INTRODUCTION
Brazil is considered the first country in the world ranking of aesthetic surgical
procedures according to the International Society of Aesthetic Plastic Surgery (ISAPS).
Liposuction represents 14% and abdominoplasty 7.4% of all surgeries performed. Women
are those who most resort to cosmetic surgery, with 9.9 million cases in 2013, 85%
of the total1.
Even though they are very common surgeries, abdominoplasty and liposuction frequently
present intercurrences and complications2-4 such as ecchymosis. This complication motivates a treatment routine by a dermatofunctional
physiotherapist who, over the past few years, has been looking for effective treatments
to work in the pre, intraoperative and postoperative periods, preventing and treating
bruises, so that there is a decrease in pain, severe edema, hyperpigmentations and
possible disorganized fibrosis, which can impair the recovery of plastic surgery patients.
The ecchymosis is caused by microvessels’ disruption in the operative field, leading
to intravascular extravasation to the adjacent soft tissues5. This can be a source of distress for patients, resulting in a longer postoperative
recovery time and a delay in returning to work6.
The use of taping for the prevention and treatment of ecchymosis is not yet well evidenced.
Chi et al. (2018) 7 report the prevention of ecchymosis using lymphatic taping in transoperative surgery,
with a decrease in postoperative treatment sessions (PO), complications and intercurrences
such as disorganized fibrosis.
A study with rats demonstrated a significant increase in epidermal-dermal distance
in the group with the application of taping after trauma, thus observing a reduction
in the area of edema and, consequently, an additional reduction in lymph fluid congestion
or hemorrhages under the skin8.
Kane et al. (2000) 9 reported an important finding in their immunohistochemical studies showing that there
is a reduction in the relative expression of Bcl-2 where taping was applied after
trauma. As Bcl-2 presents an increase soon after the injury to allow cell proliferation
and then has a reduction to interrupt the inflammatory process and regulate the proliferative
phase. This finding confirms the importance of taping to reduce the inflammatory process
after soft tissue injury.
Because of the above, this study proposes an unprecedented approach to the transoperative
period using lymphatic taping, intending to prevent and/or minimize ecchymosis, thus
possibly reducing the number of visits and accelerating the patient’s recovery and
promoting early discharge.
OBJECTIVE
This study aims to evaluate the occurrence of ecchymosis in patients submitted to
abdominoplasty associated with traditional liposuction of the abdomen and flanks and
to statistically correlate these occurrences with the treatment of lymphatic taping
during surgery.
METHODS
This is a controlled clinical trial conducted between August and December 2018. The
study was conducted with the consent of the Ethics Committee of the Centro de Ensino
Superior do Campos Gerais, in Ponta Grossa, PR (83210717.5.0000.5215). After signing
the appropriate terms of free and informed consent, data collection was then initiated.
Women who were in the preoperative, transoperative and postoperative phase of plastic
surgery of abdominoplasty and/or traditional liposuction of the abdomen and flanks
aged between 20 and 60 years were included in the study. The sample consisted of 20
patients, divided into 10 in the control group (CG) and 10 in the experimental group
(EG).
After signing an informed consent form, and according to the procedures to be performed,
both the CG and the EG were evaluated preoperatively and on the 4th postoperative
day.
The 20 patients did not use any form of containment such as surgical meshes or containment
plates during the 4 days postoperatively that could interfere with the results.
The CG and EG were evaluated preoperatively, with data collection such as: personal
data, surgery data, abdominal and flank semiology, and photo documentation.
The CG did not receive any form of treatment, being evaluated only preoperatively
and on the 4th postoperative day with photo documentation and VAS (visual analog pain
scale).
The EG group received transoperative treatment with the application of lymphatic taping
in the abdomen and flanks region. Lymphatic taping is considered when cutting is done
in “fan” or octopus, i.e., with cut sections in its active band and with a base of
3cm to 5cm. Thus, this form of application helps the lymphatic system to capture the
interstitial fluid8. The bandages were cut into five different parts, being positioned with minimum tension
(0 to 20%) in the lateral regions (with the base fixed in the midline of the lateral
region of the abdomen or bilateral axillary region) (Figure 1) and flanks (with the base in the bilateral coccygeal region) (Figure 2). Lymphatic taping acted until the 4th postoperative day, being removed for the reassessment
of EG patients.
Figure 1 - Lymphatic taping with fan cut in anterior region of the abdomen.
