gluteoplasty with insertion of implants 6
Hump Liposuction 4
Anterior cervical liposuction 3
Lipoabdominoplasty 3
Abdominal liposuction 3
Gluteal fat grafting 2
Facelifting 1
Mastopexy with implants 1
Augmentation mastoplasty 1
Reduction mastoplasty 1
Arm liposuction 1
Accessory breast exeresis 1
Lipodystrophy associated with HIV: epidemiological analysis
Rev. Bras. Cir. Plást. 2023;38(1):e0674 4
The main reason for seeking our Lipodystrophy
Outpatient Clinic was facial atrophy, mostly in men.
These data are similar to the literature, in which the
male gender was also predominant in this complaint.
Treatment was performed in 76.5% of them with
facial filling using polymethylmethacrylate, a nonabsorbable substance approved by the SUS, which
brings satisfactory and safe results for patients28-32.
The most frequently performed surgical procedure
was augmentation gluteoplasty with implants, and the
second in frequency was Giba liposuction. These data
contrast the literature, in which Giba liposuction was
the most performed procedure17,19.
Another piece of information worth mentioning
is the number of patients lost to follow-up, 45 (29.4%).
There is no literary reference to this data in a Plastic
Surgery outpatient clinic. However, HIV carriers have
known unsatisfactory adherence to antiretroviral
treatment, which seems to be happening in this case33.
Most of these patients had a BMI above the limit
established by the team. This value aims at greater
patient safety since the surgical and complication risk
is greater in individuals with high BMI34.
This article has limitations, such as the study’s
retrospective nature, data collection based on the
analysis of medical records, and the low number of
patients undergoing surgical procedures. However,
with these data presented, we can analyze the structure
of our care and seek to improve and optimize the
resources available in health networks to treat HIVrelated lipodystrophy.
CONCLUSION
The data found show a higher proportion of
female patients complaining of lipodystrophy compared
to general data of patients with HIV. The white race was
predominant, and the main complaint of lipodystrophy
was facial atrophy. Facial filling with PMMA was the
most common procedure.
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14. Guaraldi G, Murri R, Orlando G, Squillace N, Stentarelli C,
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COLLABORATIONS
MSS Analysis and/or data interpretation, Conception
and design study, Data Curation, Investigation,
Methodology, Project Administration, Writing -
Original Draft Preparation.
BFMN Analysis and/or data interpretation, Data
Curation, Investigation, Methodology, Writing -
Original Draft Preparation.
LBC Analysis and/or data interpretation, Data
Curation, Investigation.
WRM Data Curation, Investigation.
OTD Data Curation, Investigation.
RFRM Data Curation, Investigation.
AAP Supervision, Visualization, Writing - Review &
Editing.
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Secanho MS et al. www.rbcp.org.br
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549720210019.supl.1
28. Martins WH, Pessôa KVO, Martins MA, Silva MH, Pereira Filho
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Murilo Sgarbi Secanho
Av. Prof. Professor Mário Rubens Guimarães Montenegro, Unesp - Campus de Botucatu, Botucatu, SP, Brazil.
Zip code: 18618-687
E-mail: [email protected]
*Corresponding author:
1 Rev. Bras. Cir. Plást. 2023;38(1):e0681
Frailty syndrome, feelings of impotence and functional
capacity in elderly patients with venous ulcers
Síndrome de fragilidade, sentimento de impotência e capacidade funcional
em idosos portadores de úlcera venosa
Introduction: Chronic venous ulcers have a negative impact on the physical, psychic,
and social domains, affecting the quality of life of patients, especially the elderly. This
study aimed to assess frailty, functional capacity, and feelings of helplessness in older
people with venous ulcers. Method: 112 older people were divided into two groups
according to the presence or absence of venous ulcers. All patients were interviewed
using the Edmonton Frail Scale (EFS), Health Assessment Questionnaire-20 (HAQ20), and the Impotence Feelings Measurement Instrument (IMSI) from May 2017 to
August 2018. Results: Regarding the EFS score, 76.8% of patients with venous ulcers
were classified as vulnerable and frail, compared to 28.6% of patients in the group
without ulcers. Scores on the HAQ-20 showed statistically significant differences
between groups in all categories of the instrument, indicating that older people with
venous ulcers had reduced general functional capacity compared to older people
without ulcers. The mean IMSI score was 41.2 for the group with venous ulcers and
33.4 for the group without ulcers. Conclusion: Venous ulcers had a negative impact on
functional capacity and increased frailty and feelings of powerlessness in the elderly.
Descritores: Idoso; Idoso fragilizado; Envelhecimento; Úlcera varicosa; Qualidade
de vida.
Introdução: Úlceras venosas crônicas exercem impacto negativo nos domínios
físico, psíquico e social, afetando a qualidade de vida de pacientes, especialmente os
idosos. O objetivo deste estudo foi avaliar o nível de fragilidade, capacidade funcional
e sentimento de impotência em idosos com úlcera venosa. Método: Um total de 112
idosos foram distribuídos em dois grupos de acordo com a presença ou ausência
úlcera venosa. Todos os pacientes foram entrevistados utilizando-se os questionários
Edmonton Frail Scale (EFS), Health Assessment Questionnaire-20 (HAQ-20) e o
Instrumento de Medida de Sentimento de Impotência (IMSI) no período de maio
de 2017 a agosto de 2018. Resultados: Em relação à pontuação na EFS, 76,8% dos
pacientes com úlcera venosa foram classificados como vulneráveis e frágeis, em
comparação a 28,6% dos pacientes do grupo sem úlcera. Pontuações no HAQ-20
mostraram diferenças estatisticamente significantes entre os grupos em todas as
categorias do instrumento, indicando que idosos com úlcera venosa apresentavam
redução da capacidade funcional geral em comparação aos idosos sem úlcera. A
pontuação média para o IMSI foi de 41,2 para o grupo com úlcera venosa e 33,4 para
o grupo sem úlcera. Conclusão: Úlceras venosas causaram impacto negativo na
capacidade funcional e aumento de fragilidade e sentimento de impotência nos idosos.
■ ABSTRACT
■ RESUMO
Original Article
Keywords: Aged; Frail elderly; Aging; Varicose ulcer; Quality of life.
ELIANA GONÇALVES
AGUIAR1
*
GERALDO MAGELA SALOMÉ1
LYDIA MASAKO FERREIRA1
1
Universidade Federal de São Paulo, Programa de Pós-graduação em Cirurgia Translacional, São Paulo, SP, Brazil.
DOI: 10.5935/2177-1235.2023RBCP681-EN
Institution: Universidade Federal
de São Paulo, Programa de
Pós-graduação em Cirurgia
Translacional, São Paulo, SP, Brazil.
Article received: December 14, 2021.
Article accepted: April 7, 2022.
Conflicts of interest: none.
Frailty, feelings of powerlessness and functional capacity in elderly patients with venous ulcers
Rev. Bras. Cir. Plást. 2023;38(1):e0681 2
INTRODUCTION
Since the middle of the last century, significant
changes have been taking place in the demographic
and health patterns of the world’s population, leading
to significant growth in the elderly population, many
of whom have some chronic diseases. It is estimated
that, in 2025, Brazil will have the sixth largest elderly
population in the world, around 32 million people1-4.
The negative impact of chronic venous ulcers on
quality of life is particularly reported concerning pain,
physical function, and mobility domains5-8. Depression
and social isolation are also reported as manifestations
resulting from the presence of venous ulcers7-11.
Most older people with venous ulcers feel frustrated,
impotent, lose faith in the treatment and feel vulnerable,
unable to carry out daily activities8,12-15, culminating
in growing dependence, whose evolution can change
and even be prevented or reduced if there is adequate
environment and assistance11,16. Dependence can also
be considered as a state in which people find themselves
lacking or losing autonomy (physical, psychological,
social) and needing help to carry out basic activities. It is
a serious health problem that interferes with the quality
of life of the elderly and their caregivers14,17.
When evaluating the functional capacity of older
people with venous ulcers, it is observed that patients
have a reduced capacity for self-care and meeting basic
needs6,9,12. Functional capacity or limitation can be defined
as the individual’s ability to maintain physical and mental
capacities in basic and instrumental activities15,16.
The frailty in the elderly with venous ulcers
becomes chronic, resulting in a feeling of impotence,
low self-esteem, and self-image16-19.
Most studies about the frailty syndrome and
elderly individuals with chronic diseases are justified
because this condition makes this population more
prone to progressive reduction in functional capacity,
repeated hospitalizations, and greater demand for
health services at different levels17,18,20-24.
In this sense, the frailty syndrome acquires
importance as a target for investigations and interventions
because of the impact on elderly individuals, especially
those with venous ulcers, their families, and society as
a whole. No national or international literature studies
evaluated the frailty syndrome and its consequences
(decreased functional capacity in activities of daily living
and instrumental activities of daily living, feelings of
impotence and its consequences) in elderly patients with
venous ulcers and who also consider pre-frail individuals.
OBJECTIVE
Assess the level of frailty, feelings of powerlessness,
and functional capacity in older people with venous ulcers.
METHOD
Analytical, cross-sectional, descriptive, controlled
study, approved by the Institutional Ethics Committee,
on opinion: 2,939,899, whose data were collected at the
Federal University of São Paulo from March 2017 to
August 2018.
Two groups of participants over 60 were established:
with venous ulcer and without ulcer, each group with 56
patients.
The inclusion criteria for both groups were: 60
years or older and being literate, adding an ankle/arm
index between 1.0 and 1.4 for the group with venous
ulcers. The non-inclusion criteria for both groups were:
mixed or arterial ulcer, sequelae of stroke, or lower
limb amputation.
Data were collected through interviews using
self-administered and public domain questionnaires,
including a form for collecting demographic data, the
Edmonton Frail Scale (EFS) instrument18, the Health
Assessment Questionnaire-20 (HAQ-20)21, and the
Instrument for Measuring Feelings of Powerlessness
(IMSI)15.
The EFS was chosen to assess whether individuals
in both groups were frail or pre-frail. This instrument
assesses the level of frailty in nine domains represented
by 11 items, including cognition, general health status
and health description, functional independence, social
support, medication use, nutrition, mood, continence,
and functional performance. The scoring ranges for
frailty level analysis are 0-4, no frailty; 5-6, apparently
vulnerable; 7-8, mild frailty; 9-10, moderate frailty; 11
or more, severe frailty, with a maximum score of 1718.
The HAQ-20 consists of 20 questions divided into
eight categories representing functional activities – getting
dressed, getting up, eating, walking, hygiene, reaching,
gripping, and other activities. The patient’s responses are
measured on a scale ranging from zero (no difficulty) to
three (unable to do). The final score is calculated by the
sum of the components divided by 8 and can be classified
as HAQ-20 from 0 to 1, mild deficiency; HAQ-20 >1 to
2, moderate deficiency; and HAQ-20 >2 to 3, severe
deficiency21.
The IMSI consists of 12 Likert-type questions with
a five-point frequency ranging from “never” to “always.”
In this scale, the following scores are assigned to items
that mean the presence of a feeling of powerlessness:
1 = never; 2 = rarely; 3 = sometimes, 4 = often, and
5 = always, totaling a maximum of 60 points. The 12
questions are divided into three domains: the ability
to perform a behavior (Cronbach’s alpha = 0.845), the
perceived ability to make decisions (Cronbach’s alpha =
0.834), and the emotional response to controlling
situations (Cronbach’s alpha = 0.578). The scores are
3 Rev. Bras. Cir. Plást. 2023;38(1):e0681
Aguiar EG et al. www.rbcp.org.br
added by domain and total score; the higher the score,
the more intense the feeling of powerlessness15.
Data were entered and analyzed using the
SPSS-8.0 statistical program (SPSS Inc., Chicago, IL,
USA). Pearson’s chi-square test was used to assess the
homogeneity of responses, comparing the two study
groups, with a significance level equal to 0.05 (p<0.05).
Comparison between groups was performed using the
Mann-Whitney test. Spearman’s correlation test was
applied to assess the correlation of continuous variables
with semicontinuous variables.
RESULTS
The sample consisted of 112 patients with the
following sociodemographic characteristics: 68 (60.7%)
were female, 56 (50.0%) had venous ulcers, 64 (57.1%) were
70 years old or older, 43 (38.4%) could read, and write; 88
(78.6%) were retired; 45 (40.2%) were married, 40 (35.7%)
lived with family members, 100 (89.3%) used medication,
60 (53.6%) had an adequate body mass index (BMI), 76
(67.9%) did not practice physical activity, and 84 (75.0%)
suffered a fall in the 30 days prior to the interview.
According to the mean overall EFS score by
group (Table 1), patients with venous ulcers were
considered vulnerable (mean EFS = 6.46) in contrast
to patients without ulcers who were identified as not
vulnerable (mean EFS = 3.38), with a statistically
significant difference between groups (p=0.001).
Regarding the EFS score by category, patients in
the ulcer group were concentrated in the “apparently
vulnerable” and “mildly frail” categories, while the
group without ulcers was concentrated in the “nonfrail” category. Table 2 indicates that 76.8% (n=43)
of patients with venous ulcers were classified as
vulnerable and fragile, compared to 28.6% (n=16) of
patients in the group without ulcers, with a statistically
significant difference between groups (p=0.001).
Table 3 shows that patients with venous ulcers
had greater difficulty performing activities of daily
living (mean overall HAQ-20 = 1.08) compared to
patients without ulcers (mean overall HAQ-20 = 0.37),
with a difference statistically significant between
groups (p=0.002).
Patients with venous ulcers had a stronger
feeling of powerlessness than those without it. It is
observed in Table 4 that the average score for the IMSI
was 41.2 for the group with venous ulcer and 33.4 for
the group without ulcer, with a statistically significant
difference between groups (p=0.001).
DISCUSSION
When the older person acquires a wound, he may
find it difficult to carry out various activities in his daily
life. Often, these changes in activities of daily living
can cause emotional, psychological, and biological
suffering in individuals, leading to changes in style and
quality of life and sleep, making it impossible for them
to carry out their social activities, perform self-care,
and participate in leisure and family life, in addition
to causing absenteeism at work and even loss of work
functions in the productive age group. These factors
can make the elderly feel fragile22-26.
In this study, most older people without ulcers
were not frail, while most older people with venous
ulcers were vulnerable.
Being frail was related to higher incidences of
hospitalization during follow-up. Results were shared
Table 1. Comparison of Edmonton Frail Scale scores between
groups.
Group
EFS - Overall Score
p-Value n Mean Median SD
With ulcer 56 6.46 6.0 3,086
No ulcer 56 3.38 3.0 2,253 0.001*
Total 112 4.92 5.0 3.105
EFS: Edmonton Frail Scale; n: sample size; SD: standard deviation; *:
significance level p<0.05 (Chi-square test).
Level of Fragility
Group
With ulcer Without ulcer Total p-Value
n % n % n %
Does not present Fragility 13 23.2 40 71.4 53 47.3
Apparently Vulnerable 16 28.6 11 19.6 27 24.1 0.001*
Mild frailty 12 21.4 4 7.1 16 14.3
Moderate frailty 11 19.6 0 0.0 11 9.8
Severe frailty 4 7.1 1 1.8 5 4.5
Total 56 100 56 100 112 100
Table 2.Distribution of the level of frailty in the study groups according to Edmonton Frail Scale.
EFS: Edmonton Frail Scale; n: sample size; *: significance level p<0.05 (Chi-square test)
Frailty, feelings of powerlessness and functional capacity in elderly patients with venous ulcers
Rev. Bras. Cir. Plást. 2023;38(1):e0681 4
with other scientific evidence, especially when there
was a prevalence ranging from 50% to 80% of frail
among hospitalized elderly25-29.
In a study in which the authors verified the levels
of frailty and functional independence in instrumental
activities of daily living among the elderly identified as
frail, it was found: 29.8% with minimal dependence/
supervision and 81.9% with partial dependence for
instrumental activities of daily living30. The authors
showed greater dependence on activities in frail older
people, with females having a higher prevalence of frailty30.
In this research, the means of the total score of
elderly patients with venous ulcers in the HAQ-20 and
IMSI instruments were high, indicating that these
individuals have difficulties performing some daily
living activities.
Deficits in functional, cognitive, and psychic
capacity are the main causes of loss of independence13,15,
leading the elderly to need greater care to carry out
activities of daily living.
This issue has become a challenge to be faced by
elderly patients with venous ulcers since the population’s
life expectancy has increased, leading to a consequent
growth in the number of older people with chronic
disease and functional disabilities.
Bearing in mind that the functional capacity of
human beings declines with age, it is necessary to plan
strategies that improve the lifestyle of these individuals
with or without wounds, especially concerning
programs that promote and improve muscle and joint
strength, with social integration inside and outside the
family context. These actions would make it possible
to minimize the dependence of these individuals on
family, social, leisure, and daily activities28,29.
This research reinforces the need to direct the
health care of elderly patients with venous ulcers,
seeking to identify, in the daily routine of health
services, whether in hospitals, outpatient clinics, the
Family Health Program, and others, the presence of
reduced functional capacity and increase in fragility
and a feeling of powerlessness among patients who live
with the wound in their daily lives, the main care needs
of this population and the caregiver’s knowledge to deal
with the assisted person’s disabilities. Furthermore,
Domains
Group
With ulcer Without ulcer Total p-Value
n Mean SD n Mean SD n Mean SD
Ability to perform
Behavior 56 15.59 2,130 56 9.04 3.063 112 12.31 4.211 0.001*
Ability to take
instructions 56 11.96 2,607 56 13.95 3,272 112 12.96 3.109 0.001*
Emotional response to
control situations 56 13.54 2,565 56 10.57 3.173 112 12.05 3.235 0.001*
General 56 41.21 4,853 56 33.41 7.081 112 37.31 7.202 0.001*
Table 4. Comparison of the mean score in the Feelings of Powerlessness Measurement Instrument domains between groups.
IMSI: Instrument for Measuring Feelings of Powerlessness; n: sample size; SD: standard deviation; *: significance level p<0.05 (Mann-Whitney non-parametric test).
Categories
Group
With ulcer Without ulcer Total p-Value
No Mean SD n Mean SD n Mean SD
Dress up/ Take care of himself 56 0.86 0.841 56 0.20 0.401 112 0.53 0.735 0.001*
Wake up 56 1.07 0.912 56 0.39 0.593 112 0.73 0.838 0.002*
Eat 56 0.52 0.687 56 0.13 0.384 112 0.32 0.586 0.002*
To walk 56 1.59 0.890 56 0.57 0.759 112 1.08 0.969 0.001*
Hygiene 56 1.00 0.653 56 0.29 0.594 112 0.64 0.815 0.001*
Catch up 56 1.13 0.974 56 0.61 0.679 112 0.87 0.875 0.001*
Hold 56 1.18 1.081 56 0.36 0.616 112 0.77 0.968 0.001*
Others Activities 56 1.32 0.917 56 0.43 0.599 112 0.87 0.892 0.001*
General 56 1.08 0.729 56 0.37 0.407 112 0.73 0.686 0.002*
Table 3. Comparison of mean scores in Health Assessment Questionnaire-20 categories between groups.
HAQ-20: Health Assessment Questionnaire-20; n: sample size; SD: standard deviation; *: significance level p<0.05 (Mann-Whitney non-parametric test).
5 Rev. Bras. Cir. Plást. 2023;38(1):e0681
Aguiar EG et al. www.rbcp.org.br
given the needs that have arisen in recent decades
with the increase in chronic diseases and patients with
wounds, it is imperative that the academic training and
qualification of health professionals value the content
and care practice.
CONCLUSION
Venous ulcers negatively impact functional
capacity and increase frailty and feelings of
powerlessness in the elderly.
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et al. Assessment of frailty in elderly patients attending a
multidisciplinary wound care centre: a cohort study. BMC
Geriatr. 2021;21(1):727. DOI: 10.1186/s12877-021-02676-y
COLLABORATIONS
EGA Analysis and/or data interpretation, Conception
and design study, Conceptualization, Data
Curation, Final manuscript approval, Formal
Analysis, Investigation, Methodology, Project
Administration, Realization of operations and/or
trials, Resources, Visualization, Writing - Original
Draft Preparation, Writing - Review & Editing.
LMF Analysis and/or data interpretation, Conception
and design study, Conceptualization, Final
manuscript approval, Formal Analysis,
Methodology, Project Administration,
Supervision, Visualization, Writing - Review &
Editing.
GMS Analysis and/or data interpretation, Conception
and design study, Conceptualization, Final
manuscript approval, Formal Analysis,
Methodology, Project Administration,
Supervision, Visualization, Writing - Original
Draft Preparation, Writing - Review & Editing.
REFERENCES
1. Rudnicka E, Napierała P, Podfigurna A, Męczekalski B,
Smolarczyk R, Grymowicz M. The World Health Organization
(WHO) approach to healthy ageing. Maturitas. 2020;139:6-11.
2. Carvalho JA, Rodríguez-Wong LL. The changing age distribution
of the Brazilian population in the first half of the 21st century.
Cad Saúde Pública. 2008;24(3):597-605.
3. Da Mata FA, Pereira PP, Andrade KR, Figueiredo AC, Silva
MT, Pereira MG. Prevalence of Frailty in Latin America and
the Caribbean: A Systematic Review and Meta-Analysis. PLoS
One. 2016;11(8):e0160019. DOI: 10.1371/journal.pone.0160019
4. Brasil. Instituto Brasileiro de Geografia e Estatística (IBGE).
Projeção da população do Brasil e das Unidades de Federação
[Internet]. Rio de Janeiro: IBGE; 2021. [acesso 2021 Nov 15].
Disponível em: http://www.ibge.gov.br/apps/populacao/projecao/
index.html
5. Salomé GM, de Almeida SA, Pereira MT, Massahud Junior
MR, Moreira CN, de Brito MJ, et al. The impact of venous
ulcers on body image and self-esteem. Adv Skin Wound Care.
2016;29(7):316-21.
6. Barnsbee L, Cheng Q, Tulleners R, Lee X, Brain D, Pacella R.
Measuring costs and quality of life for venous leg ulcers. Int
Wound J. 2019;16(1):112-21.
Frailty, feelings of powerlessness and functional capacity in elderly patients with venous ulcers
Rev. Bras. Cir. Plást. 2023;38(1):e0681 6
Eliana Gonçalves Aguiar
Disciplina de Cirurgia Plástica. Rua Botucatu 740, 2o andar, Vila Clementino, São Paulo, SP, Brazil.
Zip code: 04023-062
E-mail: [email protected]
*Corresponding author:
27. Vicente JB, Mariano PP, Buriola AA, Paiano M, Waidman MA,
Marcon SS. Acceptance of patients with mental illness: a family
perspective. Rev Gaúcha Enferm. 2013;34(2):54-61.
28. Costa EC, Nakatani AY, Bachion MM. Elder’s community
capacity to develop Daily Life Activities and Daily Instrumental
Life Activities. Acta Paul Enferm. 2006;19(1):43-8.
29. Silva MCP, Salomé GM, Miguel P, Bernardino C, Eufrásio C,
Ferreira LM. Evaluation of feelings helplessness and body image in
patients with burns. Rev Enferm UFPE On Line. 2016;10(6):2134-40.
30. Fhon JRS, Diniz MA, Leonardo KC, Kusumota L, Haas VJ,
Rodrigues RAP. Frailty syndrome related to disability in the
elderly. Acta Paul Enferm. 2012;25(4):589-94.
1 Rev. Bras. Cir. Plást. 2023;38(1):e0680
Double transposition flap for lower eyelid reconstruction:
case report of a new surgical approach
Retalho de dupla transposição para reconstrução de pálpebra inferior: relato
de caso de uma nova abordagem cirúrgica
Introduction: Non-melanoma tumors frequently affect the lower palpebral region
and constitute a challenge for reconstructing the surgical wound without causing
functional or aesthetic changes. Primary closure is generally impossible, and
flaps are preferred over grafts as they generate less eyelid retraction. This article
aims to describe a new surgical reconstruction technique. Method: A modified
McGregor flap technique is described for correcting a surgical defect greater
than 50% of the anterior lamella of a recurrent basal cell carcinoma lesion in
the lower eyelid. Results: The patient was evaluated on the 7th, 14th, 21st, and 45th
postoperative days. She presented a good functional and aesthetic response to the
technique used. Conclusion: Using the double transposition flap, we demonstrate
a new technique for closing defects larger than two-thirds in the lower eyelid.
Descritores: Procedimentos cirúrgicos reconstrutivos; Retalhos cirúrgicos;
Carcinoma basocelular; Neoplasias palpebrais; Pálpebras.
Introdução: Os tumores não melanomas acometem frequentemente a região
palpebral inferior e consistem em um desafio para a reconstrução da ferida
operatória sem ocasionar alteração funcional ou estética. O fechamento primário
geralmente não é possível e os retalhos são preferenciais aos enxertos por gerarem
menor retração palpebral. Este artigo tem como objetivo descrever uma nova
técnica de reconstrução cirúrgica. Método: Descreve-se técnica modificada
do retalho de McGregor para correção de defeito cirúrgico maior que 50% da
lamela anterior, de lesão recidivada de carcinoma basocelular localizada em
pálpebra inferior. Resultados: Paciente foi avaliada no 7º, 14º, 21º e 45º dia de pósoperatório. Apresentou boa resposta funcional e estética com a técnica utilizada.
Conclusão: Demonstramos uma nova técnica de fechamento de defeitos maiores
do que dois terços na pálpebra inferior através do retalho de dupla transposição.
■ ABSTRACT
■ RESUMO
Ideas and Innovations
Keywords: Reconstructive surgical procedures; Surgical flaps; Carcinoma, basal
cell; eyelid neoplasms; Eyelids.
1
Instituto de Dermatologia Prof. Rubem David Azulay, Cirurgia Dermatológica, Rio de Janeiro, Rio de Janeiro, Brazil.
DOI: 10.5935/2177-1235.2023RBCP680-EN
Institution: Instituto de
Dermatologia Professor Rubem
David Azulay, Rio de Janeiro,
RJ, Brazil.
Article received: December 31, 2021.
Article accepted: September 13, 2022.
Conflicts of interest: none.
neoplasia or trauma is challenging due to the small
amount of excess tissue.
The choice of the best flap depends on the
location, size, and depth (if there is tarsal involvement,
that is, the posterior lamella). Superficial surgical defects
only require reconstruction of the anterior lamella (skin
and muscle), whereas full-thickness defects require both
anterior and posterior lamellae (tarsus and conjunctiva)
INTRODUCTION
Cutaneous neoplasms are frequent on the
face and cause functional and aesthetic morbidity in
patients, with basal cell carcinoma (BCC) being the
most common type1
. Melanoma and non-melanoma
skin cancer affect the eyelid region in 5 to 10% of cases2
.
Reconstruction of the lower eyelid after excision of
LISSIÊ LUNARDI SBROGLIO
BASTIAN1
*
MARCELA DUARTE BENEZ
MILLER1
MARINA ARAÚJO
FONTE BOA 1
GUILHERMO LODA1
Double transposition flap for lower eyelid reconstruction
Rev. Bras. Cir. Plást. 2023;38(1):e0680 2
to be reconstructed3,4. This article aims to describe a new
technique option for surgical wound reconstruction.
Flaps are preferred in defects greater than 33%
of the affected eyelid to avoid retraction of the area
and prevent ectropion due to the vertical tension at
the site. The flaps most used for eyelid reconstruction
are advancement with or without canthotomy;
transposition; mustard; McGregor; Fricke; LandoltHughes; Dutupuys-Dutemps-Hughes (uses skin and
mucosa of the upper eyelid); and Abbe3
.
OBJECTIVE
This article presents a new surgical proposal to
facilitate the reconstruction of the lower eyelid when
the anterior lamella is affected by more than two-thirds,
using a double transposition flap.
METHOD
Female patient, 70 years old, with recurrence,
9 years after the first surgery without margin control,
of BCC in the topography of the lower right eyelid,
was admitted to Instituto Azulay in Rio de Janeiro,
RJ. A pearly lesion appeared 6 months ago on clinical
examination, with exulcerations and 19x12mm in
diameter (Figure 1). Dermoscopy revealed the presence
of erythema, ulceration, maple leaves, some ovoid nests,
and chrysalis.
On October 19, 2021, the patient underwent local
anesthesia with Klein’s modified tumescent solution
and complete tumor excision with intraoperative
freezing. After enlarging the surgical margins of an
infiltrative BCC, a defect greater than 50% of the
anterior lamella was obtained (Figure 2).
