The impact of dermolipectomy in improving the quality of life in patients with abdominal lipodystrophy

Introdução: A valorização da aparência, aliada a padrões e parâmetros impostos pelas indústrias de beleza e moda e difundidos pelas mídias geram questionamentos sobre o real valor da beleza. Distorções nesses parâmetros levam pacientes, insatisfeitos com seus corpos, aos consultórios médicos. Concomitantemente, existem queixas físicas disfuncionais e suas consequências. A Cirurgia Plástica, nesse contexto, tem como objetivo a melhora da qualidade de vida e maior aceitação do próprio corpo. A abdominoplastia ou dermolipectomia abdominal é um procedimento cirúrgico com grande ênfase, mas ainda com poucas avaliações a respeito da imagem pessoal e qualidade de vida no pós-operatório. O objetivo é avaliar a melhoria da qualidade de vida e da imagem corporal nos pacientes submetidos à dermolipectomia abdominal como procedimento eletivo e compreender implicações físico-psicológicas relacionadas aos distúrbios corporais. Métodos: Aplicação do instrumento WHOQOL bref em 15 pacientes do Ambulatório de Cirurgia Plástica do Hospital Universitário da Universidade Federal de Juiz de Fora e da Clínica Plastic Center, portadoras de lipodistrofia abdominal submetidas à dermolipectomia abdominal em três momentos: pré-operatório, dois e seis meses de pós-operatório. Resultados: Após análise dos dados, foi observada melhora na qualidade de vida dos pacientes comparando os resultados nos estágios de pré e pós-operatório, analisados no domínio psicológico com resultados estatisticamente significativos (p < 0,05). No domínio físico, a relação entre as três etapas também é estatisticamente significativa, considerando valor p < 0,07. Conclusões: A abdominoplastia no tratamento da lipodistrofia abdominal tem impacto na melhora da qualidade de vida destes pacientes, principalmente nos aspectos físico e psicológico, concordando com literatura pré-existente. ■ RESUMO

The impact of dermolipectomy in improving the quality of life in patients with abdominal lipodystrophy

INTRODUCTION
The appreciation of appearance today is a reality that has aroused constant assessments regarding the real value of beauty.Standards and parameters have been created and recreated from the beauty and fashion industries, being massively disseminated by the press and television media.Women and men with sculptured bodies are more than objects of desire for some, as these individuals represent examples of an ideal to be achieved.
According to the American Psychiatric Association (APA), many mental disorders arise from the incessant desire to be physically equal or similar to another person.One of these, body dysmorphic disorder 1,2 , displays a direct relationship between selfdemand and the development of this mental disease.
Along with this disorder, there are dysfunctional physical complaints that lead to various other consequences.Cutaneous deformities, lipodystrophies, and changes in the myoaponeurotic layer, can generate alterations in the function of the abdominal wall, and requires reparative surgical intervention to restore the aesthetic, function, and balance of the abdominal muscles.
These individuals tended to develop abdominal hypotonia, after pregnancy (in women), abdominal hernias, increased intrabdominal volume 3 , excessive weight loss in a short time 4 , or through a combination of these elements.
Plastic surgery, in these cases, is intended to improve the quality of life 5 , generating a positive impact 6 on improving satisfaction with the body.Surgery Clinic in the city of Juiz de Fora, who had undergone a conventional abdominal dermolipectomy without liposuction or other complementary procedures between June and December 2011 were included.
The patients were selected by convenience, being the first 15 candidates for abdominoplasty, those classified as V in the classification system proposed by Bozola 10 , and those in which a conventional abdominoplasty was performed (Figure 1).Patients with prior dermolipectomy, or even individuals unable to respond to the questionnaire were excluded from the study.This study was approved by the Ethics and Research Committee of the University Hospital of the Federal University of Juiz de Fora (HU/UFJF); under opinion number 130/11, May 23, 2011.
Abdominoplasty or abdominal dermolipectomy, initially described in 1961 7 , is a surgical procedure that has gained prominence today, but which has undergone few evaluations that have examined patient evaluations of personal image and quality of life in the postoperative period.
In the perspective of mental health, abdominoplasty is understood as a way to modify the actual image of the individual through the restoration of the body-structure, generating as a consequence, an improvement in psychosocial function.Likewise, it allows the confluence of images that the individual presents both to others and to oneself, producing a synergistic effect in the improvement of personal symptoms regarding their physical body.
There are few published cases, which depict the improvement of the personal image and satisfaction in the postoperative period of this type of aestheticrepair procedure 8 .Given this, it is essential to qualify and quantify the subjective evaluation of patients in relation to mental, physical, emotional, social, and sexual functions, understanding their complaints and intimate perceptions about their problem.

OBJECTIVE
The proposed objective is the evaluation of the improvement in the quality of life and of body image in patients who underwent abdominal dermolipectomy as an elective procedure, involving the physical and psychological well-being related to body disorder.

