Single-Layer Plication for Repair of Diastasis Recti: The Most Rapid and Efficient Technique

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1 Body Contouring Single-Layer Plication for Repair of Diastasis Recti: The Most Rapid and Efficient Technique Aesthetic Surgery Journal 2017, Vol 37(6) The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: DOI: /asj/sjw263 Luiz José Muaccad Gama, MD; Marcus Vinicius Jardini Barbosa, MD, PhD; Adriano Czapkowski, MD; Sergio Ajzen, MD, PhD; Lydia Masako Ferreira, MD, PhD, MBA; and Fábio Xerfan Nahas, MD, PhD, MBA Abstract Background: Plication of the anterior rectus sheath is the most commonly used technique for repair of diastasis recti, but is also a time-consuming procedure. Objectives: The aim of this study was to compare the efficacy and time required to repair diastasis recti using different plication techniques. Methods: Thirty women with similar abdominal deformities, who had had at least one pregnancy, were randomized into three groups to undergo abdominoplasty. Plication of the anterior rectus sheath was performed in two layers with 2-0 monofilament nylon suture (control group) or in a single layer with either a continuous 2-0 monofilament nylon suture (group I) or using a continuous barbed suture (group II). Operative time was recorded. All patients underwent ultrasound examination preoperatively and at 3 weeks and 6 months postoperatively to monitor for diastasis recurrence. The force required to bring the anterior rectus sheath to the midline was measured at the supraumbilical and infraumbilical levels. Results: Patient age ranged from 26 to 50 years and body mass index from to kg/m 2. A significant difference in mean operative time was found between the control and study groups (control group, 35 min:22 s; group I, 14 min:22 s; group II, 15 min:23 s; P < 0.001). Three patients in group II had recurrence of diastasis. There were no significant within- and between-group differences in tensile force on the aponeurosis. Conclusions: Plication of the anterior rectus sheath in a single-layer with a continuous suture showed to be an efficient and rapid technique for repair of diastasis recti. Level of Evidence: 1 Editorial Decision date: December 8, 2016; online publish-ahead-of-print March 3, The abdominal wall is an anatomical structure responsible for the protection of the abdominal viscera, maintaining its position during changes in gravitational forces and increased intra-abdominal pressure. Although abdominoplasty improves the patient s quality of life, self-esteem, self-image, 1 and sexuality, 2,3 efforts should continue to be made to reduce complications related to the procedure. 4 Diastasis of the rectus abdominis muscles is responsible for the protrusion of abdominal wall, hernia formation, and triggering functional problems such as back pain. Different techniques have been proposed for the treatment of deformities caused by laxity of the abdominal wall Dr Gama is a Graduate Student in Translational Surgery and Dr Czapkowski is a Graduate Student in Clinical Radiology, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil. Dr Barbosa is an Affiliate Professor and Coordinator of the Morphology Laboratory, University of Franca Medical School, São Paulo, Brazil. Dr Ajzen is a Full Professor, Department of Diagnostic Imaging, UNIFESP, São Paulo, Brazil. Dr Ferreira is a Full Professor and Dr Nahas is an Affiliate Professor, Division of Plastic Surgery, Department of Surgery, UNIFESP, São Paulo, Brazil. Corresponding Author: Dr Fábio Xerfan Nahas, Division of Plastic Surgery, UNIFESP, Rua Napoleão de Barros 715, 4o. andar, CEP São Paulo, Brazil. fabionahas@uol.com.br

2 Gama et al 699 musculature, with plication of the anterior rectus sheath being the most commonly used technique After repair of the diastasis recti, the suture site is exposed to tensile stress due to increased intraperitoneal pressure, tissue elasticity (the mobilized tissue tends to return to its original position), muscle contraction, and wound contraction. 