Patricio Andrades

Composition of Postabdominoplasty Seroma

BackgroundThis study aimed to analyze the composition of postabdominoplasty seroma fluid at different intervals, compare it with blood and lymph, and determine whether it meets the criteria for being considered an exudate.MethodsThe study enrolled 18 female patients with postabdominoplasty seroma diagnosed by clinical and ultrasound evaluation. All the patients had a Matarasso type 4 anterior abdominal wall deformity. None of the patients were overweight, and none had comorbidities. They all underwent a classical abdominoplasty procedure. Fluid samples were taken from the drains between postoperative days 5 and 7, and from needle aspiration between postoperative days 15 and 20. The fluids were assayed in the clinical laboratory at the University of Chile Clinical Hospital for chemical and cellular composition. Blood, lymph, and seroma values were compared by independent group analysis using a Tukey multiple comparison test with an alpha error of 0.05.ResultsThe total protein, lactate dehydrogenase (LDH), and cholesterol levels for the early and late seroma fluids were lower than in the blood, but higher than in the lymph. The total protein seroma-to-plasma ratio was approximately 0.5; the LDH seroma-to-plasma ratio was approximately 0.6; and the cholesterol seroma-to-plasma ratio was 0.32. The platelet level was very low in the late seroma fluid, showing no statistical differences with the lymph level. The leukocyte level was low in the seroma fluid, with a higher percentage of neutrophils than found in the blood or the lymph.ConclusionsThe serous fluid formed under the flap after an abdominoplasty seems to be an exudate. In the early postoperative period, it is an inflammatory exudate that slowly turns into an exudate with some characteristics similar to those of lymph.

Implications of Transaxillary Breast Augmentation: Lifetime Probability of Breast Cancer Development and Sentinel Node Mapping Interference

After the “fifth-generation” breast implants with ultracohesive silicone gel technology are introduced, the Food and Drug Administration (FDA) will sooner or later retire the ban on the use of these devices in the United States. When this happens, the plastic surgery community must be prepared to face a massive demand for reoperations to change saline-filled breast implants because cohesive gel devices have the potential to provide a more natural breast shape, to minimize the risk of postoperative rippling, and to provide a greater degree of safety if the implant loses its integrity. Despite these advantages and extensive use throughout the rest of the world during the ban in the United States, silicone implants also have disadvantages. One drawback is that transaxillary breast augmentation with more “rigid” gel-filled implants may produce trauma to the armpit, may interfere with sentinel node mapping for breast cancer treatment, and may have future medicolegal implications.

Abdominoplasty: The use of polypropylene mesh to correct myoaponeurotic-layer deformity

The aponeurotic layer is a very important element to consider during abdominoplasty. For most patients, a simple midline plication is enough to obtain good results. However, for in patients with severe aponeurotic laxity, some other maneuvers must be performed. The purpose of this study was to evaluate the use of polypropylene mesh in this group of patients. We analyzed the results for 20 patients in whom three types of mesh anchoring were used on the basis of intraoperative findings. Adequate long-term follow-up results were obtained, with no recurrence of rectus diastases, as shown by ultrasonography.

Suction-assisted lipectomy fails to improve cardiovascular metabolic markers of disease: a meta-analysis.

BACKGROUND The purpose of this study was to determine whether suction-assisted lipectomy (SAL) decreases the incidence of early cardiovascular disease risk factors or its biochemical and clinical risk indicators. METHODS A systematic review of the literature was performed by conducting a predefined, sensitive search in MEDLINE without limiting the year of publication or language. The extracted data included the basal characteristics of the patients, the surgical technique, the amount of fat extracted, the cardiovascular risk factors and the biochemical and clinical markers monitored over time. The data were analysed using pooled curves, risk ratios and standardised means with meta-analytical techniques. RESULTS Fifteen studies were identified involving 357 patients. In all of the studies, measurements of predefined variables were recorded before and after the SAL procedure. The median follow-up was 3 months (interquartile range (IQR) 1-6, range 0.5-10.5). The mean amount of extracted fat ranged from 2063 to 16,300 ml, with a mean ± standard deviation (SD) of 6138 ± 4735 ml. After adjusting for time and body mass index (BMI), leptin and fasting insulin were the only markers that were significantly associated with the amount of aspirated fat. No associations were observed for high sensitive C-reactive protein (hCRP), interleukin-6 (IL-6), adiponectin, resistin, tumour necrosis factor-α (TNF-α), Homeostasis Model of Assessment (HOMA), total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides, free fatty acids or systolic blood pressure. CONCLUSIONS Based on the results of our analysis, we conclude that there is no evidence to support the hypothesis that subcutaneous fat removal reduces early cardiovascular or metabolic disease, its markers or its risk factors.

