Plastic and Reconstructive Surgery • November 2015 vessels. This is just a theory, and probably an inflammatory reaction is also involved when friction between the subcutaneous tissue and the aponeurosis occurs during the postoperative period. However, it is not only that. In 2010,6 we demonstrated that lipoabdominoplasty with preservation of the Scarpa fascia has a lower rate of seroma. In this case, there is still friction, but some of the lymphatic vessels underneath the Scarpa fascia are not severed during this operation. This fact supports the idea that the section of lymphatic vessels is involved in seroma formation. Therefore, as shown by clinical experience and in our previous studies, the fourth postoperative day is not the peak of seroma formation. For this reason, this study focused on the later postoperative period, with the evaluation of many postoperative moments after postoperative day 11. It is very clear that the fourth postoperative day was not relevant, as the average drain removal was at 4.4 days, with a drainage below 40 ml in a 24-hour period. It is important to differentiate the early from the late fluid composition that may occur after abdominoplasty. According to Andrades and Prado,7 in the early postoperative period, the fluid is an inflammatory exudate that slowly turns into an exudate, with some characteristics similar to those of lymph. Therefore, the early fluid is produced by the early inflammatory reaction to the local trauma, whereas the late fluid is what we know as seroma. These are different fluids with different origins. Having said that, we believe that most of the studies should now focus on the decrease in the time spent to attach the flap to the myoaponeurotic layer and to understand seroma formation, which is still an unclear phenomenon. DOI: 10.1097/PRS.0000000000001670
Fábio X. Nahas, M.D., Ph.D. Marcello Di Martino, M.D., M.S. Alexandro K. Kimura, M.D., M.S. Natasha Sallum, M.D. Lydia M. Ferreira, M.D., Ph.D. Division of Plastic Surgery Federal University of São Paulo São Paulo, Brazil Correspondence to Dr. Nahas Division of Plastic Surgery Federal University of São Paulo Rua Napoleão de Barros, 715 4o andar, Vila Clementino São Paulo, Brazil [email protected]
disclosure None of the authors has a financial interest in any of the products or devices mentioned in this communication. references 1. McGraw-Hill Concise Dictionary of Modern Medicine. New York: McGraw-Hill; 2002.
2. Mosby’s Medical Dictionary. 8th ed. St. Louis: Mosby/Elsevier; 2009. 3. Nahas FX, Ferreira LM, Ghelfond C. Does quilting suture prevent seroma in abdominoplasty? Plast Reconstr Surg. 2007;119:1060–1064. 4. Nahas FX, di Martino M, Ferreira LM. Fibrin glue as a substitute for quilting suture in abdominoplasty. Plast Reconstr Surg. 2012;129:212e–213e. 5. Nahas FX, Di Martino M, Ferreira LM. Reply: Seroma after lipoabdominoplasty: Fat thickness of the abdominal wall is probably a contributory factor. Plast Reconstr Surg. 2011;127:2133–2134. 6. Di Martino M, Nahas FX, Barbosa MV, et al. Seroma in lipoabdominoplasty and abdominoplasty: A comparative study using ultrasound. Plast Reconstr Surg. 2010;126:1742–1751. 7. Andrades P, Prado A. Composition of postabdominoplasty seroma. Aesthetic Plast Surg. 2007;31:514–518.
Frequency and Risk Factors of Blood Transfusion in Abdominoplasty in Post–Bariatric Surgery Patients: Data from the Nationwide Inpatient Sample Sir:
W
e read with great interest the article entitled “Frequency and Risk Factors of Blood Transfusion in Abdominoplasty in Post–Bariatric Surgery Patients: Data from the Nationwide Inpatient Sample.”1 We congratulate the authors on conducting one of the largest studies investigating blood transfusion in abdominoplasty for post–bariatric surgery patients. The Nationwide Inpatient Sample contains procedure information, which is recorded as International Classification of Diseases, Ninth Revision, Clinical Modification codes for procedures. The International Classification of Diseases, Ninth Revision, Clinical Modification code for abdominoplasty is 86.83, which is also used for other body contouring procedures, such as adipectomy; cutaneolipectomy; lipectomy; liposuction; panniculectomy; and size reduction of arms, buttocks, and thighs. Therefore, the information from the Nationwide Inpatient Sample database cannot differentiate abdominoplasty from many other common body contouring procedures. As a result, it is very difficult to determine the exact number of patients that underwent abdominoplasty after bariatric surgery from the Nationwide Inpatient Sample database. We are puzzled by the overall complication rate listed in Table 2. It seems that the overall complication rate should be the sum of all the listed complications, including urinary tract infection, pneumonia, acute kidney injury, venous thromboembolism, and others. The values of the listed complications for the patients with and without transfusion are 34.05 and 7.9 percent, respectively, which are quite different from the numbers listed in the article (10.1 percent for patients with transfusion and 4.8 percent for patients without transfusion). We are wondering about the authors’ calculating process for the overall complication rate.
