Composite Body Contouring

Background  Aesthetic surgery of the thoracoabdominal region is one of the most frequently performed surgical procedures in plastic surgery.The combination of circumferential liposuction, autologous fat grafting of the buttocks and/or lower limbs, and the modified transverse abdominoplasty as an adjuvant procedure all done in a single surgical procedure is not very common. The authors present a prospective study of the surgical technique of composite body contouring, emphasizing the low rate of complications and the high overall patient satisfaction. Methods  A total of 64 consecutive female patients were operated on between January 2004 and January 2007. All the patients who were included in the study were candidates for a classical abdominoplasty. Posterior and lateral syringe-assisted liposuction combined with fat insertion into the buttocks and/or lower limbs was performed. Autologous fat grafting was done in the gluteal area for buttocks enhancement and in the lower limbs to correct contour deformities. Anterolateral liposuction with modified transverse abdominoplasty was done as an adjuvant procedure. Overall satisfaction with body appearance after composite body contouring was rated on a scale of 1–5. Results  From 1,500 to 4,600 ml of fat was obtained with liposuction (mean = 2,478 ml). Forty-five patients had fat grafting only to the buttocks area. Six patients had fat insertion into the lower limbs and 13 had fat injection into the buttocks and lower limbs. The amount of fat transplanted to the buttocks varied from 165 to 625 ml (mean = 346 ml) and to the lower limbs it varied from 75 to 270 ml (mean = 195 ml). Three patients (5%) suffered from early complications, including infection (3%) and hematoma formation (2%). Nine patients (14%) had late complications, including hypertophic scars (7.5%), dog ears (4.5%), and localized fat excess (2%). Nine patients (14%) underwent revision surgery. Sixty-three percent reported that their appearance after composite body contouring was “very good” (42%) or “excellent” (21%) and 27% responded that their appearance was “good.” Only 10% thought their appearance was less than good, (7% “fair” and 3% “poor”).The average follow-up time has been 3.2 years (range = 2–5 years). Conclusion  Composite body contouring combines circumferential liposuction, fat grafting of the buttocks and lower limbs, and modified transverse abdominoplasty to accomplish very good aesthetic results in a single surgical procedure with a low rate of complications and high patient satisfaction.     

GLP-1 and Adiponectin: Effect of Weight Loss After Dietary Restriction and Gastric Bypass in Morbidly Obese Patients with Normal and Abnormal Glucose Metabolism

Background  It has been proposed that there is improvement in glucose and insulin metabolism after weight loss in patients who underwent diet restriction and bariatric surgery. Methods  Eleven normal glucose tolerant (NGT) morbidly obese patients [body mass index (BMI), 46.1 ± 2.27 g/m²] and eight abnormal glucose metabolism (AGM) obese patients (BMI, 51.20 kg/m²) were submitted to diet-restriction and bariatric surgery. Prospective study on weight loss changes, over the glucose, insulin metabolism, glucagon-like peptide-1 (GLP-1), and adiponectin levels were evaluated by oral glucose tolerance test during three periods: T1 (first evaluation), T2 (pre-surgery), and T3 (9 months after surgery). Results  Insulin levels improved after surgery. T1 was 131.1 ± 17.60 pmol/l in the NGT group and 197.57 ± 57.94 pmol/l in the AGM group, and T3 was 72.48 ± 3.67 pmol/l in the NGT group and 61.2 ± 9.33 pmol/l in the AGM group. The major reduction was at the first hour of the glucose load as well as fasting levels. At 9 months after surgery (T3), GLP-1 levels at 30 and 60 min had significantly increased in both groups. It was observed that the AGM group had higher levels of GLP-1 at 30 min (34.06 ± 6.18 pmol/l) when compared to the NGT group (22.69 ± 4.04 pmol/l). Homeostasis model assessment of insulin resistance from the NGT and AGM groups had a significant reduction at periods T3 in relation to T1 and T2. Adiponectin levels had increased concentration in both groups before and after surgical weight loss. However, it did not have any statistical difference between periods T1 vs. T2. Conclusions  Weight loss by surgery leads to improvement in the metabolism of carbohydrates in relation to sensitivity to the insulin, contributing to the reduction of type 2 diabetes incidence. This improvement also was expressed by the improvement of the levels of adiponectin and GLP-1.     

