INTRODUCTION
Brazil ranks the highest in plastic surgeries worldwide, when nonsurgical
procedures are also considered, second only to the United States. According to
recent data from a study conducted by the International Society of Aesthetic
Plastic Surgery (ISAPS) and published by the Brazilian Society of Plastic
Surgery (SBCP), more than 23 million plastic surgeries were performed worldwide
in 2013, of which 1,491,721 were performed in Brazil. Abdominoplasty accounts
for 7.1% of these surgeries, second only to rhinoplasty, blepharoplasty,
liposuction, and breast augmentation1.
Abdominoplasty is an effective and specific procedure for the improvement of body
contour2. It has evolved over the
years with the improvement of techniques that initially had high complication
rates. Currently, it is considered safe and refined and with optimal results,
and research is aimed at improving the performance of the procedure, reducing
the occurrence of complications, and obtaining better results in the long
term3. Small details, such as
omphaloplasty, muscle plication, association with liposuction, and the
development of techniques for detachment and treatment of the abdominal flap
are
now considered important in this procedure.
However, even with the evolution of the operative technique, seroma remains the
most frequent early complication of this procedure. This fact motivated the
study and practice of several methods such as the use of aspiration drains,
reduced flap manipulation, fixation of the flap to the abdominal wall using
quilting sutures, and use of postoperative (PO) compression
sleeves to reduce this complication4.
OBJECTIVE
The objective of this study was to compare the development of seroma after
abdominoplasty in patients operated using the Baroudi-Ferreira technique.
METHODS
This is a retrospective study conducted according to the principles established
by the Declaration of Helsinki. Twenty patients undergoing abdominoplasty were
evaluated at the Gaffrée and Guinle University Hospital (HUGG) of the Federal
University of the State of Rio de Janeiro (UNIRIO) between April 2016 and
September 2016. All patients were female, with ages ranging from 22 to 51
years.
All patients underwent a preoperative evaluation consisting of anamnesis,
physical examination, and complementary exams. The exclusion criteria were as
follows: age below 18 and more than 70 years, hematocrit below 37%, smoking,
body mass index (BMI) ≥30 kg/m2, large amount of weight
losses, abdominal wall hernias, surgeries and/or previous abdominal scars
(except cesarean section/Pfannenstiel incision), and surgical risk higher than
ASA II.
After signing the Informed Consent Form, the patients were alternately
distributed into two groups in order of arrival:
- Group A (n = 10): Abdominoplasty with the use of quilting
sutures (Baroudi-Ferreira technique).
- Group B (n = 10): Abdominoplasty without the use of quilting
sutures
Student’s t-test was used for statistical analysis, considering
p-values < 0.05 as statistically significant.
Operative technique
All patients were administered general anesthesia, and preventive care for
deep venous thrombosis (DVT) was implemented according to individual risk
factors.
Subsequently, abdominoplasty was performed with a periumbilical incision,
followed by suprapubic incision, extending laterally almost to the iliac
crests in a previously demarcated area.
A dermis-fat flap of the muscle aponeurosis was detached in both groups using
electrocautery at 40 watts for dissection and coagulation throughout the
supra-aponeurotic plane. The central and lateral regions of the flap,
extending almost to the anterior axillary line in the infraumbilical region,
were detached. Subsequently, regions up to 3 cm inferior to the xiphoid
appendix and 4 cm lateral to the medial margins of the rectus abdominis
muscles were detached, similarly to that described by other authors3,4.
Muscle diastasis was corrected by plication of the anterior lamina of the
rectus abdominis sheath in a single plane with three inverted “X”
supraumbilical and two infraumbilical “X” points followed by “lock-stitch
suture” throughout the plication area, using a 2-0 nylon monofilament.
After resection of the dermis-fat flap excess, marking of the neoumbilicus
position, and checking for bleeding, quilting sutures were made in 16
patients in Group A, as recommended by Baroudi-Ferreira5,6.
