Abnormal Vessel Architecture Persists in the Microvasculature of the Massive Weight Loss Patient:

Litigation Cases After Post-Bariatric Surgery: Lesson from the Past

BACKGROUND

Due to the high demand of post-bariatric surgeries, the number of litigation cases is rapidly growing. Even if surgical mistakes still represent one of the main causes of medico-legal issues, many disputes depend on what happens in the post-operative course. In this article we analyzed the litigation cases that occurred in our Plastic Surgery Department, the current literature about medico-legal disputes and the importance of the doctor-patient relationship.

PATIENTS AND METHODS

The medical records of 788 post-bariatric surgeries, the post-operative complications and the related litigation cases from January 2015 to December 2019 were collected, analyzed and compared.

RESULTS

We performed 380 abdominoplasties, 28 torsoplasties, 65 breast reductions, 99 mastopexies, 94 brachioplasties, 52 thighplasties, 65 liposuctions and 5 facelifts between 2015 and 2019. Eight patients complained of medical issues and claimed for litigation. Despite in all cases the judges highlighted the risk of consent misinterpretation, the payout was granted only in one case.

CONCLUSION

Post-bariatric patients often mistake their preoperative condition and consider body contouring procedures as an aesthetic surgery treatment. Patients should be therefore clearly informed about the complexity of body contouring procedures after massive weight loss, which should never be compared to aesthetic surgery. Surgeons should always promote the communication with their patients and build a strong and trustworthy relationship. This attitude will allow to deal more easily with complications and, in the worst situations, with medico-legal litigations.

LEVEL OF EVIDENCE IV

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Autologous Breast Reconstruction with Bilateral Stacked Free Flaps in Massive Weight Loss Patients

Patients with a history of massive weight loss who are undergoing autologous breast reconstruction after mastectomy represent a unique surgical challenge. Although these patients often have an abundance of excess skin, it may be difficult to acquire sufficient tissue volume for adequate reconstruction of bilateral breasts using single flap techniques due to the paucity of subcutaneous fat. Stacked flap techniques have emerged as an effective method in thinner patients with suboptimal fat distribution who desire autologous breast reconstruction. This can serve as an ideal strategy, specifically in this patient population, when it serves the dual function of providing adequate volume for bilateral breast reconstruction and the secondary benefit of removing the excess skin present after massive weight loss. In this article, we discuss surgical techniques used during two cases of bilateral stacked flap breast reconstruction in cancer patients subsequent to massive weight loss.

Standards and Trends in Lipoabdominoplasty

BACKGROUND

Lipoabdominoplasty has evolved over the last 6 decades through contributions from numerous luminaries in plastic and reconstructive surgery.

METHODS

The authors review historical perspective and provide a contemporary examination of trends in lipoabdominoplasty.

RESULTS

In 1967, Pitanguy popularized abdominoplasty (without liposuction) as a technique for augmenting ventral hernias repairs and subsequently for aesthetic improvement of the abdomen. After the introduction of suction assisted lipectomy by Illouz in 1983, abdominoplasty became a central tool in a diverse armamentarium of anterior and lateral abdominal wall contouring procedures. Liposuction was initially utilized with mini-abdominoplasty in order to improve contour. Subsequently, Matarasso advanced the safe combination of liposuction with full abdominoplasty. Additionally, he systematized the variety of cutaneous undermining, excision, and liposuction procedures utilized in abdominal contouring as indicated by the degree of skin laxity and musculofascial diastasis. Lockwood advocated high lateral tension closure of the superficial fascial system of the abdomen to improve the contour of the hips and flanks. Saldanha advanced selective undermining and anterior abdominal wall perforator preservation to minimize wound healing and seroma complications associated with lipoabdominoplasty procedures.

CONCLUSION

In abdominal contour surgery, surgeons can rely on classic techniques and algorithms that have withstood the test of time while modifying their approaches with advances backed by compelling and rigorously obtained evidence.

Abdominoplasty after bariatric surgery: comparison of three different techniques

BACKGROUND

Abdominoplasty after massive weight loss is not a cosmetic procedure. The aim of this study was to compare three different techniques for postbariatric abdominoplasty.

METHODS

All postbariatric patients that have undergone abdominoplasty from January 2013 to December 2016 were included in the study. Patients were divided into 3 groups: subjects who underwent standard procedure were allocated ingroup A; those cases performed using a synthetic glue were assigned to group B; cases performed with an energy device were inserted in group C. Operative time, length of stay and complications were recorded.

RESULTS

Seventy-one abdominoplasties were performed in the selected period. Mean operative time was shorter (P<0.01) in group C (94.3±2.7 minutes) than in group A (112.1±16.8 minutes) and in group B (121±13.2 minutes). Mean length of stay was significantly reduced (P<0.01) in group C (2.4±0.7) when compared to group A (3.5±0.6 days) and group B (3.1±0.5 days). Bleeding occurred in 21 (29.5%) patients (15 in group A, 4 in groupB, 3 in group C; P<0.01). Seroma was detected in 22(30.9%) subjects (14 in group A, 2in group B, 6 in group C; P<0.01). Wound dehiscence and umbilical necrosis were recorded in 7 (9.9%) and 9 (12.6%) patients respectively, without statistical differences.

CONCLUSIONS

Both synthetic glue and energy device improve outcomes of postbariatric abdominoplasties. The glue reduces rates of bleeding and seroma. The energy deviceimproves intraoperative hemostasis and shortens operative time.

Perfil farmacoterapêutico de pacientes obesos no pós-operatório de cirurgia bariátrica

Contexto

A obesidade pode estar relacionada a doenças como diabetes, hipertensão arterial e dislipidemia. A cirurgia bariátrica é um dos tratamentos mais eficazes, levando à diminuição de peso e comorbidades.

Objetivo

Avaliar o perfil metabólico e farmacoterapêutico de pacientes obesos após cirurgia bariátrica.

Métodos

Trata-se de um estudo observacional transversal retrospectivo, realizado em um hospital localizado na cidade de Porto Alegre, RS, Brasil. Foram avaliados 70 prontuários de pacientes que realizaram cirurgia bariátrica, nos períodos de antes de 2 meses e mais de 6 meses após a cirurgia bariátrica. A análise estatística foi realizada no programa SPSS 17.0®.

Resultados

A pressão arterial inicial foi de 130/85 mmHg, passando para 120/80 mmHg (p < 0,01). Com relação ao perfil metabólico antes de dois meses, o HDL foi de 34 mg/dL, o colesterol total foi de 195,07 ± 40,17 mg/dL, o LDL foi de 118,22 ± 41,28 mg/dL, os triglicerídeos foram de 141,09 ± 43,39 mg/dL, e a glicemia de jejum foi de 90 mg/dL. Após 6 meses de cirurgia, os valores passaram para 43 mg/dL, 133,67 ± 28,14 mg/dL, 65,53 ± 24,3 mg/dL, 104,41 ± 29,6 mg/dL, e 77 mg/dL, respectivamente (p < 0,01). Com relação ao uso de medicamentos, 41% utilizaram anti-hipertensivos, 39% utilizaram hipolipemiantes, 10% utilizaram hipoglicemiantes orais e 97% utilizaram suplementos antes dos 2 meses de cirurgia. Após os 6 meses, os percentuais foram alterados para 21%, 19%, 9% e 99%, respectivamente.

Conclusões

O estudo mostra o sucesso da cirurgia bariátrica em pacientes obesos com comorbidades, revelando melhora no perfil metabólico e redução na utilização de medicamentos para tratamento de comorbidades.