DOI: 10.1097/PRS.0000000000001714
704e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 136, Number 5 • Letters Jiuzuo Huang, M.D. Nanze Yu, M.D. Xiao Long, M.D. Division of Plastic and Reconstructive Surgery Department of Surgery Peking Union Medical College Hospital Beijing, People’s Republic of China Correspondence to Dr. Long Peking Union Medical College Hospital Plastic and Reconstructive Surgery 1 Shuaifuyuan, Wangfujing, Dongcheng District Beijing 100032, People’s Republic of China [email protected]
disclosure None of the authors has a financial interest to declare in relation to the content of this communication. reference 1. Masoomi H, Rimler J, Wirth GA, Lee C, Paydar KZ, Evans GR. Frequency and risk factors of blood transfusion in abdominoplasty in post-bariatric surgery patients: Data from the nationwide inpatient sample. Plast Reconstr Surg. 2015;135:861e–868e.
Vaginal Labiaplasty: Current Practices and a Simplified Classification System for Labial Protrusion Sir: read with great interest the recent article by Motakef et al. in which a simplified labial classification system based on the distance of the lateral edge of the labia minora from that of the labia majora, rather than from the introitus, is proposed.1 As their well-written article also provides a comprehensive and systematic review of the different methods of labiaplasty, I would like to take the opportunity to further expand on this topic. In 2011, my colleagues and I published a labiaplasty technique named “bidimensional labia minora reduction.”2 Further communications were published later in other major plastic surgery journals.3,4 Our technique involves the central deepithelialization of the upper labium associated with a lower wedge resection less than 90 degrees (Fig. 1). Such association allows the preservation of the naturally darker corrugated edges and reduces both labial width and labial length. In this way, the festooned appearance, sometimes observed when applying just labial deepithelialization, is avoided.2,5 By resecting a smaller wedge of labium, a tensionfree closure and good vascularization to the healing edges are ensured, thus reducing the chances of wound dehiscence, which is the most common complication for all techniques according to the authors.1 In contrast, the scar resulting from wedge resection is placed posteriorly, where it is easily hidden, with a reduced chance of labial distortion in case of scar contracture.
I
Fig. 1. Schematic representation of the technique showing the area of deepithelialization and the posterior wedge resection.
Because just a partial-thickness repair takes place on the deepithelialized sides of the upper labium, this usually results in imperceptible scars that heal very well, with excellent aesthetic results. The technique has proven useful for treating class I and II defects according to this recently proposed classification of labial protrusion.1 Because the closure of deepithelialized areas telescopes the labial tissue, cases of labia with excessive subcutaneous tissue or width (class III) might not be good candidates for the bidimensional technique. In summary, our technique is a valid resource that attains an effective reduction in both length and width, preserving the dark corrugated labial border and avoiding a festooned appearance. Because in plastic surgery “no key fits every lock,” each technique should have its own indication according to the characteristics of every case. We, as plastic surgeons committed to delivering the best possible surgical result, should be aware of all available techniques and choose the most applicable one in every case. DOI: 10.1097/PRS.0000000000001663
Horacio F. Mayer, M.D. Department of Plastic Surgery Hospital Italiano de Buenos Aires Peron 4190, 1er. Piso Buenos Aires C1181ACH, Argentina [email protected]
disclosure The author has no financial interest to declare in relation to the content of this communication. references 1. Motakef S, Rodriguez-Feliz J, Chung MT, Ingargiola MJ, Wong VW, Patel A. Vaginal labiaplasty: Current practices and
705e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Fábio X. Nahas, M.D., Ph.D. Marcello Di Martino, M.D., M.S. Alexandro K. Kimura, M.D., M.S. Natasha Sallum, M.D. Lydia M. Ferreira, M.D., Ph.D. Division of Plastic Surgery Federal University of São Paulo São Paulo, Brazil Correspondence to Dr. Nahas Division of Plastic Surgery Federal University of São Paulo Rua Napoleão de Barros, 715 4o andar, Vila Clementino São Paulo, Brazil [email protected]
disclosure None of the authors has a financial interest in any of the products or devices mentioned in this communication. references 1. McGraw-Hill Concise Dictionary of Modern Medicine. New York: McGraw-Hill; 2002.
2. Mosby’s Medical Dictionary. 8th ed. St. Louis: Mosby/Elsevier; 2009. 3. Nahas FX, Ferreira LM, Ghelfond C. Does quilting suture prevent seroma in abdominoplasty? Plast Reconstr Surg. 2007;119:1060–1064. 4. Nahas FX, di Martino M, Ferreira LM. Fibrin glue as a substitute for quilting suture in abdominoplasty. Plast Reconstr Surg. 2012;129:212e–213e. 5. Nahas FX, Di Martino M, Ferreira LM. Reply: Seroma after lipoabdominoplasty: Fat thickness of the abdominal wall is probably a contributory factor. Plast Reconstr Surg. 2011;127:2133–2134. 6. Di Martino M, Nahas FX, Barbosa MV, et al. Seroma in lipoabdominoplasty and abdominoplasty: A comparative study using ultrasound. Plast Reconstr Surg. 2010;126:1742–1751. 7. Andrades P, Prado A. Composition of postabdominoplasty seroma. Aesthetic Plast Surg. 2007;31:514–518.
