Volume 136, Number 5 • Letters disclosure The author has no financial interest to declare in relation to the content of this communication. There was no funding for this work. references 1. Bitik O, Uzun H, Kamburoğlu HO, Çaliş M, Zins JE. Revisiting the role of columellar strut graft in primary open approach rhinoplasty. Plast Reconstr Surg. 2015;135:987–997. 2. Rohrich RJ, Hoxworth RE, Kurkjian TJ. The role of columellar strut in rhinoplasty: Indications and rationale. Plast Reconstr Surg. 2012;129:118–125.
Natural Evolution of Seroma in Abdominoplasty Sir:
W
e read with great interest the article entitled “Natural Evolution of Seroma in Abdominoplasty.”1 We congratulate the authors on finding the highest incidence of seroma on postoperative day 11. Based on the data from Figure 3, there should be some overlap among patients with seroma formation at different time points. However, by definition, the incidence of seroma formation on postoperative day 18 should not include the patients with seroma since postoperative day 11; otherwise, the parameter should be prevalence instead of incidence. According to the authors’ practice, suction drains were removed when output was less than 40 ml in 24 hours. If the output is 39 ml on postoperative day 2, the drains will be removed on postoperative day 3. However, if fluid collection is over 20 ml on postoperative day 3, which is possible in practice, seroma formation will be identified by ultrasound, because the definition of seroma is fluid collection greater than 20 ml. Therefore, the indication for drain removal might be adjusted to output less than or equal to 20 ml in 24 hours. A possible explanation for the low incidence of seroma on postoperative day 4 might be the presence of suction drains, because many patients still have their suction drains in place. We suggest that data on complications would be available with more details, such as local infection, hematoma, and others. The authors wrote that “all patients still had suction drains on postoperative day 4” on page 695e. However, Table 2 of the article mentioned that the minimum time to drain removal was 3 days. Those figures seem to be paradoxical. Seroma is an important complication associated with abdominoplasty, and we hope there will be more large scale investigations in this field. DOI: 10.1097/PRS.0000000000001662
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 The authors have no financial interest in any of the products or devices mentioned in this communication. reference 1. Di Martino M, Nahas FX, Kimura AK, Sallum N, Ferreira LM. Natural evolution of seroma in abdominoplasty. Plast Reconstr Surg. 2015;135:691e–698e.
Reply: Natural Evolution of Seroma in Abdominoplasty Sir:
We would like to thank Dr. Huang et al. for their observations about our study. Regarding the question about incidence and prevalence, a definition will help us to understand these terms better. According to the McGraw-Hill Concise Dictionary of Modern Medicine,1 incidence is the rate of occurrence of new cases of a disease or condition in a population at risk during a given period. Prevalence, instead, according to the Mosby’s Medical Dictionary,2 is the number of all new and old cases of a disease or occurrences of an event during a particular period. In the Methods section, page 693e, it is written, “Cases presenting a fluid volume greater than 20 ml for the five regions combined were considered positive for seroma.8 Ultrasound-guided aspiration was performed in patients with fluid collections greater than 20 ml.” It means that every patient who presented seroma (>20 ml) had aspiration. Therefore, if there was seroma in these cases at a new point in time, it was counted as a new case of seroma in the evaluated time point and the term incidence was used. Ideally, if we could leave the seroma being formed by accumulation along the timeline of the studied points, it would be a perfect model, but this is not what occurs in real life. If a seroma is detected by a plastic surgeon, it should be aspirated to avoid a capsular formation and a consequent pseudobursa. This is the reason why seroma had to be aspirated and the term incidence was used rather than prevalence. Seroma is a very frequent complication after abdominoplasty. We have been studying this complication for 10 years now, since we started our study on quilting suture efficacy, which was published in 2007.3 In all of these articles,4,5 we have shown that the beginning of seroma formation is not soon after the operation. The reason for that is still unknown, and this is what new studies should focus on. As the composition of seroma is similar to the lymphatic fluid, possibly seroma formation is related to the section of lymphatic
703e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
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.
Natural Evolution of Seroma in Abdominoplasty Sir:
W
e read with great interest the article entitled “Natural Evolution of Seroma in Abdominoplasty.”1 We congratulate the authors on finding the highest incidence of seroma on postoperative day 11. Based on the data from Figure 3, there should be some overlap among patients with seroma formation at different time points. However, by definition, the incidence of seroma formation on postoperative day 18 should not include the patients with seroma since postoperative day 11; otherwise, the parameter should be prevalence instead of incidence. According to the authors’ practice, suction drains were removed when output was less than 40 ml in 24 hours. If the output is 39 ml on postoperative day 2, the drains will be removed on postoperative day 3. However, if fluid collection is over 20 ml on postoperative day 3, which is possible in practice, seroma formation will be identified by ultrasound, because the definition of seroma is fluid collection greater than 20 ml. Therefore, the indication for drain removal might be adjusted to output less than or equal to 20 ml in 24 hours. A possible explanation for the low incidence of seroma on postoperative day 4 might be the presence of suction drains, because many patients still have their suction drains in place. We suggest that data on complications would be available with more details, such as local infection, hematoma, and others. The authors wrote that “all patients still had suction drains on postoperative day 4” on page 695e. However, Table 2 of the article mentioned that the minimum time to drain removal was 3 days. Those figures seem to be paradoxical. Seroma is an important complication associated with abdominoplasty, and we hope there will be more large scale investigations in this field. DOI: 10.1097/PRS.0000000000001662
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 The authors have no financial interest in any of the products or devices mentioned in this communication. reference 1. Di Martino M, Nahas FX, Kimura AK, Sallum N, Ferreira LM. Natural evolution of seroma in abdominoplasty. Plast Reconstr Surg. 2015;135:691e–698e.
Reply: Natural Evolution of Seroma in Abdominoplasty Sir:
We would like to thank Dr. Huang et al. for their observations about our study. Regarding the question about incidence and prevalence, a definition will help us to understand these terms better. According to the McGraw-Hill Concise Dictionary of Modern Medicine,1 incidence is the rate of occurrence of new cases of a disease or condition in a population at risk during a given period. Prevalence, instead, according to the Mosby’s Medical Dictionary,2 is the number of all new and old cases of a disease or occurrences of an event during a particular period. In the Methods section, page 693e, it is written, “Cases presenting a fluid volume greater than 20 ml for the five regions combined were considered positive for seroma.8 Ultrasound-guided aspiration was performed in patients with fluid collections greater than 20 ml.” It means that every patient who presented seroma (>20 ml) had aspiration. Therefore, if there was seroma in these cases at a new point in time, it was counted as a new case of seroma in the evaluated time point and the term incidence was used. Ideally, if we could leave the seroma being formed by accumulation along the timeline of the studied points, it would be a perfect model, but this is not what occurs in real life. If a seroma is detected by a plastic surgeon, it should be aspirated to avoid a capsular formation and a consequent pseudobursa. This is the reason why seroma had to be aspirated and the term incidence was used rather than prevalence. Seroma is a very frequent complication after abdominoplasty. We have been studying this complication for 10 years now, since we started our study on quilting suture efficacy, which was published in 2007.3 In all of these articles,4,5 we have shown that the beginning of seroma formation is not soon after the operation. The reason for that is still unknown, and this is what new studies should focus on. As the composition of seroma is similar to the lymphatic fluid, possibly seroma formation is related to the section of lymphatic
703e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
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.