15 A technique that provides a reliable correction of abdominal deformities with long-term results is highly desirable in abdominoplasty. An important point to consider when choosing a surgical technique is the operative time. No prospective studies were found comparing the operative time and efficacy of the two-layer plication technique with those of the single-layer plication technique. The aim of this study was to compare the efficacy and time required to repair diastasis recti using different types of suture for plication of the anterior rectus sheath. METHODS This interventional, analytic, randomized, single-center clinical trial was approved by the Research Ethics Committee of the Universidade Federal de São Paulo (UNIFESP), Brazil (approval no / ), and performed in accordance with the Resolution 196/96 of the Brazilian National Health Council (Conselho Nacional de Saúde, CNS) and Brazilian Ethical Review System on research involving human beings. Written informed consent was obtained from all patients prior to their inclusion in the study and anonymity was ensured. The study was conducted between June 2012 and October Patients, who expressed a desire to undergo abdominoplasty, were recruited at the Abdominal Plastic Surgery Unit of the São Paulo Hospital, UNIFESP. Inclusion criteria were female gender, 25 to 50 years of age, history of at least one pregnancy; body mass index (BMI) between 18 and 30 kg/m 2, desire to undergo abdominoplasty as a single procedure without receiving liposuction or other cosmetic surgeries, deformities of the skin and subcutaneous tissues in the abdominal region (Nahas type III deformity, for which resection of skin and subcutaneous tissue between the umbilicus and pubis is indicated), 16 and musculoaponeurotic defect (Nahas type A deformity, for which plication of the anterior rectus sheath is indicated to correct a fusiform diastasis of the rectus abdominis muscles secondary to pregnancy). 17 Smokers and patients who had abdominal wall scars (except for a Pfannenstiel scar related to a Cesarean section), abdominal wall hernias, history of deep-vein thrombosis, chronic obstructive pulmonary disease, cancer, hypertension, diabetes or other chronic systemic diseases, and use of corticosteroids were not included in the study. Thirty patients met study criteria and were randomized into three groups. The allocation sequence was generated using a computer-generated randomization program (Microsoft Office Excel 2010, Redwood, WA), according to a uniform distribution. A number between 0 and 1 was generated for each patient. Numbers between 0 and 0.33 determined allocation to the control group, those between 0.34 and 0.66 were assigned to group I, and numbers higher than 0.66 were allocated to group II. Coincidently, 10 patients were allocated per group. All patients were blinded to group assignment. In the control group, repair of diastasis recti was performed with plication of the anterior rectus sheath in two layers. The first layer was made with interrupted, inverted stitches (2-0 nylon) and the second layer with was a continuous 2-0 monofilament nylon suture (Mononylon, Ethicon, Inc., Summerville, NJ). In group I, plication was carried out in a single layer, also with a continuous 2-0 monofilament nylon suture, locking the stitch every 2 bites. Patients in group II underwent plication of the anterior rectus sheath in a single-layer using a continuous, non-absorbable (nylon), #1 Quill Self-Retaining System (SRS) bidirectional barbed suture (Angiotech Pharmaceuticals, Inc., Vancouver, British Columbia, Canada). The two primary outcomes evaluated in this study were operative time to correct diastasis recti and diastasis recurrence, measuring the efficacy of the technique. Diastasis recurrence was defined as a separation between the rectus abdominis muscles greater than 1.0 and 0.9 cm above and below the umbilicus, respectively, in patients 45 years of age; and greater than 1.5 and 1.4 cm above and below the umbilicus, respectively, in patients older than 45 years. 18 The secondary outcome was the overall operative time for the complete abdominoplasty. Outcomes were compared among groups. Prior to surgery, all patients underwent ultrasound of the abdominal wall using a Logiq P6 system (General Electric Health Care, Seoul, Korea) with an 11L probe. Measurements of the distance between the medial edges of the recti muscles were made at two different levels (always at the end of normal inspiration) to confirm and register the diastasis. The end of normal inspiration is a way to simulate the patient s inspiration when intubated (not after a Valsalva maneuver). It is important to say that the measurements were not taken during forced inspiration. This could cause a higher tension on the muscles compared to what really occurs when the patient is awake. This was done to make possible the comparison among the preoperative, intraoperative, and postoperative measurements of the distances between the medial edges of the rectus abdominis muscles. The supraumbilical and infraumbilical levels were defined 3 cm above the upper edge and 2 cm below the lower edge of the umbilicus, respectively.