The McGregor flap was chosen first to close the
wound; however, due to the tissue’s low mobility, it was
impossible to perform the programmed flap advancement
movement after interpolating the z-plasty triangles.
Therefore, the McGregor flap was modified.
After making an M-shaped incision in the temporal
region – lateral to the defect – two symmetrical triangles
were created with their largest axis, the size of the
largest radius of the wound (Figure 3). The tissue was
detached from the malar and temporal regions, and
the first triangle was transposed towards the wound to
close the primary defect, and then the second triangle
was transposed to close the area of the first triangle.
Finally, the space of the second triangle was primarily
closed. Thus, the movement of the first triangle was a
combination of transposition and rotation movements
to move the tissue toward the surgical wound.
Gilles stitches were made to fix each tip of the
transposed triangles and internal and external stitches
with mononylon 5.0 (Figure 4).
Figure 1. Dermoscopic delimitation of basal cell carcinoma in the lower right
eyelid, measuring 19x12mm.
Figure 2. After enlarging the surgical margins of an infiltrating basal cell
carcinoma, a defect greater than 50% of the anterior lamella was obtained.
3 Rev. Bras. Cir. Plást. 2023;38(1):e0680
Bastian LLS et al. www.rbcp.org.br
Eyelid reconstruction is challenging due to this
area’s anatomical and physiological characteristics. It is
mainly based on two factors: thickness and extension of
the defect5
. The lower eyelid and medial canthus are the
most affected regions, and these periorbital cutaneous
tumors can be difficult to manage, commonly treated
with surgical excision6
.
Although many surgical techniques are available,
there is no preferred method of choice. Among the available
modalities for closing the lower eyelid transposition flaps
such as the Tripier, which consists of a myocutaneous
transposition flap, the Fricke flap, the Kreibig flap,
and the nasolabial flap with an upper base. Among the
advancement flaps, there is the McGregor (which associates
the advancement technique with z-plasty) and the Imre
flap. As for the rotation ones, the Mustardè technique is a
widely used option to repair extensive defects in the anterior
lamella of the lower eyelid or combination with cartilage
and mucosa grafts to close the posterior lamella7
.
The transposition flap with zetaplasty is a
possibility for closing several surgical defects on the
face, as it allows a complete redirection of the stress
vector through islands of healthy skin. Due to these
characteristics, it is indicated for closing defects close
to the free margins, such as the nasal wing, lips, helix,
and eyelids8
.
In 1973, McGregor published the lateral periorbital
z-plasty associated with forward movement, an excellent
alternative within the reconstructive therapeutic
arsenal6,9. In this case, z-plasty is performed at the lateral
end of the incision, with the defect’s width corresponding
to the central branch of the Z. The lateral descending
branch and the ascending branch of the Z are the same
length as the central branch and form an angle of 60
degrees with it. Lateral canthotomy is performed to
allow advancement of the flap and coverage of the eyelid
defect. After interpolation of the flaps, any excess skin
is trimmed6,9.
RESULTS
The patient had no major complications during
the postoperative period. Eyelid swelling is expected,
with difficulty opening the eyes and a slight hematoma
in the first days after surgery, which usually resolves
Figure 3. Modification of the McGregor Flap Technique. Two symmetrical
triangles were made with their largest axis, the size of the largest radius of
the wound. Transpose the first triangle toward the wound to close the primary
defect, and then transpose the second triangle to close the area of the first
triangle.
Figure 4. Immediate postoperative.
Figure 5. 45th postoperative day, good aesthetic and functional result.
within a week. She received prophylactic antibiotic
therapy with cefadroxil. The stitches were removed
on the 14th postoperative day, and from the 21st day
onwards, massage was recommended for drainage
of residual edema and photoprotection. The photos
were taken immediately, on the 7th, 14th, 21st, and 45th
postoperative days (Figure 5).
The result was satisfactory, maintaining aesthetics
and local functionality and providing a discreet and
barely perceptible scar.
DISCUSSION
Double transposition flap for lower eyelid reconstruction
Rev. Bras. Cir. Plást. 2023;38(1):e0680 4
In contrast, instead of performing the forward
movement after interpolation of the z-plasty triangles,
in this patient, we performed an M-shaped incision. We
combined the movement of transposition and rotation
of the first triangle (Figure 6) with the subsequent
transposition of the second triangle. In the other
studies found in the literature, the construction of a
double, triple, or even quadruple transposition flap
is performed at opposite angles and equidistant from
the largest diameter of the surgical defect. However, in
this case, there would be a risk of ectropion, a different
technique than those already published.
Thus, this report demonstrates a technique of
a double transposition flap, in which its design was
inspired by the McGregor flap, differing from the other
described techniques.
Lissiê Lunardi Sbroglio Bastian
Departamento de Cirurgia Dermatológica, Instituto de Dermatologia Professor Ruben David. Azulay. Rua
Santa Luzia, 206, Centro, Rio de Janeiro, RJ, Brazil.
Zip code: 20020-022
E-mail: [email protected]
*Corresponding author:
Figure 6. The drawing compares the previously described McGregor technique
(A) and the modified flap (B) with transposition and rotation of the first lobe
(illustrated by a star or circle) for closure of the primary defect and transposition
of the second lobe (3) for closure of the secondary defect.
COLLABORATIONS
LLSB Conception and design study, Conceptualization,
Final manuscript approval, Writing - Original
Draft Preparation.
MDBM Conception and design study, Conceptualization,
Final manuscript approval, Supervision, Writing -
Original Draft Preparation, Writing - Review &
Editing.
MAFB Conceptualization, Final manuscript approval,
Writing - Original Draft Preparation.
GL Conceptualization, Final manuscript approval,
Supervision, Writing - Review & Editing.
REFERENCES
1. Rodrigues EW, Moreira MR, Menegazzo PB. Análise do
Tratamento do Carcinoma Basocelular. Rev Bras Cir Plást.
2014;29(4):504-10.
2. Kanski JJ, Bowling BB. Pálpebras. In: Kanski JJ, Bowling BB.
Oftalmologia Clínica: uma abordagem sistemática. 8ª ed. Rio de
Janeiro: Elsevier; 2016. p. 15-20.
3. Benez MDV, Sforza D, Mann D, Silva SCM. Reconstrução de
pálpebra inferior com retalho cutâneo e enxerto de mucosa oral.
Surg Cosmet Dermatol. 2014;6(2):17882.
4. Lima DA. Reconstrução total de pálpebra inferior com associação dos
retalhos de Hughes e Destro. Rev Bras Cir Plást. 2018;33(3):364-73.
5. Vieira R, Pinho A, Brinca A. Reparo da pálpebra inferior por
fechamento direto com cantopexia lateral e elevação da fáscia
suborbicular dos olhos: uma técnica simples para evitar o ectrópio
pós-operatório. Surg Cosmet Dermatol. 2018;10(4):346-8.
6. Almeida ACM, Alves JCRR, Pereira NA, Jamil LC, Portugal EH,
Fonseca RPL, et al. Retalho de McGregor: uma alternativa para
reconstrução de pálpebra inferior e região periorbital. Rev Bras
Cir Plást. 2018;33(2):229-35.
7. Vieira R, Goulão J. Algoritmo para reparo das pálpebras. Surg
Cosmet Dermatol. 2019;11(2):91-6.
8. Stolf HO, Abbade LPF. Principais tipos e indicações de Retalhos.
In: Gadelha AR, Costa IMC, eds. Cirurgia dermatológica em
consultório. São Paulo: Atheneu; 2017.
9. McGregor IA. Eyelid reconstruction following subtotal resection
of upper or lower lid. Br J Plast Surg. 1973;26(4):346-54.
1 Rev. Bras. Cir. Plást. 2023;38(1):e0610
The main abdominoplasty techniques used in
post-bariatric patients after massive weight loss:
systematic review
As principais técnicas utilizadas de abdominoplastia em pacientes
pós-bariátricos após massiva perda de peso: Revisão sistemática
Introduction: Obesity is defined by a body mass index (BMI) ≥30 kg/m2, and
today approximately 2.1 billion adults are obese. With this high number of obese
people, the demand for treatment via bariatric surgery has been increasing to
reduce weight, resolve comorbidities and improve quality of life. However, intense
weight loss can cause adverse physical, aesthetic, and psychological effects.
Plastic surgery becomes essential to resolve these adverse effects. According
to the International Society of Plastic Surgery, 112,116 abdominoplasties were
performed in 2020, representing 8.6% of all plastic surgeries performed in
Brazil. The objective is to present the main abdominoplasty techniques in postbariatric patients. Method: Studies that met the previously defined inclusion
criteria were included. Results: A total of 28 references were included in this
systematic review. Discussion: Most seek abdominoplasty due to the excess
skin remaining in various body regions and the impact on post-bariatric
patients’ quality of life and mental health. The surgical techniques addressed
are classic abdominoplasty; fleur-de-lis or anchor; circumferences; and
Scarpa’s fascia. The total number of complications was 42%; the main ones
observed were scarring, skin dehiscence, infection, and necrosis; the three
added up to 32%. Conclusion: The improvement in the quality of life of patients
undergoing abdominoplasty is evident, but further research is needed to relate
abdominoplasty techniques to these patients with postoperative complications.
DOI: 10.5935/2177-1235.2023RBCP0610-EN
Institution: Universidade Santo
Amaro, Faculdade de Medicina,
São Paulo, SP, Brazil.
Article received: July 7, 2021.
Article accepted: November 16, 2022.
Conflicts of interest: none.
Review Article
Introdução: A obesidade é definida pelo índice de massa corporal (IMC) ≥30 kg/m2
,
e hoje cerca de 2,1 bilhões de adultos são obesos. Com esse alto número de obesos, a
procura por tratamento via cirurgia bariátrica vem aumentando com o intuito de redução
de peso, resolução de comorbidades e melhora da qualidade de vida. Entretanto, a
intensa perda de peso pode ocasionar efeitos adversos físicos, estéticos e psicológicos.
A cirurgia plástica passa a ser fundamental para resolução desses efeitos adversos.
Segundo a Sociedade Internacional de Cirurgia Plástica, foram realizados 112.116
abdominoplastias em 2020, representando 8,6% de todas as cirurgias plásticas realizadas
no Brasil. O objetivo é apresentar as principais técnicas de abdominoplastia em pacientes
pós-bariátricos. Método: Foram incluídos estudos que cumprissem os critérios de
inclusão previamente definidos. Resultados: Foi incluído nesta revisão sistemática
um total de 28 referências. Discussão: Devido ao excesso de pele remanescente em
■ ABSTRACT
■ RESUMO
Keywords: Abdominoplasty; Patients; Bariatric surgery; Reconstructive surgical
procedures; Body contouring.
1
Sociedade Brasileira de Cirurgia Plástica, São Paulo, SP, Brazil.
2
Universidade Santo Amaro, Faculdade de Medicina, São Paulo, SP, Brazil.
EURICO ARTEAGA
SANTIAGO-JUNIOR1
THAIS CONTE DIAS BENCINI
ANDRIGHETTI1
MATHEUS LUCENA MIRANDA
MERONI2
*
THAYS FAVARO FERNANDES
NOLASCO2
RODRIGO CONTENTE2
CAROLINA LACERDA SOUZA2
Abdominoplasty techniques after massive weight loss
Rev. Bras. Cir. Plást. 2023;38(1):e0610 2
Plastic surgery then plays a fundamental role
in tissue replacement and psychological and social
reintegration of these individuals who underwent
gastroplasty and with weight loss, and abdominoplasty is
the most requested procedure for treating post-bariatric
treatment patients. According to the International
Society of Plastic Surgery, 112,116 abdominoplasties
were performed in 2020, representing 8.6% of all plastic
surgeries in Brazil12.
However, there are indication criteria: a minimum of
12 to 18 months after bariatric surgery, weight stability
for at least 3 to 4 months, and BMI below 30kg/m2
. These
parameters are important, as nutritional homeostasis
is a positive nitrogen balance necessary to heal large
surgical wounds13. Thus, the theme’s relevance and
its main and most current techniques for the scientific
society are highlighted.
OBJECTIVE
This systematic review aims to present the
main abdominoplasty techniques in post-bariatric
patients, their main postoperative complications, and
the improvement in the patient’s quality of life and
psychosocial status after the surgery.
METHOD
A systematic literature review was carried out
following the PRISMA statement using epidemiological
data from the Brazilian Institute of Geography and
Statistics (2019) and the International Society of Plastic
Surgery (2020) in order to answer the PICO question -
What are the main techniques used of abdominoplasty
in post-bariatric patients after massive weight loss? -.
The search was carried out on 07/19/2022 in
the PubMed, BVS, SciELO, and Cochrane databases,
applying the following descriptors, respectively:
“Abdominoplasty” AND “Patients” OR “Bariatric
surgery” AND “Plastic surgery” AND “Body contouring.
“ All descriptors were validated in DeCS/MeSH. Time
limitation between 2017 and 2022 and articles in Portuguese,
English, Spanish, Italian, and French were used.
INTRODUCTION
Obesity is initially characterized by a body
mass index (BMI) ≥30kg/m2
, it is a condition that has
grown in many countries, and today it has become a
serious public health problem in most of them; around
2.1 billion adults are obese1,2. In Europe, the United
Kingdom has the largest population of obese people
on the continent, reaching a rate of 28%; in the United
States of America, there are about 150 million obese
adults, while in Brazil, according to the Brazilian
Institute of Geography and Statistics (IBGE), 41.2
million people over 18 years old are obese3-6.
The National Health System in the United Kingdom
invests 5.3 billion pounds a year in actions to control obesity,
as it understands the seriousness of this problem, as it is
linked to the development of several comorbidities, such
as hypertension, cardiovascular diseases, hyperlipidemia,
stroke, osteoarthritis, obstructive sleep apnea, diabetes
mellitus, and carcinomas. All can directly affect the health
of these people and reduce their life expectancy3,7.
The first step in treating patients with a BMI
of 30kg/m2
to 34.9kg/m2
is lifestyle changes, physical
exercise, and nutritional and endocrinological follow-up7
.
Those with a BMI >40kg/m2
or >35kg/m2
with severe
comorbidities are eligible for bariatric surgery7
.
The search for treating type II obesity with
comorbidities and type III obesity has been increasing,
considering that gastroplasties can be associated
with reducing weight and secondary comorbidities
to this disease8,9. Of course, always in conjunction
with changes in lifestyle, habits, and nutritional and
endocrine monitoring, making it the most effective way
to accelerate weight loss9
.
However, this intense and rapid loss of adipose
tissue can also involve adverse effects. The main
disadvantages are dermoadipose ptosis caused by
collagen changes in post-bariatric patients, characterized
by dimorphism in regions of the thighs, arms, breasts,
and abdomen7,10,11. In addition to the psychological
damage caused, poor hygiene, skin infection, dermatitis,
and difficulty walking are also observed, which can
aggravate the psychological condition11.
várias regiões do corpo e o impacto na qualidade de vida e saúde mental dos pacientes
pós-bariátricos, a maioria procura por abdominoplastia. As técnicas cirúrgicas
abordadas são abdominoplastia clássica; flor-de-lis ou âncora; circunferências;
e fáscia de Scarpa. O total de complicações foi de 42%, as principais observadas
foram de cicatrização; deiscência de pele, infecção e necrose; as três somaram 32%.
Conclusão: A melhora na qualidade de vida dos pacientes submetidos a abdominoplastia
é evidente, porém é necessária a realização de mais pesquisas que relacionem as
técnicas de abdominoplastia nesses pacientes com suas complicações pós-operatórias.
Descritores: Abdominoplastia; Pacientes; Cirurgia bariátrica; Procedimentos
cirúrgicos reconstrutivos; Contorno corporal.
3 Rev. Bras. Cir. Plást. 2023;38(1):e0610
Santiago-Junior EA et al. www.rbcp.org.br
Therefore, studies that met the following criteria
were included in this review: (1) case reports, randomized
or quasi-randomized clinical trials, prospective/
retrospective case series, retrospective/prospective
cohorts; (2) in humans; (3) revisions; (4) post-bariatric
patients; (5) the most used abdominoplasty techniques
in post-bariatric patients. Finally, all papers that did not
meet the inclusion criteria were excluded.
The main techniques to be addressed in this review
are traditional or classic horizontal abdominoplasty,
fleur-de-lis or anchor, circumferences, and with Scarpa’s
fascia. These four techniques can be associated with other
surgeries, for example, neophalloplasty and liposculpture;
however, they are not addressed in this research8,12-14.
Traditional or classic horizontal abdominoplasty
Vernon, Callia, Pitanguy, Regnaul, Grazer, and
Baroudi described it. The markings of this technique
may have anatomical variations. In general, a straight line
begins above the pubic symphysis and extends parallel to
the height of the iliac crest, then the clamping test occurs
to delimit the region to be removed, and it is then possible
to delimit the upper marking, which can have variation
concerning its positioning. At the end of the marking,
something similar to an ellipse is expected8,14 (Figure 1).
Fleur-de-lis or anchor abdominoplasty
Castanhares and Goethel described it. The
markings begin at the xiphoid process and extend to
the pubic symphysis region, forming a large ellipse. In
sequence, the inferior marking is performed in the region
of the pubic symphysis through the “pinch test” for
marking the base of the T, containing a slight convexity,
which will extend from one iliac crest to the other. In this
way, the markings will overlap, forming a single marking
with the shape of a fleur-de-lis8,14 (Figure 1).
Circumferential abdominoplasty
Gonzalez Ulloa described it. Markings must be
performed with the patient in a supine position. In the
anterior part, the standards of the classical technique must
be followed, respecting the anatomical variations already
described above. In the posterior part, the intergluteal
groove must be identified to start the marking where a
point just above it is indicated, called the “A” point. Superior
to point “A”, a new point is marked, which is called point
“B”, which is the upper limit of the resection14 (Figure 2).
Abdominoplasty with preservation of Scarpa’s fascia
Described by Saldanha. Patient marking is the
same as the fleur-de-lis and traditional technique8,9,14.
However, there are differences regarding the surgical
technique (Figure 1).
Figure 1. Markings of Abdominoplasty techniques. (A) Fleur-de-lis; (B)
Classical; (C) Fleur-de-lis with Scarpa’s fascia; (D) Classic with Scarpa’s fascia.
Copyright image.
Figure 2. Marking of the Circumferential technique. (A) Anterior portion of
the marking; (B) Posterior portion.
Copyright image.
RESULTS
In the identification of studies via databases
and registrations, the electronic search carried out
in PubMed (n=111), Medline (n=30), LILACS (n=5),
SciELO (n=1), Cochrane (n=102), Binacis (n=1). Two
hundred fifty references were found, and duplicated,
or ineligible records or records that did not open were
excluded before screening (n=11).
Soon after, screening was performed, divided into
three phases. All 239 titles were read in the first, and 119
were excluded, as they did not contemplate the theme. In
phase 2, all 120 abstracts were analyzed, and 89 references,
which were not relevant to the study, were excluded.
In phase 3, the 31 full texts were deeply examined, and
6 articles were removed because they did not pass the
eligibility criteria: Portuguese, English, Spanish, Italian,
French, and last 5 years. This resulted in an n=25.
In addition, studies were identified using other
methods at the Brazilian Institute of Geography and
Statistics - IBGE (n=44) and the International Society
of Plastic Surgery (n=7). In the screening, 48 records
were excluded, as they were not surveys carried out
in the last 5 years and did not address the subject of
abdominoplasty or obesity, which resulted in three
findings. Therefore, 28 references were included in this
systematic review (Figure 3).
Abdominoplasty techniques after massive weight loss
Rev. Bras. Cir. Plást. 2023;38(1):e0610 4
DISCUSSION
Post-bariatric patients undergoing sleeve
gastrectomy or Roux-en-Y gastric bypass can usually
develop a lack of vitamin B12, folic acid, iron, calcium,
vitamin D and vitamin K, minerals, and protein-caloric
malnutrition, with iron deficiency and nutritional
deficiency the most frequent7,8,13,15-19. It is noteworthy
that vitamin K is necessary for normal blood clotting;
its deficiency can lead to major secondary bleeding8
.
Therefore, follow-up with the nutritional team
is essential to improve the parameters before the
abdominoplasty mentioned in the present study8,20.
Most patients with marked weight loss after
bariatric surgery seek body contouring surgery
due to excess skin in various body regions (arms,
thighs, lower abdomen, breasts, and inguinal region).
This loss of skin elasticity can cause skin folds,
resulting in fungal infections, eczema, ulcers, and
edema, in addition to a worsening in the quality of
life, leaving them socially isolated, without practicing
daily activities and with low self-esteem, feeling even
dissatisfied with their aesthetic image after the bariatric
procedure3,7,15,20-22.
In this sense, body contouring surgery improves the
quality of life and promotes psychosocial reintegration17,20.
A study in the United Kingdom showed that patients
who underwent abdominoplasty significantly improved
their body image and quality of life. 92% of these patients
recommended plastic surgery to their friends, and 96%
have no regrets3
.
Patients with the so-called “apron abdomen”
are recommended to undergo abdominoplasty due
to the possible complications generated by this
condition23. It is clear that the plastic surgeon must
perform a thorough physical examination to identify
all deformities and detect comorbidities, BMI, body
type, amount of adipose tissue, localized fat deposits,
the existence of diastasis of the abdominal muscles,
folds, and the presence of hernias24-26.
The body fat distribution in these patients is
variable, influencing the surgical options24. To facilitate
the analysis of deformities in each anatomical region
of the body, Luján applied a four-point scale called
the Pittsburgh Scale, which serves as a guide for
choosing the best abdominoplasty technique related
to the specificities of the patients7,20. Abdominoplasty
techniques have their specificities for each indication23.
Figure 3. Organization chart of the results obtained in this systematic review, which used the PRISMA method.
Identification of studies via databases and records Identification of studies through other methods
Database used with the
descriptors: abdominoplasty,
post-bariatric surgery, plastic
surgery, body contouring.
PubMed (n = 111)
Medline (n = 30)
Lilacs (n = 5)
SciELO (n = 1)
Cochrane (n = 102)
Binacis (n = 1)
Total (n = 250)
Records removed before the
screening:
Duplicate records removed or
ineligible or
not opened (n=11)
Records identified from the
Brazilian Institute of
Geography and Statistics - IBGE
(n=44) International
Society of Plastic
Surgery (n=7)
Phase 1: Analysis of titles
(n=239)
Excluded records that did not
include the topic
(n=119)
Phase 2: Analysis of abstracts
(n=120)
Excluded records that did not
include the abstract
(n=89)
Included records: Brazilian
Institute of Geography and
Statistics – IBGE (n=44)
International Society of Plastic
Surgery (n=7)
Records excluded as they did not
meet the eligibility criteria: last 5
years, abdominoplasty or obesity:
(n=48)
Phase 3: Analysis of full texts
(n=31)
Records excluded because they
do not fit the eligibility criteria:
Portuguese, English,
Spanish, Italian, French,
last 5 years
(n=6)
Included records: Brazilian
Institute of Geography and
Statistics – IBGE (n=2)
International Society of Plastic
Surgery (n=1)
Studies included in review
(n=25)
Report of included studies
(n=3)
Total (n=28)
Included Screening Identification
5 Rev. Bras. Cir. Plást. 2023;38(1):e0610
Santiago-Junior EA et al. www.rbcp.org.br
The conventional one is indicated for the correction
of abdominal diastasis, as well as correction of ptosis,
removal of stretch marks, and dermoadipose panicle
in the lower abdomen8
. The traditional fleur-de-lis
technique for patients with medium-sized scars on the
abdomen, abdominal hernias, and/or excess horizontal/
vertical dermoadipose panicle8,24. The circumferential
technique, in cases where, even after a great loss of
body mass, there is a trace of adipose tissue together
with excess skin in the lower abdomen, flanks, and
back and in the elevation of the trochanteric fossa11,17.
Finally, the one that maintains Scarpa’s fascia is still
not very clear9,25.
The applicability of abdominoplasty techniques
may contain some similarities and differences. The
classic one begins with a scalpel incision in the
delimited area, without a specific order, and can then
occur in the suprapubic region up to the anterior
superior iliac spine, bilaterally as the fleur-de-lis.
With the preservation of Scarpa’s fascia, since in the
circumferential one, the incision occurs in the posterior
region of the patient, the anterior part is a traditional
abdominoplasty9,13,14,24,25,27.
In sequence, the first part of the adipose tissue
dissection takes place in its entirety until the depth of
the aponeurosis of the abdominal muscles, following
the height of the navel in the traditional technique,
fleur-de-lis; in contrast, the circumferential one starts
from point “A” and goes towards the flanks, leaving
only the deep fat fascia as in the abdominoplasty with
preservation of Scarpa’s fascia9,20,25,26.
The second part of the subcutaneous dissection
occurs up to the height of the xiphoid process (vertical)
and costal margin (horizontal) in the classic and
anchor8. In the latter and the technique of preserving
Scarpa’s fascia, an incision is made from the navel
to the xiphoid process, forming a flower8
. So, at this
moment, it is evident that the abdominoplasty with the
preservation of the deep subcutaneous tissue is very
similar to the classic fleur-de-lis; however, it differs
only in terms of the maintenance of the deep fat layer.
In all techniques, the flaps are resected, and diatheses
are treated8,9,27.
A detailed analysis of possible surgical complications
between the techniques above is essential8
. In this
way, the plastic surgeon can potentially reduce
risks and determine the most convenient choice for
post-bariatric surgery8
. De Macedo et al.28 divided
post-bariatric patients into two groups (n=207) with
BMI ≥30kg/m2
and <30kg/m2
. The authors observed
that patients with a BMI ≥30kg/m2
did not have a
higher risk of postoperative complications than those
with a BMI <30 kg/m2
; however, there is no exposure
of which abdominoplasty techniques were used.
Schlosshauer et al.8
, in a retrospective study
at the Agaplesion Markus Hospital, Frankfurt,
Germany, with 406 post-bariatric patients undergoing
abdominoplasty, compared the three techniques -
traditional abdominoplasty, fleur-de-lis, and miniabdominoplasty with preservation of Scarpa’s
fascia - and just like Macedo et al. they were also
divided according to the same BMI criteria. The two
most used techniques were the traditional one (64%;
n=261), followed by fleur-de-lis (27%; n=141), and
with preservation of deep adipose tissue (8.4%; n=4)8
.
The total number of complications was 42%; the
main ones observed were scarring, skin dehiscence,
infection, and necrosis; the three added up to 32%.
The horizontal had fewer total complications than the
anchor (38.7% and 47.7%, respectively)8
. Therefore,
the importance of reducing BMI is notorious,
regardless of the technique used, because, in this
way, the patient is less susceptible to postoperative
complications
As mentioned above, the most reported complication
was skin healing; however, it is not understood
whether seroma formation is directly related
to quality9,25. For this reason, two other studies
that compare the anchor and classic techniques
with and without preservation of Scarpa’s fascia
observed that the maintenance of deep adipose
tissue is beneficial, simply because drainage is more
efficient because in both studies in the postoperative
bariatric patients, there was no development of
seroma and complications. However, when evaluating
scar satisfaction using the Pittsburgh Scale, there
was no difference between the two groups9,25. It is
understood, then, that seroma, when analyzed in
isolation, does not directly interfere with the quality
of healing.
Finally, circumferential abdominoplasty has
little statistical data to compare it with complications.
In a retrospective study with 180 post-bariatric
patients, only four patients underwent surgery;
Bunting also cited only two patients out of a total of
1611.17.
CONCLUSION
It is concluded that the improvement in the quality
of life of patients submitted to any abdominoplasty is
evident; however, there is still a lack of research that
relates abdominoplasty techniques in post-bariatric
patients with their postoperative complications.
It is extremely important to use evidence-based
medicine in the applicability of techniques in these
patients, as surgeons can reduce this way risks and
complications.
Abdominoplasty techniques after massive weight loss
Rev. Bras. Cir. Plást. 2023;38(1):e0610 6
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da Saúde; 2020. Disponível em: https://aps.saude.gov.br/
noticia/10137
7. Jiang Z, Zhang G, Huang J, Shen C, Cai Z, Yin X, et al. A
systematic review of body contouring surgery in post-bariatric
patients to determine its prevalence, effects on quality of life,
desire, and barriers. Obes Rev. 2021;22(5):e13201. DOI: https://
doi.org/10.1111/obr.13201
8. Schlosshauer T, Kiehlmann M, Jung D, Sader R, Rieger UM.
Post-Bariatric Abdominoplasty: Analysis of 406 Cases With
Focus on Risk Factors and Complications. Aesthet Surg J.
