Fabio Lopes Saito

Importance of lateral row perforator vessels in deep inferior epigastric perforator flap harvesting

Free flaps based on perforator vessels, and in particular the deep inferior epigastric perforator (DIEP) flap, are currently being applied in abdominal reconstruction. However, one of the main disadvantages is the operative complexity. Through anatomical study and clinical experience with the DIEP flap in breast reconstruction, the intramuscular path of the perforator vessels was comparatively studied, to establish the main anatomical parameters that favor procedure planning. Thirty DIEP flaps from 15 fresh cadavers were used. The number, location, and intramuscular course of the perforator vessels were determined. In addition, an initial clinical study was performed in 31 patients using 35 DIEP flaps in breast reconstruction. The number, location, and the intramuscular course of the perforators were assessed. In the cadaver study, 191 perforator vessels were detected (6.4 vessels per flap). Thirty-four percent were located in the lateral row, and the rectilinear course was observed in 79.2 percent of these vessels. In the medial row, only 18.2 percent of the perforator vessels presented this configuration (p = 0.001). Thirty-one patients underwent DIEP flap breast reconstruction, with 26 immediate and four bilateral reconstructions. In 22 of 35 flaps (62.9 percent), two perforators were used. In 25 flaps (71.4 percent), the lateral row perforators with a rectilinear course were observed. Mean operative time was 7 hours and 37 minutes. Two total flap losses and two partial necroses were observed. The majority of the lateral row perforators presented a rectilinear intramuscular course, which was shorter than that of the medial row perforators. This anatomical characteristic favors dissection with reduced operative time and vascular lesion morbidity, resulting in an important anatomical parameter for DIEP flap harvesting.

Tensor fasciae latae perforator flap: minimizing donor-site morbidity in the treatment of trochanteric pressure sores.

Background: To report a new technique with less morbidity for coverage of trochanteric defects, an anatomical and clinical study was performed. Methods: Twenty-four fresh cadavers were dissected. The following parameters were measured: origin, location, number, and length of the perforating vessels. In addition, a clinical study was performed on 21 patients with trochanteric pressure sores. Results: The anatomical study of 24 fresh cadavers revealed the constant presence of perforator pedicles anterior to the greater trochanter, which provides an adequate arc of rotation arc for flap harvest without sacrificing the underlying muscles. The mean length of the pedicles was 9.59 ± 2.16 cm. This flap is nourished by perforator vessels arising from the ascending branch of the lateral circumflex femoral artery, which arises from the deep femoral artery and runs through the intermuscular septum, tensor fasciae latae, and rectus femoralis muscles. In this study, flaps were raised based on perforators located preoperatively using a unidirectional Doppler probe. Good results were obtained with primary closure of the donor site, with only two donor-site dehiscences. Conclusions: This flap is an alternative to myocutaneous flaps, as it preserves local musculature without functional sequelae in patients who walk. It also preserves the local musculature in the event of recurrence, as is usually seen in paralytic patients with pressure sores.

Liposuction Induces a Compensatory Increase of Visceral Fat Which Is Effectively Counteracted by Physical Activity: A Randomized Trial

CONTEXT Liposuction is suggested to result in long-term body fat regain that could lead to increased cardiometabolic risk. We hypothesized that physical activity could prevent this effect. OBJECTIVE Our objective was to investigate the effects of liposuction on body fat distribution and cardiometabolic risk factors in women who were either exercise trained or not after surgery. DESIGN, SETTING, AND PARTICIPANTS Thirty-six healthy normal-weight women participated in this 6-month randomized controlled trial at the University of Sao Paulo, Sao Paulo, Brazil. INTERVENTIONS Patients underwent a small-volume abdominal liposuction. Two months after surgery, the subjects were randomly allocated into two groups: trained (TR, n = 18, 4-month exercise program) and nontrained (NT, n = 18). MAIN OUTCOME MEASURES Body fat distribution (assessed by computed tomography) was assessed before the intervention (PRE) and 2 months (POST2), and 6 months (POST6) after surgery. Secondary outcome measures included body composition, metabolic parameters and dietary intake, assessed at PRE, POST2, and POST6, and total energy expenditure, physical capacity, and sc adipocyte size and lipid metabolism-related gene expression, assessed at PRE and POST6. RESULTS Liposuction was effective in reducing sc abdominal fat (PRE vs. POST2, P = 0.0001). Despite the sustained sc abdominal fat decrement at POST6 (P = 0.0001), the NT group showed a significant 10% increase in visceral fat from PRE to POST6 (P = 0.04; effect size = -0.72) and decreased energy expenditure (P = 0.01; effect size = 0.95) when compared with TR. Dietary intake, adipocyte size, and gene expression were unchanged over time. CONCLUSION Abdominal liposuction does not induce regrowth of fat, but it does trigger a compensatory increase of visceral fat, which is effectively counteracted by physical activity.