Recent developments in the ability to predict and modify breast cancer risk

The identification of women at higher risk for breast cancer is a matter of public health and anyone who participates in any treatment modality of this condition (this includes the plastic surgeon) should be aware of the tools and predictive models of breast cancer. Screening for breast cancer in the community, and probably during the daily plastic surgery consultation, until recently, was limited to decisions about when to initiate a mammography study. New developments that predict and modify breast cancer risk must be clearly understood by our specialty through identification of women at higher risk for breast cancer and be familiar with the current issues related to screening and risk-reduction measures. In this review, we discuss current knowledge regarding the recent data of breast cancer risk, screening strategies for high-risk women and medical and surgical approaches to reduce breast cancer risk. Patients with breast cancer belong to one of three groups: a. Sporadic breast cancer (75%)--patients without family history or those who have a breast biopsy with proliferative changes. b. Genetic mutation breast cancer (5%)--women who have a genetic predisposition, and most of these are attributable to mutations in the breast cancer susceptibility gene 1 (BRCA1) and breast cancer susceptibility gene 2 (BRCA2). c. Cluster family breast cancer (20%)--seen in women with a relevant history of breast cancer in the family and breast biopsy with proliferative breast changes with no association with mutations.Those at high risk for breast cancer should investigate the family history with genetic testing consideration, clinical history, including prior breast biopsies and evaluation of mammographic density. Tools for breast cancer risk assessment include the Gail and Claus model, genetic screening,BRCAPRO and others that are evaluated in this review.

Creativity in Plastic Surgery

Creativity in plastic surgery has been a hot topic of the past decade. This is explained by the nature of plastic surgery, with its intense pressure for innovation and maintenance of a competitive edge. Creativity is the ability to make or bring into existence something new, whether a new solution to a problem or a new method, technique, or device, or simply the act of making something new. Creativity also may be seen as a mental process involving the generation of new ideas or concepts or the process of making new associations between existing ideas or concepts [1]. The creative thought is original, and innovation applies such creative ideas in some specific context. For example, ‘‘invention,’’ is a term usually understood as referring to new devices, instruments, and machines, but this is a narrowing of its original meaning, ‘‘to come on something, to fabricate in the mind.’’ For this reason, it is equally proper to speak of an invention of an idea [2]. How do we define creativity in plastic surgery? Plastic surgeons are seen by other specialties as imaginative, original, inventive, and ingenious people. What the others do not see is that innovations in our specialty appear after the complete picture of principles is grasped, as shown in the Principalization of Plastic Surgery by Millard [3]. Attendance at several courses, meetings, and symposia enables us to recognize creative individuals when they communicate something partly or wholly new, invest an existing object with new properties or characteristics, imagine new possibilities not conceived previously, or perform something in a manner different from what was thought possible or normal previously. It is easy to distinguish these individuals from other less creative peers because they have a rich body of domain-relevant knowledge and well-developed skills. They are intrinsically motivated by their work; tend to be independent, unconventional, and more risk taking; have a wide interest and greater openness to new experiences; and have skill in recognizing differences and similarities and in making connections. These creative individuals have a true appreciation of and ability for writing and drawing, flexibility to change, and willingness to question norms and assumptions. They tend to have a discovery orientation and ask novel questions. In work contexts, creative plastic surgeons tend to take the initiative, to work in teams, and to have extensive networks. The presence of stimulating coworkers promotes more creativity by adding excitement, energy, and synergy. Competitive pressure leads to enhanced individual and group creativity. The affective context also is important because it influences creative problem solving. An important aspect of being in the University is the ability to teach, investigate, promote extension, communicate, publish, and finally, with free will, create. Observation of how things work and develop is transcendental. For this purpose, the creative individual must have time, imagination, and an open mind. The Greeks developed leisure so they could observe because this was the first step to innovation. It is said that the University gives its academics a sabbatical year to ‘‘think and have time to create.’’ But this utopia in our globilized world requires each one of us to ‘‘kill our own pig’’ to survive and ‘‘feed the family.’’ Creative minds in plastic surgery have imagination that sparks ‘‘brainstorming of ideas,’’ the same as a schizophrenic A. Prado (&) P. Andrades Plastic Surgery Division, Department of Surgery, School of Medicine, Jose Joaquin Aguirre Clinical Hospital, University of Chile, Santiago, Chile e-mail: pradoplast@yahoo.com

Perioperative thromboelastography analysis during suction-assisted lipectomy: a prospective cohort study

OBJECTIVE The purpose of this study was to prospectively investigate coagulation during suction-assisted lipoplasty (SAL) and to compare it to other plastic surgery where no SAL was used, with the aid of a computerised thromboelastograph coagulation analyser (TEG). METHODS A prospective cohort study enrolled 50 pure SAL patients and 50 patients presenting for other aesthetic plastic surgery operations, without the need of liposuction. TEG evaluates in real time the competency of the blood clot in samples that are studied under a low shear environment resembling venous flow. Six thromboelastographic measurements were performed in each patient: one preoperative, two intraoperative at the middle and end of the surgery and three postoperative at 60, 90 minutes and 24 hours. All the patients also had standard pre- and postoperative coagulation studies. RESULTS R (time of clot to form) and K (time or speed the clot takes to be firm) were shorter in the SAL group vs control (P<0.001). Angle (growth and stranding process of fibrin) and MA (dynamic properties of the platelets and the final strength and elasticity of the fibrin clot) were greater in SAL vs control (P<0.001). None of the cases had pre- or postoperative coagulation study abnormalities. CONCLUSIONS TEG analysis demonstrates that SAL patients have decreased initial clotting time, decreased time to full clot formation, increased pro-coagulability state, and increased clot rigidity. The clot lysis time was not different between the studied groups.

