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Evaluation of Aesthetic Abdominal Surgery Using a New Clinical Scale
Abstract
Evaluation of outcomes after aesthetic surgery still is a challenge in plastic surgery. The evaluation frequently is based on subjective criteria. This study used a new clinical grading scale to evaluate aesthetic results for plastic surgeries to the abdomen. The method scores each of the following five parameters: volume of subcutaneous tissue, contour, excess of skin, aspect of the navel, and quality of the scar on the abdominal wall. The scale options are 0 (poor), 1 (fair), and 2 (good), and the total rate can range from 0 to 10.
The study included 40 women ages 18-53 years. Of these 40 women, 20 underwent traditional abdominoplasty, and 20 had liposuction alone. Preoperatively and at least 1 year later, photographic results were analyzed and scored by three independent plastic surgeons.
In the abdominoplasty group, the average grade rose from 2.9±0.4 to 6.8±0.4 postoperatively. In the liposuction group, the average grade was 5.3±0.5 preoperatively and 7.7±0.4 postoperatively. In both groups, the average postoperative grade was significantly higher than the preoperative grade. The mean scores for groups A and L were significantly different, demonstrating that the scale was sensitive in identifying different anatomic abnormalities in the abdomen.
The rating scale used for the aesthetic evaluation of the abdomen was effective in the analysis of two different procedures: conventional abdominoplasty and liposuction. Abdominoplasty provided the greater gain according to a comparison of the pre- and postoperative scores.
... Sau 3 tháng: đánh giá cân nặng, chụp hình thẩm mỹ vùng bụng, các số đo thẩm mỹ thành bụng: số đo vòng quanh bụng dưới mũi kiếm xương ức 10cm, số đo vòng quanh bụng ngang qua rốn, khoảng cách mũi kiếm xương ức -rốn, khoảng cách rốn -mép trước âm hộ, khoảng cách rốn -vết mổ, khoảng cách vết mổ -mép trước âm hộ. Chúng tôi đánh giá hình ảnh BN trước và sau mổ 3 tháng bởi 3 bác sĩ ngoại khoa (không là phẫu thuật viên) theo thang điểm nhóm phẫu thuật viên phẫu thuật tạo hình Khoa Y, trường Đại học São Paulo [6]. ...
... Thành bụng đã trải qua quá trình sưng viêm, phù nề nên có thể đánh giá chính xác qua hình ảnh. Nghiên cứu chúng tôi phù hợp nghiên cứu Salles ở nhóm tạo hình thành bụng [6]. ...
Mục tiêu: Đánh giá tính an toàn và sự thay đổi hình dạng thẩm mỹ vùng bụng, sự thay đổi cân nặng sau tạo hình thẩm mỹ thành bụng theo phương pháp Saldanha tại khoa Tạo hình - Thẩm mỹ bệnh viện Chợ Rẫy. Đối tượng và phương pháp: Nghiên cứu hàng loạt ca tiến cứu, thực hiện trên 20 bệnh nhân được phẫu thuật tạo hình thẩm mỹ thành bụng toàn thể theo phương pháp Saldanha tại khoa Tạo hình - Thẩm mỹ bệnh viện Chợ Rẫy từ tháng 6/2020 đến 6/2021. Kết quả: Tuổi trung bình: 41.45 ± 9.58. Số đo vòng bụng ngang qua rốn sau 3 tháng giảm so với trước mổ trung bình 10.05 cm. Cải thiện về hình ảnh thẩm mỹ thành bụng sau mổ so với trước mổ theo thang điểm nhóm phẫu thuật viên tạo hình Khoa Y, trường đại học São Paulo. Có sự giảm cân nặng sau 3 tháng so với trước mổ. 1/20 trường hợp bị tụ huyết thanh, 1/20 trường hợp có vết mổ mất cân xứng giữa 2 bên. Kết luận: Tạo hình thẩm mỹ thành bụng theo phương pháp Saldanha giúp cải thiện hình dáng thẩm mỹ thành bụng, là phương pháp an toàn, ít biến chứng, có sự giảm cân nặng sau mổ 3 tháng. Abstract Objectives: Investigate the safety and improvement of the aesthetic shape of the abdomen and the change of weight after the Saldanha technique in aesthetic abdominoplasty at the Department Plastic and Aesthetic - Cho Ray hospital. Methods: Prospective cases report was carried out on 20 patients who performed a total aesthetic abdominoplasty with the Saldanha technique from 6/2020 to 6/2021. Results: The average age was 41.45 ± 9.58 years; The measure of circumference abdomen via umbilical reduced 10.05 cm after surgery; Aesthetic abdomen improved in the scale to evaluate aesthetic results for plastic surgeries to the abdomen of the group surgeons, Faculty of Medicine, University of São Paulo; The weight decreased significantly at three months after surgery; 1/20 case was seroma; 1/20 case was asymmetry of the scars. Conclusion: Aesthetic abdominoplasty with the Saldanha technique improves the abdomen’s shape aesthetic; the technique is a safe method with a low complication rate. The weight was reduced three months after surgery.
... Abdominoplasty is among one of the most common plastic surgery procedures in the USA and continues to grow in popularity, with over 130,000 surgeries completed in 2018-a 107% increase since 2000 [1]. This procedure is associated with high levels of patient satisfaction, with studies even showing significant mood i m p r o v e m e n t an d b o d y s a t i s f a c t i on fo l l o w i n g abdominoplasty in patients with psychiatric illnesses [2][3][4][5][6][7][8]. Aesthetic appeal remains a crucial feature in determining the success of plastic surgery procedures and also plays a large role in shaping patient satisfaction. ...
... Previous studies have examined the influence of various incision patterns on the aesthetic quality of abdominoplasties; however, studies defining the salient features that draw focus when assessing aesthetics in abdominoplasty are limited [4,5]. While qualitative assessments including rating scales are not rigorously validated and offer low consistency between users, quantitative approaches, such as 2D clinical imaging, also demonstrate high rates of intra-and inter-observer variability due to the lack of standardization of anatomical landmarks [9]. ...