Cirurgia do contorno corporal no paciente após perda ponderal maciça: experiência de três anos em hospital público secundário

OBJETIVO: Apresentar a experiencia clinico-cirurgica de tres anos relacionada as cirurgias de contorno corporal no paciente apos perda ponderal macica, realizadas pela equipe de Cirurgia Plastica do Hospital Estadual de Sapopemba. METODOS: Estudo retrospectivo realizado no Hospital Estadual de Sapopemba, vinculado ao Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, no periodo de julho de 2005 a julho de 2008. Foram operados 98 pacientes submetidos a tratamento de obesidade morbida por meio de gastroplastia redutora, com sucesso para a tecnica, ou emagrecimento por metodo nao-cirurgico. Os criterios de exclusao foram tabagismo, intencao gestacional e instabilidade ponderal, exigindo-se peso estavel por pelo menos seis meses apos atingido a perda ponderal satisfatoria. RESULTADOS: Dos 98 pacientes operados, 97% eram do sexo feminino, com idade media de 40,5 anos e o metodo de emagrecimento foi cirurgico em 88% deles. Das 177 cirurgias plasticas realizadas, 46% foram abdominoplastias, seguidas por mastoplastias (15%), suspensoes de coxa (13%) e braquioplastias (12%). O periodo medio de internacao foi dois dias e as principais complicacoes diagnosticadas foram: seroma (28%), necroses/deiscencias de pequeno porte (18%), necroses/ deiscencias de grande porte (4%), hematomas (4%), tromboflebite superficial de veia safena (2%) e trombose venosa profunda (1%). CONCLUSAO: O desejo de cirurgias para melhora do contorno corporal apos perda ponderal macica constitui demanda crescente. Cabe ao cirurgiao plastico conhecer as peculiaridades clinicas e os riscos maiores de complicacoes desses pacientes, ponderar suas expectativas, analisar os resultados e manter a busca constante pelo aperfeicoamento das tecnicas cirurgicas.

Lacrimal Gland Prolapse: Management During Aesthetic Blepharoplasty: Review of the Literature and Case Reports

AbstractProlapse of the lacrimal gland is an acquired clinical condition caused mainly by relaxation of the local suspending ligaments. Before an aesthetic blepharoplasty, there should be a preoperative clinical suspicion of lacrimal gland pathology for patients with bulging lateral thirds of the upper eyelids. It should be borne in mind that inadvertent removal of the lacrimal gland can lead to important alterations in ocular lubrication. This report describes two clinical cases of patients with lacrimal gland prolapse associated with dermatochalasis and their treatment.

Alternative surgical treatment of paralytic lagophthalmos using autogenic cartilage grafts and canthopexy.

PurposeThis study aims to analyze the use of autogenic auricular cartilage grafts as weight for the upper eyelid in conjunction with lateral canthopexy for patients with mild paralytic lagophthalmos. This procedure was also accompanied by elevation of the lower eyelid using the cartilage graft for moderate cases. MethodsWe conducted a retrospective study including case series of 30 patients with paralytic lagophthalmos from 1997 to 2010. For mild cases, cartilage from the auricular scapha was placed in pretarsal space of the upper eyelid and cartilage from the concha was inserted in preaponeurotic space and then sutured to the levator aponeurosis in conjunction with lateral canthopexy. For moderate cases, lower eyelid was also elevated by suturing cartilage graft to tarsum and resting it by the inferior orbital rim. ResultsAll patients had some degree of keratopathy before the intervention. After treatment, they presented with evident clinical improvement, reduction of eye symptoms, and resolution of keratopathy. During the mean postoperative follow-up of 37.3 months, none of the patients presented with cartilage graft exposition, reabsorption, visibility, infection, or warping. Complete eye closure was achieved in 24 (80%) patients, whereas the remaining 6 (20%) patients had residual asymptomatic lagophthalmos. ConclusionsThe intervention using autogenic auricular cartilage grafts explained in this study was only effective for the treatment of mild and moderate cases of paralytic lagophthalmos. This outpatient surgery is associated with low morbidity and achievement of functional and aesthetic improvement.

