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Objective: A burn injury has two defined areas: central necrosis and an adjacent area of ischaemia, which may or may not progress to necrosis. The concentration of nitric oxide (NO) increases after burn injury and may originate from potent oxidising agents. Methylene blue (MB) may act as an antioxidant and is supposed to reduce burn progression. This investigation was carried out to evaluate the effects of intradermal MB on necrosis progression in burns. Methods: Full-thickness burn injuries were performed by applying a heated metal comb on the shaved back of male Wistar rats. The animals were divided into three groups: Control (C, n=7); MB (2mg/kg) one hour after burn injury (MB1h, n=11); and MB (2mg/kg) six hours after burn injury (MB6h, n=8). After seven days the lesions were photographed for visual assessment of burn necrosis; full-thickness cuts of lesions were dyed with Masson and Giemsa for microscopic histopathology; and tissue fragments of unburned interspaces were processed for chemiluminescence with nitrite/nitrate (NOX) and malondialdehyde (MDA) as oxidative stress markers. Results: No statistically significant differences between groups were observed during visual analysis and NOX dosage. However, in microscopic analysis, the MB1h and MB6h groups showed smaller areas of necrosis, less inflammatory infiltration, and a more significant extension of interspaces. Furthermore, the dosage of MDA revealed that the MB1h group showed lower values when compared with the control group (p=0.001). Conclusions: The study provided good evidence that MB intradermal injection can reduce necrosis progression in ischaemic perilesional areas and suggests an alternative to treating burns.

Since the first publication of gluteal fat augmentation, vacuum-assisted liposuction (VAL) continues to be used for fat harvesting due to its effectiveness and predictability. A vacuum pump is connected to an intermediary glass container that will store and decant the lipoaspirate to be grafted. Its pressure can be lowered down to a level that allows to harvest fat without causing excessive tissue and cell damage. Fat grafting is then performed using syringes.

According to recent data, augmentation gluteoplasty continues to gain popularity in the United States and globally, especially in procedures involving fat grafts. However, serious concerns about its safety have been raised over the past 2 years. Will this trend continue or has it already reached its peak? The answer depends on how the technique is going to be performed hereafter. In this article, the following seven learning objectives for performing gluteal augmentation safely and effectively are covered: (1) the concept of what is a beautiful buttock and how to select the patients who will have better outcomes; (2) diagram each patient's needs for liposuction and graft; (3) use maneuvers for contouring and projection; (4) compare specific indications for fat graft and gluteal implants; (5) evaluate ptosis grade to indicate whether volume repositioning is sufficient; (6) formulate care protocols for risk management; and (7) develop lasting and high-satisfaction-rate results. It is pivotal to recognize each patient's body characteristics and ability to achieve a good result, and to work on her expectations preoperatively and accordingly to perform the procedure in the safest manner possible. Clinical question/level of evidence Therapeutic, V.

Conventional abdominoplasty in anchor (with “en bloc” resection of the vertical and horizontal skin components) for patients after massive weight loss is related to some disadvantages. This study aimed to evaluate the outcomes of patients undergoing abdominoplasty in anchor with staged skin resection. This was a retrospective case series based on clinical evaluation of patients undergoing abdominoplasty in anchor with the technique of staged skin resection (first the vertical skin component followed by the horizontal component). We evaluated patient data, postoperative complications, patient satisfaction, and esthetic analysis of the postoperative outcomes using photographs at 12 months after surgery (performed by three independent plastic surgeons through a scale from 0 to 10, in which scores were assigned to the visual parameters). The 24 patients included in this study had a mean age of 42.58 years and a pre-abdominoplasty body mass index of 26.94 kg/m2. The overall mean of complications was 45.8%; the most common postoperative complication was seroma (n = 6), followed by infection (n = 3), dehiscence (n = 2), hematoma (n = 2), hypertrophic scar (n = 2), unaesthetic scar (n = 1), and retraction of the umbilicus (n = 1). Postoperative esthetic evaluation provided an average score of 5.61 for these patients. Compared with the literature about the conventional technique of en bloc resection, abdominoplasty in anchor with staged skin resection showed a similar rate of postoperative complications, and the esthetic evaluation of postoperative outcomes was considered satisfactory.