Background
Eye-tracking technology objectively measures the visual focus of subjects when assessing aesthetics. Identifying attention-drawing features can assist in improving patient satisfaction and perceived outcomes. Using eye-tracking technology, we characterized visual gaze patterns among plastic surgery patients versus laypeople when assessing pre- and post-abdominoplasty images.Methods
Sixteen pairs of pre- and post-abdominoplasty images in AP and lateral views were shown to twenty women with and twenty women without a cosmetic procedure history. An eye-tracking device recorded visual gaze data as participants assessed the aesthetic value of the images.ResultsThe patient group spent 22.6% less time evaluating images (p < 0.05) but spent proportionally more time fixated on features of interest: the umbilicus (25.6% of their average viewing time vs 11.6%, p < 0.001), scar line (13.2% vs 5.1%, p < 0.001), and abdominal curvature (7.6% vs 3.6%, p < 0.001). Both groups most commonly first fixated on the umbilicus and abdominal curvature for AP and lateral views, respectively. The patient group’s average increase in aesthetic rating between pre- and post-procedural images was 30.4% higher than the lay group (p < 0.05). No correlation was noted between aesthetic ratings and time spent viewing the areas of interest.Conclusions
Females who previously underwent cosmetic procedures are more favorable, faster, and focused reviewers of abdominoplasty images, fixating more on relevant anatomy and features than their peers. New patients may benefit from an eye-tracking-based assessment to align procedural planning and consultation with the anatomic areas they visually fixate upon.Level of evidence: Not ratable.
... Demographic characteristics, indications, details of the operative technique, and complications were recorded. I quantified the results according to the Salles et al 23,24 clinical scale. The Salles clinical scale is a 10-point scale that includes 5 parameters, each of which is assigned 2 points. ...
... Continued= 164; range, 0-10; Salles et al.23 ...
Background
TULUA is a fundamentally different lipoabdominoplasty technique intended to reduce the risk of vascular compromise, correct wall laxity through a unique plication, allow freedom in choosing umbilical position, reduce tension on closure, and keep the final scar low.
Objectives
The objectives of this article were to describe the TULUA technique and its variations, delineate the indications and contraindications, show the expected results, and determine its safety profile.
Methods
A series of 164 patients is presented. The technique’s basic tenets were (1) infraumbilical wide transverse plication; (2) no undermining above the umbilicus; (3) unrestricted liposuction, including the supraumbilical tissues; (4) umbilical amputation and neoumbilicoplasty in the ideal position with a skin graft; and (5) low transverse scar placement. Complications were recorded and tabulated. Results were evaluated utilizing Salles’ and the author’s graded scales.
Results
Scores averaged 9.4 out of 10 on the Salles’ scale and 5.6 out of 6 on the author’s scale, demonstrating adequate correction of the abdominal contour and the wall and skin laxity, with properly placed scars and umbilici, without compensatory epigastric bulging. Overall, 20% of the patients experienced a complication; 9.7% experienced delay in healing or graft take of the umbilicus, 0.6% developed skin necrosis, 0.6% experienced a wound dehiscence, 2.4% had an infection, and 4.9% developed a seroma.
Conclusions
The TULUA lipoabdominoplasty technique was found to improve abdominal wall laxity and aesthetics similar to traditional abdominoplasty, based on the evaluated parameters. The complications associated with the procedure are within the range of other abdominoplasty techniques, and the technique potentially has a reasonable safety profile with less risk of vascular compromise.
... A patient survey was created based on Salles et al. for generation of a clinical score scale to objectively measure outcomes of aesthetic surgery of the abdomen. 11 This outcomes assessment scale was developed as a tool striving for standardization of outcomes following aesthetic surgery. The five parameters in the scale include abdominal volume, contour, skin excess, appearance of the navel, and scar quality of the abdominal wall. ...
Background:
The ideal body is characterized by a muscular physique and defined anterior abdominal wall. Despite diet and exercise, many are unable to achieve this desired result. Liposuction with abdominal etching is used to achieve high-definition abdominal aesthetics. The etching technique is performed with liposuction in a superficial plane, to create indentures consistent with "six-pack abs," or definition of vertical abdominal lines.
Methods:
The authors' abdominal etching preoperative markings, surgical technique, and postoperative care are discussed. The surgeons' experience with abdominal etching in 50 consecutive patients is reviewed, including rate of complications and patient satisfaction.
Results:
The average patient age was 36.4 years. We had an almost equal number of men (n = 26) and women (n = 24), with an average body mass index of 26.7 kg/m. The average blood loss was 275 ml, the average tumescence was 6 liters, and the average lipoaspirate was 5 liters. There were no major complications such as fat embolus, deep venous thrombosis, or intraabdominal injury. The most common minor postoperative complications were contour irregularities (12 percent), seromas (10 percent), and hyperpigmentation (2 percent). The majority of patients were satisfied (98 percent). The average length of postoperative follow-up was 27 months.
Conclusions:
Abdominal etching is a safe and effective method of creating a defined anterior abdominal wall for patients who desire the muscular definition of vertical abdominal lines. Almost all of our patients reviewed were satisfied with this procedure, maintained long-term results, and had an acceptable rate of complications.
Clinical question/level of evidence:
Therapeutic, IV.
... Objective descriptions of abdominoplasty results are scarce. Salles et al. [40] in 2011 and Saldanha et al. [41] in 2013 quantitatively evaluated their results according to a scale that included five parameters (abdominal volume, lateral contour, skin laxity, umbilicus, and scar), each scored as 0, 1, or 2 points. ...
T.U.L.U.A. Transverse plication abdominoplasty. Abdominoplasty without flap elevation, full liposuction, transverse infraumbilical plication and neoumbilicoplasty with skin graft. Congreso mundial de cirugía plástica, IPRAS, Santiago de Chile, Feb 24- Marzo 1, 2013.