2021;41(1):59-71. DOI: https://doi.org/10.1093/asj/sjaa067
9. Inforzato HCB, Garcia EB, Montano-Pedroso JC, Rossetto
LA, Ferreira LM. Anchor-Line Abdominoplasty with Scarpa
Fascia Preservation in Postbariatric Patients: A Comparative
Randomized Study. Aesthetic Plast Surg. 2020;44(2):445-52.
DOI: https://doi.org/10.1007/s00266-019-01547-7
10. Rocha RI, Cintra Junior W, Modolin ML, Takahashi GG, Caldini
ET, Gemperli R. Skin Changes Due to Massive Weight Loss:
Histological Changes and the Causes of the Limited Results
of Contouring Surgeries. Obes Surg. 2021;31(4):1505-13. DOI:
https://doi.org/10.1007/s11695- 020-05100-3
11. Cintra Junior W, Modolin MLA, Colferai DR, Rocha RI, Gemperli
R. Post-bariatric body contouring surgery: analysis of complications
in 180 consecutive patients. Rev Col Bras Cir. 2021;48:e20202638.
DOI: https://doi.org/10.1590/0100-6991e-20202638
12. International Society of Aesthetic Plastic Surgery (ISAPS).
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2021. Disponível em: https://www.isaps.org/media/evbbfapi/
isaps-global-survey_2020.pdf
13. Luján CM. Abdominoplastia en pacientes posbariátricos.
Técnicas más usadas. Rev Argent Cir Plást. 2018;24(2):73-87.
DOI: https://doi.org/10.32825/racp/201802/0073- 0087
14. Sadeghi P, Duarte-Bateman D, Ma W, Khalaf R, Fodor R, Pieretti G,
et al. Post-Bariatric Plastic Surgery: Abdominoplasty, the State
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15. Marouf A, Mortada H. Complications of Body Contouring
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https://doi.org/10.1007/s00266-021-02315-2
16. Sandvik J, Hole T, Klöckner C, Kulseng B, Wibe A. The Impact
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17. Maia M, Costa Santos D. Body Contouring After Massive Weight
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18. de Vries CEE, Kalff MC, van Praag EM, Florisson JMG, Ritt
MJPF, van Veen RN, et al. The Influence of Body Contouring
Surgery on Weight Control and Comorbidities in Patients After
Bariatric Surgery. Obes Surg. 2020;30(3):924-30. DOI: https://doi.
org/10.1007/s11695- 019-04298-1
19. Martin-Del-Campo LA, Herrera MF, Pantoja JP, Sierra M,
Iglesias M, Butrón P, et al. Absence of an Additional Metabolic
Effect of Body Contour Surgery in Patients With Massive
Weight Loss After Laparoscopic Roux-En-Y Gastric Bypass.
Ann Plast Surg. 2017;79(6):533-5. DOI: https://doi.org/10.1097/
sap.0000000000001168.
20. Capla J, Shikowitz-Behr L. Patient Evaluation and Surgical
Staging. Clin Plast Surg. 2019;46(1):9-14. DOI: https://doi.
org/10.1016/j.cps.2018.08.002
21. Pajula S, Jyränki J, Tukiainen E, Koljonen V. Complications
after lower body contouring surgery due to massive weight loss
unaffected by weight loss method. J Plast Reconstr Aesthet Surg.
2019;72(4):649-55. DOI: https://doi.org/10.1016/j.bjps.2018.12.030
22. ElAbd R, Samargandi OA, AlGhanim K, Alhamad S, Almazeedi
S, Williams J, et al. Body Contouring Surgery Improves Weight
Loss after Bariatric Surgery: A Systematic Review and MetaAnalysis. Aesthetic Plast Surg. 2021;45(3):1064-75. DOI: https://
doi.org/10.1007/s00266-020-02016-2
23. Krauss S, Medesan R, Black J, Medved F, Schaefer R, Schaller
HE, et al. Outcome of Body-Contouring Procedures After
Massive Weight Loss. Obes Surg. 2019;29(6):1832-40. DOI: https://
doi.org/10.1007/s11695-019-03773-z
24. Rosenfield LK, Davis CR. Evidence-Based Abdominoplasty
Review With Body Contouring Algorithm. Aesthet Surg J.
2019;39(6):643-61. DOI: https://doi.org/10.1093/asj/sjz013
25. Mendes FH, Donnabella A, Fagotti Moreira AR. Fleur-delis Abdominoplasty and Neo-umbilicus. Clin Plast Surg.
2019;46(1):49-60. DOI: https://doi.org/10.1016/j.cps.2018.08.007
26. Mendes FH, Viterbo F, Luna ALAP. Inner Scar Umbilicus:
New Horizons for Vertical Abdominoplasty. Plast Reconstr
Surg. 2018;141(4):507e-16e. DOI: https://doi.org/10.1097/
prs.0000000000004258
COLLABORATIONS
EASJ Final manuscript approval, Formal Analysis,
Supervision, Validation, Writing - Review &
Editing
TCDBA Supervision, Writing - Review & Editing
MLMM Analysis and/or data interpretation, Conception
and design study, Conceptualization, Data
Curation, Formal Analysis, Methodology,
Project Administration, Software, Supervision,
Writing - Original Draft Preparation, Writing -
Review & Editing
TFFN Analysis and/or data interpretation, Conception
and design study, Conceptualization, Investigation
RC Conceptualization, Investigation
CLS Conception and design study, Conceptualization,
Methodology
7 Rev. Bras. Cir. Plást. 2023;38(1):e0610
Santiago-Junior EA et al. www.rbcp.org.br
Matheus Lucena Miranda Meroni
Faculdade de Medicina da Universidade Santo Amaro, Rua Prof. Enéas de Siqueira Neto, 340, Jardim das
Imbuias, São Paulo, SP, Brazil.
Zip code: 04829-300
E-mail: [email protected]
*Corresponding author:
27. Novais CS, Carvalho J, Valença-Filipe R, Rebelo M, Peres H,
Costa-Ferreira A. Abdominoplasty with Scarpa Fascia Preservation:
Randomized Controlled Trial with Assessment of Scar Quality and
Cutaneous Sensibility. Plast Reconstr Surg. 2020;146(2):156e-64e.
DOI: https://doi.org/10.1097/prs.0000000000007024
28. de Macedo JLS, Rosa SC, Canedo LR, Casulari LA. What Is the
Impact of Residual Obesity on the Risk for Postoperative BodyContouring Surgery Complications in Postbariatric Patients?
Obes Surg. 2020;30(10):4149-54. DOI: https://doi.org/10.1007/
s11695-020-04711-0
1 Rev. Bras. Cir. Plást. 2023;38(1):e0641
Complications in liposuction: systematic review
Complicações em lipoaspiração: revisão sistemática
Liposuction is among the most performed plastic surgery procedures in Brazil.
According to data from the International Society of Aesthetic Plastic Surgery
(ISAPS), 231,604 liposuctions were performed, 15.5% of all aesthetic procedures in
the country in 2019. Adopting liposuction as a single procedure or adjunct to other
cosmetic procedures stimulated its technical evolution from simple fat aspiration
to more sophisticated body shaping. Thus, this review aimed to systematically
evaluate the published data regarding the complications found in liposuction.
A review was conducted using PubMed, SciELO, LILACS, Cochrane Library,
SCOPUS, Web of Science, and gray literature databases, published between
2016 and 2021, using the descriptors “Liposuction” and “Complications.” A total
of 187 articles were found in the searched databases, of which 16 were selected
according to the outcome “to assess safety through the prevalence of complications
in liposuction as a single procedure and associated with other procedures such as
abdominoplasty and fat grafting.” We found a mortality rate ranging from 0 to 0.06
among all procedures and a predominance of venous thromboembolism, hematoma,
seroma, and hyperpigmentation concerning all complications, being more common
when liposuction is associated with other procedures. Therefore, through this
review, it was possible to verify that liposuction as a single procedure has lower
complication rates when compared to liposuction combined with other procedures.
Review Article
A lipoaspiração está entre os procedimentos da cirurgia plástica mais realizados no
Brasil. Segundo dados da International Society of Aesthetic Plastic Surgery (ISAPS),
foram totalizadas 231.604 lipoaspirações, 15,5% dentre todos os procedimentos
estéticos realizados no país em 2019. A adoção da lipoaspiração como procedimento
único ou coadjuvante a outros procedimentos cosméticos estimulou sua evolução
técnica da simples aspiração de gordura para uma modelagem corporal mais
sofisticada. Desse modo, esta revisão objetivou avaliar sistematicamente os dados
publicados em relação às complicações encontradas na lipoaspiração. Foi realizada
uma revisão utilizando os bancos de dados PubMed, SciELO, LILACS, Cochrane
Library, SCOPUS, Web of Science e grey literature, publicados entre os anos de
2016 e 2021, através dos descritores “Liposuction” and “Complications”. Foram
encontrados 187 artigos nas bases de dados pesquisadas, dos quais 16 foram
selecionados de acordo com o desfecho “avaliar a segurança através da prevalência
de complicações na lipoaspiração como procedimento único e a associada a outros
procedimentos como abdominoplastia e lipoenxertia”. Encontramos uma taxa de
mortalidade que varia de 0 a 0,06 dentre todos os procedimentos e um predomínio
■ ABSTRACT
■ RESUMO
LUIZ FERNANDO LIMA
BARROS1
*
VINÍCIUS FIALHO TEIXEIRA1
JOSÉ AUGUSTO
PÚPIO REIS JÚNIOR2
REBECA ANDRADE FERRAZ1
DINÉIA DA CONCEIÇÃO
ARAÚJO3
FABIEL SPANI VENDRAMIN4
1
Universidade Do Estado do Pará, Departamento de Cirurgia, Belém, Pará, Brazil.
2
Universidade Federal do Amapá, Departamento de Cirurgia, Macapá, Amapá, Brazil.
3
Centro Universitário Metropolitano da Amazônia, Departamento de Cirurgia, Belém, Pará, Brazil.
4
Universidade Federal do Pará, Departamento de Cirurgia, Belém, Pará, Brazil.
DOI: 10.5935/2177-1235.2023RBCP0641-EN
Institution: Universidade do
Estado do Pará, Belém, PA, Brazil.
Article received: October 7, 2021.
Article accepted: September 13, 2022.
Conflicts of interest: none.
Keywords: Lipoabdominoplasty; Lipectomy; Adipose tissue; Postoperative complications; Intraoperative complications.
Complications in liposuction
Rev. Bras. Cir. Plást. 2023;38(1):e0641 2
liposuction and its complications and compares the
surgery with other procedures such as abdominoplasty
and fat grafting.
OBJECTIVE
This review aimed to systematically review
the data published in the last 5 years regarding the
complications encountered in liposuction as a single
and combined procedure.
METHOD
This is a systematic, descriptive literature
review based on the search for accessible studies,
using the PRISMA12 guideline, in which the following
strategy was adopted: 1) elaboration of a guiding
research question for the search strategy; 2) variety
of sources for the location of studies; 3) definition of
inclusion and exclusion criteria and 4) evaluation of the
methodological quality of the included articles.
The survey of articles was carried out in May 2021
using the databases: PubMed (US National Library
of Medicine/National Institute of Health), SciELO
(Scientific Electronic Library Online), LILACS (Latin
American and Caribbean Information Center in Health
Sciences), Cochrane Library, SCOPUS, Web of Science
and gray literature, published between 2016 and 2021.
Using the PICO strategy, which represents
an acronym for Patient, Intervention, Comparison,
and “Outcomes” (outcome), the following guiding
question, “What are the complications of the liposuction
procedure?” was elaborated. The descriptors related to
the investigated themes were crossed after searching
for synonyms using the MeSH (Medical Subject
Headings) and DeCS (Health Sciences Descriptors)
tools, so the descriptors were defined: ((“Liposuction”
OR “Lipectomies” OR “Aspiration Lipectomies” OR
“Lipectomies, Aspiration” OR “Lipectomy, Aspiration”
OR “Aspiration Lipolysis” OR “Lipolysis, Aspiration”
OR “Lipectomy, Suction” OR “Lipectomy, Suction”
OR “Suction Lipectomies” OR “Lipolysis, Suction”
OR “Liposuctions” OR “Lipoplasties” OR “lipectomy”
OR “Aspiration Lipectomy” OR “Suction Lipectomy”
INTRODUCTION
Liposuction is among plastic surgery’s most
common aesthetic procedures and is increasingly
combined with other procedures1,2. Introduced by Illouz
in the early 1980s, the liposuction technique underwent
a major transformation to reach its current state3
. In
Brazil, according to data from the International Society
of Aesthetic Plastic Surgery (ISAPS)4
, this is the most
performed aesthetic surgical procedure, totaling 231,604
(15.5%) among all procedures in 2019.
Adopting liposuction as a single procedure or
adjunct to other cosmetic procedures stimulated its
technical evolution from simple fat aspiration to more
sophisticated body shaping5
. In line with the growing
demand for safety standards for cosmetic treatments,
medical societies have developed guidelines and
consensus to guide decisions and define safety criteria
for procedures. Therefore, the discussion about
liposuction, one of the most performed procedures, is
at the forefront 6,7.
Regarding the risk factors that can trigger
complications related to liposuction, it was observed that
errors in patient selection are key factors in the outcome,
pointing to prior evaluation as one of the pillars of the
success of the procedure, contraindicating liposuction
in patients with cardiovascular disease and severe
pulmonary disorders, severe coagulation disorders,
including thrombophilias, and during pregnancy, in
addition to patients with diabetes and smoking 8,9.
Concerning complications, the incidence after
liposuction ranges from 0% to 10%, even with inconsistent
data reported between different specialties, such as
Plastic Surgery and Dermatology, making the accurate
assessment of the risk profile of liposuction a challenge10.
Regarding mortality, a study of 25 years of experience with
26,259 patients11 observed a rate of 0.01%. Accordingly,
ISAPS published a survey in which a mortality rate of
19.1 was reported for every 100,000 liposuctions4
.
In line with the growing demand for safety
standards for cosmetic treatments, medical societies have
developed guidelines and consensus to guide decisions
and define safety criteria for procedures. Therefore,
this article addresses an update of knowledge about
de tromboembolismo venoso, hematoma, seroma e hiperpigmentação em relação a
todas as complicações, sendo mais encontradas quando a lipoaspiração é associada
a outros procedimentos. Logo, por meio desta revisão foi possível constatar que a
lipoaspiração como procedimento único apresenta menores taxas de complicações
quando comparada à lipoaspiração combinada com outros procedimentos.
Descritores: Lipoabdominoplastia; Lipectomia; Tecido adiposo; Complicações
pós-operatórias; Complicações intraoperatórias.
3 Rev. Bras. Cir. Plást. 2023;38(1):e0641
Barros LFL et al. www.rbcp.org.br
OR “Lipoplasty” OR “Suction Lipolysis”) AND
(“Postoperative Complications” OR “Complication,
Postoperative” OR “Complications, Postoperative”
OR “Postoperative Complication” OR “Intraoperative
Complications” OR “Perioperative Complication” OR
“Surgical Injury”).
At this point in the search, broader terms were
intentionally used to identify more productions,
preventing any important study from being excluded
from the survey. Afterward, the title and abstract were
analyzed to select studies evaluating the population,
the intervention of interest, and at least one defined
outcome. Case reports and case series were removed
due to their low level of evidence. In addition, duplicate
articles and studies not written in English, Spanish, or
Portuguese were excluded.
Therefore, regarding eligibility, the articles
were read in full, and studies with a high risk of
methodological bias were excluded, using the Risk Of
Bias 2 (RoB 2) tool, a revised tool to assess the risk of
bias in randomized studies. The outcomes defined for
this research were: To assess the degree of safety through
the prevalence of complications in liposuction in a single
procedure and combined with other procedures such as
abdominoplasty and fat grafting (Figure 1).
RESULTS
Types of study
A total of 187 articles were found in the researched
databases, of which 16 were selected for data use, with
their interpretation and synthesis. Among the 16 studies,
five were literature reviews, seven were cohort studies,
and four were cross-sectional.
In addition, regarding the outcome of the articles
included in the study, four analyzed the complications
of liposuction as a single procedure, eight discussed
the complications of liposuction combined with other
procedures such as abdominoplasty and fat grafting,
and four studies developed a comparison between
safety and the level of complications in isolated and
combined liposuction (Table 1).
Risk factors
Regarding the procedure’s risks, patients with
cardiovascular, pulmonary, diabetic, and vascular
diseases face a higher risk. In addition to these
comorbidities, smoking is a risk factor for surgical
complications13,14.
Figure 1. Article selection flowchart. IDENTIFICATION SELECTION ELIGIBILITY INCLUSION
Reading the titles and
summary/abstract
Articles excluded for not
meeting the inclusion
criteria for the results
(N=108)
Selected Articles
(N=79)
Reading the manuscripts in
full
Articles excluded
due to high risk of
bias and low level of
evidence
(N=63)
Articles included in the review
(N=16)
Complications in liposuction
Rev. Bras. Cir. Plást. 2023;38(1):e0641
4
Table 1. Complications of liposuction alone and combined with other procedures.
Systemic and local complications in (%)
Study Technique Number of patients Mortal age Venous Throm- boembolism (VTE) Blood loss Surgical site infec- tion Seroma Hyperpig- mentation Irregular Contour Bruise Others
Xia et al.,
20191
Isolated and
combined
liposuction
14,061 - 0.2
Infection,
dehiscence
wound and
fat necrosis: 5.6
4.1 0.7 0.8
Halk et al.,
2019*6
Isolated liposuction -
up to
0.05%
every
1000 surgeries
- - - - - - -
Combined
procedures
had an almost
5 times greater
risk of serious
adverse events
than isolated
procedures,
especially for
VTE and infection.
Wu et al.,
2020*14
Isolated and
combined
liposuction
-
0.01 in
26,259
patients
0.03% in 1,000
patients
- -
2% in 451
patients
-
9% in
11,016
patients
- -
Sozer et
al., 201815
Combined
liposuction 1,000 0.01 1.5 - 1.5 19 - - 0.40 -
Vieira et
al., 201816
Combined
liposuction 9,638 0.06 0.46 0.24 1.83 3.6 - - 0.84 -
Montrief et
al., 2020*17
Isolated and
combined
liposuction
- -
The incidence
of deep vein
thrombosis
(DVT) and
pulmonary embolism (PE) in liposuction is less
than 1%. However, there is a
marked increase
in the incidence
of DVT when
liposuction is
performed.
combined with
abdominoplasty
- - - - - 3 - 15 Visceral perfo- ration: 0.00014
continued...
5 Rev. Bras. Cir. Plást. 2023;38(1):e0641
Barros LFL et al. www.rbcp.org.br Table 1. Complications of liposuction alone and combined with other procedures. Systemic and local complications in (%) Study Technique Number of patients Mortal age Venous Throm- boembolism (VTE) Blood loss Surgical site infec- tion Seroma Hyperpig- mentation Irregular Contour Bruise Others Kaoutzanis et al.,201718 Isolated and combined liposuction 31,010 Isolated li- posuction (11,490 - 37.1%) and combined (19.520 - 62.9%) 0.06 isolated 0.6 combined - 0.1 isolated 0.7 combi- ned - - - 0.15 isolated 0.60 combined Pulmonary disorders: 0.1 isolated 0.2 combined Campos et al., 201819 Isolated and combined liposuction 30 - - Drop in hemo- globin between 2 - 6g/dl, with an average of 3.01g/dl cor- responding to 22.16% of the preoperative hematocrit operative - - - - - 50% had dizzi- ness, dyspnea, tachycardia, orthostatic hypotension Vendra- min et al., 201920 Combined liposuction 16 - - Post-surgical Hb values be- tween 8.92 g/dL and 10.4 g/dL. The percentage reduction in Hb between the beginning and the end of the surgery avera- ged 19.7% - - - - - - Restifo 201921 Combined liposuction 304 - - - 4.27 14.38 - - 0.9 5.92 of the patients had fat necrosis Al Dujai- li et al., 201822 Isolated lipo- suction 15,336 - 0.34- 0.6 - - 0.17 - 1.6 0.02 0.26-2.1 - - Husain et al., 201923 Isolated lipo- suction 50 - - - - 10 two 12 - - continued...
...continuation
Complications in liposuction
Rev. Bras. Cir. Plást. 2023;38(1):e0641
6
* In the studies by Wu, Halk, and Montrief, there were no specifications about the number of patients undergoing the procedures. No., number; Hb. Hemoglobin; ATX, Trenaxamic Acid; VTE, Venous
Table 1.
Thromboembolism; g/dL, grams per deciliter.
Complications of liposuction alone and combined with other procedures.
Systemic and local complications in (%)
Study Technique Number of patients Mortal age Venous Throm- boembolism (VTE) Blood loss Surgical site infec- tion Seroma Hyperpig- mentation Irregular Contour Bruise Others
Gould et
al., 201824
Combined
liposuction 619 - - - -
2.16 with
drain
9.17
without
drain
- - - -
Massignan
201925
Combined
liposuction 76 - - - - - 2.67 - - -
Weissler et
al., 202126
Isolated liposuction 120 - - - - - - -
Hematomas in
patients who
received ATX
were significantly smaller
than in patients who did
not (1.6 / 10 vs.
2.3/10)
-
Bertheuil et al.,
201727
Isolated liposuction 25 - - - 8 - - - -
40% presented
dehiscence of
the surgical
wound, and
8% had some
degree of necrosis of fat
...continuation
7 Rev. Bras. Cir. Plást. 2023;38(1):e0641
Barros LFL et al. www.rbcp.org.br
Mortality
Among the included studies regarding liposuction
as a single procedure, the review by Wu et al. in 202014
indicated a mortality rate of 0.01% in approximately
26,000 patients. In another review, Halk et al., in
20196
, demonstrated a variation of 0 to 0.55 deaths per
1000 procedures. On the other hand, when we look
at liposuction combined with abdominoplasty, two
observational studies in 201815,16 indicated 0.01% of
deaths in 1,000 and 0.06% in 9,638 patients, respectively.
Venous thromboembolism (VTE)
There is an agreement in the articles published
by Montrief et al.17 and Wu et al.14 that venous
thromboembolism is the main cause of death after
combined or isolated liposuction, responsible for up
to 21% of postoperative deaths17.
In the liposuction procedure combined with
other techniques, the mean chance of VTE was 0.56%,
numbers that ranged from 0.2% in 1,406 patients, found
by Xia et al.1
, and 0.46%, in 9,638 patients evaluated
by Vieira et al.16, to 1.50% patients undergoing
abdominoplasty with liposuction by Sozer et al.15.
Concerning liposuction as a single procedure, the
number of patients with VTE is five times lower, 0.06%,
as indicated by Kaoutzanis et al.18, in 31,010 patients,
of which 37.1% underwent only liposuction and 62.9%
combined with other procedures.
Blood loss and anemia
In a prospective study of 30 post-surgical
liposuction patients conducted by Campos in 201819,
a drop in hemoglobin (Hb) between 2 and 6g/dl was
observed, with a mean of 3.01g/dl, corresponding to
22.16 % of preoperative hematocrit, in which 15 patients
complained of symptoms such as dizziness, dyspnea,
tachycardia, and orthostatic hypotension. In addition
to this study, Vendramin et al.20 observed Hb in 16
patients at the end of surgery and at hospital discharge,
with values of 10.4g/dl and 8.92g/dl, respectively. The
percentage reduction in Hb between the beginning and
the end of the surgery averaged 19.7%, and in none of
the cases observed, did the patients require a blood
transfusion in the postoperative period.
Surgical site infection
Restifo21 reported infection in 13 of 304 patients
(4.27%) who associated abdominoplasty with liposuction.
Sozer et al.15 and Vieira et al.16 also analyzed the two
associated procedures and described 1.5% of surgical
site infections in 1,000 procedures and 1.83% in 9,638
patients, respectively. Kaoutzanis et al.18 showed
inferior results: in 19,520, only 0.7% of patients had this
complication.
Regarding isolated liposuction, the literature
review by Al Dujaili et al.22 points to values that vary
between 0.34% and 0.6% in approximately 15 thousand
procedures. In addition to this study, Kaoutzanis et
al.18 compared liposuction versus lipoabdominoplasty
and reported infection rates of 0.1% in 11,490 and
0.7% in 19,520 procedures; finally, Xia et al., in 20191
,
combined the results of surgical wound infection,
wound dehiscence, and fat necrosis, finding a rate of
5.6% in 14.61 patients.
Seroma
According to Vieira et al.16, 3.6% of 9,638 patients had
this complication when undergoing lipoabdominoplasty,
whereas Restifo, in 201921, found 14.38% of 723 patients
undergoing abdominoplasty associated with subScarpa lipectomy. The study by Sozer et al.15 associated
abdominoplasties with circumferential liposuction and
pointed out that seroma was presented by 190 out of
1000 patients. The meta-analysis by Xia et al.1
showed
the occurrence of seroma in 4.1% of 14,000 patients
undergoing lipoabdominoplasty. In the review by Wu
et al.14, a 2% prevalence of seroma in liposuctions was
observed; the cohort by Husain et al.23, with 50 patients,
inferred a 10% rate of appearance of seroma in patients
undergoing liposuction. Gould et al., in 201824, indicated
in 619 lipoabdominoplasties the appearance of 2.16% of
seromas in procedures using a drain and 9.17% when
there was no use of a drain in the surgery.
Hyperpigmentation
Complications are described in only two analyzed
articles. The review by Al Dujaili et al.22 found 0.02%
of this complaint in approximately 15,000 patients
who underwent liposuction as a single procedure; in a
prospective study by Massignan25, in which liposuction
associated with VASER (Vibration Amplification of
Sound Energy at Resonance) was performed in 76
patients, two (2.67%) had skin hyperpigmentation, and
one (1.31%) presented a thermal lesion at the insertion
site of the device.
Irregular outline
Three literature reviews described irregular
outlines. Wu et al.14 pointed out that contour irregularity
is the most common complication of liposuction. Up to
9% of patients may report soft tissue depressions or
elevations, skin panicles, folds, or wrinkles. Accordingly,
Husain et al.23 indicate that the least severe and most
Complications in liposuction
Rev. Bras. Cir. Plást. 2023;38(1):e0641 8
prevalent complication was irregular contour, observed
in 12% of 50 patients who underwent liposuction with
a “six-pack” abdomen design (“abdominal etching”).
The review by Al Dujaili et al.22 does not indicate
the number of patients with this complication;
however, it demonstrates that surface irregularities,
such as depressions or skin undulations, can be
caused by excessive liposuction, superficial suction,
pre-existing adhesions, redundant skin or inadequate
compression. Patients with pre-existing cellulitis, poor
skin elasticity, and scarring are more likely to have
surface irregularities. Preventive measures include
setting the maximum vacuum pressure to 250 to
400mmHg and aspirating the surface layer under low
pressure21.
Bruise
Hematoma was one of the most common
complications in the literature related to liposuction
and its combinations. The cohort carried out by
Kaoutzanis et al., in 201718, with 31,000 patients,
compared single and combined procedures, finding a
prevalence of 0.15% in 11,490 liposuctions and 0.60%
in 19,520 liposuctions combined with other procedures.
Hematoma as a complication of lipoabdominoplasty
was described by Sozer et al.15, Vieira et al.16, and Xia et
al.1, resulting in 0.40% in 1,000, 0.90% in 1,500 and 0.8%
in 14,000 procedures, respectively. Furthermore, in work
by Weissler et al., in 202126, with 120 patients divided
into two equal groups, there was a chance of bruising of
2.3/10 among patients who did not use tranexamic acid
infiltration during the procedure and of 1.6/10 in which
there was infiltration, showing a statistically significant
difference. In the literature review by Montrief et al.17, a
prevalence variation of 3 to 15% of this complication in
lipoabdominoplasty was observed.
Other complications
Bertheuil et al.27 indicated that in 25 lipo bodylift procedures, there were 10 cases of surgical wound
dehiscence treated with secondary intention healing
and two cases of fat necrosis. The study carried out by
Restifo21 evaluated 304 sub-Scarpa lipectomies that
indicated approximately 5% of cases of fat necrosis.