Following burn, increased nitric oxide (NO) combine with superoxide anion forming peroxynitrite. Methylene blue (MB) has NO blocking and antioxidant effects. Male Wistar rats (250g) were burned bilaterally in dorsum with a comb metal plate heated inside boiling water and applied during 30s, creating four rectangular 10×20mm full-thickness burned areas separated by three 5×20mm unburned interspaces (stasis zone). 30 rats were randomized into three groups (n=10): treated groups received one dose of intraperitoneal (IP) MB injections (2mg/kg), one or six hours after injury, and control group received saline. Seven days after injury, wounds were visually analyzed for interspaces necrosis; full-thickness sections were evaluated with Masson staining; tissue fragments were processed for nitrite/nitrate (NOx) and malondialdehyde (MDA) dosages. Photographic analysis: interspaces progression to necrosis were higher in control (64.8%) than in one (44.7%) and six (13.3%) hours MB groups (P=0.0060). Histopathology showed lower necrosis percentage in one (34.85%) and six (41.62%) hours MB groups than control (77.03%) (P=0.0034) and higher normal skin percentage in one (25.33%) and six (26.85%) hours MB groups than control (8.32%) (P=0.0037). Re-epithelialization skin areas were higher in both MB groups (39.94% for one and 31.89% for six hours) than control (14.63%) (P=0.0210). Interspace's NOx increased in both MB groups (P=0.0130) with no difference in burned areas. No MDA difference was observed. IP MB injection one or six hours after injury reduced necrosis progression in stasis area in the rat comb burn model suggesting an antioxidant effect reducing oxidative stress.

Patients who underwent orthotopic liver transplantation (OLT) frequently develop chronic kidney disease, with those who present postoperative acute kidney failure and require renal replacement therapy (RRT) at higher risk. The objective of the study was to assess the kidney function and long-term survival of patients who underwent OLT and required RRT during or in the immediate postoperative period. Medical records of OLT and postoperative RRT patients with over 6-month survival were reviewed between January 1, 2005, and December 31, 2015. A variance analysis was carried out for repeated measurements to compare the estimate glomerular filtration rate (eGFR) baseline with the different periods (statistical significance level P .05). Kaplan-Meier estimator was used to estimate the survival rate. Of 539 patients, 20 (3.7%) met the selection criteria. The basal eGFR at 6 months and 1, 3, 5, and 7 years was 93.41 ± 25, 78.28 ± 33, 73.06 ± 29, 65.96 ± 19, 79.81 ± 28, and 59.06 ± 24 mL/min/1.73 m

Background Gluteal fat augmentation has increased worldwide, and so have major complications. Brazilian plastic surgeons have been performing this procedure for more than 30 years, and more often every year. Therefore, the authors performed a study among board-certified plastic surgeons, members of the Brazilian Society of Plastic Surgery, to evaluate their techniques; identify their preferences, complications, and outcomes with this procedure; and make some recommendations. Methods An anonymous Web-based survey consisting of 16 questions was sent to 5655 members in July of 2017. A supplementary survey was subsequently sent to obtain more information about major complications. Results A total of 853 responses were analyzed. The highest percentage of responses in the different categories were as follows: fat decantation for processing, injection with a 3-mm-diameter cannula, use of superior incisions, subcutaneous fat grafting only, and with a volume of 200 to 399 ml of fat per buttock. The majority of surgeons received training in this procedure during residency. The most common complications were contour irregularities. The estimated mortality rate was one in 20,117 cases, and the rate of nonfatal fat embolism was one in 9530. The risk of death was 16 times greater when fat was injected intramuscularly. Conclusions Based on this survey, the authors recommend injecting fat only subcutaneously, by means of superior incisions, using cannulas 3 mm in diameter or more. They find that by following these recommendations, this procedure can be as safe as any other. More research to establish guidelines and increase its safety is necessary.