Bone repair following bone grafting hydroxyapatite guided bone regeneration and infra-red laser photobiomodulation: a histological study in a rodent model

The aim of the investigation was to assess histologically the effect of laser photobiomodulation (LPBM) on a repair of defects surgically created in the femurs of rats. Forty-five Wistar rats were divided into four groups: group I (control); group II (LPBM); group III (hydroxyapatite guided bone regeneration; HA GBR); group IV (HA GBR LPBM). The animals in the irradiated groups were subjected to the first irradiation immediately after surgery, and it was repeated every day for 2 weeks. The animals were killed 15 days, 21 days and 30 days after surgery. When the groups irradiated with implant and membrane were compared, it was observed that the repair of the defects submitted to LPBM was also processed faster, starting from the 15th day. At the 30th day, the level of repair of the defects was similar in the irradiated groups and those not irradiated. New bone formation was seen inside the cavity, probably by the osteoconduction of the implant, and, in the irradiated groups, this new bone formation was incremental. The present preliminary data seem to suggest that LPMB therapy might have a positive effect upon early wound healing of bone defects treated with a combination of HA and GBR.     

Stereological and biochemical analysis of muscular and connective tissue components in the penile corpus cavernosum adjacent to the fibrous plaque of Peyronie's disease

OBJECTIVE

To investigate the structural organization of the connective tissue in the corpus cavernosum (CC) adjacent to the fibrous plaque in Peyronie’s disease (PD) using stereological and biochemical techniques, as most studies on PD have focused on the analysis of the fibrous plaque that forms in the tunica albuginea (TA). Because this fibrotic reaction is mediated by various inflammatory soluble factors, adjacent connective tissues might also be affected and this secondary effect might explain, for example, the erectile dysfunction that occurs in PD.

PATIENTS AND METHODS

During surgery biopsies were taken from the CC adjacent to the fibrous plaque and from the plaque itself in seven patients with PD (mean age 48.3 years). All the patients had normal erections. Control samples were similarly located samples from ‘normal’ penises obtained during autopsy of five men (mean age 52.3 years). Tissue samples were stained with Weigert’s stain (elastic fibres), Van Gieson’s stain (connective tissue), and Sirius red (collagen). Stereological analysis was done using a 42‐point grid to determine volumetric densities (Vv). Total collagen content was estimated as micrograms of hydroxyproline per milligram dry CC.

RESULTS

The Vv of elastic fibres was significantly reduced in PD by 17.3% compared with controls, at a mean (sd ) of 19.49 (3.27)% vs 23.56 (1.87)% (P < 0.05). While in PD the Vv of smooth muscle at 34.46 (2.06)% and connective tissue at 35.39 (6.15)% were not significantly different from those of controls at 38.38 (3.17)% and 38.02 (5.03)%, respectively. The Vv of elastic fibres in the fibrous plaque was decreased by 38.3% compared with the normal TA, at 20.25 (5.49)% vs 32.81 (4.75)% (P < 0.02). The mean (sd ) collagen concentration in the CC from controls was 77.94 (24.26) µg/mg and in the patients with PD was 66.57 (19.39) µg/mg, which did not differ significantly. Sirius red‐stained sections under polarized light showed that, in the normal CC, collagen‐associated colours were homogeneously distributed. However, in the PD samples, stained collagen had a disrupted orientation and had a more heterogeneous birefringence, implying looser collagen bundles.

CONCLUSIONS

The quantitative analyses indicated that collagen in the CC close to the fibrous plaque was not affected, although its organization was noticeably altered. The CC elastic fibres were reduced though, and there was a similar change in the fibrous plaque of the TA. These results suggest that, although occurring primarily in the TA, the PD fibrous plaque may induce changes in the adjacent CC.     