Mastopexia após perda ponderal maciça: suspensão dérmica, remodelação do parênquima e aumento com tecido autógeno

BACKGROUND: Patients who experience major weight loss may have pronounced breast ptosis, loss of projection of the higher pole, and excessive tissue in the lateral thorax. Rubin & Khachi described a mastopexy technique with dermal suspension and parenchymal remodeling associated with augmentation with autologous tissue. This technique treats the mammary deformity and the excessive tissue in the lateral thorax in a single surgery. In this study, we describe this surgical technique and demonstrate its reproducibility and the possible complications. METHODS: From December 2008 to December 2009, surgery was performed using the technique described above on 14 patients with grade 2 and 3 deformities according to the Pittsburgh scale. The following data were analyzed: type of breast deformity, translocation of the papillary-areolar complex (PAC), dimension of the flaps used, surgical time, permanence time of the drain, and the incidence of complications. RESULTS: The mean age of the patients was 41.21 ± 7.67 years and the mean body mass index was 29.30 ± 2.77. The follow-up period ranged from 3 months to 18 months, with a mean of 8 months. Among the 14 patients that underwent surgery, 4 patients (28.6%) had grade 3 deformities and 10 patients (71.4%), had grade 2 deformities. The mean translocation of the PAC was 6.38 cm, the mean dimensions of the flap were 25.21 cm × 6.92 cm, and the mean surgical time was 188.57 minutes. The drains remained for an average of 6.21 days. The following complications were observed: PAC epitheliosis, dehiscence of the T-junction, a small hematoma, and lateral thoracic lymphedema. CONCLUSIONS: Mastopexy with dermal suspension, parenchyma remodeling, and augmentation with autologous tissue is a reproducible technique that can be performed quickly and has a low complication rate.

Z brachiothoracoplasty for body contouring after massive weight loss

DOI: 10.5935/2177-1235.2015RBCP0155 Institution: Hospital Estadual de Sapopemba HESAP, São Paulo, SP, Brazil. Introduction: Brachioplasty treats deformities of the upper limbs. Lateral thoracoplasty treats the upper torso. Brachioplasties, thoracoplasties, and brachiothoracoplasties have been performed with Z-plasty for deformities of the upper limbs and upper third of the chest, in the Sapopemba State Hospital. Objective: We describe modifications of surgical technique for the performance of Z brachiothoracoplasty, and evaluate the results of treatment of deformities of the lateral chest. Method: Thirty-one Patients underwent brachiothoracoplasty and lateral thoracoplasty. The demarcation was made with the patient upright, and the upper limbs abducted at 90o. Marking for brachioplasty was performed using a double-ellipse, to lengthen the modified demarcation along the anterior axillary line toward the inframammary crease in a Z shape. Results: All patients reported an improvement in the contour of the region, and there were no complaints regarding the positioning of the scar. Discussion: Z brachiothoracoplasty consists of extending the incision line on the medial aspect of the arm, passing proximally to the axilla, and continuing through the midaxillary line to the inframammary crease. There was an improvement in the contour of the dorsal region and the skin folds of the lateral thoracic region. Conclusion: Z brachiothoracoplasty and lateral thoracoplasty have the great advantage of eliminating a circumferential scar on the upper torso, thereby improving the contour of the region through skin resection in both the craniocaudal and anteroposterior directions. ■ ABSTRACT

Análise comparativa da evolução e das complicações pós-operatórias nas cirurgias plásticas do contorno corporal em pacientes idosos e jovens com perda ponderal maciça

BACKGROUND: Increasing numbers of procedures are being used to treat elderly ex-obese patients after bariatric therapies. However, reliable data regarding the evolution and complications of this population are scarce in the literature. In this study, we aimed to analyze the evolution and complications of abdominoplasty performed in patients with advanced age after massive weight loss and compare them to the corresponding data from younger patients. METHODS: We retrospectively reviewed patients who experienced massive weight loss and underwent surgery for abdominal contouring between July 2005 and July 2011 in the State Hospital Sapopemba (HESAP). An age of ≥ 60 years was used as a criterion for advanced age, in order to divide patients into groups to analyze the postoperative period and complications of abdominoplasty performed after massive weight loss. RESULTS: We analyzed 264 patients, 19 of whom were 60-75 years of age (Group I) and 245 of whom were 22-59 years of age (Group J). Group I had a major complication rate of 10.5% (P > 0.999) and a minor complication rate of 41.1% (P = 0.280), whereas Group J had a major complication rate of 10.6% (P > 0.999) and a minor complication rate of 30.2% (P = 0.280). CONCLUSIONS: Patients ≥ 60 years of age do not have a higher rate of complications than younger patients after abdominoplasty.