Bullous pemphigoid (BP) is a disease caused by antibodies against components of the basement membrane, mainly two proteins: BP180 and BP230. We present two cases of BP related to chronic renal rejection. This article is protected by copyright. All rights reserved.

Acute swelling of the parotid glands after general anesthesia has become known as anesthesia mumps. Its cause is unknown. Only one case of postsurgical parotitis without general anesthesia is reported. This report describes three cases in this setting after plastic surgery. A 37-year-old women underwent breast surgery and abdominoplasty with a dual thoracic/lumbar epidural block (bupivacaine 0.5 %). The operative time totaled almost 6 h. Subsequently, 4 h after surgery, the patient experienced painless bilateral parotid swelling without palpable crepitus. The edema resolved completely within 12 h under clinical observation and parenteral hydration. A 45-year-old patient received subglandular breast implants and body contouring with liposuction, all with the patient under a dual thoracic/lumbar epidural block with 0.5 % marcaine. The total surgical time was 5 h. Subsequently, 3 h after surgery, the patient experienced a similar clinical presentation. The problem resolved completely in 36 h with clinical observation and parenteral hydration. A 30-year-old patient received a subglandular breast implant and underwent liposuction of the outer thighs using a dual thoracic/lumbar epidural block with lidocaine 1 %. The duration of surgery was 1 h. Subsequently, 5 h postoperatively, the patient experienced a similar clinical presentation. Dexamethasone and parenteral hydration were administered. The problem resolved completely in 48 h without sequelae. The occurrence of parotitis in patients undergoing surgery under epidural anesthesia is a novel situation, which increases the range of possible etiologies for this little known condition. Dehydration leading to transient parotid secretion obstruction may play a significant role. Further reports of parotitis occurring in the regional anesthesia setting are expected to help elucidate its pathophysiology. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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Erythropoietin (EPO) is a hematopoietic growth factor and an alternative to avoid blood transfusion in high-blood-loss surgeries. We evaluate EPO efficacy to reduce clinically relevant anemia and dehydration in patients undergoing liposuction. We prospectively evaluated 50 consecutive patients subjected to liposuction greater than 2.5 L and alternately assigned into two comparable groups (25 patients each), except for the postoperative administration of erythropoietin (4000 UI per day subcutaneously) during five consecutive days. Incidence data for blood transfusion or parenteral hydration were collected. Statistical analyses were performed with significance at p value

The experimental investigation was performed to study the effects of methylene blue (MB) on hemodynamic, biochemical, and tissue changes among rabbits undergoing liver ischemia and reperfusion (IR). Twenty-four rabbits were randomized into 5 groups: 1, SHAM, control; 2, MB infusion bolus (3 mg/kg); 3, IR, hepatic ischemia for 60 minutes followed by 120 minutes of reperfusion; 4, MB-R, undergoing ischemia that had received an MB bolus infusion (3 mg/kg) prior to reperfusion; 5, R-MB, undergoing ischemia and MB bolus infusion after hemodynamic instability caused by reperfusion. The analysis included continuous recording of vital signs. Blood samples were collected at 0, 60, and 180 minutes of IR to determine blood gases as well as biochemical markers of liver function, nitric oxide, lipid peroxidation, and neutrophil activity. At the end of each experiment, liver tissue samples were collected for histological evaluation of parenchymae markers. Statistical analysis used two-way analysis of variance (ANOVA) tests with significance set at P < .05. Vital signs significantly improved with MB infusion, irrespective of whether it was applied before or after reperfusion. Blood gas data revealed different patterns among the SHAM, MB, IR, MB-R, and R-MB groups, without statistical significance, except for favorable lactate results in the R-MB group (P < .01), which displayed greater survival. Biochemical tests did not show significant differences among the groups, whereas histological analysis revealed favorable appearances for the MB-R and R-MB groups. The MB effect lasted long after reperfusion, suggesting that improvement in the hemodynamic parameters was not based on liver integrity, but rather was possibly related to endothelial function.