Surgical treatment of hepatic tumors in children: lessons learned from liver transplantation

Purpose

Hepatectomy remains a complex operation even in experienced hands. The objective of the present study was to describe our experience in liver resections, in the light of liver transplantation, emphasizing the indications for surgery, surgical techniques, complications, and results.

Methods

The medical records of 53 children who underwent liver resection for primary or metastatic hepatic tumors were reviewed. Ultrasonography, computed tomographic (CT) scan, and needle biopsy were the initial methods used to diagnose malignant tumors. After neoadjuvant chemotherapy, tumor resectability was evaluated by another CT scan. Surgery was performed by surgeons competent in liver transplantation. As in liver living donor operation, vascular anomalies were investigated. The main arterial anomalies found were the right hepatic artery emerging from the superior mesenteric artery and left hepatic artery from left gastric artery. Hilar structures were dissected very close to liver parenchyma. The hepatic artery and portal vein were dissected and ligated near their entrance to the liver parenchyma to avoid damaging the hilar vessels of the other lobe. During dissection of the suprahepatic veins, the venous infusion was decreased to reduce central venous pressure and potential bleeding from hepatic veins and the vena cava.

Results

Fifty-three children with hepatic tumors underwent surgical treatment, 47 patients underwent liver resections, and in 6 cases, liver transplantation was performed because the tumor was considered unresectable. There were 31 cases of hepatoblastoma, with a 9.6% mortality rate. Ten children presented with other malignant tumors—3 undifferentiated sarcomas, 2 hepatocellular carcinomas, 2 fibrolamellar hepatocellular carcinomas, a rhabdomyosarcoma, an immature ovarian teratoma, and a single neuroblastoma. These cases had a 50% mortality rate. Six children had benign tumors—4 mesenchymal hamartoma, 1 focal nodular hyperplasia, and a mucinous cystadenoma. All of these children had a favorable outcome. Hepatic resections included 22 right lobectomies, 9 right trisegmentectomies, 8 left lobectomies, 5 left trisegmentectomies, 2 left segmentectomies, and 1 case of monosegment (segment IV) resection. The overall mortality rate was 14.9%, and all deaths were related to recurrence of malignant disease. The mortality rate of hepatoblastoma patients was less than other malignant tumors (P = .04).

Conclusion

The resection of hepatic tumors in children requires expertise in pediatric surgical practice, and many lessons learned from liver transplantation can be applied to hepatectomies. The present series showed no mortality directly related to the surgery and a low complication rate.     

Dietary calcium and phosphorus ratio regulates bone mineralization and turnover in vitamin D receptor knockout mice by affecting intestinal calcium and phosphorus absorption.

The effects of the dietary Ca and P ratio, independent of any vitamin D effects, on bone mineralization and turnover was examined in 60 VDRKO mice fed different Ca/P ratio diets. High dietary Ca/P ratio promoted bone mineralization and turnover with adequate intestinal Ca and P transports in VDRKO mice. INTRODUCTION: To clarify the effects of the dietary calcium (Ca) and phosphorus (P) ratio (Ca/P ratio) on bone mineralization and turnover in null-vitamin D signal condition, vitamin D receptor knockout (VDRKO) mice were given diets containing different Ca/P ratios. MATERIALS AND METHODS: Five groups of 4-week-old VDRKO mice, 10 animals each, were fed diets for 4 weeks. Group 1 was wild-type littermate mice, fed the diet containing 0.5% Ca and P (Ca/P = 1). Group 2 was the control and was fed a similar diet (Ca/P = 1). Groups 3, 4, 5, and 6 were fed the following diets: 0.5% Ca and 1.0% P (Ca/P = 0.5), 1.0% Ca and 1.0% P (Ca/P = 1), 1.0% Ca and 0.5% P (Ca/P = 2), and 0.5% Ca and 0.25% P (Ca/P = 2). RESULTS AND CONCLUSIONS: Compared with group 2, serum calcium and phosphorus levels in groups 4-6 significantly increased. Serum parathyroid hormone levels increased in group 3 and decreased in group 5. The amounts of intestinal calcium absorption decreased in groups 3 and 4. Phosphorus absorption increased in group 3 and decreased in groups 4-6. Bone mineral content (BMC) and bone mineral density (BMD) of the femur in group 3 significantly decreased and increased in group 5. In the primary spongiosa of the proximal tibia, the trabecular bone volume (BV/TV) and osteoid thickness (O.Th) in group 3 significantly increased, and decreased in group 6. In groups 5 and 6, the numbers of the trabecular osteoclasts increased. In groups 2 and 4, and the secondary spongiosa was identified in 5 of 10 mice. In group 3, there was no secondary spongiosa in either mouse. Osteoid maturation time (OMT) significantly decreased, and bone formation rate (BFR/BS) increased in groups 4-6. These data indicate that the dietary Ca/P ratio regulates bone mineralization and turnover by affecting the intestinal calcium and phosphorus transports in VDRKO mice. They may suggest the existence of Ca/P ratio-dependent, vitamin D-independent calcium and phosphorus transport system in the intestine.     