3 700 Aesthetic Surgery Journal 37(6) Figure 1. Intraoperative photograph of a 35-year-old woman showing the extent of the undermining. Surgical Procedure All surgical procedures were performed by the same plastic surgeon (L.J.M.G.). The surgical procedure was performed under general anesthesia standardized with isoflurane and nitrous oxide, sufentanil ( mcg/kg), a single dose of propofol 200 mg, and pancuronium (1 mg/kg) used only for anesthetic induction. At the end of surgery, 100 mg of tramadol was administered. All patients underwent conventional abdominoplasty. The dermal-fat flap was superiorly dissected to the xiphoid process. A narrow tunnel was undermined in the supraumbilical region, extending laterally to a line 1 cm from the medial edges of the rectus abdominis muscles (Figure 1). The limits of the diastasis recti were marked with methylene blue and the distance between the medial edges of the rectus abdominis muscles (inter-recti distance) was measured with a ruler at the same supraumbilical and infraumbilical levels where ultrasound examinations were performed. At these same locations, two points were marked in the medial edge of the anterior rectus sheath for the placement of 2-0 monofilament nylon loops to hold a digital force gauge (Crown DBC 5000 gf, Filizola, São Paulo, Brazil) for measuring the force required to bring the medial edges of the anterior rectus sheath to midline. The midline was marked with a nylon thread placed from the xyphoid process to the pubis (Figure 2). Next, the diastasis recti was repaired differently in each group. Plication was not performed in the area of the Figure 2. Intraoperative photograph of a 35-year-old woman showing the measurement of the tensile force using a force gauge. umbilicus in any of the groups. The correction of diastasis recti in the control group was carried out in two layers with 2-0 monofilament nylon: the first layer was made with interrupted, inverted sutures placed 0.4 cm apart and a second layer with a continuous suture locked every two bites. In group I, plication was performed in a single layer with a continuous 2-0 monofilament nylon suture locked every two bites. In group II, diastasis recti was repaired in a single layer with a continuous, non-absorbable, #1 Quill SRS bidirectional barbed suture, starting in the middle of the supraumbilical region and running the suture up and down until the end of the diastasis, and then using other suture to the infraumbilical region, not suturing around the umbilicus. The time spent on each technique for repair of diastasis recti and the overall operative time for the complete abdominoplasty were recorded. Operative time for abdominoplasty was defined as the period from the start of the suprapubic incision to the end of skin closure. The time spent on each plication technique was recorded from the first insertion of the needle into the aponeurosis to the last suture. Excess skin and subcutaneous tissue of the abdominal flap were excised, the umbilicus was transposed 19 and the skin was closed in layers. The results of rectus sheath plication were monitored at 3 weeks and 6 months postoperatively by clinical and ultrasound examination at the same preoperative and intraoperative supraumbilical and infraumbilical levels. Ultrasound examination was always performed by the same radiologist (A.C.), who was blinded to group assignment.

4 Gama et al 701 Statistical Analysis Statistical analysis was carried out using Minitab 16 (Minitab, Inc., State College, PA). The power of the sample was estimated retrospectively. The diferences detected among patients in the variables tensile force on the aponeurosis, distance from pubis to the xiphoid process, and distance between the iliac crests, measured preoperatively and intraoperatively, were considered to be half the value of the standard deviation (SD) obtained by descriptive statistics. These differences were also considered to be 1.4 times the 95% confidence interval (CI). By using the tool Power and Sample Size from Minitab, it was possible to calculate that, for a sample with 30 patients, the power of the study was 78.1% (0.781). Parametric tests were used for the analysis of continuous quantitative data. Comparisons among groups were carried out using analysis of variance (ANOVA). ANOVA was also used to compare force-gauge readings between patients with and without recurrence of rectus diastasis in group II. As there were significant differences among groups in mean time spent on the plication procedure, total operative time, and number of pregnancies, the Tukey s multiple comparison test for pairwise comparisons was not used. Paired t test was utilized for comparisons between preoperative ultrasound measurements and intraoperative measurements of diastasis within groups. Statistical significance was set at 0.05 (P < 0.05) for a 95% CI. RESULTS The flow diagram showing inclusion and allocation of patients in the final sample can be found in Appendix A (available online as Supplementary Material at www. aestheticsurgeryjournal.com). The 30 patients had a mean Table 1. Comparison of Age, BMI, IS