The literature review by Montrief et al.17 indicated
visceral perforation as the second most common cause
of mortality after liposuction, with ileal perforation
being the most common site, followed by perforation
of the jejunum, spleen, cecum, transverse colon, and
sigmoid. It is important to emphasize that risk factors
for visceral perforation during liposuction are: morbid
obesity, previous surgical scars, and abdominal wall
hernias.
DISCUSSION
According to the results obtained, we found
evidence that liposuction as an isolated procedure tends
to demonstrate a lower chance of complications when
compared to procedures combined with liposuction and
abdominoplasty or liposculpture.
In addition, the evidence found demonstrated
that complications with higher incidence rates, such as
hematomas, seromas, and contour irregularities, have
less serious repercussions for patients. On the other hand,
more serious complications that require hospitalization
for treatment, for example, VTE, visceral perforation,
and surgical site infections, are less common.
Likewise, a review carried out in 2016 byAlmutairiet
al.28 showed the same early complications found in the
present study, also with a low percentage of prevalence
(5-15%), with emphasis on surgical wound dehiscence
and late healing of the wound, as the most common,
followed by the formation of seromas, hematomas, and
wound infections. This finding suggests that there have
been no major variations in liposuction complications
over the past 10 years; on the contrary, maintaining safety
and optimizing patient outcomes.
Some limitations must be considered. Not all
liposuction safety factors have been reviewed, for
example, the type of anesthesia used, immediate
postoperative follow-up by a multidisciplinary team, the
ideal composition of the humectant solution, time before
starting liposuction, details about techniques such as
the exact type of cannula, depth and body location of
liposuction, and patient selection criteria. Furthermore,
the meta-analysis could not be conducted due to
heterogeneity between studies to meet all interest criteria.
Certain points about combined liposuction or not
still require further clarification, such as the amount of
liposuctioned content and its possible relationships with
more serious complications in patients, in addition to
understanding the importance of the multidisciplinary
team in the immediate postoperative period and
its impact on the appearance of intraoperative and
postoperative complications.
CONCLUSION
Liposuction is a safe procedure with a low rate
of complications. Liposuction as a single surgery has
lower rates of complications than liposuction combined
with other procedures, such as lipoabdominoplasty
and fat grafting. The wide range of methods to aspirate
subcutaneous fat allows for an optimal individual
treatment plan, considering the correct indications.
Thorough surgeon training and in-depth knowledge
of possible complications are essential, as although
liposuction is often offered as a minor, harmless
9 Rev. Bras. Cir. Plást. 2023;38(1):e0641
Barros LFL et al. www.rbcp.org.br
surgery, it is a complex procedure. Therefore, more
long-term studies should be carried out to consolidate
the procedure’s understanding and safety further.
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COLLABORATIONS
LFLB Analysis and/or data interpretation, Conception
and design study, Conceptualization, Data
Curation, Final manuscript approval, Formal
Analysis, Funding Acquisition, Investigation,
Methodology, Project Administration, Realization
of operations and/or trials, Resources, Software,
Supervision, Validation, Visualization, Writing -
Original Draft Preparation, Writing - Review &
Editing.
VFT Analysis and/or data interpretation, Conception
and design study, Conceptualization, Data
Curation, Final manuscript approval, Formal
Analysis, Funding Acquisition, Investigation,
Methodology, Project Administration, Realization
of operations and/or trials, Resources, Software,
Supervision, Validation, Visualization, Writing -
Original Draft Preparation, Writing - Review &
Editing.
JAPRJ Analysis and/or data interpretation, Conception
and design study, Conceptualization, Data
Curation, Final manuscript approval, Formal
Analysis, Funding Acquisition, Investigation,
Methodology, Project Administration, Realization
of operations and/or trials, Resources, Software,
Supervision, Validation, Visualization, Writing -
Original Draft Preparation, Writing - Review &
Editing.
RFA Analysis and/or data interpretation, Conception
and design study, Conceptualization, Data
Curation, Final manuscript approval, Formal
Analysis, Funding Acquisition, Investigation,
Methodology, Project Administration, Realization
of operations and/or trials, Resources, Software,
Supervision, Validation, Visualization, Writing -
Original Draft Preparation, Writing - Review &
Editing.
DCA Analysis and/or data interpretation, Data
Curation, Formal Analysis, Methodology.
FSV Analysis and/or data interpretation, Conception
and design study, Conceptualization, Data
Curation, Final manuscript approval, Formal
Analysis, Funding Acquisition, Investigation,
Methodology, Project Administration, Realization
of operations and/or trials, Resources, Software,
Supervision, Validation, Visualization, Writing -
Original Draft Preparation, Writing - Review &
Editing.
Complications in liposuction
Rev. Bras. Cir. Plást. 2023;38(1):e0641 10
Luiz Fernando Lima Barros
Rua Municipalidade 985, sala 2005. Ed Mirai Office, Umarizal, Belém, PA, Brazil.
Zip code: 66055-200
E-mail: [email protected]
*Corresponding author:
23. Husain TM, Salgado CJ, Mundra LS, Perez C, AlQattan HT,
Bustillo E, et al. Abdominal Etching: Surgical Technique and
Outcomes. Plast Reconstr Surg. 2019;143(4):1051-60.
24. Gould DJ, Macias LH, Saeg F, Dauwe P, Hammoudeh Z, Grant
Stevens W. Seroma Rates Are Not Increased When Combining
Liposuction With Progressive Tension Suture Abdominoplasty:
A Retrospective Cohort Study of 619 Patients. Aesthet Surg J.
2018;38(7):763-9.
25. Massignan F. Evaluation of the safety of VASERTM in
liposuction surgery to improve body contour. Rev Bras Cir Plást.
2019;34(4):458-67.
26. Weissler JM, Banuelos J, Molinar VE, Tran NV. Local Infiltration of
Tranexamic Acid (TXA) in Liposuction: A Single-Surgeon Outcomes
Analysis and Considerations for Minimizing Postoperative Donor
Site Ecchymosis. Aesthet Surg J. 2021;41(7):NP820-8.
27. Bertheuil N, Chaput B, De Runz A, Girard P, Carloni R, Watier
E. The Lipo-Body Lift: A New Circumferential Body-Contouring
Technique Useful after Bariatric Surgery. Plast Reconstr Surg.
2017;139(1):38e-49e.
28. Almutairi K, Gusenoff JA, Rubin JP. Body Contouring.
Plast Reconstr Surg. 2016;137(3):586e-602e. DOI: 10.1097/
PRS.0000000000002140.
1 Rev. Bras. Cir. Plást. 2023;38(1):e0645
Body Dysmorphic Disorder and the influence of the
media in demand for plastic surgery: the importance
of proper evaluation
O Transtorno Dismórfico Corporal e a influência da mídia na procura por
cirurgia plástica: a importância da avaliação adequada
Introduction: Since the beginning, plastic surgery has improved self-esteem
and acceptance in a society that idealizes the cult of the body. The pressure of
consumption and the ease of undergoing plastic surgery becomes an obsession
in these patients’ lives. Method: Female patients who underwent psychological
evaluation and follow-up throughout the surgical and plastic surgery procedure,
aged between 19 and 57, answered the Sociocultural Attitudes Questionnaire
concerning appearance and the Body Dysmorphophobia Symptom Scale. Results:
Of the 38 patients evaluated, 17 have the media as an influence concerning
their body image and have symptoms of Body Dysmorphic Disorder (BDD), 13
patients have the media as an influence on their body image, but they do not have
BDD symptoms, and in eight patients the media does not influence their body
image, and they do not have BDD symptoms. Conclusion: The importance of a
multidisciplinary team, with a psychologist, is highlighted to evaluate and monitor
the patient throughout the surgical process, as the early diagnosis of BDD will avoid
dissatisfaction with the result of the plastic surgery and, mainly, future court lawsuits.
Review Article
Introdução: Desde os primórdios, a cirurgia plástica melhora a autoestima e a
aceitação em uma sociedade que idealiza o culto ao corpo. A pressão do consumo
e a facilidade de se submeter a um procedimento de cirurgia plástica acabam
tornando-se obsessão na vida desses pacientes. Método: Pacientes do sexo
feminino que passaram por avaliação e acompanhamento psicológico em todo o
processo cirúrgico, e procedimento de cirurgia plástica, com a idade entre 19 e
57 anos, responderam ao questionário de Atitudes Socioculturais em relação a
aparência e a Escala de Sintomas de Dismorfobia Corporal - Body Dysmorphic
Scale. Resultados: Dos 38 pacientes avaliados, 17 têm a mídia como influência em
relação a sua imagem corporal e apresentam sintomas do Transtorno Dismórfico
Corporal (TDC), 13 pacientes têm a mídia como influência em relação a sua
imagem corporal, mas não apresentam sintomas do TDC, e em oito pacientes a
mídia não influencia em relação a sua imagem corporal e não apresentam sintomas
do TDC. Conclusão: Destaca-se a importância de uma equipe multidisciplinar,
■ ABSTRACT
■ RESUMO
ALEXANDRE KATAOKA1
*
RENATO ROCHA LAGE2
CAMILA CRISTINA SILVA
MENDES1
NIKOLE GUIMARÃES
SOARES3
1
Hospital Ruben Berta, Cirurgia Plástica, São Paulo, São Paulo, Brazil.
2
Hospital da Baleia, Belo Horizonte, Minas Gerais, Brazil.
3
Fundação Hospitalar do Estado de Minas Gerais, Hospital João XXIII, Belo Horizonte, Minas Gerais, Brazil.
DOI: 10.5935/2177-1235.2023RBCP0645-EN
Institution: Hospital Ruben Berta,
São Paulo, SP, Brazil.
Article received: October 12, 2021.
Article accepted: April 7, 2022.
Conflicts of interest: none.
Keywords: Body dysmorphic disorders; Reconstructive surgical procedures; Mass
media; Health’s judicialization; Obsessive-compulsive disorder.
Body Dysmorphic Disorder and the influence of the media in the search for plastic surgery
Rev. Bras. Cir. Plást. 2023;38(1):e0645 2
Evolution of the doctor-patient relationship
Camila Vasconcelos cites Foucault in her article
“Medical responsibility and judicialization in the doctorpatient relationship” that: “[...] the power relationship
is articulated to discourse, configuring an underlying
dimension of communication between people. It is a
relationship between power and knowledge inherent in
the discourse itself, in which someone carrying the fact of
knowledge – knowledge – elevates him to the condition
of power in a given environment that recognizes him
as such” 6
.
The relationship between service providers and
their customers has ethical and unethical aspects.
For a professional in Plastic Surgery to carry out
his work, 6 years of graduation in Medicine, 2 years
of medical residency in General Surgery, and 3 years
of medical residency in Plastic Surgery are required.
The professional without adequate training harms
patients’ health, physical, and, mainly, mental well-being.
Many carry out procedures outside the legislation.
On the other hand, the increase in the number
of professionals, even qualified ones, puts pressure on
relationships towards a purely mercantilist trajectory,
ignoring the main thing, which is the patient’s emotions.
When looking for a plastic surgeon, the person has
numerous questions, insecurities, and uncertainties. The
professional present there is often fixated on the number
of patients to be operated on, not on the service quality.
The doctor-patient relationship to provide
humanized care is increasingly scarce in Plastic Surgery.
This ends up becoming negative in all aspects, as there
may be dissatisfaction on the part of the patient with
the result of the surgery, and if he has a personality
disorder that was not identified from the beginning in
the preoperative consultations, this patient is a candidate
to cause future problems for that professional.
According to Pellegrino (1993), quoted by
Vasconcelos6
, “The doctor’s knowledge, therefore, is
not private property; it is not intended primarily for
personal gain, prestige or power. Rather, the profession
holds medical knowledge in trust for the patient’s good.
By accepting the provenance of medical education,
those who enter medicine become part of an alliance
with the society that cannot be unilaterally dissolved.
INTRODUCTION
“Currently, we live in an exaggerated litigation
society, where even the small details of everyday life
and common annoyances end up in front of a judge”
(the numbers of judicialization in medicine)1
.
We become people who are psychically weakened
by society’s demands and run the risk of becoming
spiritually and psychically ill.
According to a survey carried out in 2016 (ISAPS/
IBOPE), Brazil was the second country where the
most cosmetic surgeries were performed, with 1.45
million in total. The United States led, with 1.48 million
procedures, and Russia appeared in third place, with
579,000 surgeries2
.
Since the beginning, plastic surgery has improved
self-esteem and acceptance in a society that idealizes
the cult of the body.
According to Lima et al.3
, in the article “The
ideology of the perfect female body. A question with the
real”, “[...] the body is an object of private property in
which the subject can do anything; however, capitalist
society omits that ‘this can do anything’ is an illusion, as
it imposes standards for the body ideal. Therefore, the
subject is a mere executor of the norms of consumption
in his own body [...]” (p. 50).
The pressure of consumption and the ease of
undergoing plastic surgery becomes an obsession in
these patients’ lives.
This enormous suffering increases when these
standards are exposed at all times by the media as
attainable, purchasable, and healthy, transforming
bodies into true laboratories to achieve complete wellbeing and especially the solution to all problems in the
lives of these people4
.
The details of the human mind, such as personality
disorders and image disorders, are decisive in the search
for plastic surgery. If they are not correctly diagnosed,
they cause future problems, such as dissatisfaction with
results and lawsuits.
“The screening of psychological aspects in the
selection phase is decisive for the success or failure
of the aesthetic surgical procedure. That is, patients’
mental health interferes with the perception of surgery
results” 5
.
com a presença de um psicólogo, para avaliar e acompanhar o paciente em todo
processo cirúrgico, pois o diagnóstico precoce do TDC evitará uma insatisfação
com o resultado da cirurgia plástica e, principalmente, futuros processos judiciais.
Descritores: Transtornos dismórficos corporais; Procedimentos cirúrgicos
reconstrutivos; Meios de comunicação de massa; Judicialização da saúde;
Transtorno obsessivo-compulsivo.
3 Rev. Bras. Cir. Plást. 2023;38(1):e0645
Kataoka A et al. www.rbcp.org.br
Medical students, from day one, enter a community
bound by a moral pact. They accept the privileges
of medical education in exchange for the physician’s
knowledge management responsibility” 6
.
Psychic disorders and the influence of the media and
social networks
“Human beings traverse history in search of the
fullness and perfection of the body. The actors change,
the scenario changes, the sociocultural context, the
tastes and interpretations, the meaning, and the search
for the ideal body remains4
.”
To what extent does undergo plastic surgery have
its limitations? Due to the influence of the media, it
ends up becoming an obsession in some people’s lives,
wanting to “be” or look like a certain celebrity, such as
famous actresses and actors, comic book characters,
and dolls like Barbie and Ken.
Many of these images posted on social networks,
which directly influence these people, undergo several
modifications, not correspond to reality.
“The body is a living organism that has its own
characteristics and with its own uniqueness. Performing
cosmetic surgery means improving an imperfection and
increasing the positive traits of each patient. Therefore,
the final objective of the surgery is to seek a positive
aesthetic improvement and never a transformation. A
dysmorphic patient is a dissatisfied person constantly
looking for a mutation, getting into a loop from
which he will not easily get out. When the patient has
dysmorphophobia, he usually complains of a spot that
cannot be objectified and should be an alarm for the
specialist visiting him” 7
.
According to Pereira de Oliveira8
, behind this great
fantasy, there is mental suffering, often unconscious,
unfortunately not diagnosed by the professional, due
to not having sufficient preparation, or for not having
an interdisciplinary team, or else that professional who
does not follow ethical norms, performing the procedure
on the patient.
The doctor-patient relationship is also an extremely
important factor in managing these conditions.
Today, in the artistic world, we can encounter
several celebrities with customs and habits that are not
common in our daily lives, influencing people worldwide.
Anonymous people transformed themselves
physically to become famous. Many do not know, but
behind that exposed image, obsessive psychic factors
transform the lives of these subjects.
Body Dysmorphic Disorder is one of the
psychopathologies observed in these people. “The recently
published World Health Organization International
Classification of Diseases states that BDD is characterized
by persistent preoccupation with one or more perceived
defects or flaws in appearance that are unnoticeable
or faintly noticeable to others. Individuals experience
excessive self-consciousness, usually with ideas of
reference (i.e., the conviction that people are noticing,
judging, or talking about the perceived defect or flaw).” 9
.
The individual triggers an obsession, in which
the imaginary defect migrates to various parts of his
body. Undergoing an aesthetic surgical procedure will
alleviate the psychic pain he feels. Mental pain will turn
into bodily pleasure.
In an interview for Revista Quem10, Rodrigo Alves
(36), the “human Ken,” reported that he started having
aesthetic procedures because he felt ugly and excluded
in childhood, with few friends. After the surgery and the
apparent changes, people began to notice him: “Today I
am the fruit of my imagination. I am everything I wanted
to be in life.”
As a teenager, he had no friends; he felt insecure;
he used to wear black clothes and sat in the background
in the classroom. His colleagues called him a little potato
and beat him. “It had nothing to do with my appearance;
it was more with my psychology. I excluded myself” 10.
Goulart11 mentions that the perception of the
body as one’s own seems natural and intuitive; however,
in reality, it is not quite like that: [...] “throughout
life, the vision of the body will be marked not only by
images but also by definitions ( signifiers) and own
sensations. So, we have a body that is apprehended
by its imaginary aspect (appearing), by its symbolic
aspect (being), and by its real aspect (body experience
not imagined or symbolized by the subject and which
emerges abruptly)”.
OBJECTIVE
In this study, we intend to evaluate how the
media influences body standards in adopting behavior
to modify the body, which can cause dissatisfaction and
disappointment with the result, leading to lawsuits.
METHOD
The study consisted of 38 patients who underwent
a plastic surgery procedure, all female (aged between
19 and 57 years).
All procedures were performed in different locations
and by four different teams.
The patients underwent psychological assessment
and follow-up throughout the surgical process and
were invited to participate in the study, having received
the Sociocultural Attitudes Questionnaire (SATAQ-3)
concerning appearance and the Body Dysmorphophobia
Symptom Scale - Body Dysmorphic Symptoms Scale.
Body Dysmorphic Disorder and the influence of the media in the search for plastic surgery
Rev. Bras. Cir. Plást. 2023;38(1):e0645 4
The Questionnaire of Sociocultural Attitudes
towards Appearance (SATAQ-3) is an instrument developed
to assess sociocultural pressure and internalization of the
standard of beauty. It is composed of 30 questions, with
answers in the form of a Likert scale from 1 (totally disagree)
to 5 (totally agree), intended to assess the influence of the
media on the body. The sum of the responses calculates
the final score, and the score proportionally represents the
influence of sociocultural aspects on body image12.
The Body Dysmorphophobia Symptom Scale is
designed to measure the symptoms of Body Dysmorphic
Disorder (BDD) in individuals seeking plastic surgery
who are preoccupied and distressed about their
physical appearance. The scale consists of ten items that
objectively and quickly identify BDD’s psychopathological
characteristics in individuals concerned about their
physical appearance and who seek plastic surgery. The
final score corresponds to the sum of positive responses
to all questions. Higher scores indicate the presence of
BDD symptoms13.
RESULTS
Of the 38 patients evaluated, 17 (44.74%) have the
media as an influence concerning their body image and
have symptoms of BDD, 13 (34.21%) patients have the
media as an influence on their body image, but do not
have BDD symptoms, and in eight (21.05%) patients the
media does not influence their body image, and they
do not have BDD symptoms.
Tables 1 to 4 show the items that prevailed in
evaluating the sum of the results of the four subscales
of the SATAQ-3 questionnaire.
Figure 1 shows the subscales of the SATAQ-3
questionnaire that had the highest scores.
DISCUSSION
The results show that the media greatly influences
people to opt for surgical and/or non-surgical correction,
especially in patients with image disorders.
The “media” effect sometimes generates “surreal”
expectations or even sublimation of results.
In cases of dysmorphia, the acceptance of the
result obtained with the intervention will rarely be
positive, which can lead to problems in the relationship
with the doctor, becoming an endless “motus continuo”.
CONCLUSION
It is up to the plastic surgeon to explain the
possibilities and their results, clearly and realistically,
with details and risks associated with the surgery. No
makeup to avoid future problems. The plastic surgeon
should establish a good doctor-patient relationship,
based on an attentive look, with sensitivity, acceptance,
and care when relating to the patient. Based on ethical
principles and moral conscience when dealing with the
patient. They are inseparable factors in the interaction
of this binomial that will result in professional success.
We cannot ignore that, aware of the professional
and ethical commitment, the doctor, in addition to human
Table 1. Sum of scores for the subscale “General internalization
of socially established standards. “
Patients evaluating scores
Media influences the patient’s body image
(presents dysmorphophobia) 323
Media influences the patient’s body image
(does not have dysmorphophobia) 254
Media does not influence the patient’s body
image (does not have dysmorphophobia) 191
Total 768
Table 2. Sum of the scores of the “Ideal athletic body” subscale.
Evaluated patients scores
Media influences the patient’s body image
(presents dysmorphophobia) 197
Media influences the patient’s body image
(does not have dysmorphophobia) 157
Media does not influence the patient’s body
image (does not have dysmorphophobia) 129
Total 483
Table 3. Sum of scores for the subscale “Media as a source
of information about appearance.”
Evaluated patients Scores
Media influences the patient’s body image
(presents dysmorphophobia) 480
Media influence on the patient’s body image
(does not have dysmorphophobia) 403
Media does not influence the patient’s body
image (does not have dysmorphophobia) 205
Total 1088
Table 4. Sum of scores for the subscale “Pressures exerted
by these standards.”
Evaluated patients Scores
Media influences the patient’s body image
(presents dysmorphophobia) 274
Media influences the patient’s body image (does
not have dysmorphophobia) 214
Media does not influence the patient’s body
image (does not have dysmorphophobia) 97
Total 585
5 Rev. Bras. Cir. Plást. 2023;38(1):e0645
Kataoka A et al. www.rbcp.org.br
solidarity, has an indispensable role in the political
and social commitment inherent to the citizen in the
transformation the now globalized world has undergone.
The Code of Medical Ethics brings the rules of
conduct that physicians must practice and observe.
Article 2nd, Chapter I, states that “the target of all
physician attention is the human being, for whose
benefit he must act with the utmost zeal and to the
best of his professional capacity.” It is evident that the
professional must have zeal, appreciation, respect for the
human condition, and technical competence. Chapter V
(Relationship with patients and family members) focuses
on the principle of patient autonomy: priority of life over
material and moral goods, responsibility in dealing with
the patient, and respect for their vulnerability14.
Body Dysmorphic Disorder should no longer
be neglected and should be identified; therefore, the
psychologist must participate with the plastic surgeon
in the diagnostic and therapeutic process. We know
that surgical and plastic treatments seem ineffective in
BDD and can pose risks to the physicians who perform
them since patients can become aggressive and violent
and generate litigation.
REFERENCES
1. Pinheiro RA. Os números da judicialização da medicina. Rev
Jus Navigandi. 2017;5066. Disponível em: https://jus.com.br/
artigos/57497
2. International Society of Aesthetic Plastic Surgery. 2017 Global
Survey Press Release BR | PDF | Cirurgia plástica | Cirurgia
(scribd.com). Disponível em: file:///C:/Users/User/Downloads/2017-
Global-Survey-Press-Release- br.pdf
3. Lima AF, Batista KA, Lara Junior N. A ideologia do corpo feminino
perfeito: questões com o real. Psicol Estud. 2013;18(1):49-59.
4. Dourado CS, Fustinoni SM, Schirmer J, Brandão-Souza C.
Corpo, cultura e significado. J Hum Growth Dev. 2018;28(2):
206-12.
5. Juan K. O impacto da cirurgia e os aspectos psicológicos do
paciente: uma revisão. Psicol Hosp. (São Paulo). 2007;5(1):48-59.
6. Vasconcelos C. Responsabilidade médica e judicialização na
relação médico-paciente. Rev Bioét. 2012;20(3):389-96.
7. Barone M, Cogliandro A, Persichetti P. Dysmorphophobia:
When Should the Plastic Surgeon Say No? Aesthetic Plast Surg.
2021;45(5):2512-3. DOI: 10.1007/s00266-021-02219-1
8. Pereira de Oliveira M. Melanie Klein e as fantasias inconscientes.
Winnicott e-prints. 2007;(2):2:1-19.
9. American Psychiatric Association. Manual diagnóstico e
estatístico de transtornos mentais-DSM 5. Porto Alegre: Artmed;
2014.
10. Nascimento D. Rodrigo Alves sobre suas 72 cirurgias plásticas:
“Sei que exagerei, mas fiz porque precisei”. Revista Quem. 2019
Jun 12. Disponível em: https://revistaquem.globo.com/Entrevista/
noticia/2019/06/rodrigo-alves-sobre-suas-72-cirurgias-plasticassei-que-exagerei-mas-fiz-porque-precisei.html
11. Goulart GC. Razões para a insatisfação da paciente mesmo com
bom resultado cirúrgico. Rev Bras Cir Plást. 2019;34(Suppl
2):69-70.
12. Amaral ACS, Cordás TA, Conti MAC, Ferreira ME. Equivalência
semântica e avaliação da consistência interna da versão em
português do Sociocultural Attitudes Towards Appearance
Questionnaire- 3 (SATAQ-3). Cad Saúde Pública. 2011;2(8):
1487-97.
13. Masako LF, Brito MJ, Cordás TA, eds. Transtorno Dismórfico
Corporal: A mente que mente. São Paulo: Hogrefe Cettep; 2018.
14. Brasil. Conselho Federal de Medicina. Código de Ética Médica:
Resolução CFM nº 2.217, de 27 de setembro de 2018, modificada
pelas Resoluções CFM nº 2.222/2018 e 2.226/2019. Brasília:
Conselho Federal de Medicina; 2019.
Figure 1. The media as a source of information about appearance
was the subscale with the highest score, mainly influencing
patients with symptoms of Body Dysmorphic Disorder.
COLLABORATIONS
AK Conceptualization, Final manuscript approval,
Methodology, Supervision, Visualization, Writing -
Original Draft Preparation, Writing - Review &
Editing.
Alexandre Kataoka
Av. Paulista, 2494, cj 14, Bela Vista, São Paulo, SP, Brazil.
Zip code: 01310-300
E-mail: [email protected]
*Corresponding author:
RRL Final manuscript approval, Formal Analysis,
Methodology, Supervision, Writing - Original
Draft Preparation, Writing - Review & Editing.
CCSM Conceptualization, Data Curation, Final
manuscript approval, Investigation, Methodology,
Writing - Original Draft Preparation, Writing -
Review & Editing.
NGS Conceptualization, Final manuscript approval,
Methodology, Visualization, Writing - Original
Draft Preparation.
Influence of the media on body
image in patients with symptoms of body
dysmorphic disorder
General internalization of socially established standards
Media as a source of information about the appearance
Pressures exerted by these standards
Ideal athletic body
1 Rev. Bras. Cir. Plást. 2023;38(1):e0709
Preoperative clinical management of patients who
are candidates for facial transplantation
Manejo clínico pré-operatório de pacientes candidatos ao transplante facial
Case Report
MARTIN IGLESIAS
MORALES1
MATEUS DE SOUSA
BORGES1, 2*
MARIO ROBERTO TAVARES
CARDOSO DE
ALBUQUERQUE2
RODOLFO COSTA LOBATO2
1
Grupo de Ayuda para la Mano Artrítica AC, “Tlalpan Team”, Medicina, Tlalpan, Cidade do México, Mexico.
2
Centro Universitário do Estado do Pará (CESUPA), Medicina, Belém, Pará, Brazil.
DOI: 10.5935/2177-1235.2023RBCP0709-EN
Institution: Grupo de Ayuda para
la Mano Artrítica AC, “Tlalpan
Team”, Cidade do México, Mexico.
Article received: March 6, 2022.
Article accepted: September 13, 2022.
Conflicts of interest: none.
Introduction: Face transplantation has gained recognition, changing the clinicalsurgical scenario for restoring complex facial defects, as it attributes functional and
aesthetic recovery to patients who have suffered serious accidents. At the time of
writing this article, in official publications, 43 patients had already undergone facial
transplantation worldwide. Face transplantation has numerous pieces of evidence
that can irrefutably provide improvements to the patient. For this, preoperative care
for the patient must be carefully established so that there is good surgical performance.