Figure 1 - Lymphatic taping with fan cut in anterior region of the abdomen.
Figure 2 - Lymphatic taping with fan cut in flank region.
Figure 2 - Lymphatic taping with fan cut in flank region.
The CG was evaluated on the 4th postoperative day with photo documentation to analyze
ecchymosis (type, location and resolution) and VAS (visual analog pain scale) for
pain analysis.
From the collected data, a database was created, which was submitted for data analysis.
Descriptive statistics and variance analysis were used as statistical methods.
They were statistically analyzed: type, location and resolution of the ecchymosis
and pain in both groups.
RESULTS
With the data collected during the pre and postoperative period in the control and
experimental group, the variables ecchymosis were evaluated and compared in both groups.
Descriptive statistics and variance analysis were performed to evaluate the results.
The standard deviations of the variables by groups approved in the normality tests
were submitted to the T-test to guide the choice of the most appropriate parametric
test to analyze the variance of the means (t-test or t-test with Welch correction).
It was considered as significant a value of p£0.05.
The quantitative variables data were submitted to the Kolmogorov-Smirnov normality
test (KS) to guide the choice between parametric or nonparametric tests.
The data sets not approved in the KS tests were submitted to the Mann-Whitney nonparametric
test.
The ecchymosis resolution variable showed a significant difference between the means(p<0.05).
From the unpaired t-test, evidence of significant differences was found, at the level
of 5% probability, between the experimental treatment group and the control group
concerning the resolution of the ecchymosis (Table 1). Rejecting, therefore, the null hypothesis.
Table 1 - Summary and p-value statistics of the analysis of variance of ecchymosis resolution
between groups.
Variable |
Group |
p-value |
Experimental Control |
Ecchymosis resolution |
µ |
17.6 |
7.8 |
0.0002 |
|
5.0 |
4.3 |
|
Table 1 - Summary and p-value statistics of the analysis of variance of ecchymosis resolution
between groups.
The experimental group presented a lower mean in the resolution of the ecchymosis(µ=7.8±4.3),
statistically significant (p=0.0002) concerning the control group (µ=17.6±5.0).
The results of the p-value less than 5% indicate that the deviations are significant,
that the variables are dependent and that the samples differ significantly in the
proportions of these classes. Rejecting, therefore, the null hypothesis (Table 2).
Table 2 - Summary and p-value statistics of variance analysis between groups. Sites of ecchymosis
compared in CG and EG.
Variable |
Classes |
Control |
Experimental |
p-value |
Sugilation-type ecchymosis |
Abdomen and flanks |
2 |
0 |
*0.0056 |
Lower abdomen |
0 |
1 |
Side abdomen D and E |
2 |
0 |
Flank D |
0 |
1 |
Flanks |
6 |
0 |
Flanks D and E |
0 |
1 |
Lower lumbar |
0 |
1 |
No |
0 |
6 |
Table 2 - Summary and p-value statistics of variance analysis between groups. Sites of ecchymosis
compared in CG and EG.
As shown in Table1, statistically significant results were found between the experimental treatment
group and the control group about the resolution of ecchymosis. The experimental group
presented a better response in the resolution of ecchymosis (µ=7.8±4.3), concerning
the control group (µ=17.6±5.0) (p=0.0002).
Table 2 compared the distribution of classes in the two samples. The results presented demonstrate
an improvement in EG with the use of lymphatic taping. The appearance of sugilation-type
ecchymosis was lower in the EG when compared to the CG, with statistically significant
results(p=0.0056). These results can be observed in Figures 3, 4, 5, 6, 7 and 8.
Figure 3 - 4th PO control group.
Figure 3 - 4th PO control group.
Figure 4 - 4th PO experimental group.
Figure 4 - 4th PO experimental group.
Figure 5 - 4th PO control group.
Figure 5 - 4th PO control group.
Figure 6 - 4th PO experimental group.
Figure 6 - 4th PO experimental group.
Figure 7 - 4th PO control group.
Figure 7 - 4th PO control group.
Figure 8 - 4th PO experimental group.
Figure 8 - 4th PO experimental group.
No pain was reported in the region operated in the experimental group, while the control
group presented an average of up to 5.50±1.58 PO (Table 3).
Table 3 - Summary and p-value statistics of variance analysis between groups. Pain table compared
in CG and EG.