Despite the close focus on the anterior abdominal wall and the classification, maneuvers and materials related to the rectus abdominis and its fascia, there is no established standard concerning the extent of plication. The anterior abdominal wall is a musculoaponeurotic structure and a dynamic motor system with innervation and tonus. Therefore, the timing of the plication is as important as the suture technique and material, since the muscle relaxant will lose its effect in varying time periods. The aims of our study were to determine the change in the amount of plication between groups with and without muscle relaxants before plication and whether the amount of this change can be standardized using train-of-four (TOF) monitoring. In 2022 and 2023, 12 women aged between 25 and 48 years with a body mass index between 24 and 38 years were included in the study. Neuromuscular blockade was monitored by train-of-four (TOF) monitoring in all patients. Maximum plication areas at above-zero TOF value and zero TOF value were calculated and compared with each other. The reduction in the area of group 1, which represents the phase without muscle relaxant, and group 2, which represents the phase with neuromuscular blockade, were compared using the t-test. When assessed for above-zero TOF, the area between plication lines (a, a′) was always smaller than the area between the plication lines (b, b′) when the TOF value was zero. The t test comparison of group 1, which includes (a, a′) values, and group 2, which includes (b, b′) values, resulted in a value of p = 0.000. All cases, the plication value obtained with above-zero TOF value was lower than the plication value when the TOF value was zero. This difference was also confirmed statistically on a group basis. This suggests that neuromuscular measurements should be taken during the plication phase in the routine flow of surgery. Muscle relaxants are not routinely administered to patients undergoing abdominoplasty or rectus diastasis repair who are already under sufficient analgesia, unless there is a pressure alert on the anesthesia device. The surgeon cannot always determine the degree of muscle laxity accurately by palpation. TOF monitoring is a cost-effective quantitative method that can be easily and quickly performed, accurately determining the timing of muscle-fascia plication of the rectus abdominis. Through this approach, the anterior abdominal wall can be plicated with maximum tightness and maximum aesthetic gain can be obtained.
Level of Evidence V 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.
Recently, the frequency of treatment of patients with various deformities of the anterior abdominal wall has increased dramatically. Abdominoplasty is a large-scale surgical intervention that entails a number of complications, such as impaired lymphatic drainage, chronic seroma, the formation of “dog ears”, displacement of the navel from the central line. A technology of Scarpa’s fascia preservation (SFP) has been developed to prevent these complications. The aim of this work is to study the effectiveness of treating patients with correction of the tissues of the anterior abdominal wall using SFP technology in comparison with standard abdominoplasty. Material and мethods . The study involved 30 males and females aged 35 to 60 years with class I-II obesity who underwent complex plastic surgery of the anterior abdominal wall. Patients were divided into 2 groups of 15 people: in the 1st group, classical abdominoplasty was performed, in the 2nd, complex plastic surgery of the anterior abdominal wall using SFP technology. Observation of the patients took place in the early and late postoperative periods. Results . Group 2 patients lacked both early postsurgical and chronic seromas, did not develop so-called “dog ears”, which indicates the most favorable course of the postoperative rehabilitation period and the achievement of the best aesthetic results. Also, when using the SFP technology, there were no longterm inflammatory processes, the amount of postoperative exudative fluid in the drains decreased, the pain syndrome was significantly lower, and earlier restoration of the sensitivity of the anterior abdominal wall was noted in comparison with patients who underwent classical abdominoplasty. Complex plastic surgery of the anterior abdominal wall using SFP technology makes it possible to reduce the intensity of pain on the first day by 1.75 times (to 4 ± 1 points, p ≤ 0.05), to speed up the removal of drains (reduce the duration of exudation) by 3 times (to 16 ± 1 h, p ≤ 0.05). According to the BODY-Q scale, in the main group, satisfaction with the aesthetic result was 2 times higher than in the comparison group. Conclusions . Complex anterior abdominal wall plastics with Scarpa’s fascia preservation has a number of significant advantages over classical abdominoplasty.
Since 2005 a modified lipoabdominoplasty has been performed in selected cases, modifications are transverse elliptical plication across the lower abdominal wall, no detachment of the flap above the umbilicus, unrestricted liposuction of the abdominal flap including midline, flanks, and epigastrium; direct resection of skin and fat in the lower abdomen from the navel to the pubis and from an anterior iliac crest to the other; umbilicus amputation and immediate reconstruction in the ideal position with a skin graft, and low transverse scar placement (TULUA). It is believed that TULUA has advantages in terms of vascular safety, recovery of sensitivity, position, and quality of the neo-umbilicus and location of the transversal scar, with normal or superior aesthetic results, which could expand the indications to a larger group of patients as obese, secondary cases, umbilical hernias, ventral hernias of the hypogastrium and those with massive weight loss due to bariatric surgery. During abdominoplasty, liposuction of the detached supraumbilical flap is not recommended because of its vascular impairment and the possibility of skin and fat necrosis [1].
Background:
A growing body of literature aims to describe abdominal aesthetic goals in order to tailor surgical and non-surgical treatment options to meet patient goals. We aimed to integrate lay-person perceptions into the design of a novel professional aesthetic scale for the abdomen.
Methods:
An iterative process of expert consensus was used to choose 5 domains -1) abdominal muscle lines, 2) abdominal shape, 3) scar, 4) skin, and 5) umbilicus. A survey was developed to measure global and domain-specific aesthetic preferences on 5 abdomens. This was distributed through Amazon Mechanical Turk to 340 respondents. Principal component analysis was used to integrate survey data into weights for each of the scale's sub-questions. Attending plastic surgeons then rated abdomens using the final scale, and reliability and validity were calculated.
Results:
The final scale included eleven sub-questions - hourglass shape, bulges, hernia, infraumbilical skin, supraumbilical skin, umbilicus shape, umbilicus medialization position, umbilicus height position, semilunar lines, central midline depression, scar - within the 5 domains. Central midline depression held the highest weight (16.1%) when correlated to global aesthetic rating, followed by semilunar lines (15.8%) and infraumbilical skin (11.8%). The final scale demonstrated strong validity (Pearson r=0.99) and was rated as easy to use by 7 attending plastic surgeons.
Conclusion:
The final scale is the first published professional aesthetic scale for the abdomen that aims to integrate lay-person opinion. In addition, this analysis and survey data provide insights into the importance of eleven components in overall aesthetic appeal of the abdomen.
Background:
The assessment of the human body, whether for aesthetic or reconstructive purposes, is an inherently visual endeavor. Ideally, reproducible, prompt, and cost-effective systems of visual evaluation would exist that can provide validated assessments of the aesthetic endpoints of treatment. One method to accomplish a standardization of the appreciation of visual endpoints is the use of visual scales. The goal of this systematic review is to summarize and evaluate the use of validated visual scales within aesthetic medicine, dermatology, and plastic and reconstructive surgery.
