Heitor Carvalho Gomes

Ultrasonography for measuring rectus abdominis muscles diastasis

PURPOSE Preoperative imaging evaluation may be useful for determining the position of recti abdominis muscles before their correction. The purpose of this study is to evaluate the accuracy of ultrasonography to measure the width of rectus abdominis muscle diastasis. METHODS Rectus diastasis was measured by ultrasonography preoperatively in 20 females. Rectus diastasis was measured in seven levels along the anterior rectus sheath by ultrasound after sustained deep inspiration and after expiration. Rectus diastasis, at the same levels, was also measured after its exposition during abdominoplasty by two independent observers, using a surgical compass. These values were compared using Wilcoxons statistical text, for non independent values. RESULTS There was no significant difference between the values obtained by ultrasound and those measured during surgery in the supra-umbilical levels and at the level of the umbilicus. However, below the umbilicus these values differed significantly, showing smaller values in the imaging evaluation. CONCLUSION Ultrasonography is an accurate method to measure rectus diastasis above the umbilicus and at the umbilical level.

Effect of low-level laser therapy (GaAlAs) on bone regeneration in midpalatal anterior suture after surgically assisted rapid maxillary expansion.

OBJECTIVE The aim of this study was to evaluate the effects of laser therapy on bone regeneration in the midpalatal anterior suture (MPAS) after surgically assisted rapid maxillary expansion (SARME). METHODS Thirteen patients aged between 18 and 33 years old with maxillary transverse deficiency (> or =7.0 mm) were evaluated. All patients underwent subtotal Le Fort I osteotomy with separation of the pterygomaxillary suture with the use of Hyrax expander, and were divided into 2 groups: control group (n = 6) and laser group (n = 7). A GaAlAs laser (P = 100 mW, lambda = 830 nm, Ø = 0.06 cm(2)) was used. The laser was applied in 8 treatment sessions with intervals of 48 hours. Each treatment session consisted of laser applications, per point (E = 8.4J, ED = 140J/cm(2)), at 3 points on the MPAS, and total dose of E = 25.2 J, ED = 420 J/cm(2). Digital radiographs were taken before the surgical procedure and at 1-, 2-, 3-, 4-, and 7-month follow-up visits. Optical density analysis of the regenerated bone was performed using Adobe Photoshop 8.0 software. RESULTS Bone regeneration associated with the use of laser after SARME showed a statistically significant difference. A higher mineralization rate was found in the laser group (26.3%, P < .001) than the control group. CONCLUSION Low-level laser irradiation (GaAlAs) accelerates bone regeneration in MPAS after SARME. However, the optical density measurements after 7 months of follow-up were lower in comparison with the preoperative measurements.

Transcutaneous electrical nerve stimulation in viability of a random skin flap in nicotine-treated rats.

Background:Skin flaps are extensively used in plastic surgery, the main postoperative problems being ischemia and necrosis. Nicotine has acute vasoconstrictive properties, diminishing blood flow and increasing the risk of flap necrosis. Transcutaneous electrical nerve stimulation (TENS) was effective in reducing necrosis in random skin flaps in rats. Therefore, the authors decided to test the efficacy of TENS to reduce necrosis in the presence of nicotine. Methods:Sixteen adult male Wistar-Escola Paulista de Medicina (EPM) rats were distributed, at random, in 2 groups of 8 animals. The nicotine group (NG) received this drug subcutaneously (1.2 mg/kg/d), for 1 week before flap elevation. The nicotine plus TENS group (NTG) followed the same routine. Immediately after the operative procedure and on the next 2 postoperative days, the treatment group (NTG) was submitted to TENS during an hour under anesthesia. NG animals were sham exposed. After 7 days, the percentages of necrosis were determined. Results:The NG had a mean value of 45% and the NTG, 21% of necrosis, a difference statistically significant (P < 0.001). Conclusion:TENS was effective in the reduction of necrosis in this flap model.