Case Report: Male patient, 46 years old, reports that, at the age of 6, he had burns due
to exposure to gasoline, with 72% of his body surface burned, showing sequelae of
burns and surgical reconstructions on the face, with redundant and ptotic skin flap on
the left cheek, absence of upper and lower lip and exposure of lower teeth. Conclusion:
It is important to publicize this innovative procedure in different medical specialties
and preoperative care through a thorough investigation, which attributes better
surgical effectiveness, allowing the rescue of their facial identity, once stigmatized.
Descritores: Cuidados pré-operatórios; Transplante de face; Procedimentos
clínicos; Procedimentos cirúrgicos reconstrutivos; Queimaduras; Relatos de casos.
Introdução: O transplante de face adquiriu reconhecimento, alterando o panorama
clínico-cirúrgico para a restauração de defeitos faciais complexos, visto que atribui
recuperação funcional e estética a pacientes que sofreram acidentes graves. Até o
momento da redação deste artigo, em publicações oficiais, 43 pacientes já haviam
realizado o transplante facial em todo mundo. O transplante de face possui inúmeras
evidências que podem fornecer melhorias ao paciente de forma irrefutável. Para isso,
cuidados pré-operatórios ao paciente devem ser cuidadosamente estabelecidos para
que haja um bom desempenho cirúrgico. Relato de Caso: Paciente sexo masculino,
46 anos, relata que, aos 6 anos de idade, teve queimadura por exposição à gasolina,
com 72% de superfície corporal queimada, apresentando sequelas de queimaduras
e reconstruções cirúrgicas na face, com retalho cutâneo redundante e ptótico em
bochecha esquerda, ausência de lábio superior e inferior e exposição dos dentes
inferiores. Conclusão: Ressalta-se a importância da divulgação desse procedimento
inovador em diferentes especialidades médicas e dos cuidados pré-operatórios
através de uma investigação minuciosa, que atribuem uma melhor eficácia
cirúrgica, possibilitando o resgate de sua identidade facial, uma vez estigmatizada.
■ ABSTRACT
■ RESUMO
Keywords: Preoperative care; Facial transplantation; Critical pathways;
Reconstructive surgical procedures; Burns; Case reports.
Preoperative management of candidates for facial transplantation
Rev. Bras. Cir. Plást. 2023;38(1):e0709 2
INTRODUCTION
Face transplantation has acquired recognition,
changing the clinical-surgical panorama in restoring
complex facial defects since it attributes functional and
aesthetic recovery.
A study in 2019 in the United States revealed
that the incidence of craniofacial injuries by firearms
increased by about 31.7%, that of burns reached
240.2%, and that of animal attacks to 173.9%1
. Thus, the
insertion of facial transplantation in medical practice
aims to improve the quality of life, as it reintegrates
the functions of swallowing, speech, and the patient’s
psychosocial integration.
In 2005, in Amiens (France), the first partial face
transplant was performed after the patient was affected
by an animal attack. Since then, the procedure has been
performed for more than 10 years, seeking surgical
improvement, as there is a great clash regarding the
numerous risks and immunosuppression, making this
procedure, for many, something experimental with
unfinished ethical questions, such as adherence and
psychological maturity, risks of opportunistic infections
and malignancies due to extensive tissue exposure2
.
To perform the transplant, the degree of health
of the patient and their comorbidities are taken into
account, in which the main method of choice for
surgeons is vascularized composite allotransplantation
(VCA). It refers to the transplant that includes the
three embryological layers of multiple tissues in a
functional unit, such as muscle, bone, nerve and skin,
subcutaneous tissue, blood vessels, and tendons; being
from a deceased donor to a recipient with a severe
injury, tolerating only a limited period of ischemia, with
the rapid establishment of blood flow3
.
Adequate revascularization and the functional
and aesthetic reintegration of the surgical process
are the ultimate goals to be achieved with facial
transplantation. However, the major obstacle still
being faced is immunosuppression due to the need to
change numerous structures on the face and in adjacent
areas, making long-term pharmacological use almost
inevitable, with potentially fatal side effects, which
requires a rigorous medical assessment concerning
risk-benefit3,4.
In official publications, at the time of writing
this article, 43 patients have already undergone
facial transplantation, with only five deaths due to
complications of non-adherence to medication, the
appearance of tumors, trauma, neoplasms, or unknown
cause4
. Face transplantation has numerous pieces of
evidence that can irrefutably provide improvements to
the patient. Thus, it becomes relevant to carry out the
present work, which aims to describe an experience of
a candidate for facial transplantation in Mexico City -
Mexico, in addition to conducting a discussion with an
emphasis on preoperative clinical management.
CASE REPORT
Identification
ASM, male, 46 years old, brown, with a high school
education, works in a company that manufactures sports
uniforms, with residence in Celaya, Mexico.
History of current illness (HDA) (Figures 1 and 2)
He reported no visual acuity complications but
with the presence of epiphora and bilateral ectropion.
Concerning hearing, he denied alterations, with the
Figure 1. Patient with face and neck showing multiple
healed transverse flaps and depressed lower eyelids, without
mobility and with multiple scars.
Collection made available by the hospital (2020)
3 Rev. Bras. Cir. Plást. 2023;38(1):e0709
Morales MI et al. www.rbcp.org.br
absence of the left ear and half of the right ear, intact
tongue, and difficulty swallowing fluids. He had a loss
of nose, with predominantly oral breathing. He had
sequelae from burns and surgical reconstructions on
his face, with unstable skin.
After an initial evaluation with the plastic surgeon, he
underwent a multidisciplinary analysis, namely: specialist
in Transplants; Psychiatry; Psychology; Social work;
Anesthesiology; Infectology; Occupational Therapist;
Neurology; Cardiology; Dentistry; Oral and maxillofacial
surgeon; Ophthalmologic Oculoplastics; Urology;
Otolaryngology; Internal medicine; Bioreproduction and
Nutrology.
Personal Physiological Background (PPB)
History of 44 surgeries in total and 35 blood
transfusions.
Pathological Personal History (PPH)
Diagnosed with type 2 diabetes mellitus in
2017, controlled with metformin; latent tuberculosis
diagnosed and treated with isoniazid; multinodular
goiter with aspiration biopsy, reporting a hyperplastic
nodule and Bethesda II and epidermoid cancer in the
burned area of the right forearm, resected in 2017.
Figure 2. Timeline of current illness history.
Created by the author (2020)
1980 6 years old
“Burn accident.”
• After the accident, he
spent 3 days hospitalized
in Celaya (his hometown)
• Transferred to León
hospital (Mexican capital)
6 months of intensive
care and 3 months
hospitalized under
observation
During 16 years,
he performed 32
surgeries with
the application of
grafts, arm, leg,
and face At 16, he
was referred
to continue
treatment at the
“La Raza” medical
center. After 12 years,
around 12
reconstructive
surgeries were
performed with
support from
Mexican social
security until the
age of 28
He was evaluated at
Hospital General Dr.
Manuel Gea González
(Mexico City) without
applying surgical
procedures, and a face
protocol was started but
without success
Entry into the “Tlaplan
Team,” Asociación Civil
Grupo de Ayuda para
la Mano Artrítica AC,
where he started the
protocol to carry out
the preoperative care
for the face transplant
Preoperative management of candidates for facial transplantation
Rev. Bras. Cir. Plást. 2023;38(1):e0709 4
Life Habits
Former alcoholic discharged from rehabilitation
treatment in 2017. He denies smoking.
General Physical Examination (GPE)
The patient was in good condition, conscious and
oriented in time and space, with indifferent attitude
and decubitus, facies with changes secondary to facial
burn. Patient with severe limitation of movement of the
left hand and other extremities with cicatricial lesions.
Orofacial Clinical Examination (OCE)
The skin flap that replaced the nose has two
orifices, the left of which is permeable with a flattened
shape in a microstoma aspect (resembles the nostrils of
a fish) (Figure 3). The atrophic upper lip with a thin red
border. The hypertrophic lower lip with multiple scars,
both rigid, which prevent manual traction to visualize
the labial vestibules.
The malpositioned right maxillary second molar
turned inwards partially. Maxillary dental arch with
dental crowding. Generalized gingivitis. The right
anterior dentoalveolar process is protuberant and
exposed outside the mouth.
It has gingival retraction, with lingual root
exposure on the right second molar (Figure 4). Other
regions analyzed in the buccal area without other
alterations. He has Angle class I malocclusion with a
crossbite. The maximum oral cavity opening of 3.6 cm
is not painful.
Specialty Assessments (SA)
Ophthalmology
The patient reports chronic lacrimation. Upper
eyelids with mild dermatochalasis. Lower lid of the
Figure 3. Left side view.
Collection made available by the hospital (2020)
Figure 4. Right side view.
Collection made available by the hospital (2020)
5 Rev. Bras. Cir. Plást. 2023;38(1):e0709
Morales MI et al. www.rbcp.org.br
right eye with severe tarsal ectropion; Lower left eyelid
with retraction. Anterior lamina of the eyelid with a
skin graft. 5mm lagophthalmos bilaterally. The cornea
with fine dots, a photo-reactive iris, transparent lens.
Psychology
He has the intellectual resources necessary
for efficient decision-making, allowing him to be
voluntarily and responsibly involved in this transplant
protocol. No evidence of symptoms of depression or
anxiety. He has stabilized cognitive capacity concerning
his physical image (face).
In addition, one of the required criteria is applying
a Stanford Integrated Psychosocial Assessment form for
Transplantation (SIPAT). It is identified as a high risk of
rejection, infection, and mortality. A score greater than 42
is considered incompatible with a successful transplant.
However, ASM was considered psychologically adequate
for being below the value.
Donor preoperative plan
In the frontal region, the compound flap will
be raised subperiosteally until it finds the origin of
the supraorbital nerves. The dissection of the frontal
flap will be continued in its superficial lateral portion
of the aponeurosis of the temporal muscle up to the
upper edge of the zygomatic arch. At the neck level,
the common carotid, internal and external carotid, and
facial arteries will be identified, as well as the external
and internal jugular vein and facial vein.
The upper eyelid will be dissected bilaterally
above the levator palpebrae aponeurosis in the orbital
region.
Elevation of the nasal floor mucosa and the
mucosa of the lateral wall of the upper jaw will be
performed. It will be sectioned from the insertion of
the nasal septum of the palatine crest.
Complementary Exams (CE)
Electrodiagnosis and Electromyography
In the functional evaluation of the facial muscles,
facial asymmetry was found at the expense of the
right hemiface; on muscle examination, the following
classification was identified (Table 1).
Assessment of facial movement according to
House and Brackmann (1985) presenting grade IV, being
moderately severe dysfunction with normal symmetry
and tone at rest and in movement. The frontal region
is absent, the eyes with incomplete closure, and the
asymmetrical mouth with maximum effort.
Echocardiogram (January/2019)
Systolic function with an ejection fraction of 68%
and impaired systolic dysfunction with a type I filling
pattern.
Carotid and vertebral Doppler ultrasound
(January/2019)
Presence of common carotid artery, internal and
external carotid artery with regular walls; thickness
of the intima and media layer in normal parameters,
not being identified atheromatous plaques or stenotic
lesions. Doppler demonstrates anterograde flow and
maintains its settings, velocities, and resistance index
within normal parameters.
Vertebral arteries with anterograde flow and
velocity in normal parameters. A tracing of the
jugular and external veins is also performed, in which
permeable veins with an adequate flow are observed.
Table 1. Report of the patient’s electromyography examination performed preoperatively.
Muscle Qualification Sensitivity
Right Left Trigeminal Nerve
Frontal 3 3
Eyebrow Corrugator 2 2 Preserved ophthalmic branch Preserved ophthalmic branch
Orbicularis oculi 2 3 Preserved maxillary ascending
branch
Preserved maxillary ascending
branch
Buccinator 1 1 Maxillary descending branch
preserved
Maxillary descending branch
preserved
Nasal wing lift 2 2
Orbicularis oris 1 1
Mentonian 2 2
Platysma 3 3
Source: Collection made available by the hospital (2019).
Preoperative management of candidates for facial transplantation
Rev. Bras. Cir. Plást. 2023;38(1):e0709 6
Laboratory tests (January/2020) (Table 2)
Surgeons (SACP) and the Society for Reconstructive
Microsurgery (SMR), facial transplantation should be
performed in patients with severe facial dysfunction,
with a loss greater than 25% and after exhaustion of
conventional techniques with results unsatisfactory.
Therefore, the patient continues to be able to perform
preoperative management7
.
Furthermore, due to the extent and depth of
the burns on the central units of the face, the patient
is using a nasal prosthesis in addition to presenting
occlusion of the nasal passage, which is reflected in
the change in his sleeping habits and the appearance
of sinusitis in the left maxillary sinus.
This was similarly demonstrated in two patients
who had an exposed nasal cavity with airway occlusion
before the transplant and required a prosthetic nose.
After facial transplantation, although there was no
significant improvement in sleep disturbance, there
was a successful restoration of the airways, nasal
breathing without obstacles, and the disappearance
of sinusitis after some surgical corrections due to the
alignment of the donor’s septum7,8.
I n a d e q u a t e c h a r a c t e r i s t i c s s u c h a s
immunosensitization, neuropathology, and adverse
DISCUSSION
Among the 43 cases already published, in which 13
patients had trauma etiology from extensive burns, only
28 mentioned some management guidelines regarding
the pre-transplantation period. In addition, only one
study correlates the necessary preoperative care and its
applications in the context of immunizations necessary
to perform the procedure5
.
In general, before transplantation, patients
report depressive symptoms and changes in quality
of life. In this way, potential candidates undergo a
psychosocial assessment. As in the report, the patient
can perform his daily activities6
.
Caring for these patients offers unique challenges,
including immunosuppression, allograft rejection, and
impaired communication. ASM underwent a strict
screening established by the protocol, identifying
new comorbidities that influenced the delay of such a
procedure.
The patient was chosen because he was a victim
of a burn accident, with 72% of his body surface
burned, with more than 40 surgeries without significant
progress. According to the American Society of Plastic
Exams Result Exams Result
Glycemia 106 mg/dl Hematocrit 45%
Erythrocytes 5.10 106
/mm3 Hemoglobin 15.2 g/dl
Leukocytes 5,295 mm3 Segmented 68%
Platelets 155,000 mm3 AST 38 U/L
Glycated hemoglobin 6.2% ALT 58 U/L
Urea 29.96 mg/dl GGT 93 U/L
Serum creatinine 0.73 mg/dl Prothrombin time (TAP) 12s
Serum sodium 140.0 mmol/L Activated partial thromboplastin time (APTT) 31s
Serum potassium 4.2 mmol/L Hbsag Negative
Serum chlorine 105.0 mmol/L Anti-HCV total Non-reactive
Serum calcium 11.33 mg/dl Anti HAV Negative
Serum phosphorus 1.9 mg/dl Anti HIV Non-reactive
Uric acid 7.45 mg/dl Anti-hepatitis D Negative
Total cholesterol 145 mg/dl C-reactive protein Ultrasensitive 1.59 mg/dl
Direct bilirubin 0.21 mg/dl Anti Epstein Baar Ag capsid VCA IgM 1.56 index
Indirect bilirubin 0.34 mg/dl Anti-Epstein Baar Ag capsid VCA IgG 4.56 index
Creatine phosphokinase (CKMB) 26 U/L Cytomegalovirus IgG Negative
Globulin 4 gr/dl toxoplasma IgG Negative
Lactic dehydrogenase (LHL) 240 U/L
Table 2. Laboratory tests performed by the patient in the preoperative period.
Source: Collection made available by the hospital (2020).
7 Rev. Bras. Cir. Plást. 2023;38(1):e0709
Morales MI et al. www.rbcp.org.br
reactions represent obstacles to performing surgery.
What was not identified in the report, as it presented
complete stability in the evaluations and without
reactional manifestations8
.
Similar to the reported case, a patient who
underwent a face transplant was found with the same
orofacial characteristics, in which, after the transplant,
there was a return of facial agraphesthesia and motor
improvements after the 6th month9
.
Laboratory monitoring of fasting blood glucose
and glycated hemoglobin is of great importance in the
patient already has type 2 diabetes mellitus, one of the
early complications found in post-transplant patients:
transient diabetes9
. A patient with a similar clinical
picture was identified, who evolved positively with drug
treatment after transplantation.
The negative reaction to the cytomegalovirus
immunological test was a preponderant factor for
management since it influences the degree of allograft
dysfunction and patient morbidity and mortality.
The mechanism is still unclear, but all patients who
developed such an infection were successfully treated
with antiretroviral therapy10.
Multiprofessional strategies are launched
because of the complexity of this procedure and its
repercussions in the pre- and post-surgical phases.
Currently, the patient is in the stabilization phase
under control of diabetes mellitus and systemic arterial
hypertension, identified during the preoperative period,
necessitating the postponement of the procedure. In
addition, he is waiting for a compatible donor.
CONCLUSION
A case on the preponderant care for a facial
transplant was detailed. Although there is little medical
knowledge in Brazil, this is a reality in many developed
countries, where the patient manages to enable
the return of his skills and facial expressions with a
potentially natural appearance.
Furthermore, laboratory and multidisciplinary
follow-up within the scope of the preoperative evaluation
over a long period is essential since it increases the
possibility of detecting possible comorbidities, and they
are resolved before the surgical procedure.
It is important to publicize this innovative
procedure in different medical specialties and
preoperative care through a thorough investigation,
enabling the recovery of their facial identity once
stigmatized.
REFERENCES
1. Kantar RS, Alfonso AR, Ramly EP, Diaz-Siso JR, Jacoby A, Sosin
M, et al. Incidence of Preventable Nonfatal Craniofacial Injuries
and Implications for Facial Transplantation. J Craniofac Surg.
2019;30(7):2023-5.
2. Suchyta MA, Sharp R, Amer H, Bradley E, Mardini S. Ethicists’
Opinions Regarding the Permissibility of Face Transplant. Plast
Reconstr Surg. 2019;144(1):212-24.
3. Rodrigues IQ, Cunico C, Silva ABDD, Brum JS, Robes RR,
Freitas RDS. Analysis In Vivo of the Hemifacial Transplantation
Surgical Technique. J Craniofac Surg. 2019;30(3):944-6.
4. Morales MI. Protocolo de Trasplante Compuesto Vascularizado
“Cara”. Ciudad del México: Instituto Nacional de Ciencias
Médicas y Nutrición Salvador Zubirán; 2018.
5. Siemionow M. The past the present and the future of face
transplantation. Curr Opin Organ Transplant. 2020;25(6):568-75.
6. Oser ML, Nizzi MC, Zinser JL, Turk M, Epstein R, Bueno E, et al.
Quality of Life and Psychosocial Functioning 2 Years Following
Facial Transplantation. Psychosomatics. 2018;59(6):591-600.
7. Geoghegan L, Al-Khalil M, Scarborough A, Murray A, Issa F.
Pre-transplant management and sensitisation in vascularised
composite allotransplantation: A systematic review. J Plast
Reconstr Aesthet Surg. 2020;73(9):1593-603.
8. McQuinn MW, Kimberly LL, Parent B, Diaz-Siso JR, Caplan AL,
Blitz AG, et al. Self-Inflicted Gunshot Wound as a Consideration
in the Patient Selection Process for Facial Transplantation.
Camb Q Healthc Ethics. 2019;28(3):450-62.
9. Lassus P, Lindford A, Vuola J, Bäck L, Suominen S, Mesimäki K,
et al. The Helsinki Face Transplantation: Surgical aspects and
1-year outcome. J Plast Reconstr Aesthet Surg. 2018;71(2):132-9.
10. Tasigiorgos S, Kollar B, Krezdorn N, Bueno EM, Tullius SG,
Pomahac B. Face transplantation-current status and future
developments. Transpl Int. 2018;31(7):677-88.
COLLABORATIONS
MIM Conceptualization, Funding Acquisition,
Investigation, Project Administration,
Validation, Visualization, Writing - Original
Draft Preparation.
MSB Analysis and/or data interpretation,
Conceptualization, Formal Analysis,
Investigation, Methodology, Resources,
Visualization, Writing - Original Draft
Preparation, Writing - Review & Editing.
MRTCA Analysis and/or data interpretation, Conception
and design study, Conceptualization, Data
Curation, Final manuscript approval,
Formal Analysis, Methodology, Supervision,
Validation, Visualization, Writing - Original Draft
Preparation.
RCL Analysis and/or data interpretation, Final
manuscript approval, Methodology, Supervision,
Visualization, Writing - Review & Editing.
Mateus de Sousa Borges
Rua Municipalidade, 985, sala 2112, Umarizal, Belém, PA, Brazil.
Zip code: 66050-350
E-mail: [email protected]
*Corresponding author:
1 Rev. Bras. Cir. Plást. 2023;38(1):e0693
Augmentation mammoplasty and autologous fat
transplantation: an alternative for the treatment of
hypomastia and mild pectus excavatum - Case report
Mamoplastia de aumento e transplante de gordura autóloga: uma alternativa
para o tratamento da hipomastia e pectus excavatum leve - Relato de caso
Pectus excavatum(PE) is a congenital chest deformity characterized by
deep depression in the sternum. Autologous fat transplantation has been
used for aesthetic purposes, mainly on the face, and has recently gained
relevance in thoracic and breast surgeries. The present study aims to
present a case of mild PE associated with hypomastia. A 24-year-old
female patient attended the consultation for breast augmentation due
to hypomastia, but the clinical examination also revealed an associated
mild PE that the patient did not notice. Surgical planning included
breast augmentation and autologous fat transfer. A 260ml silicone breast
implant was used, and 250ml of fat was injected in the sternal region and
the lower medial contour of the breasts. There were no complications
during the 12-month follow-up period. The combination of augmentation
mammoplasty and fat transplantation in treating PE deformity proved to
be a minimally invasive, good, safe option with high patient satisfaction.
Descritores: Tórax em funil; Implantes de mama; Lipectomia; Mamoplastia;
Parede torácica.
Pectus excavatum (PE) é uma deformidade torácica congênita, caracterizada
como uma depressão profunda no esterno. O transplante autólogo de gordura
tem sido utilizado para fins estéticos, principalmente na face, e recentemente
ganhou relevância nas cirurgias torácica e das mamas. O objetivo do
presente estudo é apresentar um caso de PE leve associado a hipomastia.
Uma paciente de 24 anos compareceu à consulta para mamoplastia de
aumento por hipomastia, mas o exame clínico também revelou um PE leve
associado que não foi percebido pela paciente. O planejamento cirúrgico
incluiu a mamoplastia de aumento e a transferência de gordura autóloga.
Foi utilizado um implante mamário de silicone de 260ml, e uma quantidade
total de 250ml de gordura foi injetada na região esternal e no contorno
medial inferior das mamas. Não houve complicações durante o período de
acompanhamento de 12 meses. A associação de mamoplastia de aumento e
transplante de gordura no tratamento da deformidade de PE revelou-se uma
opção minimamente invasiva, boa, segura e com alta satisfação da paciente.
■ ABSTRACT
■ RESUMO
Case Report
Keywords: Funnel chest; breast implants; Lipectomy; Mammaplasty; Thoracic wall.
MARCUS VINICIUS JARDINI
BARBOSA1
*
BARBARA RODRIGUES
BATISTA1
FABIO XERFAN NAHAS2
LYDIA MASAKO FERREIRA2
1
Universidade de Franca, Faculdade de Medicina, Franca, São Paulo, Brazil.
2
Universidade Federal de São Paulo, Disciplina de Cirurgia Plástica, São Paulo, São Paulo, Brazil.
DOI: 10.5935/2177-1235.2023RBCP0693-EN
Institution: Faculdade de
Medicina da Universidade de
Franca, São Paulo, SP, Brazil.
Article received: January 31, 2022.
Article accepted: September 13, 2022.
Conflicts of interest: none.
Augmentation mammaplasty and autologous fat transplantation
Rev. Bras. Cir. Plást. 2023;38(1):e0693 2
INTRODUCTION
Congenital chest deformities affect both genders
and, in general, manifest as changes in the chest wall,
such as pectus excavatum (PE)1
, associated or not with
muscle deformities as in Poland’s syndrome2
. Losses
and limitations are more significant when affecting
women due to aesthetic aspects2
. In these patients,
breast asymmetry is the most frequent reason for
consultation, despite any other problem that may be
associated3
.
Clinical presentation ranges from mild to severe
defects, which may be associated with cardiopulmonary
dysfunction1-3; in these cases, extensive thoracic
surgical corrections may be necessary4
. However,
when the deformity is mild or moderate, other surgical
resources such as custom-made silicone implants5
,
cartilage fragments, local flaps, tissue expansion, etc.6
can be used.
Autologous fat transplantation has been used for
aesthetic purposes, mainly on the face, and has recently
gained relevance in breast and thoracic surgeries7
.
Despite the variation in the resorption rate in the first
three months after transplantation, Ho Quoc et al.8
highlighted that a learning curve is an important point
for greater stability of the result. Since autologous fat
transplantation presents stable long-term results in
small deformities, low cost, low rate of complications1,9,
and the possibility of repeating the procedure, its
use for reconstructive and aesthetic purposes has
been considered, including thoracic deformities and
mammary.
OBJECTIVE
Therefore, the study aims to present a case of
mild pectus excavatum associated with hypomastia
in a patient who presented for a breast augmentation
appointment.
CASE REPORT
A 24-year-old female patient attended the
consultation for breast augmentation due to hypomastia,
but the clinical examination also revealed the presence
of mild pectus excavatum (PE), which the patient had
not noticed (Figure 1). The cardiopulmonary physical
examination was normal. Likewise, the chest X-ray,
electrocardiogram, and blood count were within
normal limits.
The proposed surgery included subglandular
breast augmentation and autologous fat transfer
to treat the thoracic deformity and improve breast
contour. The area to be aspirated was previously
marked in the infraumbilical region of the abdomen.
The patient was placed in dorsal decubitus, and after
general anesthesia, 500ml of saline solution with
adrenaline was injected subcutaneously.
Syringe-assisted liposuction was performed
with a 3.5 mm cannula, and the same volume was
aspirated (tumescent liposuction). The manipulation
of the fat to be transferred was less traumatic as
possible, and only a saline solution was added to
remove excess blood. Then, the fat was decanted into
20ml syringes.
A 5cm incision was made in the inframammary
fold. After subglandular dissection with electrocautery,
subglandular augmentation mammaplasty was
performed bilaterally with a 260ml round nanotextured
breast implant, and the wound was closed in layers.
The fat transplant was performed with a 2mm
cannula in different paths and depths (in a fan shape)
through the incision in the inframammary fold to
improve the medial contour of the breast. A 2 mm
incision was made in the anterior region of the chest
(at the level of the xiphoid process) to treat the pectus
excavatum deformity. These trajectories were crossed
with each other to treat the defect (Figure 2) better.
Figure 1. Preoperative aspect of pectus excavatum. (A) The marked area and the
arrows show the limits of the defect. (B) Arrows show the upper limits of the defect.
Figure 2. Schematic drawing of the operative access showing the different
crossed paths of the 2mm cannula through the incision in the inframammary
fold and anterior thorax to treat pectus excavatum.
3 Rev. Bras. Cir. Plást. 2023;38(1):e0693
Barbosa MVJ et al. www.rbcp.org.br
A total volume of 250ml of fat was injected as
follows:
• 50ml in the inferior-medial contour of each
breast (total of 100ml).
• 150ml in sternal deformity to correct pectus
excavatum (PE).
The follow-up period was 12 months. No minor
or major complications were reported, and a second
procedure was not required.
Pre- and postoperative aspects of the result after
12 months are shown in Figure 3.
Different approaches and techniques have been
described for the treatment of pectus excavatum6
.
However, the best choice will depend on the severity
of the malformation and the surgical experience of
the team.
Since the improvement of the use of autologous
fat injection by Coleman10, the technique has been
widely disseminated and studied by several authors,
including its use in aesthetic and reconstructive
surgeries8
. Delay & Guerid7
stated that breast fat
grafting is likely to greatly improve the results of
thoracic malformations, including pectus excavatum.
Schwabegger6
recommended the technique for adults
with good nutritional status. Therefore, in this case,
the option for autologous fat transplantation occurred
because it is a mild defect and is considered a simple
and minimally invasive option that avoids any need for
implantation or bone remodeling in the sternal region.
The ways of collecting and treating the fat
to be grafted have been the subject of clinical and
experimental studies. More recently, fat enrichment
has been investigated to guarantee more stable and,
consequently, more predictable results. Hamed et al.11
carried out an experimental study using erythropoietin
for fat enrichment, which resulted in greater integration
in the transplanted site.