Methods:
A literature search was performed with a defined search strategy and extensive manual screening process. The Medical Outcomes Trust guidelines for visual scales in medicine were used, with special attention paid to each study's validation metrics. The review process identified 44 publications with validation data of sufficient quality from an initial survey of 27,745 articles. All rating scales based on imaging other than standardized clinical photographs were excluded.
Results:
The review demonstrates that validated visual assessment in plastic surgery is incomplete. Within specific subfields of aesthetic medicine and dermatology, many of the (n = 20) facial aging scales were well-validated and demonstrated high reliability. Publications (n = 8) focused on the evaluation of facial clefts demonstrated heterogeneity in the methods of validation and in overall reliability. Within the areas of breast surgery (n = 9), body contouring (n = 2), and scarring (n = 5), the scales were variable in the methods used and the validation procedures were diverse. Scales using a visual guide tended to have better interrater (kappa = 0.75) and intrarater reliability (kappa = 0.78), regardless of the specific area of interest.
Conclusions:
The fields of aesthetic medicine, and aesthetic and reconstructive plastic surgery require assessment of visual states over time and between many observers. For these reasons, the development of validated and reliable methods of visual assessment are critical. Until recently, the use of these tools has been limited by their time-consuming nature and cost.
Background:
TULUA (transverse plication, no undermining, full liposuction, neoumbilicoplasty, and low transverse abdominal scar) is the acronym for a radically different lipoabdominoplasty, intended to add simplicity, improve vascular safety, and attain good results. Modifications are unrestricted liposuction, no flap detachment, massive transverse infraumbilical plication, umbilicus amputation, neoumbilicoplasty, diminished tension wound closure, and low transverse scar settlement. The objectives of this article are to describe the technique and analyze a multicenter experience.
Methods:
Sixty-eight plastic surgeons from 10 countries provided data for a retrospective review of 845 patients. Aesthetic results were scored by each surgeon using the Salles scale and analyzed in combination with complications to identify associations between patient and surgery characteristics.
Results:
Of the patients, 95.5 percent were female patients, 19.7 percent were obese, 35.6 percent had prior scars, 10.4 percent had undergone previous abdominoplasty, 6.5 percent were postbariatric, and 6.6 percent were smokers. One patient had a kidney transplant, and 16.5 percent had comorbidities. Surgery characteristics varied widely, being on average as follows: lipoaspirate, 2967 ml; resection, 1300 g; and surgical time, 3.9 hours; 46.5 percent were not hospitalized. Averaged results were 8.68 of 10 points, besides adequate positioning and proportion of scar and umbilicus, without epigastric compensatory bulging (4.9 of 6 points). Overall complications were 16.2 percent, mostly seroma (8.8 percent); vascular-related complications (i.e., necrosis, wound dehiscence, and infection) constituted 2.7 percent. There were no fatalities. The logistic regression model demonstrated that smoking and obesity duplicate the risk of complications; if age older than 60 years is added, the risk of complication increases seven to nine times. Reported indications were multiple; however, pathologic diastasis was excluded.
Conclusion:
TULUA lipoabdominoplasty is a new reproducible procedure with good quantified results and an acceptable complication rate.
Clinical question/level of evidence:
Therapeutic, IV.
Background:
The superficial fascial system is routinely closed to alleviate tension at the abdominal donor site after harvest of the deep inferior epigastric artery perforator flap (DIEP) for breast reconstruction. This is thought to decrease rates of wound dehiscence and improve contour postoperatively. There has been no comparative analysis on closure of the superficial fascial system and its effect on donor-site outcomes.
Methods:
The authors retrospectively evaluated outcomes of DIEP flap breast reconstructions performed between 2017 and 2019. After May of 2018, the surgeons collectively agreed to stop closure of the superficial fascial system. All subsequent patients underwent closure of rectus abdominis fascia followed by skin closure. Patient demographic data and abdominal donor-site comorbidities were recorded between the superficial fascial system closure and no-superficial fascial system closure groups. Representative photographs of patients from the two groups were blindly assessed for scar appearance and contour using previously published grading scales. The results were compared.
Results:
DIEP flap breast reconstruction was performed in 103 consecutive women. Among patients with abdominal donor-site reconstruction, 66 had superficial fascial system closure and 37 did not. There was not a significant difference in fat necrosis or wound dehiscence between the two groups (p = 0.29 and p = 0.39, respectively). Postoperative abdominal scar and contour were evaluated by 10 independent raters and showed no significant difference between the two groups.
Conclusion:
Omission of superficial fascial system closure resulted in no difference in wound dehiscence or fat necrosis rates and aesthetic appearance of the abdominal scar and contour.
Clinical question/level of evidence:
Therapeutic, III.
Background
The aesthetic and functional outcomes of the donor site following abdominal-based free flap breast reconstruction have been suboptimal. The objective of this study is to evaluate a modified liposuction-assisted abdominoplasty technique combined with rectus plication (LPARSP) adopted from cosmetic abdominoplasty practice.Patients and Methods
All abdominal-based free flap breast reconstructions from 01/2017 to 03/2019 were reviewed. Patients with central fullness and sufficient tissue surplus on the abdomen, thighs and flanks who received LPARSP and rectus plication were identified (LPARSP group) and matched for age and body mass index with patients who underwent conventional abdominoplasty (CA group). Abdominal skin sensation, objective functional and aesthetic measures of the abdomen, as well as patient-reported outcomes (Breast-Q), were analyzed.ResultsA total of 28 patients were included. Groups were similar in demographics. The mean amount of lipoaspirate in the LPARSP group was 1054±613.5 ml. The postoperative course was similar in both groups. The LPARSP technique resulted in a lower positioned horizontal scar (p = 0.03). The aesthetic outcome was superior in the LPARSP group (p < 0.0001). Furthermore, the LPARSP group presented with a decreased bulging rate (p = 0.05), and secondary refinement procedures were less frequently demanded (p = 0.02). In addition, the abdominal wall sensation of the flanks was improved in the LPARSP group (p = 0.05), whereby patient-reported outcome measures did not differ between groups.Conclusions
Lipoabdominoplasty with rectus plication represents a safe approach for donor-site closure in selected patients undergoing abdominal-based free flap breast reconstruction. Superior functional and aesthetic results paired with improved abdominal wall sensation are achieved compared to CA.Level of Evidence IVThis 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.
Introducción y objetivo.