Four of them were made in the supraumbilical midline, and 12 were evenly
distributed in the infraumbilical region, different from the procedure
performed in Group B. The suture was followed by planes and surgical
dressing.
It is important to point out that no liposuction was performed and no
aspiration or any other drain was used in the patients in this study.
Furthermore, low-molecular-weight heparin was not regularly used in the
preoperative and PO periods, but calf massaging and early ambulation were
performed after the surgical procedure.
Antibiotic medication such as cefadroxil and analgesia were used in the PO
period. The dressings were applied during medical consultation. Lymphatic
drainage was recommended from the 5th PO day (POD), and the
patients were recommended to use a girdle for 30 days.
PO evaluation consisted of consultations on the following PODs:
7th, 15th, 21st, 45th, and
60th. The presence of seroma was evidenced by symptoms such
as pain, sensation of fluid and “weight” in the abdomen and the presence of
bulging or fluctuation detected during palpation upon physical examination
or by active inspection using the aspiration method with a syringe in
suspected cases.
The presence of seroma was considered positive when the volume of aspirated
fluid was ≥10 mL. Other signs such as hyperemia, edema, and local
heat and complications such as dehiscence and epitheliolysis, associated or
not with the presence of seroma, were also considered for the analysis.
Photographic documentation was performed preoperatively, on the
45th, 90th, and 180th PODs.
RESULTS
Twenty female patients were studied, all of them not meeting the exclusion
criteria mentioned above.
In Group A, the age of the patients ranged from 22 to 47 years (mean = 33.6
years), BMI ranged from 21 to 25.4 kg/m2 (mean = 23.7
kg/m2), and mean time of surgery was 170 min. In Group B, the age
of the patients ranged from 25 to 51 years (mean = 39.1 years), BMI ranged from
20.3 and 25.5 kg/m2 (mean = 23.8 kg/m2), and mean time of
surgery was 163 min, as shown in Table 1.
Table 1 - Sample characteristics.
| |
Group A |
Group B |
Total |
| Age (years) |
33.6 ± 8 |
39.1 ± 7.6 |
36.4 ± 8.1 |
| BMI (kg/m2)
|
23.7 ± 1.34 |
23.8 ± 1.6 |
23.7 ± 1.45 |
| Surgical time (min) |
170 ± 17.2 |
163 ± 25 |
166 ± 21.1 |
Table 1 - Sample characteristics.
There was no statistical difference between the two groups regarding age
(p = 0.09), BMI (p = 0.78), and time of
surgery (p = 0.45).
Two patients (20%) in Group A had seroma, which was significantly lower
(p = 0.05) than that in Group B, in which seven patients
(70%) were diagnosed with seroma. The mean volume observed was 26.5 mL in Group
A but 146.5 mL in Group B. The highest volume aspirated in Group A was 130 mL,
on the 15th POD, whereas in Group B, it was 230 mL, on the
21st POD of a total of 590 mL aspirated over 21 days
postoperatively from the same patient, who had the largest seroma of not only
the group but also the whole sample. From the 21st POD, seroma was no
longer detected in this patient.
Whereas the highest mean volume in Group A (16 mL) was observed on the
15th POD, the highest mean volume in Group B (59.5 mL) was
observed on the 7th POD. However, no statistical difference was
observed regarding the total volume of seroma aspirated (p =
0.12) when comparing both groups. From the 45th POD, seroma was no
longer observed in Group A, whereas in Group B, only one patient had seroma on
the 45th POD. Then, 45 mL of serous fluid was aspirated in that time,
and on the 60th POD, no seroma was observed, as shown in Table 2.