Distance, XP-PS Distance, and the Number of Pregnancies Among Groups Variables Range (n = 30) Control group age of years (range, years), a mean BMI of kg/m 2 (range, kg/m 2 ), mean distance between the anterior superior iliac spines of cm (range, cm), and mean distance between the xiphoid process and the pubic symphysis of cm (range, cm), without significant differences among groups (Table 1). Patients in group I had a significantly higher number of pregnancies than those in group II (P = 0.029), but not higher than controls (P = 0.161); no significant difference was found between the control group and group II (P = 0.682). The mean operative time for the complete abdominoplasty was 3 h:34 min, 3 h:06 min and 2 h:55 min in the control, group I, and group II, respectively (Table 2), with significant differences between the control group and both group I (P = 0.045) and group II (P = 0.005); no significant difference was found between group I and group II (P = 0.636). There were also significant differences in the time spent on the plication procedure between the control group (mean time, 35 min:22 s) and both the group I (mean time, 14 min:22 s; P < 0.001) and group II (mean time, 15 min:23 s; P < 0.001); no significant difference was found between group I and group II (P = 0.875), as shown in Table 2. No significant differences were observed in the interrecti distance measured in the intraoperative period when patients were at the end of normal inspiration or normal expiration. A significant difference in the inter-recti distance was found between preoperative ultrasound measurements and those obtained intraoperatively both at the supraumbilical and infraumbilical levels (Table 3) in the three groups and when all the patients were considered together (whole sample). The mean distances between the medial edges of the rectus abdominis muscles for the whole sample (n = 30) were 1.52 cm (measured preoperatively by ultrasound) and cm (obtained intraoperatively by direct measurements), for a mean difference between preoperative and Group I Group II Mean SD Mean SD Mean SD P-value Age (yr) BMI (kg/m 2 ) IS (cm) XP-PS (cm) No. of Preg * BMI, body mass index; IS, distance between anterior superior iliac spines; preg, pregnancies; SD, standard deviation; XP-PS, distance between the xiphoid process and pubic symphysis. *Statistical significance (ANOVA; P < 0.05).

5 702 Aesthetic Surgery Journal 37(6) Table 2. Comparison of Overall Operative Time for Complete Abdominoplasty and Time Spent on the Plication Procedure Among Groups Operative time Control group Group I Group II P-value Plication Mean 35min:22s 14min:22s 15min:23s < 0.001* SD 7min:21s 2min:31s 2min:25s Abdominoplasty Mean 3h:34min 3h:06min 2h:55min 0.005* SD 0h:32min 0h:19min 0h:21min SD, standard deviation. *Statistical significance (ANOVA; P < 0.05). Table 3. Comparison of Inter-Recti Distances Measured Preoperatively (by Ultrasound) and Intraoperatively at the Supraumbilical and Infraumbilical Locations Level Inter-recti distance (cm) Control group intraoperative measurements of cm. Mean ultrasound measurements were always lower than mean intraoperative measurements. No significant differences in tensile force on the aponeurosis were observed among the three groups (Table 4). Three patients (30%) in group II (barbed suture) had rectus diastasis recurrence, which was detected by ultrasound. In the first patient, the 6-month ultrasound examination revealed recurrent diastases of 1.52 and 1.13 cm at the supraumbilical and infraumbilical levels, respectively. A second patient showed recurrent diastasis of 1.09 cm at the supraumbilical level 3 weeks postoperatively, increasing to 2.51 cm at the 6-month follow-up. The third patient had recurrent diastasis 1.12 cm wide at the supraumbilical level 6 months after surgery. No significant differences in pain were observed in the early or in the late postoperative period among groups. All 30 patients received only common painkillers and non-steroidal, anti-inflammatory drugs during the first postoperative week. The retrospective power of the sample (n = 30) was estimated as 78.1% (0.781), which was considered as good, showing that the study had a good sample size. DISCUSSION Group I Group II Whole sample (n = 30) Supraumbilical Preoperative US Mean SD Intraoperative Measurement Mean SD P-value 0.021* 0.008* 0.001* < 0.001* Infraumbilical Preoperative US Mean SD Intraoperative Measurement Mean SD, standard deviation; US, ultrasound. *Statistical significance (Paired t test; P < 0.05). SD P-value 0.002* < 0.001* 0.017* < 0.001* Repair of diastasis recti has been used for many decades during abdominoplasty as a resource to correct the anterior abdominal projection and improve the contour of the waistline. 20 Plication of the rectus abdominis muscles reposition these muscles in a more anatomical manner, similar to the pre-pregnancy period, bringing a functional benefit to patients. Numerous imaging methods, such as computed tomography (CT), magnetic resonance imaging (MRI), and ultrasonography, 14,21-23 have been proven effective in the diagnosis of diastasis recti. Limiting factors for the use of CT and MRI include high costs, patient exposure to radiation in the specific case of CT, and patient discomfort during MRI. Ultrasonography has the advantage of being a reliable