Desde 2005 el autor ha realizado una lipoabdominoplastia fundamentalmente diferente para evitar complicaciones como necrosis, dehiscencia, redundancia epigástrica, cicatriz alta, mala posición del ombligo y seromas. Las modificaciones son: 1- liposucción sin restricción, 2- no despegamiento del colgajo epigástrico, 3- amputación umbilical, 4- plicatura transversal inferior de la pared abdominal, 5- neoumbilicoplastia con injerto de piel en la posición ideal y 6- ubicación baja de la cicatriz transversal (TULUA).
El objetivo del presente trabajo es recoger una serie de casuística, resaltando algunos detalles técnicos y valorando resultados.
Material y método.
Presentación de una serie de 176 pacientes con detalles de técnica y estadísticas descriptivas, cuantificando resultados con énfasis en la posición de cicatriz y ombligo y su proporción, lo mismo que el resultado de la cintura y epigastrio. Comparamos estadísticamente los cambios de la cintura y la disminución de la tensión necesaria para el cierre de la herida quirúrgica atribuidos a la plicatura transversa.
Resultados.
Los resultados estéticos fueron cuantificados en 9.4 según escala (0-10). Globalmente el porcentaje de complicaciones fue de 18.7%, la mayoría debidas a problemas con la integración del injerto del ombligo. Resaltar que solo una paciente presentó necrosis distal del colgajo y otra dehiscencia parcial de la herida. Encontramos diferencias estadísticas en la disminución de la tensión para el cierre de herida quirúrgica y cambios en la circunferencia de la cintura (p=0.001)
Conclusiones.
Los resultados estéticos cuantificados fueron altos con ventajas adicionales en términos de seguridad vascular, disminución de tensión de la herida, buena posición y calidad del ombligo, ubicación baja de la cicatriz transversal, disminución del perímetro de la cintura y corrección del epigastrio. Se trata de una técnica simple y segura que incrementa las indicaciones de abdominoplastia a un grupo más amplio de pacientes.
Background:
Abdominoplasty procedures have been proven highly valuable in promoting better quality of life for post-bariatric surgery patients. The literature reveals that the aspect of the navel is one of the most problematic issues regarding surgical results and many different surgical techniques have been proposed to obtain a satisfactory outcome. However, little is known about patients' preferences regarding these different techniques and their results. The aim of the present study was to compare evaluations made by plastic surgeons and patients of the results of two different techniques-traditional omphaloplasty and neo-omphaloplasty with lateral flaps.
Methods:
Five plastic surgeons analyzed postoperative pictures of 54 post-bariatric abdominoplasties performed between 2008 and 2013 at the Unicamp Hospital. Pictures of 12 cases were selected and evaluated by 50 patients waiting for a post-bariatric abdominoplasty. A standardized scale was used that contained the following criteria: volume of the abdomen, lateral contour, quality of the scars, umbilicus and skin excess/flaccidity.
Results:
Surgeons gave the highest scores to 71.6% of neo-omphaloplasty cases and patients to 43.7%. Both surgeons and patients graded navels operated on using this technique higher, although the comparison was not statistically significant for patient evaluations (p = 0.062). The navel aspect was considered the fourth most relevant aspect among those evaluated.
Conclusion:
Neo-omphaloplasty results were considered better than traditional omphaloplasty for surgeons and patients, although there was not a clear differentiation of results by the latter. The navel postoperative aspect was considered secondarily important by patients to the results of post-bariatric abdominoplasties.
Level of evidence iv:
This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .
BACKGROUND: Bariatric surgeries
are becoming increasingly common in the treatment of morbidly obese patients.
The enormous weight loss resulting from these procedures causes excessive skin
and subcutaneous tissue throughout the body, especially in the abdominal
region. The objective of this study was to present the technique of vertical
abdominoplasty as an alternative for resection of excess skin in ex-obese patients. METHODS: We retrospectively evaluated the records of 40
patients who underwent vertical abdominoplasty between 2004 and 2009. The
degree of patient satisfaction was assessed through a subjective scale, with
scores ranging from 0 to 10. RESULTS: Twenty-five
percent of the patients had minor complications (3 seromas, 3 minor
dehiscences, and 5 hypertrophic scars), which were all treated on an outpatient
basis. Sixty-seven percent of the patients reported high satisfaction and
considered their results as good (grades 7 or 8) or excellent (grades 9 or 10). CONCLUSIONS: The vertical abdominoplasty technique
appears to be a new option for the treatment of excess abdominal skin in
ex-obese patients.
Lipoabdominoplasty can be associated with complications, particularly tissue necrosis, wound dehiscence, epigastric bulging, high transverse scar, low positioning of the umbilicus, and seroma.
Modified abdominoplasty characterized by (1) transverse elliptical plication of the lower abdominal wall, (2) no undermining of the flap above the navel, (3) unrestricted liposuction, (4) umbilical amputation and neoumbilicoplasty by skin graft, and (5) low transversely placed abdominal scar (TULUA) was performed for 42 patients. These procedures were elective and performed primarily to remedy epigastric skin redundancy associated with obesity or when supraumbilical undermining was considered inappropriate.
The results were objectively scored as excellent for 20 patients, good for 21 patients, and fair for 1 patient. A normal-appearing umbilicus was attained in all cases except one. The lower transverse scars were generally concealable (6.3 ± 1.4 cm from the anterior vulvar commissure), and epigastric bulging was avoided. Although four patients experienced seromas at the tail ends of incisions, no skin necrosis, wound dehiscence, or other major complications such as venothromboembolism occurred, and there were no fatalities. In four patients, postoperative magnetic resonance imaging demonstrated measurable and significant changes attributable to plicature compared with equivalent control points (p < 0.000001), which persisted over time.
The TULUA procedure offers potential advantages in terms of vascular safety, sensory recovery, position and quality of the umbilicus, and transverse scar location, with aesthetic outcomes that generally eliminate epigastric bulging. A sizeable patient population stands to benefit from this approach, especially when obesity, smoking, secondary revisions, umbilical or hypogastric hernias, and massive weight loss are clinical considerations for abdominoplasty.
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 .
Lipoabdominoplasty is nearly a daily aesthetic procedure. Despite the emergence of laser-assisted liposuction, to date, it has not been clearly evaluated combined with abdominoplasty. This prospective study aimed to evaluate the effectiveness and safety of laser-assisted liposuction relative to traditional liposuction combined with high-lateral-tension abdominoplasty.