Variable |
Classes |
Control |
Experimental |
p-value |
Pain frame |
Up to 4 PO |
4 |
0 |
*0.0005 |
Table 3 - Summary and p-value statistics of variance analysis between groups. Pain table compared
in CG and EG.
The visual analog pain scale (VAS) was also performed, in which the experimental group
did not report pain in the operated region.
DISCUSSION
The present study evaluated the response of ecchymosis after abdominal liposuction
surgeries and flanks using lymphatic taping. It should be observed that the experimental
group obtained significant results (p=0.0002) regarding the resolution of ecchymosis
compared to the control group. This data corroborates the study by Zanchet and Vecchio
(2011)10 and Chi et al. (2018) 7, who verified the absorption of ecchymosis with the application of taping.
Recent research, such as the study by Nihan et al. (2015) 11, seeks to clarify the performance of lymphatic taping physiologically. The authors
verified that the circumvolutions created in the epidermis and caused by taping increased
the distance between the epidermis and the dermis by approximately 30 min (1.5 times),
and in 6 hours approximately three times compared to the unapplied side. With this
study, it can be affirmed that this distancing of the dermis and epidermis can lead
to an even greater reduction of lymph fluid congestion or hemorrhage under the skin11. This factor could also explain the decrease in edema and ecchymosis in the present
study.
Another issue to be considered was the decrease and/or absence of pain reports in
the experimental group, especially in the operated region. In this case, according
to the findings of Chi et al. (2016) 12, postoperative treatment should be initiated as early as possible to avoid post-surgical
complications such as seroma, prolonged edema, refractory ecchymosis, and intense
pain.
In the experimental group, a low occurrence of bruises was observed. It is believed
that the use of the lymphatic taping technique to assist in the absorption of edema,
with the patient still in the operating room (transoperative), was responsible for
the low index of ecchymosis, as demonstrated by our results. When applied to the skin,
taping provides a greater opening of the initial lymphatic capillaries, favoring the
absorption of the interstitial fluid into the lymphatic vessels and the consequent
reduction of the ecchymosis13-15.
In the present study, there was a concern to preserve patients’ skin, mainly because
it is a treatment during the surgery of plastic surgery. Studies report the association
of taping with some skin and allergic reactions14,15; thus, the cut format in “ fan “uses smaller areas of skin-taping contact in an attempt
to minimize the occurrence of these problems16. Therefore, we emphasize using the “fan” cut in the transoperative treatment of plastic
surgery.
Lymphatic taping has been used extensively in several areas of physiotherapy and has
stood out in the treatment of edema17. Its results are considered empirical, and no study reports its effect on a lymphoscintigraphy
examination. Marquetti et al. (2019)17 verified the performance of lymphatic taping in the lymphatic system by lymphoscintigraphy
examination. In evaluating the lymphatic system by lymphoscintigraphy, they observed
that the values analyzed are relatively higher when the patient has lymphatic taping
applied with 10% and 20% tension in the lower limbs cut into “fan “or octopus format.
This corroborates the findings of this research, where the prevention and treatment
of ecchymosis possibly occurred due to the action on the lymphatic system, which would
be stimulated more intensely. Thus, it is suggested that when it is still applied
during the transoperative period, taping assists in the capture of blood extracted
to the interstitium and stimulates tissue oxygenation. This is visualized in the comparison
of the control group with the experimental group.
CONCLUSION
It can be concluded that the use of lymphatic taping in the transoperative period
reduces the formation of ecchymosis and the incidence of pain in the postoperative
period due to its action on the lymphatic system. In this way, the number of physiotherapy
visits is reduced, and the patient’s recovery is accelerated in the postoperative
period of liposuction and abdominoplasty surgeries with fewer complications and intercurrences.
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1. Instituto Universitario Italiano de Rosario, Doctorate in Health Sciences, Rosario,
Argentina.
2. Universidade do Sul de Santa Catarina, Physiotherapy, Florianópolis, SC, Brazil.
Autor correspondente: Anny Chi, Rua Nestor Guimarães, 77, Sala 304, Estrela, Ponta Grossa, PR, Brazil. Zip Code:
84040-130 E-mail: annychi10@hotmail.com
Article received: October 28, 2019.
Article accepted: April 23, 2021.
Conflicts of interest: none
COLLABORATIONS
AC 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
MGM Final manuscript approval, Writing - Review & Editing
MD Writing - Review & Editing