6 Gama et al 703 Table 4. Comparison of Tensile Forces on the Aponeurosis Among Groups Force gauge location Tensile force (gf) Control group Group I Group II Supraumbilical Mean (SD) (271.6) (110.2) (158.4) P-value Infraumbilical Mean (SD) (202.4) (70.8) (77.5) P-value SD, standard deviation. (ANOVA; P < 0.05). diagnostic method to measure diastasis recti at the umbilical level and supraumbilical area, 22 despite being an operator-dependent technique. For these reasons, ultrasonography was chosen for the evaluation of the position of the rectus abdominis muscles in this study and performed by the same radiologist to prevent differences in operator technique. Every effort was made to select patients with similar deformities in terms of excess skin in the abdominal region and musculoaponeurotic defect. Thus, patients with specific deformities were selected using classifications based on the excess of abdominal skin and degree of abdominal distension. In addition, ranges of age and BMI were previously established to ensure homogeneous and comparable groups. No significant differences in patient characteristics were found among groups, except for number of pregnancies. The mean number of pregnancies was lower in patients with recurrent rectus diastasis (all in the barbed suture group), indicating that number of pregnancies was not a predictive factor, but that the plication technique had an impact on the risk of recurrence. The choice of the standard suture was based on a series of studies conducted at our institution in this line of research, showing that the 2-0 monofilament nylon suture can be safely used for repair diastasis recti, providing effective and long lasting results. 6,10,15,27,28 Diastasis recti repair was done by plication of the medial edges of the anterior rectus sheath, which, when approximated and brought to the midline, bring the muscles to the same position because it is firmly attached to them. A significant difference of cm in diastasis recti measurements was observed between preoperative ultrasound measurements and those obtained intraoperatively both at the supraumbilical and infraumbilical locations. This difference, although statistically significant, has no clinical relevance in rectus diastasis, since the purpose of diastasis correction is to reduce the diameter of the abdominal circumference. In contrast, Mendes et al 22 reported no significant differences in ultrasound measurements of diastasis in the supraumbilical region, but found significant differences in the infraumbilical region, attributing these differences to fibrosis resulting from cesarean section. The difference in measurements obtained at the supraumbilical location could be attributed to the measurement methods used in the present study, which differ from that applied by Mendes et al, 22 who estimated diastasis as the average of measurements made at inspiration and expiration. This method of measuring diastasis recti simulates the muscle position during the anesthetic procedure. 22 However, no significant differences were found in the inter-recti distance measured in the intraoperative period when patients were at the end of normal inspiration or normal expiration, showing that the moment of measurement was not an important issue, as previously expected. It is also important to note that ultrasound is an operator-dependent technique. Operative time is an important variable to be considered by surgeons, as it is directly related to the occurrence of surgical complications, such as thromboembolic events. Abdominoplasty has a high incidence of thromboembolic events compared to other aesthetic surgical procedures. Several factors associated with abdominoplasty, including increased intra-abdominal pressure caused by plication of the rectus sheath, Fowler s position, and use of compression garments may lead to increased venous stasis in the common femoral vein, increasing the risk of deep venous thrombosis Also, long operative time and high blood loss are risk factors for multiple complications. 27,28 Overall operative time for complete abdominoplasty was significantly shorter in groups I and II compared to the control group. It was also found that the time spent on the two-layer plication procedure (control group) was significantly longer compared to that of the single-layer plication procedures (groups I and II). Advances in techniques to improve the abdominoplasty results (eg, rectus sheath plication, oblique muscle plication) and for seroma prevention (eg, the use of quilting sutures to attach the abdominal flap to the aponeurosis) 29,30 increased operative time, which may be compensated, for example, by reducing the time spent on diastasis recti repair. It is especially important to reduce the operative time for abdominoplasty in patients who have comorbidities. Abdominal tension is a factor that may increase the risk of diastasis recurrence, corresponding to a tensile force on