This study investigated 36 consecutive female patients who underwent high-lateral-tension abdominoplasty combined with liposuction of the upper central abdomen and both flanks. The patients were divided into three equal groups based on the technique used for liposuction. Group 1 underwent conventional liposuction with abdominoplasty. Group 2 underwent a mixture of conventional and laser-assisted liposuction with abdominoplasty. Group 3 underwent laser-assisted liposuction with abdominoplasty.
The patients in groups 2 and 3 had a better aesthetic outcome than those in group 1 with regard to abdominal contour and skin tightness. No major complications were observed in groups 1 and 2. The patients in group 3 had a higher incidence of complications (3 seromas, 3 central necroses and dehiscence), and one patient underwent secondary sutures.
Laser-assisted liposuction combined with abdominoplasty in the lateral abdomen seems to be a safe technique with good aesthetic outcomes. Although the combined use of laser-assisted liposuction in the lateral and central abdomen can achieve relatively better aesthetic results, it is associated with significant complications, and its use cannot be supported. Proper laser parameters in the central abdominal area still need further study.
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 .
The aim of this study was to evaluate the aesthetic results of lipoabdominoplasty in overweight patients (body mass index, 25 to 29.9) compared with normal weight patients (body mass index, 18.5 to 24.9).
The authors performed a retrospective and comparative analysis of late follow-up results after lipoabdominoplasty performed from 2000 to 2009 in two groups of 30 patients, one with a body mass index of 25 to 29.9 and one with a body mass index of 18 to 24.9. Aesthetic results were evaluated using a scale with five objective parameters, developed in the Faculty of Medicine, University of São Paulo. There were seven evaluators: three plastic surgeons, three nondoctors, and the surgeon performing the procedure.
For all evaluators, the postoperative average grade was significantly higher than before surgery for the entire group of patients (n = 60) and in each subgroup. The average grades for the normal weight group were consistently significantly higher than for the overweight group, both preoperatively and postoperatively, for all evaluators. However, the mean difference between the preoperative and postoperative grades, which measures the aesthetic improvement provided by the operation, was higher in the overweight group. Postoperatively, the average grade of the surgeon was significantly higher than for all other evaluator groups.
The normal weight group showed superior grades, both before and after lipoabdominoplasty, for all evaluators. However, the gain between preoperative and postoperative grades was higher in the overweight patient group, indicating that lipoabdominoplasty was beneficial even in these cases.
Therapeutic, III.
Abdominal skin overhang is not unusual after massive weight loss induced by antiobesity interventions, and poor quality of life should be feared in such circumstances, especially in women. However, long-term results of quality of life have not been often documented in this setting. With the purpose of addressing this question, a prospective study was designed.
Patients (n = 16, 100% females, age 40.1 +/- 8.0 years) submitted to standard or combined circumferential abdominoplasty were recruited for this study. All had undergone open Roux-en-Y gastric bypass between 24 and 48 months earlier with stable weight in the last 12 months. Quality of life was assessed by a trained psychologist employing of a semistructured interview, the Adaptative Operationalized Diagnostic Scale (AODS), covering affectivity/personal relations, productivity, social/cultural performance, and organic/somatic health.
Circumferential abdominoplasty was followed by few problems (serous fluid collections in 18.8%, anemia because of blood loss in 6.3%). The best overall response to the AODS questionnaire corresponded to the social and cultural domain where 81.3% of the patients had excellent adaptation (level 1). For the other three domains, results were remarkably similar with 62.5% of the tests displaying the highest value of adaptation and rare total failures.
(1) The current operation corresponded to the expectations of the patients with few complications and favorable body contouring result. (2) Quality of life, quantified by means of adaptation and social adjustment scores, was adequate in most circumstances. (3) Outstanding responses for social/cultural performance were registered with encouraging findings for affectivity/personal relations, productivity, and organic/somatic health as well.
This study investigates post-operative photographic assessment in determining the cosmetic outcome of 74 breast cancer patients who underwent a breast lumpectomy and radiotherapy. Using 10 of these patients picked at random, comparison was made between a conventional photographic print, a print produced from a digital image, and a digital image viewed on a computer screen in terms of personal preference for clinical assessment. The cosmetic outcome scores obtained on the basis of these images were compared with cosmetic outcome scores obtained by direct observation both by the clinician and by the patient. In the analysis of image preference , conventional prints scored highest, but each of the image types was considered to be acceptable for assessing breast cosmesis. Statistical analysis of the cosmetic outcome scores proved that there was a significant correlation between the scores obtained from the images and the scores obtained by direct observation both by the clinician and by the patient.
In this study designed to quantify the degree of breast enlargement produced by augmentation mammaplasty, 112 women who underwent breast augmentation were interviewed. The size increase that typically resulted from various implant volumes was measured by comparing preoperative and postoperative bra sizes. For the study group as a whole, the average increase was two bra sizes (either increased cup size or a combination of increased cup size and chest circumference), regardless of the implant volume inserted. Patients also were asked a series of questions to evaluate the impact of the surgery on various psychological parameters, including body image, feelings of self-confidence, and interpersonal relationships. Along with having a very positive body image, the group reported decreased self-consciousness (86 percent) and heightened self-confidence (88 percent); in addition, 95 percent said they felt better about themselves after surgery. The women's satisfaction with the results of augmentation and the success of surgery in meeting their expectations also were measured. Eighty-six percent reported being completely or mostly satisfied with the postoperative results, 86 percent felt the operation was a complete success, and 95 percent said that augmentation met their expectations. (C)1994American Society of Plastic Surgeons
The aim of this study was to compare live and photographic methods of assessing variables which can influence cosmetic outcome following breast conserving treatment.This study was undertaken in 47 patients who had previously received breast conserving surgery, radiotherapy and simultaneous chemotherapy for stage I and II breast cancer and a matched group of patients who had received surgery and radiotherapy alone. The assessment consisted of patient and spouse self-assessment, a live assessment by two trained observers and a photographic assessment by five observers, two trained and three untrained. Patients rated their outcome more favourably than their spouses, and both rated the outcomes above those of the other observers. Quantitative variables such as measurement of nipple retraction were assessed by different observers more consistently than qualitative variables such as overall perception of assessed cosmetic outcome. Upward retraction of the nipple emerged as the most powerful determinant of cosmetic outcome in the eyes of both the patient and the trained observers and was reproducibly measured by both live and photographic techniques. The distinction between post-surgical effects and post-radiation effects was more readily made by live assessment.Photographic assessment is as effective as live assessment in post-surgical cosmetic assessment. It provides reliable information about all of the factors which were important to both the patient and observers in formulating an overall cosmetic outcome score. The effects of surgery, which include nipple retraction, need to be taken into account in future trials of adjuvant therapy in which cosmesis is an important outcome measure. Stratification using upward retraction of the nipple is a possibility.