Frequency and Risk Factors of Blood Transfusion in Abdominoplasty in Post–Bariatric Surgery Patients: Data from the Nationwide Inpatient Sample Sir:
W
e read with great interest the article entitled “Frequency and Risk Factors of Blood Transfusion in Abdominoplasty in Post–Bariatric Surgery Patients: Data from the Nationwide Inpatient Sample.”1 We congratulate the authors on conducting one of the largest studies investigating blood transfusion in abdominoplasty for post–bariatric surgery patients. The Nationwide Inpatient Sample contains procedure information, which is recorded as International Classification of Diseases, Ninth Revision, Clinical Modification codes for procedures. The International Classification of Diseases, Ninth Revision, Clinical Modification code for abdominoplasty is 86.83, which is also used for other body contouring procedures, such as adipectomy; cutaneolipectomy; lipectomy; liposuction; panniculectomy; and size reduction of arms, buttocks, and thighs. Therefore, the information from the Nationwide Inpatient Sample database cannot differentiate abdominoplasty from many other common body contouring procedures. As a result, it is very difficult to determine the exact number of patients that underwent abdominoplasty after bariatric surgery from the Nationwide Inpatient Sample database. We are puzzled by the overall complication rate listed in Table 2. It seems that the overall complication rate should be the sum of all the listed complications, including urinary tract infection, pneumonia, acute kidney injury, venous thromboembolism, and others. The values of the listed complications for the patients with and without transfusion are 34.05 and 7.9 percent, respectively, which are quite different from the numbers listed in the article (10.1 percent for patients with transfusion and 4.8 percent for patients without transfusion). We are wondering about the authors’ calculating process for the overall complication rate.
DOI: 10.1097/PRS.0000000000001714
704e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 136, Number 5 • Letters Jiuzuo Huang, M.D. Nanze Yu, M.D. Xiao Long, M.D. Division of Plastic and Reconstructive Surgery Department of Surgery Peking Union Medical College Hospital Beijing, People’s Republic of China Correspondence to Dr. Long Peking Union Medical College Hospital Plastic and Reconstructive Surgery 1 Shuaifuyuan, Wangfujing, Dongcheng District Beijing 100032, People’s Republic of China [email protected]
disclosure None of the authors has a financial interest to declare in relation to the content of this communication. reference 1. Masoomi H, Rimler J, Wirth GA, Lee C, Paydar KZ, Evans GR. Frequency and risk factors of blood transfusion in abdominoplasty in post-bariatric surgery patients: Data from the nationwide inpatient sample. Plast Reconstr Surg. 2015;135:861e–868e.
Vaginal Labiaplasty: Current Practices and a Simplified Classification System for Labial Protrusion Sir: read with great interest the recent article by Motakef et al. in which a simplified labial classification system based on the distance of the lateral edge of the labia minora from that of the labia majora, rather than from the introitus, is proposed.1 As their well-written article also provides a comprehensive and systematic review of the different methods of labiaplasty, I would like to take the opportunity to further expand on this topic. In 2011, my colleagues and I published a labiaplasty technique named “bidimensional labia minora reduction.”2 Further communications were published later in other major plastic surgery journals.3,4 Our technique involves the central deepithelialization of the upper labium associated with a lower wedge resection less than 90 degrees (Fig. 1). Such association allows the preservation of the naturally darker corrugated edges and reduces both labial width and labial length. In this way, the festooned appearance, sometimes observed when applying just labial deepithelialization, is avoided.2,5 By resecting a smaller wedge of labium, a tensionfree closure and good vascularization to the healing edges are ensured, thus reducing the chances of wound dehiscence, which is the most common complication for all techniques according to the authors.1 In contrast, the scar resulting from wedge resection is placed posteriorly, where it is easily hidden, with a reduced chance of labial distortion in case of scar contracture.
I
Fig. 1. Schematic representation of the technique showing the area of deepithelialization and the posterior wedge resection.
Because just a partial-thickness repair takes place on the deepithelialized sides of the upper labium, this usually results in imperceptible scars that heal very well, with excellent aesthetic results. The technique has proven useful for treating class I and II defects according to this recently proposed classification of labial protrusion.1 Because the closure of deepithelialized areas telescopes the labial tissue, cases of labia with excessive subcutaneous tissue or width (class III) might not be good candidates for the bidimensional technique. In summary, our technique is a valid resource that attains an effective reduction in both length and width, preserving the dark corrugated labial border and avoiding a festooned appearance. Because in plastic surgery “no key fits every lock,” each technique should have its own indication according to the characteristics of every case. We, as plastic surgeons committed to delivering the best possible surgical result, should be aware of all available techniques and choose the most applicable one in every case. DOI: 10.1097/PRS.0000000000001663
Horacio F. Mayer, M.D. Department of Plastic Surgery Hospital Italiano de Buenos Aires Peron 4190, 1er. Piso Buenos Aires C1181ACH, Argentina [email protected]
disclosure The author has no financial interest to declare in relation to the content of this communication. references 1. Motakef S, Rodriguez-Feliz J, Chung MT, Ingargiola MJ, Wong VW, Patel A. Vaginal labiaplasty: Current practices and
705e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