Impacto da obesidade na capacidade funcional de mulheres

OBJETIVO: Avaliar a capacidade funcional em mulheres eutroficas, com sobrepeso e obesas. METODOS: Estudo transversal analitico envolvendo 90 mulheres adultas com idade entre 40 e 60 anos, alocadas em tres grupos de acordo com a classificacao do indice de massa corporal: eutroficas (n=30), sobrepeso (n=30) e obesas (n=30). As pacientes foram entrevistadas usando um instrumento de avaliacao de qualidade de vida especifico para capacidade funcional o Stanford Health Assessment Questionnaire (HAQ-20). Tambem foram submetidas a teste de esforco para comparacao do consumo maximo de oxigenio (VO2max) entre os tres grupos. Para analise estatistica foram usados o teste do Qui quadrado, a analise de variância de Kruskal-Wallis e as correlacoes de Spearman e Pearson para p= 0,05. RESULTADOS: As mulheres obesas apresentaram escores do HAQ-20 (0,375) significantemente maiores (p<0,05) do que os outros grupos (0), refletindo pior capacidade funcional. O grupo obesas apresentou valores de VO2max (25,8±5,0ml/kg/min) significantemente menores (p<0,001) que sobrepeso (29,9±6,1ml/kg/min) e eutroficas (33,8±4,1ml/kg/min), indicando pior aptidao cardiorrespiratoria. Nao houve diferenca significante entre eutroficas e sobrepeso para VO2max e escores do HAQ-20. A hipertensao arterial foi mais frequente nas mulheres obesas (p=0,012) que tambem apresentaram menores niveis de escolaridade (p= 0,026). CONCLUSAO: As mulheres obesas apresentaram reducao da aptidao fisica e da capacidade funcional em relacao as eutroficas e sobrepeso, o que vem se somar ao pior prognostico para doencas cardiovasculares dessas pacientes.

Dimethyl sulfoxide as a block to the deleterious effect of nicotine in a random skin flap in the rat.

Background: In plastic surgery, a causal relationship between heavy smoking and flap necrosis has been shown. The deleterious effect of nicotine in random skin flaps in rats has also been proven, being related to vasoconstriction and possibly reactive oxygen species. This study aimed to verify the capacity of dimethyl sulfoxide, an antioxidant, to block the deleterious effect of nicotine in a random skin flap. Methods: Fourteen adult male Wistar-EPM rats were distributed at random into two groups of seven animals. The nicotine group received this drug subcutaneously (1.2 mg/kg/day), for 1 week before flap elevation. The nicotine plus dimethyl sulfoxide group followed the same routine. Five minutes before the surgical procedure, rats in the nicotine group received distilled water orally and rats in the nicotine plus dimethyl sulfoxide group received dimethyl sulfoxide orally (2 ml/kg). Blood and skin tissue samples were collected to allow determination of malondialdehyde levels. Results: The nicotine group had a mean value of 40.2 percent and the nicotine plus dimethyl sulfoxide group had a mean value of 20.6 percent necrosis (p = 0.009). Malondialdehyde levels in both serum and skin samples were lower in the animals that received dimethyl sulfoxide. Conclusion: The deleterious effect of nicotine was effectively blocked by dimethyl sulfoxide.

Acetylcysteine in random skin flap in rats

PURPOSE Analyze the ability of Acetylcysteine to reduce distal necrosis in a random skin flap, in the rat. METHODS The present study utilized 28 adult male Wistar-EPM rats distributed, at random, in two groups of 14 animals. Control group rats (CG) received distilled water and Acetylcysteine group animals (NACG) received NAC (300 mg/kg) by oral infusion, 15 minutes before flap elevation. On the seventh postoperative day, percentage of distal necrosis was determined and skin samples collected in order to allow determination of MDA levels. RESULTS The mean necrotic area in CG group (control) was 66% and in NACG group (Acetylcysteine) 52%, a statistically significant difference according to the Mann-Whitney test (U calc = 25; U crit = 45). MDA levels were lower in the CG flap skin samples than in the NACG samples (U calc = 24; U crit = 45), the oposite being true in the normal skin samples (U calc = 10; U crit = 45). CONCLUSION Acetylcysteine was effective, according to the model used, reducing the percentage of distal necrosis in NACG rats.

Effect of low-level laser therapy with output power of 30 mW and 60 mW in the viability of a random skin flap.

OBJECTIVE To assess the effects of low-level laser therapy (LLLT) with output power of 30 and 60 mW in the viability of a random skin flap in rats. BACKGROUND DATA Output power values in LLLT are not well defined. MATERIALS AND METHODS Controlled, single-blind experimental study. Thirty-six animals were randomly distributed into three groups: sham group (SG), 30-mW output power (30G), and 60-mW output power (60G). In both treated groups, a fluency of 3 J/cm(2) was used. Two minutes after elevation of a random-pattern cranially based dorsal flap (4 x 10 cm), laser irradiation was applied and repeated on the first, second, third, and fourth postoperative days. Percentages of flap necrosis were calculated on the seventh postoperative day. Also, four fragments of each flap were collected to allow determination of the percentages of vascular density according to the bidimensional method of the morphometric analysis of blood vessels. Statistical analysis included the Wilcoxon test and Kruskal-Wallis variance analysis. A significance level of 5% was elected (p < 0.05). RESULTS Laser-treated animals presented significantly less necrosis than the sham group (SG, 53%; 30G, 24%; p < 0.05) (60G, 25%; p < 0.05). Also, laser-treated animals presented significantly more vascular density than the sham group (SG, 37%; 30G, 57%; p < 0.05) (60G, 59%; p < 0.05). CONCLUSION LLLT (660 nm) with 30-mW and 60-mW output power was efficient in the increase of skin flap viability, but there was no difference between them.