The female waist-hip ratio of around 0.7 is reachable through liposuction and gluteal fat grafting. The authors evaluated the reliability of this technique.Prospective evaluation was performed of all female patients subjected to gluteoplasty with autologous fat tissue between July of 2010 and July of 2013 without a weight change greater than 10 percent during follow-up. Results were evaluated through photographs. The degree of satisfaction (patient and surgeon) was assessed on a scale of 1 (poor outcome) to 4 (excellent improvement), and agreement was measured by Kappa statistics. The technique involved epidural anesthesia, tumescent infiltration, liposuction around the buttocks, fat decantation, and grafting with retrograde injection in different planes.A total of 106 patients were included. Patient age ranged between 18 and 62 years (mean, 33 years). The preoperative body mass index was between 19 and 31.6 kg/m (mean, 24.8 kg/m). The volume grafted to the buttocks ranged between 180 and 840 cc (mean, 505 cc). There were no medical complications. Five patients (4.7 percent) had seroma in the donor area, 103 patients felt satisfied (97.1 percent), scoring 3 and 4, one patient (0.94 percent) complained of volume resorption 4 months postoperatively, and two patients (1.88 percent) asked to diminish their lateral gluteal volume (score 2) and underwent revision surgery 6 months postoperatively.This gluteoplasty technique is simple and inexpensive, with minimal morbidity and excellent results. A good result depends on harmoniously combining fat elimination by liposuction and fat grafting for buttocks sculpting, with lasting results.Therapeutic, IV.

Wound healing is a complex regulated process that results in skin scar formation in postnatal mammals. Chronic wounds are major medical problems that can confer devastating consequences. Currently, there are no treatments to prevent scarring. In the early fetus wounds heal without scarring and the healing process is characterized by relatively less inflammation compared to adults; therefore, research aimed at reducing the inflammatory process related to wound healing might speed healing and improve the final scar appearance.

Patients who suffer from severe burns develop metabolic imbalances and systemic inflammatory response syndrome (SIRS) which can result in multiple organ failure and death. Research aimed at reducing the inflammatory process has yielded new insight into burn injury therapies. In this review, we discuss strategies used to curb inflammation in burn injuries and note that further studies with high quality evidence are necessary.

Sir: Galactocele is a rare breast augmentation complication. Addressing the risk factors involved, Harper et al1 found from previous galactocele reports that 100% of the implants were placed through periareolar incisions and 75% of patients either were on oral contraceptives at the time of their surgery or were lactating after pregnancy, with a remote history of augmentation mammaplasty. A recent retrospective study involving 832 patients and 3 (0.36%) cases of galactocele2 found that the use of a periareolar incision significantly increased the incidence of galactorrhea, but no mention toward increased risk of galactocele. We present a case of postaugmentation galactocele formation without periareolar incision and 8 years after her unique pregnancy. Our patient was a 26-year-old, gravida 1, para 0, abortus 1, without any significant medical or surgical history. She stopped oral contraceptives 30 days before and after surgery. An ultrasound scan showed 1 small (1.1 cm3) benign simple cyst in each breast. She underwent bilateral subglandular augmentation mammaplasty with 285 mL high-profile Silimed (Rio de Janeiro, Brazil) silicone gel implant and vertical, infra-areolar skin excess resection. She developed a painful enlargement of her left breast on postoperative day 17, without signs of inflammation or fever (Fig. ​(Fig.1).1). A postoperative ultrasound scan showed liquid collection around the implant but not suggestive of hematoma. A guided needle aspiration removed 89 mL of creamy fluid; the culture was negative for bacterial growth but biochemistry analyses concluded that it was breast milk. The patient was referred to a mastologist who started dopamine receptor agonist (bromocriptine), despite normal prolactin, for 2 weeks with no recurrence. Due to breast and implant pocket enlargement, the patient underwent revision surgery 6 months later to correct the left ptosis (Fig. ​(Fig.2)2) by skin resection, and the implant was moved to a dual plane pocket. The implant on the other side was also moved to the dual plane pocket due to breast symmetry. Fig. 1. Marked enlargement of the left breast at day 17 postoperatively. Fig. 2. Residual asymmetry due to left breast and implant pocket enlargement after galactocele’s treatment at 6 weeks postoperatively. Galactocele’s pathogenesis is still unknown, but obstruction of breast ducts associated with high levels of prolactin may play a significant role.3 Hyperprolactinemia may be due to intercostal nerve stimulation during surgery, leading to autonomic control over central neurogenic paths diminishing dopamine output into hypophysis’ portal circulation, increasing prolactin levels and milk secretion.4 Because our patient had none of the risk factors previously reported5 (periareolar incision, contraceptives intake, recent pregnancy or lactation, or hyperprolactinemia symptoms), we rely our etiopathogenesis hypothesis on duct obstruction because simple cysts were found preoperatively inside breast parenchyma. The treatment involved ultrasound-guided needle aspiration associated with dopamine agonist (bromocriptine) to halt hyperprolactinemia and milk production, which was successful with no recurrence. Other causes of hyperprolactinemia should be ruled out. Although it is rare, surgeons should be aware of this complication in augmentation mammaplasty. Considering the potential increased risk for galactocele, patients with previous thoracic or breast surgery, breast cysts, or spontaneous breast discharge should be assessed preoperatively for prolactin status to correct eventual disorders.