Tanikawa et al.12 demonstrated that enriching
adipose tissue with stromal cells promoted better
integration and maintenance of long-term results in
patients with microsomia. However, despite the good
results, the major limitation of these studies is the short
follow-up period and the fact that many researchers
still question the potential complications of stem cell
therapy.
The rate of absorption of the transplanted fat
is quite variable and is related to the total volume
transferred7
. Many authors had recently described
stable results, with low complication rates when fat
grafting was compared to other procedures9
. Ho Quoc
et al.3
reported a low resorption rate in treating pectus
excavatum with fat grafting, obtaining a satisfaction
rate of approximately 95% for both patients and the
surgical team. Another advantage is the possibility
of repeating it to improve the result or correct small
residual deformities8
.
A second procedure was unnecessary in the case
presented during the 12-month follow-up period. We
consider that overcorrection of the deformity prevented
a second procedure, following what was stated by
Pereira & Sterodimas1
, who consider overcorrection
important in a procedure with variable resorption rates.
However, despite the same authors highlighting that
lasting results in the sternal region are unpredictable1
,
Ho Quoc et al.3
described a natural and stable long-term
result.
Figure 3. 24-year-old patient with hypomastia and mild pectus excavatum.
(A) Preoperative frontal view. (B) Frontal view 12 months postoperatively.
(C) Preoperative right oblique view. (D) Right oblique view 12 months
postoperatively.
DISCUSSION
Thoracic deformities can be acquired or congenital,
such as Poland’s syndrome and pectus excavatum1-6,9.
According to Snel et al.5
, untreated PE can lead to
embarrassment and psychosocial problems, especially
in more severe deformities.
Changes in breast contour seem to be the main
reason for consultation in most female patients with
mild thoracic deformities2,3. In the case presented,
hypomastia was the patient’s main complaint, and the
diagnosis of pectus excavatum was made during the
clinical examination.
Ho Quoc et al.3
highlighted that in cases of
associated thoracic and breast deformities, breast
augmentation alone could increase the thoracic
deformity, compromising the postoperative result and
generating dissatisfaction on the part of the patient. This
fact reveals the importance of a good clinical examination
for adequate preoperative surgical planning to achieve
the best postoperative result. Thus, in the case presented,
the surgical planning sought to treat both defects:
hypomastia and pectus excavatum, simultaneously.
Augmentation mammaplasty and autologous fat transplantation
Rev. Bras. Cir. Plást. 2023;38(1):e0693 4
CONCLUSION
The presented case showed the importance of
clinical examination and preoperative planning for
better results. Otherwise, just the correction of hypomastia
could accentuate a mild pectus excavatum, initially not
noticed by the patient. Thus, combining augmentation
mammoplasty and autologous fat transplantation to
treat PE proved to be a good option, minimally invasive,
safe, and with high patient satisfaction. However, it is
important to inform that fat grafting procedures in
the sternal region may present reabsorption, and
additional procedures may be necessary.
REFERENCES
1. Pereira LH, Sterodimas A. Free Fat Transplantation for the
Aesthetic Correction of Mild Pectus Excavatum. Aesthetic Plast
Surg. 2008;32(2):393-6.
2. Michlits W, Windhofer C, Papp C. Pectus excavatum and free
fasciocutaneous infragluteal flap: a new technique for the
correction of congenital asymptomatic chest wall deformities
in adults. Plast Reconstr Surg. 2009;124(5):1520-8.
3. Ho Quoc C, Delaporte T, Meruta A, La Marca S, Toussoun G,
Delay E. Breast asymmetry and pectus excavatum improvement
with fat grafting. Aesthet Surg J. 2013;33(6):822-9.
4. Grappolini S, Fanzio PM, D’Addetta PG, Todde A, Infante M.
Aesthetic treatment of pectus excavatum: a new endoscopic
technique using a porous polyethylene implant. Aesthetic Plast
Surg. 2008;32(1):105-10.
5. Snel BJ, Spronk CA, Werker PM, van der Lei B. Pectus
excavatum reconstruction with silicone implants: long-term
results and a review of the English-language literature. Ann
Plast Surg. 2009;62(2):205-9.
6. Schwabegger AH. Pectus excavatum repair from a plastic
surgeon’s perspective. Ann Cardiothorac Surg. 2016;5(5):501-12.
7. Delay E, Guerid S. The Role of Fat Grafting in Breast
Reconstruction. Clin Plast Surg. 2015;42(3):315-23.
8. Ho Quoc C, Taupin T, Guérin N, Delay E. Volumetric evaluation
of fat resorption after breast lipofilling. Ann Chir Plast Esthet.
2015;60(6):495-9.
9. Morandi EM, Sigl S, Schwabegger AH. Autologous Lipotransfer for
Pectus Excavatum Correction. Aesthet Surg J. 2019;39(7):NP302-
NP304.
10. Coleman SR. Long-term survival of fat transplants: controlled
demonstrations. Aesthetic Plast Surg. 1995;19(5):421-5.
11. Hamed S, Egozi D, Kruchevsky D, Teot L, Gilhar A, Ullmann
Y. Erythropoietin improves the survival of fat tissue after its
transplantation in nude mice. PLoS One. 2010;5(11):e13986.
12. Tanikawa DYS, Aguena M, Bueno DF, Passos-Bueno MR, Alonso N.
Fat grafts supplemented with adipose-derived stromal cells in
the rehabilitation of patients with craniofacial microsomia. Plast
Reconstr Surg. 2013;132(1):141-52.
COLABORAÇÕES
MVJB Análise e/ou interpretação dos dados, Aprovação
final do manuscrito, Coleta de Dados,
Conceitualização, Concepção e desenho do
estudo, Gerenciamento do Projeto, Metodologia,
Realização das operações e/ou experimentos,
Redação - Preparação do original, Redação -
Revisão e Edição, Supervisão, Visualização.
BRB Aprovação final do manuscrito, Coleta de
Dados, Conceitualização, Redação - Preparação
do original, Redação - Revisão e Edição.
FXN Conceitualização, Metodologia
LMF Análise e/ou interpretação dos dados,
Conceitualização, Redação - Preparação do
original, Redação - Revisão e Edição
Marcus Vinícius Jardini Barbosa
Alameda dos Flamboyants, 700, Morada do Verde, Franca, SP, Brazil.
Zip code: 14404-409
E-mail: [email protected]
*Corresponding author:
1 Rev. Bras. Cir. Plást. 2023;38(1):e0736
Galactorrhea after breast augmentation: case report
and literature review
Galactorreia após mamoplastia de aumento: relato de caso e revisão da
literatura
Introduction: Augmentation mammoplasty is one of the most frequently performed
surgeries in plastic surgery. Among its rarer occurrences are galactorrhea,
spontaneous milk output by the papilla, and galactocele, a collection of milky
material in the surgical bed. There is little literature on this extremely rare
occurrence, and through this article, we conduct a literature review and report
on a case operated in our service. Case Report: We present a case of a 35-year-old
patient who underwent breast augmentation surgery via the inframammary fold,
with an implant placed in the subglandular plane, which evolved, on the thirtieth
postoperative day, with galactorrhea exteriorized through the incision, and we
propose a treatment for such intercurrence. Six months after the operation, the
breasts were symmetrical, without signs of contracture or additional alterations;
the patient was satisfied with the result and without new episodes of galactorrhea
or galactocele. Conclusion: Although rare, with an incidence of less than 1%,
galactorrhea can occur as a postoperative complication, and knowledge about
it, as well as the forms of treatment, will benefit both patient and surgeon.
Descritores: Galactorreia; Implante mamário; Mamoplastia; Doenças mamárias;
Procedimentos cirúrgicos reconstrutivos; Relatos de casos.
Introdução: A mamoplastia de aumento é uma das cirurgias mais frequentemente
realizadas na cirurgia plástica. Entre suas intercorrências mais raras, está a
galactorreia, saída de leite pela papila de forma espontânea, e o galactocele, uma
coleção de material leitoso no leito cirúrgico. Pouca literatura existe sobre esta
raríssima intercorrência e por meio deste artigo realizamos uma revisão da literatura
e relato de um caso operado no nosso serviço. Relato de Caso: Apresentamos um caso
de uma paciente de 35 anos que foi submetida a cirurgia de mamoplastia de aumento
via sulco inframamário, com implante alocado no plano subglandular, que evoluiu,
no trigésimo dia pós-operatório, com galactorreia exteriorizada pela incisão, e
propomos um tratamento para tal intercorrência. Com seis meses de pós-operatório,
as mamas se encontravam simétricas, sem sinais de contratura ou alterações
adicionais, paciente satisfeita com o resultado e sem novos episódios de galactorreia
ou galactocele. Conclusão: Embora rara, com uma incidência de menos de 1%, a
galactorreia pode ocorrer como intercorrência pós-operatória e o conhecimento desta,
bem como as formas de tratamento, irá beneficiar tanto paciente como cirurgião.
■ ABSTRACT
■ RESUMO
Case Report
RAPHAELA SILVEIRA DO
AMARAL1
*
ERICK SAMUEL SANTOS-DEMELLO1
RODRIGO PINTO GIMENEZ1
FERNANDO GIOVANETTI
MORANO1
SORAYA TERESA TEIXEIRA
CASSITAS GONÇALVES1
TATIANI CERIONI TOTH1
1
Hospital Irmãos Penteado, Serviço de Cirurgia Plástica Dr Ricardo Barouldi, Campinas, São Paulo, Brazil.
DOI: 10.5935/2177-1235.2023RBCP0736-EN
Institution: Hospital Irmãos
Penteado, Serviço de Cirurgia
Plástica Professor Dr. Ricardo
Baroudi, Campinas, SP, Brazil.
Article received: June 21, 2022.
Article accepted: November 16, 2022.
Conflicts of interest: none.
Keywords: Galactorrhea; Breast implantation; Mammaplasty; Breast diseases;
Reconstructive surgical procedures; Case reports.
Galactorrhea after breast augmentation
Rev. Bras. Cir. Plást. 2023;38(1):e0736 2
in the subglandular plane and via an access route in
the inframammary fold. The postoperative period was
uneventful, and the patient evolved adequately.
Thirty days after the surgical procedure, a milky
secretion (Figure 2) drains spontaneously through the
surgical wound without pain, fever, or other symptoms,
in addition to bilateral galactorrhea. Cabergoline 0.5mg
every 12 hours was used, associated with cefadroxil
500mg every 12 hours for 48 hours. This regimen of
cabergoline pulses was repeated 45 days after the
surgical procedure. With this approach, the patient
presented a progressive decrease in secretion drained
by the surgical wound, completely ceasing 60 days after
the surgery.
The patient evolved with a hypertrophic scar in
the region of the inframammary fold, which was treated
with four sessions of intra-cicatricial infiltration of
triamcinolone acetate. Six months after the operation
(Figures 3A and 3B), the breasts are symmetrical,
without signs of contracture or additional alterations;
the patient is satisfied with the result and without new
episodes of galactorrhea or galactocele.
DISCUSSION
Galactorrhea is a rare complication that occurs in
breast augmentation surgeries. It was first described in
1971 as the spontaneous release of milk not associated
with breastfeeding6,7. Initially, it can be confused with
INTRODUCTION
Augmentation mammoplasty using implants is a
procedure performed with high frequency worldwide.
In 2020 alone, 1,624,281 surgeries were performed,
according to the International Society of Aesthetic
Plastic Surgery (ISAPS)1
. Although very safe, it is not
free from complications. Some of these complications
are well known, such as hematoma, seroma, capsular
contracture, infection, unsightly scarring, and poor
positioning of implants, and some are uncommon, such
as galactorrhea2,3.
Galactorrhea and galactocele can occur in up
to 0.96% of patients undergoing breast augmentation
with implants. On average, they take 15-90 days to
manifest. Galactocele was defined as the accumulation
of milk in the surgical pocket, and this content can be
drained spontaneously through the surgical wound4
.
Galactorrhea is defined as the spontaneous excretion
of milk by the papilla without sucking stimulus3
.
The cause of postoperative galactorrhea and
galactocele has not yet been fully elucidated. It is
believed that the trigger may be due to the increase
in prolactin due to surgical stimulation or nerve
compression of the rib cage. Some theories point out
that the mechanical compression of the implants on the
gland or even the effect of other medications taken by
the patient may be responsible for such intercurrence5
.
Treatment is based on prolactin inhibitors
such as bromocriptine4,6,7 and may be associated
with percutaneous or open surgical drainage of the
galactocele7
. Because it is a rare intercurrence that
the surgeon may face one day, we present a case
experienced in our service, as well as the treatment
scheme used and the postoperative follow-up with 10
months of surgery.
OBJECTIVE
To present a case of galactocele in a patient
who underwent breast augmentation with implants,
to report on the management of the case, applied
treatment, and results.
CASE REPORT
We report the case of a 35-year-old female patient,
complaining of hypoplastic breasts and desire for breast
augmentation (Figures 1A and 1B), admitted to Hospital
Irmãos Penteado, Dr. Ricardo Barouldi, in Campinas,
SP. She had two previous pregnancies and had stopped
breastfeeding one year after the surgery. The patient
tended to form a keloid scar without other important
antecedents. In October 09, 2020 a breast augmentation
surgery was performed using 300ml textured implants
Figure 1A. Preoperative patient (front view). Figure 1B.
Preoperative patient (lateral view).
Figure 2. Spontaneous drainage from the surgical wound of
milky secretion.
A B
3 Rev. Bras. Cir. Plást. 2023;38(1):e0736
Amaral RS et al. www.rbcp.org.br
infection or breast abscess due to edema, pain, and
the appearance of secretion8
. Among the causes of
galactorrhea, we can highlight nipple stimulation,
pregnancy, use of medications that increase prolactin
production, iatrogenic hyperprolactinemia above
27ng/ml, thyroid alterations, renal alterations, and
prolactinomas9
.
Among the causes of postoperative galactorrhea
after breast augmentation, it has been suggested
that there is an increase in prolactin in response to
lactotrophic cells in the anterior pituitary, which leads
to milk production; prolactin can increase up to 5 times
due to the surgical stimulus9
. Another theory indicates
that the surgery’s irritation of the costal nerves leads to a
suppression of the hypothalamic axis, with a decrease in
the release of dopamine4
. However, the systematic review
published by Sharma & Basu4 found that not all patients
had high levels of prolactin in the postoperative period.
We can point out some risk factors associated
with galactorrhea, such as the last pregnancy close to
the surgery period, greater number of pregnancies,
previous lactation, and use of contraceptive medication.
Regarding the implant insertion plane, those
allocated in a subglandular position and periareolar
incision are more related to galactorrhea4
. According
to Chun & Taghinia10, this is due to the obstruction of
some galactophoric ducts in the breast. The onset of
symptoms is reported in an average of 15 days and may
manifest after 90 days after surgery3,6.
Some tests can be routinely used, such as
measurement of serum levels of prolactin, BetaHCG, complete blood count, C-reactive protein,
thyroid tests, and IV Sudan test to determine milk6,7,11.
Regarding imaging tests, ultrasonography, secretion
cultures, and pituitary magnetic resonance in case of
hyperprolactinemia above 100ng/ml4 may be necessary
for diagnostic confirmation.
After confirmation of the condition, we must
proceed with drug treatment. Authors propose different
approaches, including using bromocriptine at a dose of
2.5mg twice daily as the first line and cabergoline 0.5mg
1-2 tablets per week and as the second line2,4,11. Antibiotic
treatment may also be included due to the risk of infection
associated with the implant4,11, dopamine inhibitors,
leukotriene inhibitors, to avoid the chance of capsular
contracture6, and explant with pocket washing4,6,11.
In the literature review, we found that most
published studies are case reports similar to this one:
two case series and one systematic review.
We believe that expanding the number of studies
on this topic will be important to unify behaviors and
minimize this intercurrence.
CONCLUSION
Galactorrhea and galactocele are rare complications
of breast augmentation. With an adequate diagnosis and
early treatment, we managed to treat it without changing
the outcome of our surgeries. More investigations
are needed regarding this rare intercurrence to unify
conducts and minimize complications.
Figure 3A. Six-month postoperative period (frontal view).
Figure 3B. Six-month postoperative period (lateral view).
COLLABORATIONS
RSA Conceptualization, Data Curation, Writing -
Original Draft Preparation, Writing - Review &
Editing.
ESSM Conceptualization, Data Curation, Writing -
Original Draft Preparation.
RPG Final manuscript approval, Supervision,
Visualization.
FGM Final manuscript approval, Supervision,
Visualization.
STTCG Data Curation, Writing - Original Draft
Preparation.
TCT Data Curation, Writing - Original Draft
Preparation.
REFERENCES
1. International Society of Aesthetic Plastic Surgery (ISAPS).
Pesquisa global de 2020 da ISAPS observa mudanças
significativas nos procedimentos estéticos durante a pandemia.
West Lebanon: ISAPS; 2021.
2. Ayestaray B, Dudrap E, Chaibi A. Galactorrhea after aesthetic
breast augmentation with silicone implants: report of two cases
and management of postoperative galactorrhea. Aesthetic Plast
Surg. 2011;35(3):408-13.
3. Basile FV, Basile AR. Diagnosis and management of galactorrhea
after breast augmentation. Plast Reconstr Surg. 2015;135(5):1349-56.
4. Sharma SC, Basu NN. Galactorrhea/Galactocele After
Breast Augmentation: A Systematic Review. Ann Plast Surg.
2021;86(1):115-20.
5. Schusterman MA 2nd, Bruce MK, Nicholas K, Diego E, La
Cruz C. Galactorrhea After Nipple-Sparing Mastectomy: Case
Report, Review of the Literature, and Algorithmic Approach to
Management. Ann Plast Surg. 2022;88(4):467-9.
A B
Galactorrhea after breast augmentation
Rev. Bras. Cir. Plást. 2023;38(1):e0736 4
6. Batista KT, Monteiro GB, Y-Schwartzman UP, Roberti AFSSA,
Rosa AG, Correia CZ, et al. Treatment of leprosy-induced plantar
ulcers. Rev Bras Cir Plást. 2019;34(4):497-503.
7. Viaro MSS, Viaro PS, Batistti C. Galactocele due to drugs
prescribed after augmentation mammoplasty: a case report and
literature review. Rev Bras Cir Plást. 2016;31(2):287-91.
8. Guerra M, Codolini L, Cavalieri E, Redi U, Ribuffo D. Galactocele
After Aesthetic Breast Augmentation with Silicone Implants: An
Uncommon Presentation. Aesthetic Plast Surg. 2019;43(2):366-9.
9. Macedo JLS, Rosa SC, Naves LA, Motta LACR. Galactorrhea after
augmentation mastoplasty. Rev Bras Cir Plást. 2017;32(1):155-6.
10. Chun YS, Taghinia A. Hyperprolactinemia and galactocele
formation after augmentation mammoplasty. Ann Plast Surg.
2009;62(2):122-3.
11. Ascenço ASK, Graf R, Maluf Junior I, Balbinot P, Freitas RS.
Galactorrhea: how to address this unusual complication after
augmentation mammoplasty. Rev Bras Cir Plást. 2016;31(2):
143-7.
Raphaela Silveira do Amaral
Av. José Bonifácio, 2001, Campinas, SP, Brazil.
Zip code: 13092-305
E-mail: [email protected]
*Corresponding author:
1 Rev. Bras. Cir. Plást. 2023;38(1):e0487
Method of closing fasciotomies by progressive tissue
traction
ANTONINHO JOSÉ
TONATTO FILHO1,2*
JORGE LUÍS DE MORAES1,2
CAIO MUNARETTO
GIACOMAZZO3
BRUNA VALDUGA DUTRA4
JOSÉ PAULO TAPIE BARBOSA2
RENATO DA SILVA FREITAS1,2
Método de fechamento de fasciotomias por tração tecidual progressiva
High-energy trauma has increased significantly in the last decade, mostly in
the lower limbs, in many cases requiring fasciotomy due to the subsequent
compartment syndrome. In this context, its closure often leads to a delay in the
patient’s comprehensive treatment and the return to their activities and may
lead to local infection, in addition to generating high costs. There are many
options for the plastic surgeon to try to bring the edges together and reconstruct
the extremities, such as flaps, grafts, vacuum dressings, and elastic sutures,
in addition to expansion devices, sometimes with a combination of the above.
Keywords: Sutures; Fasciotomy; Traction; Kirschner wire; Wound closure techniques.
1
Hospital de Clínicas de Curitiba, Cirurgia Plástica, Curitiba, Paraná, Brazil.
2
Hospital do Trabalhador, Cirurgia Plástica, Curitiba, Paraná, Brazil.
3
Universidade Federal do Paraná, Curso de Medicina, Curitiba, Paraná, Brazil
4
Universidade de Caxias do Sul, Curso de Medicina, Caxias do Sul, Rio Grande do Sul, Brazil.
DOI: 10.5935/2177-1235.2023RBCP0487-EN
Institution: Hospital do
Trabalhador, Curitiba, PR, Brazil.
Article received: October 12, 2020.
Article accepted: September 13, 2022.
Conflicts of interest: none.
O trauma de grande energia vem aumentando de maneira expressiva na última
década, em boa parte de membros inferiores, necessitando, em muitos casos,
de fasciotomia devido à síndrome compartimental subsequente. Neste contexto
muitas vezes seu fechamento acaba por levar a um retardo no tratamento integral
do paciente, do retorno a suas atividades e podendo levar a infecção local, além
de gerar altos custos. Há muitas opções ao cirurgião plástico para a tentativa de
aproximação de bordos e reconstrução das extremidades, como retalhos, enxertos,
curativo a vácuo e sutura elástica, além de dispositivos de expansão, sendo, às
vezes, com combinação das anteriores. O método de fechamento apresentado
através do alongamento progressivo da pele com fio de Kirschnner representa uma
forma de baixo custo e facilmente reproduzível para lidar com este tipo de ferida.
■ RESUMO
■ ABSTRACT
Case Report
Descritores: Suturas; Fasciotomia; Tração; Fio de Kirschner; Técnicas de fechamento
de ferimentos.
the principle that the best repair is always the simplest3
,
the fundamentals of reconstructive surgery were
created. Therefore, primary wound closure is the first
choice whenever possible.
However, in wounds with great loss of soft
tissues, or when decompressive fasciotomy of the limbs
is performed with local skin retraction and muscle
protrusion, there is difficulty in performing such closure.
Several alternatives are proposed for the closure of the
extremity wound, such as grafts, flaps, elastic sutures,
INTRODUCTION
High-energy trauma has increased significantly
in recent decades, mainly due to motorcycle and car
accidents. Trauma victims may present varying severity
and location injuries, with the lower limbs being an
important and common site affected. These can range
from simple skin continuity solutions to major tissue
loss and exposure of noble structures1,2.
The decision for the technique to be used is
essential for successful reconstruction, and, based on
Closure of fasciotomies by progressive traction
Rev. Bras. Cir. Plást. 2023;38(1):e0487 2
adhesive tapes, and plastic clamps, the former being able
to be associated with the vacuum dressing.
Within this context, closure through intermittent
traction with Kirschner wires and steel wires becomes
a viable, inexpensive, low-morbidity option, avoiding
new scars created by flap rotation that can result in
retraction, ischemia, and tissue necrosis4,5, and being
easy to reproduce for closing numerous limb wounds,
as well as fasciotomies.
OBJECTIVE
The present study evaluates the closure of a
post-trauma lower limb wound with local fasciotomy,
through continuous and intermittent traction with
a Kirschner wire associated with steel wires, as an
alternative for highly complex injuries.
CASE REPORT
This is a retrospective, observational study of
a patient who underwent fasciotomy closure through
dermatotraction with steel wire at the Hospital do
Trabalhador, in Curitiba-PR, in 2020. Study approved
by the Research Ethics Committee, under CAAE
52788221.0.0000.5225.
Patient LFMP, male, 26 years old, previously
healthy, comes to the emergency room at the Hospital
do Trabalhador in Curitiba with a history of a fall from
the same level into a maintenance hole, with consequent
dislocation of the left knee joint. He preserved the posterior
tibial artery, popliteal artery pulses, and anterior tibial
artery pulse on admission. He was referred to the surgical
center for dislocation reduction by the Orthopedics team.
In the immediate postoperative period of transarticular
external fixation, there was a slowdown in capillary
refill time, the temperature difference concerning the
contralateral limb, and difficulty in palpating pulses.
An assessment by the Vascular Surgery team was
then requested, which on physical examination of the
patient, found the absence of anterior tibial, posterior
tibial, and popliteal pulse, pain on palpation of the calf,
and decreased movement of the toes. Angiotomography
was performed, which confirmed a lesion in the
popliteal artery, and the patient was taken back to the
surgical center for revascularization of the limb, with
interposition of the popliteal artery with the reverse
saphenous vein and medial and lateral fasciotomy.
During the postoperative period, the patient evolved
with signs of reperfusion syndrome and was referred to the
Intensive Care Unit (ICU). After 4 days, he was discharged
from the ICU, maintaining decreased foot sensitivity and
absent motricity in the toes and forefoot. Anterior and
posterior tibial pulses are present, without popliteal pulse
attributed to edema. Fluxes present on Doppler.
On the tenth postoperative day, the patient
started with a fever, progressing to blisters and hallux
necrosis. Ultrasonography was performed, which
identified the presence of a collection in the distal third
of the wound, which was drained with a large number
of clots and a purulent collection. Subsequently, he was
submitted to successive debridements of devitalized
tissues due to muscle necrosis in the deep posterior
compartment, interosseous membrane, and anterior
compartment (Figure 1).
An evaluation was requested after the patient’s
first vacuum dressing to monitor the condition,
assessing the lesion (Figure 2) and indicating the
approximation of the edges with 1.5 Kirschner wires in
association with the twisting of 0 steel wires (Figure 3)
in association with the dressing vacuum for drainage of
secretion and approximation of borders. Four sessions
were performed to approximate the edges by twisting
the steel wires (Figure 4), all in a surgical center
under spinal anesthesia; the mean interval between
procedures was 3 days. Ultimately, the surgical wound
was completely resolved with the proposed treatment
(Figure 5), without grafts, flaps, or other procedures,
ending the procedure with a primary suture of the
lesion.
Figure 1. Patient in the postoperative period of fasciotomy (photo taken by
the assistant team).
Figure 2. Patient in the postoperative period of debridement of the lesion
in association with a vacuum dressing (photo taken by the assistant team).
3 Rev. Bras. Cir. Plást. 2023;38(1):e0487
Filho AJT et al. www.rbcp.org.br
Figure 3. Patient in the postoperative period of insertion of 1.5 Kirschner
wires and 0 steel wires.
DISCUSSION
Due to the significant increase in high-energy
trauma in recent decades, mainly due to motorcycle
and car accidents, the number of complex fractures of
extremities that are difficult to close is increasing. Many
of them require fasciotomy, which momentarily becomes
necessary, but can lead to difficulty in their primary
suture, requiring flaps, grafts, vacuum dressing, elastic
sutures, or other means for closing the same.
The number of fasciotomies registered in
the Public Health System (SUS) in the last decade,
2009-2019, was 26,905 nationally, with 13,758 in the
lower limbs6
. Amid this, the plastic surgeon must have
a range of alternatives to close fasciotomies. Among
them, we found intermittent traction with Kirschner
and steel wires a cheap method, easily reproducible
by other surgeons, and of great value for this purpose.
This technique is a variation based on tissue expansion
described by Neuman in 1956, in which skin gain is
obtained through slow and intermittent expansion7
, by
Bashir (1987)8
and Callanan & Macey (1997)9
.
This expansion process can be explained by the
phenomenon of mechanical drag, in which the collagen
fibers stretch parallel to the direction of the traction
force, and the fundamental substance, composed of
mucopolysaccharides and tissue fluids, which, being
displaced, leads to a final result of increased of surface
area10-13.
1-1.5mm Kirschner wires are passed through
the healthy skin, being crossed parallel to the edges
of the wound in the dermal plane, approximately
5-7mm from the edge of the wound, the remaining
ends being cut and inverted, in order to support them
and not lose them between its ends. Then, grade 0
Figure 4. Patient in the postoperative period of steel wire traction, photo in
medial and lateral views, respectively.
The time between the first intervention by the
Plastic Surgery team and hospital discharge was two
weeks. Thus, the various surgical times for tissue
traction and approximation of the edges did not
generate an extension of hospital stay.