Hemicellulose dressing versus rayon dressing in the re-epithelialization of split-thickness skin graft donor sites: a multicenter study

The aim of this study was to compare the effectiveness of a hemicellulose dressing with that of rayon dressing in the healing of split-thickness skin graft donor sites. Twenty-eight patients were selected from five different hospitals and randomized into two groups: hemicellulose dressing group and rayon dressing group. All patients underwent split-thickness skin grafting for various reasons, and the skin graft donor site wounds were covered with hemicellulose dressing (n=14) or rayon dressing (n=14). The donor site was assessed on postoperative days 1, 7, 14, 21, and 28 for hyperemia, pruritus, pain, exudate level, and adherence of the wound dressing. At the 60-day follow-up visit, the donor site was assessed again for pruritus and pain. Touch-pressure, thermal, and pain sensibility tests were performed preoperatively and on postoperative day 60 together with the assessment of color and texture of the re-epithelialized area. In all patients, re-epithelialization was completed between 14 and 21 days after surgery. There were no significant differences between the two groups with regard to pain, hyperemia, pruritus, exudate, and final appearance (color and texture) of the skin graft donor site. The rayon dressing provided significantly better adherence than the hemicellulose dressing, and both dressings showed similar results with regard to the parameters evaluated when used in the treatment of split-thickness skin graft donor sites.

Effect of gene therapy with vascular endothelial growth factor after abdominoplasty on TRAM flap viability in a rat model.

BACKGROUND The transverse rectus abdominis musculocutaneous (TRAM) flap may develop necrosis, especially in patients with risk factors such as previous abdominoplasty, caused by damage to perforating vessels during surgical procedures. This study was designed from the perspective of using vascular endothelial growth factor (VEGF) gene therapy with plasmid vector after abdominoplasty to stimulate neovascularization of the TRAM flap, thus increasing flap viability. METHODS Thirty-two Wistar rats were divided into four groups (n = 8). A right inferiorly based TRAM flap was constructed in all animals and was the only procedure performed in group I (TRAM flap). Animals from groups II (abdominoplasty) and III (plasmid) underwent abdominoplasty and were injected intramuscularly with physiologic saline solution and empty plasmid, respectively. Group IV (VEGF) received intramuscular injection of naked plasmid DNA encoding VEGF-165 during abdominoplasty. The TRAM flap was created 30 days after abdominoplasty. RESULTS The mean necrosis was 24.65 +/- 18.13 percent in group I, 62.49 +/- 28.06 percent in group II, 57.80 +/- 25.43 percent in group III, and 18.33 +/- 16.20 percent in group IV. The number of vessels in the TRAM flap was determined by immunohistochemistry using the antibody human heart factor. Groups I and IV had a similar number of vessels, as did groups II and III. Groups I and IV had greater viability and number of vessels than groups II and III. CONCLUSION VEGF gene therapy increased viability and vessel number in the TRAM flap created after abdominoplasty in a rat model.

Electroporation of vascular endothelial growth factor gene in a unipedicle transverse rectus abdominis myocutaneous flap reduces necrosis.

Necrosis in TRAM (transverse rectus abdominis myocutaneous) still occurs in flap breast reconstruction. Blood flow may be improved by vascular endothelial growth factor (VEGF), an endogenous protein that stimulates neovascularization. Experimental studies of gene therapy with plasmid vector expressing human VEGF (hVEGF) presented inadequate results. Low level of gene expression could be the cause. To prove that high level of VEGF gene expression can minimize necrosis of TRAM flap, electroporation of VEGF plasmid was tested.Forty-two adult, male, Wistar-EPM rats were randomly distributed in 6 groups of 7 animals and 50 &mgr;g of vectors were injected in the intradermal layer of TRAM flap donor region, by electroporation: LacZ (beta-galactosidase gene); CG (no substance injected and flap elevated); P2G (empty gT plasmid in area 2); PV2G (gT-VEGF165 in area 2); P4G (empty gT plasmid in area 4); PV4G (gT-VEGF165 in area 4). Five days after flap elevation, the animals were euthanized and the degree of necrosis was analyzed by histology and paper template method.Dermal X-gal staining after electroporation with pSV2lacZ proved high rate of gene transfer. Mean values of necrosis by the paper template method were: CG (74.5%), P2G (62.2%), PV2G (41.1%), P4G (76.6%), and PV4G (59%). Degree of necrosis, preservation of muscle layer, and degree of infiltrates seen by histology were in accordance with mean values of necrosis.Intradermal injection of gT-VEGF165 in area 2, by electroporation, was effective in reducing unipedicle TRAM flap necrosis, in rats.