Functional nutrition in postoperative plastic surgery: focus on seroma and fibrosis prevention

ROCHA, CAMILE LAÍS; PAULA, VANDRESSA BUENO DE

doi:10.5935/2177-1235.2014RBCP0107

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Revista Brasileira de Cirurgia Plástica

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Review article • Rev. Bras. Cir. Plást. 29 (4) • Oct-Dec 2014 • https://doi.org/10.5935/2177-1235.2014RBCP0107 copy

Functional nutrition in postoperative plastic surgery: focus on seroma and fibrosis prevention

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Introduction:

Based on the wide range of possible consequences and complications of plastic surgery and the role of nutrition in the recovery process of these, we see the need for therapeutic practices to ensure effectiveness of the final aesthetic result.

Method:

This study is characterized as a non-systematic review of the possible associated nutrients, bioactive compounds and herbal medicines to prevent seroma and fibrosis. Thus, we used scientific journal articles from electronic media, national laws and textbooks published between 2002 and 2012.

Results:

We demonstrated that the main causes of seroma and fibrosis are changed healing, inflammation, oxidative stress and edema. Thus, we designed a practical guide with nutrients, bioactive compounds and herbal medicines that can be used to prevent, control or mitigate the complications after plastic surgery.

Conclusion:

It was emphasized that for the treatment of covered conditions is essential that there is a multidisciplinary approach, emphasizing a medical, nutritional and therapeutic monitoring covering the known changes in the pathophysiology of seroma and fibrosis.

Keywords:
Seroma; Fibrosis; Nutrition; Functional food; Phytotherapy

Macronutrients	Oral daily dose	Functions
Water	30ml/kg 1ml/kcal Minimum 1500 mL	Adequate tissue perfusion Prevents the increase in glucose levels that impairs the healing process Prevents hypovolemia Removal of catabolism products
Carbohydrates	55-60% of total energy value (TEV) from complex carbohydrates Do not exceed 5 mg/kg	Activation of hexokinase and citrate synthase used in tissue repair Activation of gene expression Cooperation with macrophages and fibroblasts in angiogenesis Energy for lymphocytes and fibroblasts Energy supply, preventing protein catabolism and mobilization of fatty acids Hormonal Inflammatory Lactate metabolism contributes to collagen synthesis Regulation of adhesion, proliferation, and migration of cells Regulation of leukocytes, epithelial cells, and endothelial cells Transport
Proteins	1.5-1.8 g/kg	Anabolism Source of energy Growth and tissue repair Controls the inflammatory phase Cellular proliferation, mainly fibroblasts Synthesis and deposition of collagen and proteoglycans Revascularization and angiogenesis Improves the humoral and cellular immunity Formation of lymphocytes Phagocytic capacity of leukocytes Prevents infection
Arginine	5-15 g 30 g arginine aspartate (17g free arginine) Up to 60 g can be tolerated	Deposition of proteins in the scar Decreases nitrogen loss Anabolic hormonal stimuli in the wound Generation of nitric oxide Induction of healing mediators such as insulin, HGH, and IGF-1 Enhances lymphocyte immune function Improves perfusion, microvascularization, and angiogenesis Improves monocytic response and restores macrophages Precursor of nitric oxide, which is a vasodilator with antibacterial and angiogenic properties Precursor of nitric oxide Collagen production, by being a precursor of proline, and facilitates the connection between the two components Cellular proliferation Secretion of growth hormone Synthesis and deposition of collagen by being a precursor of proline ^* In hepatic and renal failure, the electrolyte levels should be carefully analyzed
Carnitine	-	Helps in the enzymatic antioxidant defenses
Cysteine	-	Synthesis of connective tissue and collagen
	300-600 mg	Cofactor of enzymatic systems of collagen synthesis
Glutamine	0.3-0.6 g/kg 20-40 g in catabolic state Do not exceed 10 g in the normal state	Anabolism and anticatabolism Anabolism and anticatabolism Antioxidant, by being a component of glutathione Increases the synthesis of muscle proteins Fuel for rapidly dividing cells Stimulates the release of growth hormones Source of energy after stress and for epithelialization of cells through gluconeogenesis Intestinal integrity Precursor of purines, pyrimidines, and phospholipids Proliferation of lymphocytes Proliferation of lymphocytes, stimulating the inflammatory response Reduction of infection Fibroblast and macrophage synthesis Synthesis of purine and pyrimidine Transports and decreases nitrogen loss ^* Contraindicated in hyperammonemia, hepatic failure, and renal failure
Glycine	250 mg	Collagen formation
Lysine	250mg	Collagen formation
Methionine	-	Synthesis of collagen and connective tissue
Proline	250mg	Collagen formation
Lipids	20-25% of TEV Do not exceed 2 g/kg	Assist in the remodeling phase Energy source Formation of extracellular matrix Supply of cell membrane phospholipids and prostaglandins Metabolic, inflammatory, and vascular functions of cells Signaling molecules, through eicosanoids and other mediators Synthesis of prostaglandins
Fatty acids monounsaturated and polyunsaturated	ω6/ω3 ratio of 5:1	Alteration in free radical production Anti-inflammatory, anticoagulant, vasodilator, and antiplatelet actions Activation of protein kinase C and specific genes Composition and fluidity of the cell membrane Controls vascular permeability Lipase control Energy source and storage Inflammation Inhibition of eicosapentaenoic (attenuation of immune and inflammatory responses), tumor necrosis factor, interleukin-1, and of platelet activation generating attenuation Maintenance of the tissue microperfusion Cell proliferation, apoptosis, and angiogenesis Remodeling of collagen and cellular matrix Molecular signaling ^*High doses: delay healing due to negative effects on coagulation