METHODS
This was a longitudinal and prospective study, which applied the WHOQOL-BREF tool to compare the assessments of patients who underwent an abdominal dermolipectomy.The evaluations were performed on 15 patients of the Outpatient Clinic of Plastic Surgery at the University Hospital of the Federal University of Juiz de Fora and the Plastic Center Clinic, both in Juiz de Fora, MG, at three time points: during the pre-operative period, as well as two and six months postoperatively.
The questionnaire, standardized by the Mental Health Program of the World Health Organization (WHO) and validated in Brazil in 1998 by Dr. Marcelo Pio de Almeida Fleck 9 , contains 26 questions distributed in four areas: social, psychological, physical, and environment relations.The scores of each domain in the WHOQOL-BREF are rated on a scale of 20, with scores closer to 20 representing a better quality of life in the interviewee.
Ambulatory patients of the Clinic of Plastic Surgery at the University Hospital of the Federal University of Juiz de Fora or Plastic Center, Plastic This program performs the calculations of the scores and descriptive statistics of WHOQOL-BREF automatically, with the researcher only needing to insert the data collected through the WHOQOL-BREF questionnaire.This program can be downloaded at the URL: http://www.brunopedroso.com.br/whoqolbref.html 11.
In sequence, a statistical analysis was performed upon the data within their specific domains to check for normality by Levine's test.The results of these tests found that the data was approximately normal.In view of this finding, the means of responses were subjected to analysis of variance (ANOVA) in order to compare the means between the pre-operated data with data of two and six months following the referred surgery.

RESULTS
After the application of the questionnaire, digitalization, and data analysis, as described above, the following results were obtained: (Tables 1, 2 and 3).As we can observe in the presented tables, there was an improvement in the quality of life in our patients submitted to a dermolipectomy, when the results are compared between the pre-operative and post-operative stages, especially in the psychological domain, which presented statistically significant results (p < 0.05).
Regarding the physical the relationship between the three steps is also statistically significant if we consider a p value < 0.07.In contrast, relationships in the social and environmental domains showed no statistical significance.
The total score, which scales the quality of life in the five domains, was, in the pre-operative stage, 61.81 on a scale from 0 to 100.After 2 months postoperatively, this score was 68.81, representing an increase of 7 points in this scale.When the first score is compared with the one obtained after 6 months postoperatively, which had a value of 69.37, an increase of 7.56 was observed on the same scale.
This increase, both after two months and after six months postoperatively, highlights an improvement in the overall quality of life of these patients, which is increased with the progression of the postoperative period.In addition, there was no statistical difference between patients from a private clinic and from the Single Health System (SUS), since the selected patients were similar.Finally, it is known that the attempt to evaluate and compare the level of the quality of life by objective methods is hampered by human subjectivity.Even so, the creation of mechanisms that can demonstrate substantial gains, achieved by surgical procedures, is of vital importance for assessing ways to improve the condition of patients affected by diseases, which have an impact on their physical and mental health, as is the case with abdominal lipodystrophy.

CONCLUSION
The use of abdominoplasty in the treatment of abdominal lipodystrophy has an impact on the improvement in the quality of life of patients who underwent this procedure, mainly in the physical and psychological domains, which is in agreement with pre-existing literature.

COLLABORATIONS DISCUSSION
The use of abdominoplasty for the treatment abdominal lipodystrophy has previously been demonstrated in other studies as an effective therapy in the improvement of quality of life.This has been shown through the utilization of other forms of assessment, such as the Body Shape Questionnaire, Rosenberg Self-Esteem Scale (validated by the Federal University of SP), Short Form 36, and Multidimensional Body-Self Relations Questionnaire (used by de Brito et al. 12 and by Bolton et al. 8) .These studies have already suggested that this surgical procedure has a positive effect on the improvement of self-image and the mental health of patients with abdominal lipodystrophy.
More recently, Papadopoulos et al. 13 obtained similar results after measuring the emotional stability of patients who had undergone an abdominoplasty.Furthermore, Stuerz et al. 14 found a beneficial impact of this surgery on patients with great weight loss.The assessment of the quality of life by means of the WHOQOL-BREF questionnaire, employed herein, goes beyond the classic measures of symptoms, limitations, and dysfunctions.The current methods for the evaluation of quality of life are derived primarily from three areas of research: happiness, social indicators, and health indicators 15 , which are in agreement with the WHOQOL-BREF questionnaire on quality of life assessment by the four already cited domains: social relations, psychological, physical, and environment.
The choice of the WHOQOL-BREF as an analysis tool in the current study was based on the capacity of the questionnaire to measure objectively the quality of life of patients who underwent the procedure, as well as its applicability to the patients of our service.This is a questionnaire qualified as an instrument of good psychometric performance and of convenient use 16 , besides having a transcultural character 17 .The original model, called the WHOQOL 100, consists of 100 questions and its simplification, which features 26 questions, may be more appropriately adjusted to the cultural level of our patients, the majority of whom are exclusive users of the SUS.
The evaluation of patients undergoing abdominoplasty by the WHOQOL-BREF questionnaire, apparently unprecedented when one searches previous publications, seems to us as an important alternative in the comparison of results among patients who underwent this procedure.In addition, as the results corroborate the previous studies that provide evidence of the benefits of abdominoplasty on quality of life of patients, it gives strength to this assertion and encourages the use of abdominoplasty to improve personal self-image, respecting, of course, the appropriate indications of the procedure.

MPDC Final approval of the manuscript; conception;
study design and completion of surgeries.

MTD
Analysis; data interpretation and completion of surgeries.CESGC Drafting of the manuscript.

ENC
Review of the content.

LDC
Bibliography search and data collection.

Data collection.
FMLB Statistical analysis.

GVD
Data collection.

Table 1 .
Results obtained during the pre-operative period.
QOL: Quality of life.

Table 2 .
Results obtained two months following the operation.
QOL: Quality of life.

Table 3 .
Results obtained six months following the operation.
QOL: Quality of life.