The patient was followed up at the outpatient
clinic for 12 months without suture dehiscence, local
aesthetic complaints, or other complications inherent to
the proposed treatment. He was satisfied with the final
aesthetic result and was discharged from the service.
Figure 5. Patient in the postoperative period of new steel wire traction, photo
in medial and lateral views, respectively.
Closure of fasciotomies by progressive traction
Rev. Bras. Cir. Plást. 2023;38(1):e0487 4
steel wires are introduced through both Kirschner
wires between the edges, and they are twisted and
stretched to perform traction to approximate the
edges. The steel wires are inserted longitudinally
and parallel to the longest axis of the wound in the
intradermal plane with a manually curved 18G needle.
The representative scheme of how the method is
performed can be seen in Figure 6.
The principle was based on the fixation with
the tension of an interlaced elastic, fixed to the edges
of the skin, making a continuous tension of the skin,
putting into practice the concept of elasticity and skin
compliance. The technique was revised by Leite, in
1996, after observing the incidence of skin necrosis
at the edges of the wound when using the Raskin
technique; he then proposed the fixation of the elastic
in the subcutaneous tissue and the superficial fascia,
sparing the skin from the ischemic event induced by
the tensile force15.
Meanwhile, traction with steel wires can be
controlled, performing traction as needed so that
vascularization, which is the limiting factor for skin
traction in the various methods, can be performed
without compromising. Thickness, skin tension
of the displaced flap, skin pallor, and pain are the
indicators to assess the ugly traction with the steel
wires.
Another point that should be considered is
the procedure’s low cost. While steel wires cost
approximately R$5.00, other similar dermatotraction
devices cost around US$500-1000, and negative
pressure dressings around US$96 a day10. Other
techniques to achieve skin gain through intraoperative
distension, described by Hirshowitz et al.16, Stough
et al.17, Lam et al.18, Bjarnesen et al.19 and others, require
specialized equipment for their execution, being the
former unavailable in most hospitals and being more
expensive7
.
Unlike tissue grafting, dermatotraction requires
a longer hospital stay, especially in large wounds. In
this case, dermatotraction was performed in a surgical
center under anesthetic blockade via spinal anesthesia
in all procedures; however, depending on the patient’s
pain tolerance, it could be performed at the bedside.
We believe this method is valid mainly for patients
needing to remain hospitalized for reasons other than
closing the fasciotomy, especially if we consider that
vacuum therapy cannot be performed at home in our
country due to its unavailability in the Public Health
System ( SUS). In cases where the early discharge of
the patient is possible, other methods, such as tissue
grafting, should be considered.
CONCLUSION
The work demonstrates yet another highly
valuable, safe, inexpensive, easily reproducible, and
low-morbid alternative to the arsenal of techniques
available to surgeons for closing fasciotomy and
complex extremity injuries, often requiring prolonged
hospitalization and difficult therapeutic management.
Figure 6. Representative scheme of dermatotraction of the skin with Kirschner wires.
Epidermis
Dermis
Subcutaneous Tissue
Muscle Layer
Subsequently, every 2 - 3 days, as well as
weekly, depending on the patient’s clinical status and
tolerability, the steel wires are pulled again until the
edges are ready for primary closure; the procedure can
be performed in the operating room under anesthesia
or intravenous sedation, or at the bedside with a
locoregional blockade, depending on the patient’s pain
tolerance.
During the traction of the evaluated case,
ischemic suffering of the skin or other intercurrences
were not evaluated, respecting the traction allowed
according to the elasticity of the skin presented at each
procedure.
A meta-analysis conducted by Jauregui et al.14
compared the various types of fasciotomy closure
described in the literature, including conservative
treatment (dressings only), partial skin grafts,
elastic suture, gradual approximation, dynamic
dermatotraction (with specific devices) and negative
pressure, with the success rate defined as wound
closure without the need for partial skin grafting.
Dynamic dermatotraction with specific devices (92.7%)
and gradual approximation techniques (92.4%) had
the highest success rates. On the other hand, negative
pressure dressings obtained the worst results, with
78.1% of success14.
Elastic suture, another inexpensive and easily
reproducible modality, can gradually close complex
wounds or fasciotomies. Raskin used it for the first
time in 1993 to approximate the borders of a postcompartment syndrome fasciotomy in an upper
limb15.
5 Rev. Bras. Cir. Plást. 2023;38(1):e0487
Filho AJT et al. www.rbcp.org.br
COLLABORATIONS
AJTF Conception and design study, Conceptualization,
Formal Analysis, Methodology, Project
Administration, Visualization, Writing - Original
Draft Preparation, Writing - Review & Editing
JLM Conception and design study, Methodology,
Writing - Original Draft Preparation, Writing -
Review & Editing
CMG Analysis and/or data interpretation, Final
manuscript approval, Project Administration,
Writing - Original Draft Preparation, Writing -
Review & Editing
BVD Writing - Original Draft Preparation, Writing -
Review & Editing
JPTB Conception and design study, Conceptualization,
Methodology, Supervision, Visualization,
Writing - Review & Editing
RSF Conceptualization, Formal Analysis, Project
Administration, Supervision, Validation,
Visualization, Writing - Review & Editing
suporte metálico externo: técnica alternativa na mediastinite
pós-esternotomia. Rev Bras Cir Cardiovasc. 2008;23(4):507-11.
6. Brasil. Ministério da Saúde [Internet]. DATASUS-Procedimentos
hospitalares do SUS por local de internação. Brasília:
Ministério da Saúde; 2019 [acesso 2019 Jul 11]. Disponível
em: http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sih/cnv/
qiuf.def
7. Góes CHFS, Kawasaki MC, Mélega JM. Fechamento de Feridas
por Tração Cutânea Intra-operatória. Análise de 23 Casos. Rev
Bras Cir Plást. 2004;19(2):69-74.
8. Bashir AH. Wound closure by skin traction: an application of
tissue expansion. Br J Plast Surg. 1987;40(6):582-7.
9. Callanan I, Macey A. Closure of fasciotomy wounds. A technical
modification. J Hand Surg Br. 1997;22(2):264-5.
10. Alex JC, Bhattacharyya TK, Smyrniotis G, O’Grady K, Konior
RJ, Toriumi DM. A histologic analysis of three-dimensional
versus two-dimensional tissue expansion in the porcine model.
Laryngoscope. 2001;111(1):36-43.
11. Molea G, Schonauer F, Blasi F. Progressive skin extension:
clinical and histological evaluation of a modified procedure
using Kirschner wires. Br J Plast Surg. 1999;52(3):205-8.
12. Wilhelmi BJ, Blackwell SJ, Mancoll JS, Phillips LG. Creep vs.
stretch: a review of the viscoelastic properties of skin. Ann Plast
Surg. 1998;41(2):215-9.
13. Zhou L, Guo S, Li Z. Experimental study of the architecture of
skin following tension traction and wound closure. Zhongguo
Xiu Fu Chong Jian Wai Ke Za Zhi. 1998;12(4):193-6.
14. Jauregui JJ, Yarmis SJ, Tsai J, Onuoha KO, Illical E, Paulino CB.
Fasciotomy closure techniques. J Orthop Surg (Hong Kong).
2017;25(1):2309499016684724.
15. Raskin KB. Acute vascular injuries of the upper extremity. Hand
Clin. 1993;9(1):115-30.
16. Hirshowitz B, Kaufman T, Ullman J. Reconstruction of the tip of
the nose and ala by load cycling of the nasal skin and harnessing
of extra skin. Plast Reconstr Surg. 1986;77(2):316-21.
17. Stough DB, Spencer DM, Schauder CS. New devices for scalp
reduction. Intraoperative and prolonged scalp extension.
Dermatol Surg. 1995;21(9):777-80.
18. Lam AC, Nguyen QH, Tahery DP, Cohen BH, Sasaki GH,
Moy RL. Decrease in skin-closing tension intraoperatively
with suture tension adjustment reel, balloon expansion, and
undermining. J Dermatol Surg Oncol. 1994;20(6):368-71.
19. Bjarnesen JP, Wester JU, Siemssen SS, Blomqvist G, Jensen NK.
External tissue stretching for closing skin defects in 22 patients.
Acta Orthop Scand. 1996;67(2):182-4.
Antoninho José Tonatto Filho
Rua Ubaldino do Amaral, 124/701, Bairro Alto da Gloria, Curitiba, PR, Brazil.
Zip code: 80060-190
E-mail: [email protected]
*Corresponding author:
REFERENCES
1. Ong YS, Levin LS. Lower limb salvage in trauma. Plast Reconstr
Surg. 2010;125(2):582-8.
2. Pelissier P, Boireau P, Martin D, Baudet J. Bone reconstruction
of the lower extremity: complications and outcomes. Plast
Reconstr Surg. 2003;111(7):2223-9.
3. Mathes SJ, Nahai F. Reconstructive Surgery. Principles,
Anatomy Technique. New York: Churchill Livingstone and
Qualit Medical Publishing; 1997.
4. Figueiredo JCA, Rosique RG, Maciel PJ. Tração cutânea
intraoperatória para fechamento de ferida após mastectomia
bilateral higiênica: relato de caso. Rev Bras Cir Plást.
2011;26(1):164-6.
5. Nina VJ, Assef MA, Rodrigues RR, Mendes VG, Lages JS,
Amorim AM, et al. Reconstrução da parede torácica com
1 Rev. Bras. Cir. Plást. 2023;38(1):e0659
Diagnosis, evolution, and treatment of a patient with
pyomyositis
Diagnóstico, evolução e tratamento de paciente com piomiosite
Pyomyositis is a deep muscle infection of bacterial origin and subacute, which
can evolve with multiple intramuscular abscesses. Despite being characterized
as an affection of tropical zones, its incidence in temperate zones has been
increasing due to immunosuppression factors, such as infection by the human
immunodeficiency virus (HIV) and some types of immunosuppressive treatments.
Even though it has been known for over a century, it is a rare and potentially
serious condition that can lead to septic shock and death. This is a case report
of a descriptive nature, which found the relevance of knowledge about this
condition for an early diagnosis, enabling positive prognostic repercussions.
Descritores: Piomiosite; Infecções estafilocócicas; COVID-19; Staphylococcus
aureus; Músculo esquelético.
DOI: 10.5935/2177-1235.2023RBCP0659-EN
Institution: Universidade Federal
do Triângulo Mineiro, Hospital de
Clínicas, Uberaba, MG, Brazil.
Article received: November 11, 2021.
Article accepted: September 13, 2022.
Conflicts of interest: none.
A piomiosite é uma infecção muscular profunda, de origem bacteriana e caráter
subagudo, que pode evoluir com abcessos intramusculares múltiplos. Apesar de ser
caracterizada como uma afecção de zonas tropicais, sua incidência em zonas temperadas
vem aumentando por fatores de imunossupressão, como a infecção pelo vírus da
imunodeficiência humana (HIV) e alguns tipos de tratamentos imunossupressivos.
Mesmo sendo conhecida há mais de um século, é uma condição rara e potencialmente
grave, podendo levar ao choque séptico e óbito. Trata-se de um relato de caso
de caráter descritivo, que constatou a relevância do conhecimento desta afecção
para um diagnóstico precoce, possibilitando repercussões prognósticas positivas.
■ ABSTRACT
■ RESUMO
Case Report
Keywords: Pyomyositis; Staphylococcal infections; COVID-19; Staphylococcus
aureus; Muscle, skeleton.
LARISSA FIGUEIREDO
VIEIRA1
*
GUSTAVO OLIVIERI
BARCELLOS1
CHRISTIAN TALES ELIAS1
MARCO TULIO RODRIGUES
DA CUNHA1
ISABELLA DA SILVA
IDELFONSO2
PEDRO AUGUSTO FÁVARO
AMARAL2
zones due to infection by the human immunodeficiency
virus (HIV) or by immunosuppressive treatments3
.
Mortality ranges from 1 to 23%4
.
Three stages are correlated in the clinical
manifestation of pyomyositis: the first stage, which
corresponds to bacterial invasion of the muscle, causing
signs and symptoms such as low-grade fever, anorexia,
localized pain, edema, contraction and limitation of muscle
mobility; the second stage corresponds to the suppurative
phase, in which there is the formation of abscesses with
exacerbation of phlogistic signs and high fever. Without
a diagnosis, the disease progresses to the septic phase
(third stage), with systemic dissemination of the infection5
.
INTRODUCTION
Pyomyositis is defined as a primary acute
bacterial infection of the skeletal muscles, with
Staphylococcus aureus as the main etiological agent.
Its pathogenesis is believed to be related to a previous
history of local trauma, with consequent transient
bacteremia and dissemination to large muscle groups,
predominantly in the lower limbs1
.
In epidemiological terms, the disease has a higher
prevalence in males, in the first two decades of life, with a
ratio of 1.5 men for each woman2
, and in tropical regions.
However, there is a growing number of cases in temperate
1
Universidade Federal do Triângulo Mineiro, Hospital de Clínicas, Cirurgia Plástica, Uberaba, Minas Gerais, Brazil.
2
Universidade Federal do Triângulo Mineiro, Medicina, Uberaba, Minas Gerais, Brazil.
Diagnosis, evolution, and treatment of pyomyositis
Rev. Bras. Cir. Plást. 2023;38(1):e0659 2
The diagnosis is basically established by imaging
tests, with magnetic resonance imaging being the most
sensitive method for analyzing muscle damage. In more
limited methods, such as X-rays, there is evidence
of soft tissue enlargement, and in ultrasonography,
hyperechogenicity is observed, indicative of edema
and muscle necrosis. Computed tomography shows
muscle edema and fluid collections. For etiological
diagnosis, blood cultures and/or cultures of drained
or aspirated material are performed5
. Clinically, the
diagnosis is difficult and delayed due to its nonspecific
signs, leading to potentially fatal consequences2
.
Treatment consists of antibiotic therapy in the first
stage or associated with a surgical approach in the following
stages, usually lasting about 3 to 6 weeks. Oxacillin is a
good option for S. aureus infection; however, the chosen
antibiotics may vary according to the culture result.
This article aims to conduct a clinical analysis of
the surgical approach adopted in a case of pyomyositis
in a 21-year-old patient admitted with pain and edema
in the lower limbs in a tertiary hospital in the interior of
Minas Gerais.
CASE REPORT
FJJE, 21 years old male, previously healthy,
denied the use of drugs or injectable medication,
admitted in February 2021 to the emergency room
of the Hospital de Clínicas of the Federal University
of Triângulo Mineiro, in Uberaba, with a clinical
picture of moderate, intermittent pain, in both lower
limbs, associated with swelling and fever for 3 days.
Patient with a history of strenuous physical activity
and trauma to the lower limbs during a soccer match
a week ago. He previously sought medical attention,
was treated with symptomatic drugs, and was released
to his home.
On physical examination, he presented a
decline in general condition, fever, difficulty walking,
and significant edema in the lower limbs, mainly on
the left side. There was local heat and stiffness on
palpation.
Doppler ultrasonography and magnetic resonance
imaging showed multiple abscesses in the thigh’s anterior
and posterior muscle groups and the gastrocnemius
muscle’s topography. No signs of deep venous thrombosis
were observed (Figure 1).
The patient was admitted to the care of the Internal
Medicine and Orthopedics teams. He required four
debridements in the operating room and used cultureguided intravenous antibiotic therapy that showed the
growth of methicillin-resistant Staphylococcus aureus
(MRSA) (Figure 2).
During the 15th day of hospitalization, the
patient underwent a rapid test for the COVID-19
virus, with a positive result. Fortunately, he evolved
with only mild respiratory symptoms. He remained in
respiratory isolation for 15 days and used symptomatic
drugs.
After releasing the respiratory isolation, the
lesions looked good, granulated, superficial, and
without infectious characteristics. Thus, the patient
was referred for definitive treatment by the Plastic
Surgery team (Figure 3).
Figure 1. Sagittal and axial sections of T2-weighted magnetic resonance imaging of the left thigh, showing muscle group affected by an inflammatory process
highlighted by the green arrow and normal muscles highlighted by the yellow arrow.
3 Rev. Bras. Cir. Plást. 2023;38(1):e0659
Vieira LF et al. www.rbcp.org.br
DISCUSSION
Epidemiological issues, such as origin, age and sex,
and the manifestation of reported signs and symptoms
corroborate the data shown in the literature; however, the
patient in question did not present immunosuppression
factors prior to the event or known history of drug use
or injectable medication, unlike the observed series6-9.
The main impasses of pyomyositis include its
rarity and clinical diagnostic difficulty, which result in
late and often ineffective treatments.
The differential diagnosis includes costochondritis,
osteomyelitis, thrombophlebitis, and deep vein thrombosis4
.
The gold standard imaging test is magnetic resonance
imaging, which allows the detection of fluid collections and
muscle edema more accurately.
The treatment and the need for a surgical
approach are analyzed according to the culture results
and the stage of the disease. In this case, multiple
purulent collections and extensive lesions made serial
surgical intervention and subsequent reconstruction
with a partial skin graft imperative.
CONCLUSION
Concerning the diagnosis of uncommon diseases,
in the clinical practice of plastic surgeons, diagnostic
suspicion is only possible when there is prior knowledge
of the condition. That said, the importance of familiarizing
the professional with pyomyositis should be emphasized,
since early diagnosis and correct treatment, used promptly,
greatly alter the patient’s prognosis. Furthermore, on the
other hand, the delay in diagnosis can lead to disastrous
consequences, with injuries of high morbidity to the
patient, which may even culminate in the death of the
patient whose diagnosis was inadvertently neglected.
Therefore, specific imaging tests must be
promptly requested because of the suspicion of this
disease. A multidisciplinary team, acting coordinated,
must manage the case so that the correct diagnosis
allows for early treatment and a favorable evolution.
Figure 2. A - Aspect of the wounds after the fourth debridement in the operating
room. B - Posterior region of the right lower limb. C - Wound in the left thigh.
Figure 3. Wounds with a granulated bed and without signs of infection.
Figure 4. Aspect of the wounds in the late postoperative period. There was
complete motor rehabilitation.
COLLABORATIONS
LFV Final manuscript approval, Writing - Original
Draft Preparation, Writing - Review & Editing
GOB Final manuscript approval, Writing - Review &
Editing
CTE Final manuscript approval, Writing - Original
Draft Preparation
MTRC Supervision
ISI Data Curation, Writing - Original Draft Preparation
PAFA Data Curation, Writing - Original Draft Preparation
It was decided to perform a partial skin graft
removed with an electric dermatome, using intact
areas in the lower limbs as donors and performing a
non-adherent occlusive dressing.
The patient had excellent graft integration and
was discharged one week after surgery, with outpatient
follow-up by the Plastic Surgery and Physiotherapy
teams. Late postoperative follow-up showed complete
motor rehabilitation (Figure 4).
Diagnosis, evolution, and treatment of pyomyositis
Rev. Bras. Cir. Plást. 2023;38(1):e0659 4
REFERENCES
1. Barros AAG, Soares CBG, Temponi EF, Barbosa VAK, Teixeira
LEM, Grammatopoulos G. Piomiosite do piriforme em um
paciente com doença de Kikuchi-Fujimoto - relato de caso e
revisão da literatura. Rev Bras Ortop. 2019;54(2):214-8.
2. Shittu A, Deinhardt-Emmer S, Vas Nunes J, Niemann S,
Grobusch MP, Schaumburg F. Tropical pyomyositis: an update.
Trop Med Int Health. 2020;25(6):660-5.
3. Siqueira GS, Siqueira CMVM. Piomiosite tropical. Rev Col Bras
Cir. 1998;25(3):205-7.
4. Ngor C, Hall L, Dean JA, Gilks CF. Factors associated with
pyomyositis: A systematic review and meta-analysis. Trop Med
Int Health. 2021;26(10):1210-9.
5. Gonçalves AO, Fernandes NC. Piomiosite tropical. An Bras
Dermatol. 2005;80(4):413-4.
6. Konnur N, Boris JD, Nield LS, Ogershok P. Non-tropical
pyomyositis in pediatric and adult patients. W V Med J.
2007;103(4):22-3.
7. Martínez-de Jesus FR, Mendiola-Segura I. Clinical stage, age
and treatment in tropical pyomyositis: a retrospective study
including forty cases. Arch Med Res. 1996;27(2):165-70.
8. Yu CW, Hsiao JK, Hsu CY, Shih TT. Bacterial pyomyositis: MRI
and clinical correlation. Magn Reson Imaging. 2004;22(9):1233-41.
9. Sadarangani S, Jibawi S, Flynn T, Melgar TA. Primary
pyomyositis: experience over 9 years in temperate Michigan.
Infect Dis Clin Pract. 2013;21(2):114-22.
Larissa Figueiredo Vieira
Rua Vigário Silva, 695/804, Bairro Bom Retiro, Uberaba, MG, Brazil.
Zip code: 38022-190
E-mail: [email protected]
*Corresponding author:
1 Rev. Bras. Cir. Plást. 2023;38(1):e0642
Ear shut and Dentistry: ethical and legal approach
Ear shut e Odontologia: abordagem ética e legal
Introdução: Como ciência da saúde, a Odontologia busca elevar a autoestima
e melhorar a qualidade de vida dos pacientes. Entretanto, o surgimento
do procedimento estético “ear shut”, que propõe a correção da orelha
em abano sem cirurgia, gerou dúvidas de ordem ética e legal na classe
odontológica, sobretudo no que diz respeito aos limites de atuação profissional.
Objetivo: Realizar o levantamento das leis, normativas e resoluções sobre a
área de atuação dos cirurgiões-dentistas, bem como discutir os limites e as
consequências de sua extrapolação sob a perspectiva do procedimento propagado
como “ear shut”. Método: Foi realizada uma busca de normas administrativas
nos sites do Conselho Federal de Odontologia (CFO) e do Conselho Federal
de Medicina, bem como de dispositivos legais no site Portal da Legislação.
Resultados: Em âmbito cível, a divulgação de procedimentos como o “ear shut”
pode caracterizar promessa de resultado e levar à responsabilização judicial.
Introduction: As a health science, dentistry seeks to raise self-esteem and improve
patients’ quality of life. However, the emergence of the aesthetic procedure “ear shut,”
which proposes correcting protruding ears without surgery, has raised ethical and
legal doubts in the dental profession, especially concerning the limits of professional
activity. Objective: To conduct a survey of the laws, norms, and resolutions on the area
of performance of dental surgeons, as well as to discuss the limits and consequences
of their extrapolation from the perspective of the procedure propagated as “ear shut.”
Method: A search was carried out for administrative norms on the Federal Council of
Dentistry (CFO) websites and the Federal Council of Medicine and legal provisions
on the Portal da Legislação website. Results: In the civil sphere, the disclosure of
procedures such as the “ear shut” can characterize a promise of result and lead
to judicial accountability. Exceeding professional boundaries constitutes an illegal
exercise and a crime under the Brazilian Penal Code. In addition to not covering
the area of clinical practice of dentists, at the administrative level, CFO Resolutions
No. 198/2019 and No. 230/2020 emphasize that ear procedures are not part of the
scope of procedures relevant to Dentistry and may lead to ethical infractions and
consequent administrative proceedings. Conclusion: At present, based on the skills,
prohibitions, rights, and duties of dentists, it can be stated that performing the “ear
shut” by these professionals confronts civil, criminal, and administrative obligations.
■ ABSTRACT
■ RESUMO
PAULO HENRIQUE VIANA
PINTO1
JULIANE BUSTAMANTE SÁ
DOS SANTOS1
ANTÔNIO
CASTELO-BRANCO2
CINDY MAKI SATO1
MARCONI DELMIRO NEVES
DA SILVA3
RICARDO HENRIQUE ALVES
DA SILVA4
*
1
Universidade de São Paulo. Faculdade de Medicina de Ribeirão Preto, Departamento de Patologia e Medicina Legal, Ribeirão Preto, São
Paulo, Brazil.
2
Universidade de São Paulo. Faculdade de Odontologia de Ribeirão Preto, Departamento de Odontologia Restauradora, Ribeirão Preto,
São Paulo, Brazil.
3
Universidade Federal da Paraíba, Hospital Regional da Asa Norte, Brasília, Distrito Federal, Brazil.
4
Universidade de São Paulo. Faculdade de Odontologia de Ribeirão Preto, Departamento de Estomatologia, Saúde Coletiva e Odontologia
Legal, Ribeirão Preto, São Paulo, Brazil.
DOI: 10.5935/2177-1235.2023RBCP0642-EN
Institution: Universidade
de São Paulo, Faculdade de
Odontologia de Ribeirão Preto,
Ribeirão Preto, SP, Brazil.
Article received: October 7, 2021.
Article accepted: April 7, 2022.
Conflicts of interest: none.
Special Article
Keywords: Ear; Ear, external; Surgery, plastic; Dentistry; Reconstructive surgical
procedures; Ethics, dental; Forensic dentistry; Legislation, dental.
Ear shut and Dentistry: ethical and legal approach
Rev. Bras. Cir. Plást. 2023;38(1):e0642 2
in the head and neck region, which genetic factors,
environmental influences during development,
and auricular migration in the second trimester of
pregnancy4,5 can cause.
It is characterized by anterior prominence of
the ear, usually bilaterally, and although it does not
cause functional changes, it can affect the self-esteem
of individuals, the main reason for seeking corrective
surgeries, as it can generate psychosocial impacts,
especially in childhood and adolescence, when the
ridicule of physical characteristics tends to have a
negative influence, causing stress, anxiety, and difficulty
in social integration6
.
The ear is formed by anatomical regions directly
related to the diagnosis of prominauris (Figure 1). Thus,
there are three most frequent causes of protruding ears:
underdevelopment of the antihelix, which will increase
the scaphoconchal angle; prominence of the concha,
which will increase the auriculocephalic angle; and
lobe protrusion, and there may also be an association
between these causes7
.
INTRODUCTION
Dentistry is a health science that aims to raise
self-esteem and improve the patient’s quality of life.
These results can be achieved due to the healthy and
aesthetic-functional nature of certain dental procedures1
.
However, the search for procedures on the face with an
aesthetic purpose has become commonplace, which
results in moral, ethical, and legal dilemmas concerning
the area of work of dentists.
In this way, limits of professional performance
between different professions in the health area, such as
Medicine and Dentistry, have been the subject of debates
and even lawsuits when both professions do not reach an
administrative pact mediated by the councils of class. Thus,
contestations with this approach have already occurred,
as is the case of the removal of the adipose body from
the cheek (bichectomy) by dentists, who must perform
it exclusively for aesthetic and functional purposes2
.
However, the emergence of new clinical procedures
in different regions of the face raises doubts and debates
about the limits of the dentists’ area of expertise.
This area fits the intervention in the ear called “ear shut,”
a procedure disclosed by the dental class that promises
the correction of protruding ears without surgery3
.
OBJECTIVE
To survey the laws, regulations, and resolutions
incumbent on the area of surgeon dentists, as well
as to discuss the limits and consequences of their
extrapolation from the perspective of the procedure
propagated as “ear shut.”
CORRECTIVE PROCEDURES FOR
PROTRUDING EAR IN MEDICINE AND
DENTISTRY
Prominauris, popularly known as protruding
ear, is one of the most common congenital anomalies
Ultrapassar os limites profissionais constitui exercício ilícito e constitui crime
segundo o Código Penal Brasileiro. Além de não abranger a área de atuação
clínica dos cirurgiões-dentistas, no âmbito administrativo, as Resoluções do
CFO N° 198/2019 e N° 230/2020 enfatizam que procedimentos na orelha não
compõem o escopo de procedimentos pertinentes à Odontologia, podendo
levar a infrações éticas e consequente processo administrativo. Conclusão: No
momento atual, com base nas competências, vedações, direitos e deveres dos
cirurgiões-dentistas, pode-se afirmar que a realização do “ear shut” por estes
profissionais confronta obrigações de ordem cível, penal e administrativa.
Descritores: Orelha; Orelha externa; Cirurgia plástica; Odontologia; Procedimentos
cirúrgicos reconstrutivos; Ética odontológica; Odontologia legal; Legislação
odontológica.
Figure 1. Anatomical regions of the ear in frontal (on the left) and posterior
(on the right) norms.
3 Rev. Bras. Cir. Plást. 2023;38(1):e0642
Pinto PHV et al. www.rbcp.org.br
The auriculocephalic angle generally measures
between 25° and 30°; and can reach more than 40° of
angulation. The scaphoconchal angle, of approximately
90°, can reach values greater than 150° of angle8,9.