Micronutrients	Oral daily dose	Functions
Vitamin A b-Carotene Lycopene Lutein Zeaxanthin	Maximum 5.000-25.000 UI	Accelerates epithelialization and wound closure Antioxidant Attenuates the ischemia-reperfusion process Activation of macrophages, natural killer cells, and lymphocytes Helps in glycoprotein synthesis Controls the anti-inflammatory effects of corticosteroids Collagen cross-linking Fibroblasts differentiation Stimulates phagocytosis Cytokine expression Induces inflammatory response Lymphopoiesis Maintenance of the immune system by promoting the influx of monocytes and macrophages Modulates collagenases activity Antibody production Reverses the effects of glucocorticoids in the inflammatory phase Collagen synthesis and re-epithelialization ^*High doses: toxicity
Vitamin B complex	B2: 10 mg B3: 150 mg B5: 2.5-10 mg B6: 10-50 mg B7: 50-150 µg B9: 0.4-1 mg B12: 250-1000 µg B1: 10-100 mg	Angiogenesis Activation of protein, tissue, and DNA synthesis Increase in collagen Increase in growth hormone Cofactors in the production of energy and antibodies Collagen cross-linking Ensures leukocyte function Precursor of proline Regulates oxidative stress Removal of necrotic tissue
Vitamin C	60 mg-2 g	Accelerates tissue regeneration Adhesion of endothelial cells Angiogenesis and capillary force Antioxidant in hydrophilic medium Attenuates the ischemia-reperfusion process Decreases susceptibility to infections Decreases capillary permeability and endothelial reactivity Balance of the extracellular matrix Stability of the collagen triple helix Promotes healing and scar resistance Proline and lysine hydroxylation Induces cell mitosis and monocyte migration Antioxidant cooperative interaction with vitamin E, regenerating it Improves leukocyte action Improves phagocytosis Prevents dehiscence Protection from the damage caused by medication Chemotaxis Carnitine synthesis Complement system support ^* In the presence of transition metals such as iron, vitamin C becomes pro-oxidant
Vitamin D	-	Regulates the synthesis of structural proteins, including type 1 collagen Controls growth and cellular differentiation Improves epithelialization Stimulates fibronectin synthesis and activation of macrophages maturation
Vitamin E	200-800 mg	Antioxidant Attenuates the ischemia-reperfusion process Maintains cell membrane integrity Anti-inflammatory Improves the immune system Anti-inflammatory function identical to corticosteroids Improves coagulation Antioxidant cooperative interaction with vitamin C ^* High doses: reduce collagen production and scar resistance
Vitamin K	5 - 10 mg	Anti-bleeding Homeostatic capacity Carboxylation of glutamate in coagulation Prevents prolonged bleeding and nutrient loss, hematoma and infection
Calcium	-	Action of collagenases in degradation, blood coagulation and collagen remodeling
Cobalt	-	Antibody cofactors Guarantee leukocyte function
Copper	1-2 mg	Angiogenesis Antioxidant cofactor and from cytochrome c in energy formation Cofactor of healing enzymes Cross-linking of collagen and elastin Formation of hemoglobin, erythrocytes, and bones Function in cytochrome oxidase and superoxide dismutase Synthesis of collagen and elastin Synthesis of proteins and connective tissue ^* Associates with vitamin C for collagen formation
Iron	-	Activation of natural killer cells Cofactor of healing enzymes Ensures phagocytic capacity of neutrophils Hydroxylation of proline and lysine Cytokine production Proliferation, differentiation, and number of T cells Oxygen transport, preventing tissue hypoxia ^* In the presence of transition metals such as iron, vitamin C and quercetin become pro-oxidant
Magnesium	0,3-5mg	Cofactor of enzymes of protein synthesis, collagen, superoxide dismutase, and metalloproteins Structural stability of ATP
Manganese	0,3-0,5mg	Antioxidant - superoxide dismutase Cofactor of healing enzymes Function in metalloproteinases Hydroxylation of collagen Protein synthesis and energy
Selenium	100-210µg	Antioxidant (glutathione system) Cofactor of lipid metabolism Management of inflammation Prevents infection Vitamin E protector Regulates the generation of by-products of lymphocytes
Zinc	15-400 mg 200 mg zinc sulfate (50 g free zinc) for 14 days maximum	Antioxidant - superoxide dismutase and glutathione Apoptosis of myeloid and lymphoid cells Protein kinase C Activity of helper T cells, development and proliferation of lymphocytes and interleukin production Increases the immune function through the development and activation of lymphocytes Cofactor of enzyme synthesis, RNA polymerase, DNA, metalloproteins, and collagen Erythropoiesis Maintenance of the intestinal mucosa Proliferation of cells and fibroblasts Re-epithelialization Protein synthesis and cell replication Vitamin A transport ^* High doses: inhibit macrophage migration, negatively interfere with collagen production, copper and iron absorption, and can cause gastrointestinal problems