Table 2 - Volume of seroma aspirated.
| Group |
Patients |
7th POD (mL)
|
15th POD (mL)
|
21st POD (mL)
|
45th POD (mL)
|
60th POD (mL)
|
Total (mL) |
| A |
1 |
0 |
0 |
0 |
0 |
0 |
0 |
| A |
2 |
0 |
0 |
0 |
0 |
0 |
0 |
| A |
3 |
0 |
0 |
0 |
0 |
0 |
0 |
| A |
4 |
0 |
0 |
0 |
0 |
0 |
0 |
| A |
5 |
0 |
0 |
0 |
0 |
0 |
0 |
| A |
6 |
20 |
130 |
45 |
0 |
0 |
195 |
| A |
7 |
0 |
0 |
0 |
0 |
0 |
0 |
| A |
8 |
0 |
0 |
0 |
0 |
0 |
0 |
| A |
9 |
0 |
0 |
0 |
0 |
0 |
0 |
| A |
10 |
0 |
30 |
40 |
0 |
0 |
70 |
| B |
1 |
0 |
0 |
0 |
0 |
0 |
0 |
| B |
2 |
200 |
160 |
230 |
0 |
0 |
590 |
| B |
3 |
130 |
80 |
0 |
0 |
0 |
210 |
| B |
4 |
0 |
0 |
0 |
0 |
0 |
0 |
| B |
5 |
40 |
0 |
0 |
0 |
0 |
40 |
| B |
6 |
20 |
0 |
0 |
0 |
0 |
20 |
| B |
7 |
10 |
0 |
0 |
0 |
0 |
10 |
| B |
8 |
195 |
100 |
30 |
0 |
0 |
325 |
| B |
9 |
0 |
135 |
90 |
45 |
0 |
270 |
| B |
10 |
0 |
0 |
0 |
0 |
0 |
0 |
Table 2 - Volume of seroma aspirated.
One patient in Group A (10%) had a hematoma detected and drained on the 1st POD.
This patient also had the earliest development of seroma and the greatest volume
aspirated in this group. One patient in Group B (10%) had a hematoma detected
and drained on the 7th POD. This patient also had the greatest volume
of seroma aspirated of not only the group but also the whole sample.
Concerning the presence of other complications, in Group A, umbilical stenosis
was observed in 2 patients (20%), scar hypertrophy/hyperchromia in 3 (30%), scar
dehiscence in 1 (10%), epitheliolysis in 1 (10%), and dog ear in 1 (10%), while
in Group B, it was observed in 2 (20%), 2 (20%), 4 (40%), 3 (30%), and 1 patient
(10%), respectively. Patients in both groups who had umbilical stenosis and
scars with unsatisfactory aesthetic appearance underwent a new surgical
procedure and had to wait six months postoperatively to have their scars
retouched.
No anesthetic complications were recorded in any of the operated cases. The only
systemic complication was observed in a patient in Group B, who was diagnosed
with DVT on the 13th POD by clinical examination and in whom
resolution of symptoms after medical treatment was confirmed by Doppler
ultrasonography. This patient had no seroma or any other complication.
DISCUSSION
Seroma is characterized by the accumulation of exudative fluids under the
abdominal flap. It is considered the most frequent early complication of this
procedure, with an incidence ranging from 1 to 57% and a mean of 10% reported
in
most studies7,8. The mechanisms associated with seroma
formation are section of lymphatic channel, dead space due to the detachment
of
the dermis-fat flap, shear forces between the flap and aponeurosis, and release
of inflammatory mediators9-11.
Bozola and Psillakis12 reported that the
incidence of seroma is associated with the extension of surgery, i.e., the
greater the complexity of the surgery, the greater the predisposition to this
complication. Nahas et al.7 evaluated 21
individuals undergoing abdominoplasty and quilting sutures with ultrasonography
and found a mean volume of 8.2 mL of seroma after two weeks of surgery.
The main factors predisposing to seroma formation are obesity or a large amount
of weight loss, leading to changes in the lymphatic system (38% in obese
versus 19% in normal weight individuals)13; extension of the abdominal flap
detachment area, causing an increase in the dead space; previous supraumbilical
scar, hindering lymphatic drainage; and liposuction14.