That said, performing procedures in the ear region
requires comprehensive knowledge of its anatomy,
encompassing superficial and deep anatomy, innervation,
vascularization, embryonic origin, and formation6
.
In this context, otoplasty – plastic surgery of the
ears - encompasses several techniques for correcting the
prominauris, and the choice of the appropriate technique
depends on the analysis of several factors. Therefore,
the intervention aimed at the aesthetic correction of this
condition must be planned individually, and it is also
possible to associate techniques to obtain better results8
.
In addition, the use of surgical techniques should
consider the age at which the development of the ear
is completed, which occurs at around 6 years of age,
so that from then on, a surgical procedure to correct
protruding ears can be performed, being this procedure
is performed under general anesthesia or sedation and
local anesthesia, depending on the patient’s age and
level of compliance9
.
As for the surgical techniques themselves, they
vary according to their invasiveness, tissue detachment,
and incisions in strategic cartilage areas, with sutures
that will allow the creation of a new curvature9
. On the
other hand, less invasive techniques allow access to the
cartilage through small incisions to create weakening
zones in the cartilage, where remodeling will occur8
.
Although no gold standard technique exists, all have
advantages and disadvantages, converging on the same
aesthetic goal10.
Closed otoplasty consists of a minimally invasive
approach, which, based on the infiltration and
transcutaneous fixation of non-absorbable sutures,
proposes the treatment of protruding ears. The main
intercurrences of the technique are the development
of edema, ecchymosis, recurrence, exposure of points,
and asymmetry between the ears11.
Currently, in Dentistry, procedures related to the
correction of protruding ears have emerged as a novelty
in the market, promising their execution without the
need for cuts, using only the suture, with transcutaneous
stitches. This procedure, which became known as “ear
shut,” has been marketed as an innovative, fast, effective
technique that does not leave scars3
.
The “ear shut” technique reproduces the steps of
closed otoplasty, and no works in the literature directly
approach the subject with this nomenclature. Despite
the promise of results, Janis et al. (2005)12 state that nonsurgical techniques for the correction of prominent ears
demonstrated, until that time, unsatisfactory results in
most cases.
“EAR SHUT, “ TO DO OR NOT TO DO?
LEGISLATIVE APPROACH
Properly and diligently caring for the health of
their patients is the duty of every dentist13. Abusive
and harmful conduct that infringes this right is
described in different Brazilian legal norms14.
Furthermore, in this sense, the professional practice
of Dentistry must be practiced with a high degree
of zeal and with reliable scientific bases; in such a
way, dentists must know the procedures in depth, in
addition to practicing them in the right measure for
each patient and their clinical condition15.
The World Health Organization defines health
as a state of complete physical, mental, and social
well-being, and not just as the absence of disease
or infirmity16. In this way, the prevention, recovery,
and conservation of oral health is a basic function
of Dentistry, maintaining the integrity and proper
functionality of the stomatognathic system, restoring
health, or even preventing the worsening of certain
problems.
Dentists should not overlook moral, ethical,
and legal issues during the execution of any dental
treatment or procedure since, in addition to the
clinical act, this also covers the professional-patient
relationship in all its minutiae17. In addition to
theoretical knowledge and clinical skills, professionals
must be well informed about their civil, criminal,
ethical, and administrative obligations, to which
everyone is subject in this intimate relationship with
their patients18.
Article 5 of the Federal Constitution enacted
in 1988, item XIII establishes the right to freedom
of work or freedom to exercise any trade or
profession, which can be defined as the sovereignty
of the human being to perform any work activity
professionally, provided that they are met professional
qualifications established by law. As the literalness
of the constitutional provision suggests, there is the
possibility that, through the law, certain restrictions
may be imposed on the exercise of any professional
activity19.
Already in item XXXIII of the same article,
consumer protection is found as a constitutional
guarantee by stating that: “The State shall promote,
as provided by law, consumer protection.” To ensure
the importance of health under the focus of the
Federal Constitution, article 6 also establishes health
as one of the fundamental rights, inserted in the title
destined to the social order, which aims at well-being
and social justice. Based on this assessment, the
State began to formulate social and economic policies
aimed at the specific protection of health19.
Ear shut and Dentistry: ethical and legal approach
Rev. Bras. Cir. Plást. 2023;38(1):e0642 4
With the enactment of the Federal Constitution
and in the wake of its articles, the Consumer Defense
Code was published, which covers the whole of
society as a collective of undetermined persons, in
all their relations, being intended for the defense
of the person who acquires or uses product or
service, materializing a consumption relationship. In
particular, article 2 defines the consumer as “every
natural or legal person who acquires or uses a product
or service with a final recipient.” In this vein, any user
of dental services is a consumer to whom a service
is provided, with a provider being the professional
who develops his activity for remuneration. Thus,
it is emphasized that the dental surgeon is a liberal
profession, and the relationship with his patient is
consumerist nature20.
Preliminarily, it has to be pointed out that the
patient will have the last word about his own health. If it
is not an emergency, only the doctor can decide whether
or not to implement a certain treatment, weighing
risks and benefits. On this reasoning, article 94 of the
Brazilian Civil Code states that, in bilateral acts, the
intentional silence of one of the parties regarding a
fact or quality that the other party has ignored will
constitute a willful omission, showing that without it,
it would not have been celebrated the contract. Thus,
in understandable language, the patient must be
previously and duly clarified about his illness, the limits
of the indicated treatment, side effects, and possible
complications21.
Focusing on the legal nature of civil liability, the
Brazilian Civil Code, Law No. 10,406, of January 10, 2002,
in articles 186, 187, 927, 949, 950, and 951, establishes
that the professional must have the corresponding
academic training to the science and ethics of the
profession he embraced, exercising it within high
scientific standards, with prudence and expertise.
Regular and recognized academies and institutions
must accept such training. It is never too much to
emphasize that such articles have repercussions on
negligence, imprudence, or malpractice21.
When evaluating the criminal liability of dental
surgeons in professional practice, under the light of
the Brazilian Penal Code, Decree-Law No. 2,848 of
December 7, 1940, it should be emphasized that this
action is invasive par excellence, as it handles a sharp
instrument, blunt and cut blunt; which may cause
various injuries and which may lead to a complaint of
a violation of article 129 and its sixth paragraph22:
“Decree-Law No. 2.848, of December 7,
1940. Penal Code
Chapter II
Bodily injuries
Bodily injuries
Art. 129. Offending the bodily integrity or
health of others:
Penalty - detention, from three months to one
year. (...) Culpable bodily injury
§ 6 If the injury is culpable:
Penalty - detention, from two months to one
year. (...)”
In its article 132, the Penal Code is transparent
in explaining that the exposure of the life or health of
another to imminent danger may lead to the penalty
of detention, from three months to one year, if the
fact does not constitute a more serious crime. This
citation characterizes the crime of endangering life
and health. It is imagined when considering that
the dental surgeon will act without malicious intent
based on his good faith. With this principle in mind, a
criminal conviction will arise when the professional’s
guilt is demonstrated in his clinical practice. In this
reasoning, malpractice, imprudence, or negligence on
the part of the professional should be characterized
since these are the elements that characterize guilt,
and as a result, an injury was produced during or as a
result of their work22.
The same legal norm reinforces in article 282 that
illicit professional activity is foreseen and discusses
that exercising, even if free of charge, the profession
of doctor, dentist, or pharmacist, without due legal
authorization or exceeding its limits, is subject to a
penalty of detention, from six months to two years22.
The lack of the appropriate title and the respective legal
records characterizes failure to comply with the legal
authorization. As for the excess of limits mentioned
in the article’s writing, it is defined when the crime
is committed by one of the professionals referred to,
performing typical acts of the profession in another
field of knowledge23.
“EAR SHUT” IN DENTISTRY: CURRENT
ADMINISTRATIVE STANDARDS
In Brazil, Dentistry is regulated by Law No.
5081 of August 24, 1966, which dictates dentists’
qualifications, skills, and prohibitions. In article 6,
item I, the law mentioned above states that it is the
responsibility of dentists to practice all acts relevant
to Dentistry, whether the knowledge is acquired at the
undergraduate or postgraduate level. However, the
Law does not detail dentists’ areas of expertise, with a
description of procedures or anatomical delimitations24.
In this sense, in an attempt to resolve such doubts,
Resolution No. 176/2016, published by the Federal Council of
Dentistry (CFO), in paragraph 1, discussed the use of botulinum
toxin in anatomical areas of clinical-surgical performance.
5 Rev. Bras. Cir. Plást. 2023;38(1):e0642
Pinto PHV et al. www.rbcp.org.br
These limits consist of the upper portion of the hyoid
bone, the lower portion of the nasal bones (nasion
point), and, laterally, the anterior portion of the tragus,
encompassing what was described in the regulation
above as annex structures and the like. When in the
condition of non-surgical procedures, the upper third
of the face is also included, from the nasion point to
the hairline. However, the anatomical delimitation
presented in this standard defines that the posterior
part of the tragus is not an area of activity for dental
surgeons, in a way that it is not up to this professional to
perform any procedure for the treatment of protruding
ears, whether surgical or not (Figure 2)25.
Following CFO Resolution No. 198/2019,
orofacial harmonization was recognized as a dental
specialty, including botulinum toxin, facial fillers,
percutaneous collagen-inducing biomaterials, etc.
intradermotherapy, biophotonic procedures, laser
therapy, lipoplasty, bichectomy, and liplifting. It can
be seen in this agenda that no procedure is included
to intervene in the ears26.
Thus, to standardize, establish criteria and
clarify the limits of dentists’ activities, the CFO
issued Resolution No. 230/2020, which prohibits the
performance of certain procedures in anatomical areas
of the head and neck, listing, among these, otoplasty.
In addition, the same norm prohibits the publicity and
publicity of non-dental procedures unrelated to higher
education in Dentistry21,27.
In addition to the anatomical region, as it has
a strictly aesthetic nature, the “ear shut” procedure
directly affronts Resolution CFONº 63/2005, which
in its article 48 provides for cosmetic surgery to
be performed only by the medical class, with the
exception to those of an aesthetic-functionality
of the stomatognathic apparatus29. Moreover, at
this point, it is important to note that the Federal
Council of Medicine issued Resolution No. 2,272
of 2020, which states, in its 1st article, that it is the
exclusive competence of the physician “the practice
of surgery and procedures with aesthetic and/or
functional, with the exception, not exclusively, of
restorative surgery and with an aesthetic-functional
purpose of the stomatognathic apparatus”30, that
is, indicating an interface of action with Dentistry,
but in the case of the “ear shut” procedure, there is
Figure 2. Anatomical delimitation of the area of work of dentists according to Resolution No. 176/2016 of the Federal Council of Dentistry.
Ear shut and Dentistry: ethical and legal approach
Rev. Bras. Cir. Plást. 2023;38(1):e0642 6
no understanding in this norm of performance by a
dental surgeon.
FINAL CONSIDERATIONS
For all the above, considering the laws and
regulations in force at present, it is possible to observe that
the performance of the “ear shut” procedure by dentists,
due to the anatomical location of the ear, confronts the
current administrative norms of Dentistry itself, the which
can generate ethical accountability before the Regional
Council of Dentistry. Concerning the legality of the
technique, due to the aesthetic purpose of the procedure,
the professional can be held criminally responsible for
practicing medicine illegally. Additionally, even from a
legal point of view, how the technique has been publicized
may support judicial liability in the civil sphere since
the patient may feel aggrieved when realizing that
his expectations were not met, as well as insufficient
information about the procedure and who performs it.
REFERENCES
5. Lin J, Sclafani AP. Otoplasty for Congenital Auricular
Malformations. Facial Plast Surg Clin North Am. 2018;26(1):31-
40. DOI: http://dx.doi.org/10.1016/j.fsc.2017.09.003
6. Schneider AL, Sidle DM. Cosmetic Otoplasty. Facial Plast Surg
Clin North Am. 2018;26(1):19-29. DOI: http://dx.doi.org/10.1016/j.
fsc.2017.09.004
7. Thorne CH, Beasley RW, Aston SJ, Bartlett SP, Gurtner GC,
Spear SL. Grabb & Smith: Cirurgia Plástica. 6ª ed. Rio de
Janeiro: Guanabara Koogan; 2009. p. 290-304.
8. Almeida ARH, Isobe LRC, Pinto MSD, Mafra AVC. Tratamento
da orelha em abano, novas e simples táticas. Rev Bras Cir
Plást. 2017;32(2):190-3. DOI: http://dx.doi.org/10.5935/2177-
1235.2017rbcp0030
9. Goulart FO, Arruda DSV, Karner BM, Gomes PL, Carreirão
S. Correção da orelha de abano pela técnica de incisão
cartilaginosa, definição da antélice com pontos de Mustardé e
fixação da cartilagem conchal na mastoide. Rev Bras Cir Plást.
2011;26(4):602-7.
10. Kang NV, Sabbagh W, O’Toole G, Silberberg M. Earfold: A
New Technique for Correction of the Shape of the Antihelix.
Laryngoscope. 2018;128(10):2282-90. DOI: http://dx.doi.
org/10.1002/lary.27197
11. Rezende AM, Rezende AM, Rezende ASM, D’Andrea EB, Rauen
HF. Tratamento fechado da orelha em abano. Rev Bras Cir Plást.
2013;28(3 Suppl.1):33.
12. Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr
Surg. 2005;115(4):60e-72e. DOI: http://dx.doi.org/10.1097/01.
prs.0000156218.93855.c9
13. Orestes-Cardoso S, Melo MVS, Orestes-Carneiro R. Representação
de valores morais para o exercício profissional em estudantes
de odontologia. Rev Bioét. 2015;23(1):178-86. DOI: http://dx.doi.
org/10.1590/1983-80422015231058
14. Bitencourt CR. Código Penal Comentado. 9ª ed. São Paulo:
Saraiva; 2017.
15. Garrafa V, Costa SIF, Oselka G. A Bioética no século XXI. Rev
Bioét. 1999;7(2):207-12.
16. Bradley KL, Goetz T, Viswanathan S. Toward a Contemporary
Definition of Health. Mil Med. 2018;183(Suppl 3):204-7. DOI:
http://dx.doi.org/10.1093/milmed/usy213
17. Galindo GC. Bioética para odontólogos. Univ Odontol.
2005;25(6):41-4.
18. Amorim AG, Souza ECF. Problemas éticos vivenciados por
dentistas: dialogando com a bioética para ampliar o olhar sobre o
cotidiano da prática profissional. Cienc Saude Colet. 2010;15(3):869-
78. DOI: http://dx.doi.org/10.1590/s1413-81232010000300030
19. Brasil. Constituição da República Federativa do Brasil de 1988.
Emendas Constitucionais de Revisão. Brasília: Diário Oficial
da União; 1988 [acesso 2021 Set 3]. Disponível em: http://www.
planalto.gov.br/ccivil_03/constituicao/constituicao.htm
20. Brasil. Lei Nº 8.078, de 11 de setembro de 1990. Código de
Defesa do Consumidor. Dispõe sobre a proteção do consumidor
e dá outras providências. Brasília: Diário Oficial da União; 1990
[acesso 2021 Set 3]. Disponível em: http://www.planalto.gov.br/
ccivil_03/leis/l8078compilado.htm
21. Brasil. Lei Nº 10.406, de 10 de janeiro de 2002. Institui o Código
Civil. Brasília: Diário Oficial da União; 2002 [acesso 2021 Set 3].
Disponível em: http://www.planalto.gov.br/ccivil_03/leis/2002/
L10406compilada.htm
22. Brasil. Decreto-Lei Nº 2.848, de 7 de dezembro de 1940. Código
Penal Brasileiro. Brasília: Diário Oficial da União; 1940 [acesso
2021 Set 6]. Disponível em: http://www.planalto.gov.br/ccivil_03/
decreto-lei/del2848.htm
23. Greco R. Curso de Direito Penal - Parte Especial (arts. 250 a
361). Volume IV. 13ª ed. Niterói: Impetus; 2011.
24. Brasil. Lei Nº 5.081, de 24 de agosto de 1966. Regula o exercício da
Odontologia. Brasília: Diário Oficial da União; 1966 [acesso 2021 Ago
27]. Disponível em: http://www.planalto.gov.br/ccivil_03/leis/l5081.htm
COLLABORATIONS
PHVP Conception and design study, Writing -
Original Draft Preparation, Writing - Review
& Editing
JBSS Writing - Original Draft Preparation, Writing -
Review & Editing
ACB Writing - Original Draft Preparation, Writing -
Review & Editing
CMS Writing - Original Draft Preparation, Writing -
Review & Editing
MDNS Writing - Original Draft Preparation, Writing -
Review & Editing
RHAS Conception and design study, Final manuscript
approval, Writing - Review & Editing
1. Spanemberg JC, Cardoso JA, Slob EMGB, López-López J.
Quality of life related to oral health and its impact in adults. J
Stomatol Oral Maxillofac Surg. 2019;120(3):234-9. DOI: http://
dx.doi.org/10.1016/j.jormas.2019.02.004
2. Jacometti V, Coltri MV, Santos TS, Silva RHA. Bichectomy
procedure: a discussion on the ethical and legal aspects in
odontology. Rev Bras Cir Plást. 2017;32(4):616-23. DOI: http://
dx.doi.org/10.5935/2177-1235.2017rbcp0100
3. Ear Shut – Saiba Tudo Sobre A “Otoplastia Fechada” [Internet].
[acesso 2021 Set 6]. Disponível em: https://projetoorelhinha.com.
br/ear-shut-saiba-tudo-sobre-a-otoplastia-fechada/
4. Siegert R, Magritz R. Otoplasty and Auricular Reconstruction.
Facial Plast Surg. 2019;35(04):377-86. DOI: http://dx.doi.
org/10.1055/s-0039-1693745
7 Rev. Bras. Cir. Plást. 2023;38(1):e0642
Pinto PHV et al. www.rbcp.org.br
Ricardo Henrique Alves da Silva
USP – Faculdade de Odontologia de Ribeirão Preto. Área de Odontologia Legal. Av. do Café, s/n, Bairro
Monte Alegre, Ribeirão Preto, SP, Brazil.
Zip Code: 14040-904
E-mail: [email protected]
*Corresponding author:
25. Brasil. Conselho Federal de Odontologia. Resolução CFO
Nº 176, de 06 de setembro de 2016. Revoga as Resoluções
CFO-112/2011, 145/2014 e 146/2014, referentes à utilização da
toxina botulínica e preenchedores faciais, e aprova outra em
substituição. Brasília: Conselho Federal de Odontologia; 2016
[acesso 2021 Set 6]. Disponível em: https://transparencia.cfo.org.
br/ato-normativo/?id=2331
26. Brasil. Conselho Federal de Odontologia. Resolução CFO Nº 198,
de 29 de janeiro de 2019. Reconhece a Harmonização Orofacial
como especialidade odontológica, e dá outras providências.
Brasília: Conselho Federal de Odontologia; 2019 [acesso 2021
Set 6]. Disponível em: https://transparencia.cfo.org.br/atonormativo/?id=2918
27. Brasil. Conselho Federal de Odontologia. Resolução CFO Nº 230,
de 14 de agosto de 2020. Regulamenta o artigo 3º, da Resolução
CFO-198/2019. Brasília: Conselho Federal de Odontologia; 2020
[acesso 2021 Set 6]. Disponível em: https://transparencia.cfo.org.
br/ato- normativo/?id=3327
28. Brasil. Conselho Federal de Odontologia. Resolução CFO Nº 237, de
14 de maio de 2021. Autoriza e regulamenta a suspensão cautelar de
cirurgião-dentista cuja ação, decorrente do exercício profissional,
coloque em risco a saúde e/ou a integridade física dos pacientes,
ou que esteja na iminência de fazê-lo. Brasília: Conselho Federal
de Odontologia; 2021 [acesso 2021 Set 6]. Disponível em: https://
transparencia.cfo.org.br/ato- normativo/?id=3455
29. Brasil. Conselho Federal de Odontologia. Resolução CFO Nº
63, de 08 de abril de 2005. Aprova a Consolidação das Normas
para Procedimentos nos Conselhos de Odontologia. Brasília:
Conselho Federal de Odontologia; 2005 [acesso 2021 Set 6].
Disponível em: https://sistemas.cfo.org.br/visualizar/atos/
RESOLU%c3%87%c3%83O/SEC/200 5/63
30. Brasil. Conselho Federal de Medicina. Resolução CFM Nº
2.272/2020, de 14 de fevereiro de 2020. Revoga a Resolução CFM
Nº 1.950/2010, publicada no DOU de 7 de julho de 2010, seção
I, p.132, e estabelece critérios quanto à atuação de médicos na
área craniomaxilofacial, à luz da Lei Nº 12.842, de 10 de julho
de 2013. Brasília: Conselho Federal de Medicina; 2020 [acesso
2021 Set 6]. Disponível em: https://sistemas.cfm.org.br/normas/
visualizar/resolucoes/BR/2020/2272
1 Rev. Bras. Cir. Plást. 2023;38(1):e0753
Letter to the Editor
Complications of orofacial harmonization
Complicações da harmonização orofacial
IRINEU GREGNANIN
PEDRON1
*
RAFAELA RODRIGUES
CAVALCANTI1
1
Instituto Bottoxindent, São Paulo, SP, Brazil.
DOI: 10.5935/2177-1235.2023RBCP0753-EN
Institution: Instituto Bottoxindent,
São Paulo, SP, Brazil.
Article received: August 23, 2022.
Article accepted: September 13, 2022.
Conflicts of interest: none.
We read, with great enthusiasm, the article ‘’Complications in orofacial
harmonization procedures: a systematic review’’ by Manganaro et al. (2022)1
,
published in issue 37(2) of the Brazilian Journal of Plastic Surgery. The
manuscript was very well prepared, and we congratulate the authors. However,
we consider it important to highlight some reflections:
Regarding facial fillers, the material of choice is hyaluronic acid.
Unfortunately, complications arising from using hyaluronic acid have been
occurring, mainly due to the performance of non-medical health professionals.
The dental surgeon and co-author of this letter (RRC) considered the hyaluronic
acid application in her nose by another dental surgeon for aesthetic purposes.
In a few days, the immediate ischemia evolved into necrosis, causing deformity
caused by scar retraction (Figure 1A). Seven surgical repair procedures have
already been performed by Plastic Surgery without, however, achieving the
expected results2
(Figure 1B).
Our study group has been presenting on possible complications of
other orofacial harmonization procedures performed by dental surgeons3-5.
In addition to the possible complications, we have warned about the
judicialization of these complications at the ethical-administrative level and the
civil, consumer, and criminal actions involved in these situations6
. Considering
the possible complications arising from these procedures, which are mostly
treated by Plastic Surgery, we, the authors of this Letter to the Editor, are
against the performance of orofacial harmonization by dental surgeons.
Figure 1. A: Nasal necrosis after 6 days of hyaluronic acid application; B:
Current appearance, after the 7th reparative plastic surgery.
A B
Complications of orofacial harmonization
Rev. Bras. Cir. Plást. 2023;38(1):e0753 2
COLLABORATIONS
IGP Conception and design study, Conceptualization,
Final manuscript approval, Investigation, Methodology,
Supervision, Visualization, Writing - Original Draft
Preparation, Writing - Review & Editing.
RRC Conceptualization, Investigation, Writing -
Original Draft Preparation, Writing - Review &
Editing.
Irineu Gregnanin Pedron
Rua Flores do Piauí, 508, São Paulo, SP, Brazil
Zip code: 08210-200
E-mail: [email protected]
*Corresponding author:
Reply
As requested by the Revista Brasileira de Cirurgia Plástica, this Letter to the
Editor aims, in these short lines, to contribute to the topic for technical and scientific
development in aesthetic procedures.
Currently, as is well known, dissatisfaction with self-image and the search for
rejuvenation motivate the search for facial aesthetic procedures, especially those
less invasive that normally allow a quick recovery after the procedure and visibility
of results. Among these, as presented in Letter to the Editor authored by Pedron &
Cavalvanti, are facial fillers, with hyaluronic acid most used in medical and dental
procedures.
In this sense, it appears that several procedures are contemplated in the
performance of the dental surgeon and, specifically concerning procedures in
orofacial harmonization, there is Resolution CFO 198/2019 that recognizes this dental
specialty and also, Resolution CFO 230 /2020 that lists some surgical procedures
forbidden to dentists (alectomy, blepharoplasty, chestnut surgery or eyebrow lifting,
otoplasty, rhinoplasty and rhytidoplasty or face lifting).
It is worth noting that the performance in orofacial harmonization involves
procedures performed in aesthetic regions that influence emotional factors such
as the self-esteem and well-being of the individual. Therefore, ethical and/or legal
demands can occur in the face of complications that can be manifested immediately
or in the long term, ranging from ecchymosis to more complex manifestations that
affect the safety and health of the patient, as discussed in the systematic review
published in this Revista Brasileira de Cirurgia Plástica (Manganaro et al. 2022).
1
Universidade de São Paulo, Ribeirão Preto, SP, Brazil.
NATHALIA LOPES
MANGANARO1
JULIA GABRIELA
DIETRICHKEIT PEREIRA1
RICARDO HENRIQUE ALVES
DA SILVA1
*
REFERENCES
1. Manganaro NL, Pereira JGD, Silva RHA. Complications in
orofacial harmonization procedures: a systematic review.
Rev Bras Cir Plást. 2022;37(2):204-17.
2. Pedron IG, Cavalcanti RR, Gaujac C, Shinohara ÉH. Comments
on Bouaoud and Belloc, 2020: “Use of injectables in rhinoplasty
retouching: towards an evolution of surgical strategy? Literature
review”. J Stomatol Oral Maxillofac Surg. 2020;121(6):751-2.
DOI: 10.1016/j.jormas.2020.09.004
3. Cavalcanti RR, Pedron IG. Bichectomy (buccal fat pad reduction)
and your implications. Sci Arch Dental Sci. 2020;3(9):43-4.
4. Cavalcanti RR, Pedron IG. Rhytidoplasty and blepharoplasty
performed by dental surgeons: imminent risks. Sci Arch Dental Sci.
2021;4(7):21-2.
5. Cavalcanti RR, Pedron IG. Rhinoplasty and alectomy (nasal wing
reduction) performed by the dental surgeon: another mistake!
Sci Arch Dental Sci. 2021;4(8):22-4.
6. Cavalcanti RR, Pedron IG. Dentistry and Litigation. Sci Arch
Dental Sci. 2020;3(8):1-2.
3 Rev. Bras. Cir. Plást. 2023;38(1):e0753
Pedron IG et al. www.rbcp.org.br
Ricardo Henrique Alves da Silva
Avenida do Café, s/n, Bairro Monte Alegre, Ribeirão Preto, SP, Brazil
Zip code:14040-904
E-mail: [email protected]
*Corresponding author:
In that study, we did not obtain information regarding
the specialty of the professionals who performed the
procedures, and the scope of the systematic review was
to address the complications reported in the specialized
literature.
Thus, in any procedure performed by health
professionals, whether with an aesthetic focus or not,
it is reiterated the importance of the professional
obtaining adequate knowledge of facial and vascular
anatomy, which can be one of the causal factors of
complications, being aware of the eventual possibility
occurrence of complications, as well as their prevention
measures, aiming to avoid injuries and permanent
damage to the patient’s health.
REFERENCES
1. Brasil. Lei n° 5081, de 24 de agosto de 1966. Regula o exercício
da Odontologia. Disponível em: https://www.planalto.gov.br/
ccivil_03/leis/l5081.htm
2. Conselho Federal de Odontologia. Resolução n° 198/2019,
29 de janeiro de 2019. Reconhece a harmonização orofacial
como especialidade odontológica e dá outras providências.
Disponível em: https://sistemas.cfo.org.br/visualizar/atos/
RESOLU%C3%87%C3%83O/SEC/20 19/198
3. Conselho Federal de Odontologia. Resolução n° 230/2020, 14 de
agosto de 2020. Regulamenta o artigo 3º, da Resolução CFO198/2019. Disponível em: https://sistemas.cfo.org.br/visualizar/
atos/RESOLU%C3%87%C3%83O/SEC/2020/230
4. Manganaro NL, Pereira JGD, Silva RHA. Complicações
em procedimentos de harmonização orofacial: uma revisão
sistemática. Rev Bras Cir Plást 2022; 37(2):204-217
Complications of orofacial harmonization
Rev. Bras. Cir. Plást. 2023;38(1):e0753 4
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