Validation of the Pelvic Organ Prolapse Quantification Index (POP-Q-I): a novel interpretation of the POP-Q system for optimization of POP research

Even though very precise at describing pelvic organ position, our criticism to the Pelvic Organ Prolapse Quantification (POP-Q) system is its limited ability to quantify the prolapse itself, since it still classifies prolapse into four stages, almost the same way as Baden and Walker (Clin Obstet Gynecol 15(4):1070-1072, 1972) did in 1972. As a result, the same grade can include a wide prolapse intensity range. The objective of this study was to assess inter-observer reliability in the Pelvic Organ Prolapse Quantification Index (POP-Q-I; Lemos et al., Int Urogynecol J 18(6):609-611, 2007) on a prospective randomized trial. Fifty consecutive women were prospectively examined by two members of the urogynecology staff, blinded to each other's results. Spearman's rank correlation was used to assess inter-observer reliability. Excellent correlation coefficients were observed, with an overall coefficient of 96.5% (CI: 0.889-1.042; p < 0.0001). The POP-Q-I is a method that makes POP research more efficient by directly measuring prolapse as a continuous variable, which is statistically more powerful than the categorical variables proposed by the POP-Q system. This study suggests that the POP-Q-I is applicable to clinical POP research.     

Testicular migration: remodeling of connective tissue and muscle cells in human gubernaculum testis

PURPOSE: We present the main morphological modifications in the human gubernaculum during testicular migration in humans. MATERIALS AND METHODS: We obtained 12 gubernacula from fresh, macroscopically normal human fetuses at 15 to 29 weeks of gestation. Collagen was evidenced using trichrome and Sirius red staining procedures, while Weigert's resorcinol-fuchsin and anti-human elastin antibody were used to reveal elastic system fibers. Smooth muscle cells were detected by anti-human smooth muscle alpha-actin antibody. RESULTS: When the testes were still located in the abdomen at 15 to 16 weeks of gestation, collagen fibers were sparse and embedded in a loose extracellular matrix. The amount of fibers then gradually increased with age and at 28 weeks of gestation the gubernaculum was mostly collagenous in composition. Elastic fibers had a similar growth pattern, although they were located mainly at the distal end of the gubernaculum. Fibroblasts largely predominated over other cell types and decreased in number with gestational age, whereas smooth muscle cells were restricted to the walls of blood vessels. Striated muscle cells were detected at the scrotal end of the gubernaculum, where they were disposed as isolated and scattered bundles running in various directions. Like fibroblasts, their number also decreased with age. CONCLUSIONS: During testicular migration gubernacular connective tissue undergoes extensive remodeling and ultimately becomes an essentially fibrous structure rich in collagen and elastic fibers. Such changes should decrease the size of the gubernaculum and, thus, contribute to other forces that cause the testes to move toward the scrotum. In fact, because of the lack of smooth muscle cells, and the amount and organization of striated muscle cells, active contraction of the gubernaculum is less likely to be an important factor in testicular descent.