In the study group, the augmentation with silicone gel prostheses had a high rate (64%) of firmness (as felt by the patients), which seems not greatly affected by the surgeon or by patient exercises or manipulations. In the group, augmentations with saline-filled inflatable prostheses had a much lower incidence of firmness (40%, as felt by the patients). No deflations of the Heyer-Schulte R.T.V. "Jenny" prosthesis were found during the follow-up period. Augmentation mammaplasty by a certified plastic surgeon has a low rate of physical complications (in the range of one to two percent). However there were unfavorable cosmetic results causing patient dissatisfaction with part of the result in about 15%. The incidence of emotional dissatisfaction with the procedure as a whole, as judged by those who would not choose to repeat the operation, was less than 4%.
Among the conscious or unconscious reasons that lead a woman to ask for an esthetic procedure are the need to improve his self-appreciation and the desire to receive more love and approval from other people. We have found no article in the Brazilian literature regarding the psychological aspects of patients submitted to mastoplasty. Fifty-three patients awaiting mastoplasty were studied in the period between September 1990 and january 1992 as for their motivation, as well as for characteristics of their personality. The method used included an interview and tests of "Human being figure drawn" and "Crown-Crisp Experimental Index (CCEI)". The results of the interview and the "Human being Figure Drawn" showed that the majority of the patients was young, without children or with only one child. They were determined, self-centered, with some difficulties, related to their sexuality and sociality.
The cosmetic and functional results of breast conserving therapy were evaluated in a sample of 76 patients with early stage breast cancer, treated by wide local excision, axillary dissection and postoperative radiotherapy between 1975 and 1985. A comparison was made between patients' ratings, independent ratings by two observers (an oncology nurse and a radiation oncologist) and objective measurements. In approximately 40% of the cases, moderate to large differences in the appearance of the treated versus the untreated breast were reported by patients and clinical observers alike. When evaluated on an individual level, the observers' ratings showed relatively high inter-rater agreement (kappa = 0.64), but low levels of concordance were found between the patients' and observers' ratings (kappa < 0.10). Approximately half of the patients reported limited arm or shoulder function, generally mild in nature. Compared to the patients', the observers' ratings of arm edema were significantly lower, indicating 20% mild and 5% more severe swelling. Objective measures of cosmesis and function correlated moderately with the observers' and patients' ratings. Both cosmetic and functional results were found to be significantly related to time elapsed since treatment, with patients treated longer ago exhibiting more problems. The cosmetic and functional outcomes were not related to the patients' age. The results suggest that the patients' opinion can provide important additional information in the evaluation of cosmetic and functional results of breast conserving treatment.
The authors present the results of a comprehensive clinical and X-ray assessment of augmentation mammaplasty performed on 162 patients at the Prague Department of Plastic Surgery over 25 years, from 1960-1984. The prostheses used included both autogenous material (corium with fat) and foreign material: two types of domestic prostheses (porous hydron and double polyethylene sheet filled with polyester staple), and one imported product (Silastic prosthesis of the Cronin type filled with inert gel). From the purely medical point of view, i.e., ruling out the risk of malignant degeneration resulting from foreign material implantation, autogenous tissue is undoubtedly the only suitable implant. From the cosmetic point of view, Silastic implants of the Cronin type came out as by far the best option.
In this study designed to quantify the degree of breast enlargement produced by augmentation mammaplasty, 112 women who underwent breast augmentation were interviewed. The size increase that typically resulted from various implant volumes was measured by comparing preoperative and postoperative bra sizes. For the study group as a whole, the average increase was two bra sizes (either increased cup size or a combination of increased cup size and chest circumference), regardless of the implant volume inserted. Patients also were asked a series of questions to evaluate the impact of the surgery on various psychological parameters, including body image, feelings of self-confidence, and interpersonal relationships. Along with having a very positive body image, the group reported decreased self-consciousness (86 percent) and heightened self-confidence (88 percent); in addition, 95 percent said they felt better about themselves after surgery. The women's satisfaction with the results of augmentation and the success of surgery in meeting their expectations also were measured. Eighty-six percent reported being completely or mostly satisfied with the postoperative results, 86 percent felt the operation was a complete success, and 95 percent said that augmentation met their expectations.
This study evaluated the reliability of three commonly used measures of aesthetic outcomes of breast surgery: a four-point ordinal scale of overall aesthetics, five four-point subscales, and a visual analogue scale. Fifty patients were randomly selected from women who underwent breast reconstruction surgery at University of Michigan hospitals between July 1989 and May 1993. Postoperative photographs of these patients were provided to three plastic surgeons, who were asked to rate the photographs using the three methods. The same process was repeated 4 weeks later. Intrarater and interrater reliability ranged from poor to good for the three methods, with the subscales showing the highest reliability. The lowest reliability occurred for those scales with the least-explicit rating criteria. Without explicit criteria, raters must develop and use their own criteria, which are likely to differ for each rater. Separating the various components of the aesthetic results of breast surgery into different subscales helps make the rating criteria more explicit. Scales with demonstrated reliability are critical for ensuring comparability of results across studies.
This study investigates post-operative photographic assessment in determining the cosmetic outcome of 74 breast cancer patients who underwent a breast lumpectomy and radiotherapy. Using 10 of these patients picked at random, comparison was made between a conventional photographic print, a print produced from a digital image, and a digital image viewed on a computer screen in terms of personal preference for clinical assessment. The cosmetic outcome scores obtained on the basis of these images were compared with cosmetic outcome scores obtained by direct observation both by the clinician and by the patient. In the analysis of image preference, conventional prints scored highest, but each of the image types was considered to be acceptable for assessing breast cosmesis. Statistical analysis of the cosmetic outcome scores proved that there was a significant correlation between the scores obtained from the images and the scores obtained by direct observation both by the clinician and by the patient.