Clinical trial evaluating the results of breast reduction with ancillary lipoplasty.

BACKGROUND Suction-assisted lipoplasty (SAL) may be used in breast reduction either alone or as an adjunct to standard reduction mammaplasty procedures. Although adequate results have been attained through breast reduction with ancillary lipoplasty, the safety of this procedure has not been evaluated. OBJECTIVE The purpose of this study was to evaluate outcomes in breast reduction surgery complemented with lipoplasty of the breast area. METHOD A prospective, randomized double-blinded trial with 2 study groups was designed. A total of 25 patients were included in the control group (without SAL) and 25 in the active group (with SAL). Lipoplasty of the breast area was performed using the tumescent technique. Neither lipoplasty of the surrounding breast area nor other surgical procedures were performed. The primary outcome measure was the complication rate; the secondary outcomes were the clinical data from the patient and the surgical and aesthetic results. For comparison of paired variables, linear or logistic regression models were used with an alpha level of 5% for statistical significance. RESULTS The 2 groups were comparable with respect to sex, body mass index, comorbidities and smoking habits, but the active group (with SAL) was younger (P = .351). The overall complication rate was higher in the group that underwent reduction mammaplasty with SAL (18% vs. 6%, P = .0324), in which a higher incidence of dehiscence and tissue necrosis was observed. There were no differences with respect to aesthetic outcome. CONCLUSIONS In this study, breast reduction with ancillary lipoplasty resulted in a higher rate of complications when compared to reduction mammaplasty with no lipoplasty. Caution must be used when applying SAL in the pedicle, under the nipple-areola complex, or in the pillars during a standard reduction mammaplasty.

Long-Term Quality-of-Life Outcomes After Body Contouring Surgery: Phase IV Results for the Body-QoL® Cohort

Background Body contouring surgery (BCS) is becoming increasing popular for aesthetic and reconstructive purposes, particularly among patients with massive weight loss (MWL). However, data on quality of life (QoL) following the surgery are limited, especially long-term QoL. Objectives The authors evaluated the effect of BCS on QoL and the durability of this effect over time. Methods QoL was measured with the Body-QoL® instrument at 3 time points among consecutively treated patients: the day before BCS, 1 to 9 months postoperatively (short term), and 1 to 2.7 years postoperatively (long term). Total Body-QoL scores were compiled, as were scores for the instruments main domains: body satisfaction, sex life, self-esteem and social performance, and physical symptoms. Scores were examined for the entire study population and separately for the cosmetic and MWL cohorts. Results Fifty-seven of the 112 patients participated in the short-term assessment and 84 in the long-term assessment. Total Body-QoL scores increased significantly (P < 0.0001), from 44.0 ± 14.1 preoperatively to 85.5 ± 17.5 short-term postoperatively and to 84.4 ± 12.7 long-term postoperatively. Scores for the 2 postoperative assessments did not differ significantly. Similar results were observed for scores on each separate domain. Although preoperative scores were lower for the MWL cohort than the cosmetic cohort (33.9 ± 15.6 vs 46.1 ± 12.8; P = 0.0002), they improved substantially after BCS, approaching scores for the cosmetic cohort. Conclusions QoL increases significantly after BCS. This favorable outcome remained stable throughout long-term follow-up and was true for the cosmetic and MWL cohorts. Level of Evidence 4

Use of aerosolized bovine-prepared fibrin glue for skin fixation after primary open rhinoplasty: a prospective randomized and controlled trial.

BackgroundFibrin glue has been used in diverse areas of plastic surgery. To the authors’ knowledge, no clinical controlled trial studies have reported its use for open rhinoplasty.MethodsA prospective, randomized, masked clinical trial was designed to demonstrate that aerosolized bovine-prepared fibrin glue used in open rhinoplasty controls skin fixation (flap movement), edema, hematomas, ecchymosis, bleeding, and cosmetic results 1 and 12 months postoperatively. The results were reviewed by two blinded plastic surgeons who assessed postoperative photographs using the Strasser score. Other items such as columella scar, pain, surgery/recovery time, and patient satisfaction also were evaluated.ResultsA computer system was used to randomize 22 consecutive open primary rhinoplasties. Cosmetic analysis did not differ significantly between the group redraped with fibrin glue and the control group. Patient satisfaction was the only outcome that significantly favored the active group. None of the other items or adverse events significantly differed between the two groups, including operative time and pain.ConclusionsFibrin glue is believed to reduce bleeding and to improve the adherence of tissues. The only statistical difference in this study favored the patient satisfaction cosmetic score of the group that received fibrin glue.