Objective: This study was carried out to determine high pressure and pulsatile flow perfusion effects on human saphenous vein (HSV) segments obtained from diabetic and non-diabetic patients. Methods: The veins were perfused with oxygenated Krebs solution for 3 h, with a pulsatile flow rate of 100 mL/min and pressures of 250 × 200 or 300 × 250 mmHg. After perfusion, veins were studied by light microscopy; nitric oxide synthase (NOS) isoforms, CD34 and nitrotyrosine immunohistochemistry and tissue nitrite/nitrate (NOx) and malondialdehyde (MDA) quantification. Results: Light microscopy revealed endothelial denuding areas in all HSV segments subjected to 300 × 250 mmHg perfusion pressure, but the luminal area was similar. The percentage of luminal perimeter covered by endothelium decreased as perfusion pressures increased, and significant differences were observed between groups. The endothelial nitric oxide synthase (eNOS) isoform immunostaining decreased significantly in diabetic patients’ veins independent of the perfusion pressure levels. The inducible NOS (iNOS), neuronal NOS (nNOS) and nitrotyrosine immunostaining were similar. Significant CD34 differences were observed between the diabetic 300 × 250 mmHg perfusion pressure group and the non-diabetic control group. Tissue nitrite/nitrate and MDA were not different among groups. Conclusions: Pulsatile flow and elevated pressures for 3 h caused morphological changes and decreased the eNOS expression in the diabetic patients’ veins.

The formation of seromas after abdominoplasty is a highly prevalent complication that disturbs both the patient and the surgeon. Aspiratory drainage and adhesion sutures (Baroudi suture) are widely used to prevent this complication. This study evaluated the effectiveness of drains in preventing seromas. This retrospective study investigated women submitted to classic abdominoplasty with adhesion sutures. The women were divided into two groups. Group 1 comprised 28 individuals who received no drains, and group 2 consisted of 32 patients that had drains placed. Clinical evaluation of the patients was performed 7 days, 14 days, 1 month, 2 months, 4 months, and 6 months postoperatively. Statistical analysis was accomplished via Fisher’s exact test. Group 1 had one case of seroma (3.5%), clinically detected between the first and second postoperative months, whereas group 2 had one case (3.12%) detected 14 days postoperatively. Fisher’s test showed a P value of 1.000 (not statistically significant), for a 95% confidence interval of 0.05 to 14.08 and an odds ratio of 0.8387. Clinical evaluation showed no statistical difference in the incidence of seromas after abdominoplasty with adhesion sutures between the patients who received drains and those who did not. The use of adhesion sutures is an effective measure for preventing seromas with no need for additional surgical measures.