Aesthetic plastic surgery has received wide public attention in the past few years. Expectations of patients regarding results have been exaggerated; the real place and medical importance of the procedures are still not clear because of a lack of more objective evidence. This study discusses the difficulties encountered related to the scientific evaluation of the aesthetic operations and proposes alternatives for assessment. A frequently performed procedure, reduction mammaplasty, is presented as an example, with its specific evaluation.
An objective grading system for the evaluation of cosmetic surgical results is presented. The ideal result for the specific procedure is the standard against which the surgical result is evaluated. This is based on the concept that perfection is the lack of imperfection. The result is graded based on identification of imperfections or flaws that deviate from the ideal. All potential flaws can be classified under one of five possible flaw categories: malposition, distortion, asymmetry, contour deformity, and scar. Each flaw category is graded for severity: perfect, noticeable, obvious, and obvious and deforming. Each severity level is assigned a value: perfect, 0 points; noticeable, 1 point; obvious, 5 points; and obvious and deforming, 15 points. The total points under the flaw categories are added for the total score. A perfect result has 0 flaws and gets a score of 0. Scores of 1 to 4 are good results, 5 to 14 are mediocre, and 15 or greater are poor. The benefits of this grading system include the easy identification of deficiencies and result in easy implementation of a plan to eliminate the flaw in the future. It increases the critical observational acumen of the surgeon. It helps in the evaluation of the surgical procedure as it relates to the end result. It improves the result and it improves our ability to communicate results within our profession in a meaningful way.
Our objective is to present a new surgical concept for the aesthetic treatment of the abdominal region using the principles of liposuction associated with the traditional abdominoplasty. Lipoabdominoplasty is different from other techniques because it has the advantages of conserving perforator vessels of the abdominal wall, it preserves suprapubic sensibility, results in better abdominal contouring, has a low rate of complications, and a faster recuperation after surgery. The traditional abdominoplasty has been used for many years with several modifications intending to achieve better aesthetic contouring and to reduce complications. However, each modification solves problems only partially. The authors perform the surgery beginning with wet lipoplasty in superficial and deep fat layers. The skin below the umbilical scar is excised as in classical abdominoplasty. After that, selective and safe undermining of the dermocutaneous flap is done in the middle section of the upper abdomen between the borders of the rectus abdominis muscle, preserving mainly supply vessels of the abdominal wall.
Subjective evaluations of the appearance outcome of autologous breast reconstruction are usually performed by surgeons and not by patients. Such surgeon-based evaluations are rarely reproducible and show little interobserver agreement. Among existing patient-based subjective scales, none has been tested for reliability, and no study to date has evaluated the reliability when both surgeons and patients use the same scale.
The authors developed a new instrument for assessing the appearance of autologous breast reconstruction. The instrument's use by four plastic surgeons and 36 transverse rectus musculocutaneous flap patients was assessed for test-retest reliability, internal consistency, surgeon-patient and surgeon-surgeon interobserver agreement, and interitem correlation.
The instrument demonstrated high overall internal consistency when used by patients (Cronbach alpha = 0.92). Test-retest reliability on each aesthetic subitem in the scale was higher among patients than among surgeons (weighted kappa range, 0.57 to 0.88 versus 0.25 to 0.66). Interrater agreement was poor among both patients and surgeons (weighted kappa, 0.0 to 0.39). Poor correlation was found between surgeons' evaluations of aesthetic subitems and patients' overall appearance and overall satisfaction scores.
The instrument both demonstrates better internal consistency and is more reliable when used by patients to evaluate their own reconstructions. By contrast, the instrument's use by surgeons is not as internally consistent and reproducible. The poor interobserver agreement among surgeons and the weak correlation between surgeon and patient evaluations suggest that patient input regarding item-specific criteria should be included in evaluations of breast reconstructions.
A good aesthetic outcome is an important endpoint of breast cancer treatment. Subjective ratings, direct physical measurements, measurements on photographs, and assessment by three-dimensional imaging are reviewed and future directions in aesthetic outcome measurements are discussed. Qualitative, subjective scales have frequently been used to assess aesthetic outcomes following breast cancer treatment. However, none of these scales has achieved widespread use because they are typically vague and have low intraobserver and interobserver agreement. Anthropometry is not routinely performed because conducting the large studies needed to validate anthropometric measures (i.e., studies in which several observers measure the same subjects multiple times) is impractical. Quantitative measures based on digital/digitized photographs have yielded acceptable results but have some limitations. Three-dimensional imaging has the potential to enable consistent, objective assessment of breast appearance, including properties (e.g., volume) that are not available from two-dimensional images. However, further work is needed to define three-dimensional measures of aesthetic properties and how they should be interpreted.
Avaliação dos resultados estéticos após mamoplastias de aumento com o uso de implante redondo vs anatômico
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Une nouvelle technique pour les lipodystrophies localisées
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Aspectos de personalidade e motivaçõ de pacientes para mas-toplastia
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Avaliaçã dos resultados esté apó mamoplastias de aumento com o uso de implante redondo vs anatô
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Gemperli Division of Plastic Surgery, Faculty of Medicine, University of Sã Paulo, Av. Dr. Arnaldo, 455, sala 1360, Sã Paulo, SP 01246-903, Brazil e-mail: agsalles@uol.com.br References 1 Avaliaçã dos resultados esté apó mamoplastias de aumento com o uso de implante redondo vs anatô
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A. G. Salles (&) Á M. C. Ferreira Á A. F. do Nascimento Remigio Á R. Gemperli Division of Plastic Surgery, Faculty of Medicine, University of Sã Paulo, Av. Dr. Arnaldo, 455, sala 1360, Sã Paulo, SP 01246-903, Brazil e-mail: agsalles@uol.com.br References 1. Baptista RR, Salles AG, Remigio AFN, Cruz DP, Ferreira MC (2010) Avaliaçã dos resultados esté apó mamoplastias de aumento com o uso de implante redondo vs anatô. Rev Bras Cir Plá 25(Suppl):47
Aspectos de personalidade e motivações de pacientes para mastoplastia
- SFM Ribeiro