Seroma accumulation causes an increase in local pressure, which can lead to other
complications such as operative wound dehiscence, necrosis, spontaneous surgical
wound drainage, and infection15,16, in addition
to the possibility of chronic untreated seromas evolving with the formation of
a
fibrous capsule around them (pseudobursa), leading to deformities of the
abdominal wall17, a condition that
requires surgical treatment15,16.
Because of this frequent complication, several studies aimed at reducing the
incidence of seroma and, consequently, other complications that, if not directly
related, are associated with it have been conducted. The use of quilting
sutures, as recommended by Baroudi and Ferreira5,6, have been associated with the reduction of both the incidence and
volume of seroma drained in abdominoplasty.
This is possible due to the reduction of the “dead space” created by the
detachment of the dermis-fat flap and reduction of the flap sliding on the
aponeurotic plane, eliminating two of the main predisposing factors to the
development of seromas. Moreover, the attachment of the dermis-fat flap to the
aponeurosis muscle reduces the tensile forces exerted by the flap on the pubic
scar, reducing the prevalence of dehiscences and poorly positioned and enlarged
scars3.
Considering the statement of Borile et al.18 and Nahas et al.7 that the
use of drains did not reduce the incidence of seroma, as it is a phenomenon
occurring between the 2nd and 3rd PO week, this study
aimed to compare the development of seroma in abdominoplasty with and without
quilting sutures without the use of drains of any kind.
Although studies have indicated that ultrasonography has been the method of
choice for the diagnosis of seroma after abdominoplasty, this examination was
not included in the follow-up because of the difficulty of its standardization
and performance in the patients of this study. Thus, the presence of seroma was
verified by clinical examination, which may have reduced diagnostic sensitivity,
especially in the case of small seromas, as described by other authors4.
The incidence of seroma was significantly lower in Group A than in Group B, and
both groups had a mean above that accepted by most authors, which is around
10%7,8. Although the mean volume of seroma aspirated in Group A
was lower than that in Group B, no statistical significance was found when this
item was evaluated.
It was observed that the patients in both groups with the earliest development of
seroma (7th POD) and greater volume of seroma aspirated were those
who had hematomas, suggesting an association of this complication with onset
time and volume of seroma aspirated.
The highest volume of seroma aspirated in Group A was observed later and for a
shorter duration than in Group B, indicating that quilting sutures not only
decrease the volume of seroma produced but are also associated with later onset
and earlier resolution with a lower number of stitches (16 stitches) than that
reported in other studies (40 to 45 points)3.
Similar to the findings of other studies, there was no statistical difference
regarding BMI and age in both groups4, and
even with data showing that the use of quilting sutures increases the time of
surgery by 30 min3, no statistical
difference was observed between the groups in the time of surgery, justifying
their use when the incidence of complications such as dehiscence and
epitheliolysis of scars was reduced.
CONCLUSION
In this study, the development of seroma in abdominoplasty was significantly
lower in the group in which the Baroudi-Ferreira technique was used.
COLLABORATIONS
|
RGSC
|
Analysis and/or interpretation of data; statistical analyses; final
approval of the manuscript; conception and design of the study;
completion of surgeries and/or experiments; writing the manuscript
or critical review of its contents.
|
|
AMSA
|
Final approval of the manuscript; writing the manuscript or critical
review of its contents.
|
|
RKAF
|
Conception and design of the study; writing the manuscript or
critical review of its contents.
|
|
RCR
|
Analysis and/or interpretation of data; writing the manuscript or
critical review of its contents.
|
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1. Universidade Federal do Estado do Rio de
Janeiro, Rio de Janeiro, RJ, Brazil.
2. Hospital Universitário Gaffrée e Guinle, Rio de
Janeiro, RJ, Brazil.
Corresponding author: Rafael Garrido Souza
Costa
Rua Mariz e Barros, 775 - Maracanã
Rio de Janeiro, RJ, Brazil
Zip Code 20270-001
E-mail: rgscosta@gmail.com
Article received: November 27, 2017.
Article accepted: May 17, 2018.
Conflicts of interest: none.