7 704 Aesthetic Surgery Journal 37(6) the aponeurosis opposed to the force applied for joining the edges of the rectus abdominis muscles. For this reason, the force required to bring the anterior rectus sheath to the midline was measured on the supraumbilical and infraumbilical levels, and taken as the average resultant force acting upon the right and left sides of the plication, both at the supra and infraumbilical levels. The average resultant force corresponds to the tension that the plication had to support during the postoperative period. Since no significant difference in tensile force was found among groups, it does not appear to be the cause of diastasis recurrence. Thus, the results showed that abdominal tension was not directly related to recurrence of diastasis recti in the barbed suture group, suggesting that diastasis recurrence was more closely associated with the type of plication technique used. The take-home message is that continuous running suture was the fastest technique, reducing operative time, and the most efficient; it also showed to be reliable, is less expensive and easily found in hospitals. The self-retained barbed suture technique failed, probably because the suture was not firmly anchored to the aponeurosis, which is a strong tissue, but mostly to the muscle, which is a weak tissue that stretches over time in response to continuous contractions, causing diastasis recurrence. It is essential to stress that the repair of a wide diastasis does not have a direct effect on the intra-abdominal pressure. 31 Three cases of diastasis recurrence occurred in a group of only 10 patients (group II) for a recurrence rate of approximately 30% (3/10). Although the small number of recurrence cases does not allow the statistical comparison of tensile forces at the aponeurosis, a recurrence rate of 30% is unacceptable in such a small sample. The results show that the Quill SRS is not a good suture to correct rectus diastasis. Changes are required in the Quill suture for its use in fascial closure. Congenital diastasis is a condition that occurs from 5% to 7% in patients who seek abdominoplasty. 6,17 It is important to note that cases of congenital diastasis of the rectus abdominis muscle should not be treated with plication of the anterior rectus sheath. 6,17,33 In these cases, patients show lateral insertion of the rectus abdominis muscles in the costal margin and the medial advancement of the rectus sheath is indicated to prevent diastasis recurrence, 32,33 regardless of the suture technique used. This study has some limitations, including the relatively small number of patients in each group. Also, the mean age of patients was low (approximately 37 years in all groups). It is known that a loss of collagen types I and III occurs in the rectus abdominis muscle in older patients, and therefore diastasis recurrence is more likely to occur. 34 The mean BMI was also low (about 24 kg/m 2 in all groups), which is also a limitation. It is not possible to predict if rates of diastasis recurrence would be the same for patients with higher BMI as that of the study sample. The single-layer plication using interrupted sutures was not included in this study because this technique takes longer to be performed compared to plication using continuous running suture and operative time was an important outcome evaluated in the study. Because the two-layer plication with continuous suture was used as the standard technique, a fast and reliable technique was necessary to be evaluated. A 6-month follow-up period was probably sufficient to assess the efficacy of the technique. Some previous studies 5,10,15,21 have shown that diastasis recurrence is less likely to occur after 6 months postoperatively. It is essential to continuously search for efficient and effective techniques in plastic surgery. As the correction of diastasis recti has a functional and aesthetic role, preventing diastasis recurrence will have a positive impact on the outcome of abdominoplasty. Reduced operative time can prevent complications and decrease surgical costs. 27,28 CONCLUSION Plication of the anterior rectus sheath with a continuous suture in a single layer is a rapid and efficient method to repair diastasis recti. Two-layer suture proved to be an effective but slow plication technique. Diastasis repair with barbed suture required a short operative time, but led to a recurrence rate of 30%. Supplementary Material This article contains supplementary material located online at Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. de Brito MJ, Nahas FX, Barbosa MV, et al. Abdominoplasty and its effect on body image, self-esteem, and mental health. Ann Plast Surg. 2010;65(1): de Brito MJ, Nahas FX, Bussolaro RA, Shinmyo LM, Barbosa MV, Ferreira LM. Effects of abdominoplasty on female sexuality: a pilot study. J Sex Med. 2012;9(3): da Silva DB, Nahas FX, Bussolaro RA, de Brito MJ, Ferreira LM. The increasing growth of plastic surgery lawsuits in Brazil. Aesthetic Plast Surg. 2010;34(4):

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