Bioactive compounds	Oral daily dose	Functions
Lipoic acid	30-75 mg	Antioxidant ATP production Regeneration of other antioxidants such as coenzyme Q10, vitamin C, and vitamin E
Bromelain	1500 mg	Accelerates healing and reabsorption of the hematoma Anti-inflammatory action Reduces edema, inflammation, and pain
Coenzyme Q10	10-50 mg	Antioxidant Improves the immune system ATP production Protects the stability of cellular membranes Protects DNA Regeneration of other antioxidants, such as ascorbic acid and a-tocopherol Gene regulation
Flavonoids	600-1500 mg 30-50 mg	Anti-inflammatory Antioxidant in hydrophilic and lipophilic medium Support to the immune system ^* In the presence of transition metals such as iron, quercetin becomes a pro-oxidant
Hesperidin	15-30 mg	Antioxidant Anti-inflammatory
Isothiocyanates and indoles	-	Help in body detoxification Inhibit DNA mutation Reduce the production of 16-a-hydroxyestrone (pro-inflammatory and immuno-deregulatory)
Melatonin	-	Antioxidant Stimulates gene expression and activity of antioxidant enzymes Immunostimulant
Proanthocyanidin	-	Antioxidant Anti-inflammatory Vasodilator
Resveratrol	-	Antioxidant Anti-inflammatory
Rutin	15-30 mg	Antioxidant Improves the lymphatic and venous circulation ^* Synergy with vitamin C
Probiotics and prebiotics	-	Calcium absorption Increase the levels of vitamin B complex and amino acids, such as methionine, lysine, and tryptophan Improves macrophage production and stimulates suppressor cells Prevents the adhesion and activation of pathogens Immune modulation

Common name	Scientific name	Oral daily dose	Functions
Turmeric	Curcuma longa	1.5-3 g	Anticoagulant Anti-inflammatory Antioxidant Glycemic control Prevents fibrosis
Artichoke	Cynara scolymus	20g	Antioxidant Increases glutathione activity Diuretic
Liquorice	Glycyrrhiza glabra	-	Anti-inflammatory Antioxidant Immunomodulatory Neutralizes immunosuppressors (except glucocorticoids)
Caraway	Carum carvi	-	Antioxidant
Rosemary	Rosmarinus officinalis	3-6g	Antioxidant Anti-inflammatory Healing
Garlic	Allium sativum L.	0,5-1g	Anti-inflammatory Antioxidant (increase in glutathione) Antiplatelet Increases immunity Hypoglycemic Vasodilator ^* Contraindicated in the preoperative period
Aloe vera	Aloe barbadensis BC	-	Anti-inflammatory Antioxidant Healing Glycemic control Stimulates macrophages
Arnica	Arnica montana	3g	Anti-inflammatory Antiseptic Vasodilator Reduction of edema, bruising, and pain
Brazilian pepper	Schinus terebenthifolius	1g	Anti-inflammatory Healing
Greater burdock	Arcticum lappa L.	2,3g	Anti-inflammatory Diuretic
Boldo	Peumus boldus	-	Antioxidant Acute anti-inflammatory
Indian olibanum	Boswellia serrata	-	Anti-inflammatory
Cashew	Anacardium occidentale	4,5g	Healing
Pot marigold	Calendula officinalis L.	1.6-5 mg flavonoids	Anti-inflammatory Healing
Chamomile	Matricaria chamomilla L.	0.009-0.03 mg apigenin	Antioxidant Anti-inflammatory
Small cardamom	Cinnamomum verum Cinnamomum cássia	-	Anti-inflammatory Antioxidant Glycemic control Improves blood circulation
Cardamomo	Elettaria cardamomum	-	Antioxidant Anti-inflammatory Assists apoptosis
Cardus marianus	Silybum marianum L.	70-300mg	Antifibrotic Anti-inflammatory of the membrane Antioxidant Acts in phase 2 of detoxification Increases glutathione Blocks toxins uptake Prevents injury by xenobiotics Facilitates the action of proteins Regulates the permeability of the membrane
Field horsetail	Equisetum arvense	3g	Edema control
Green tea	Camellia sinensis	-	Antioxidant
Chapéu de couro	Echinodorus macrophyllus	1g	Anti-inflammatory Mild diuretic
Shell ginger	Alpinia zerumbet	20g	Diuretic
Cumin	Cuminum cyminum L.	-	Antioxidant
Comfrey	Symphytum officinale L.	0.03-0.16 mg allantoin	Healing
Common dandelion	Taraxacum officinale	3-12 g	Anti-inflammatory Antioxidant (increases glutathione and superoxide dismutase) Glycemic control Diuretic Prebiotic
Blacksamson echinacea	Echinacea angustifólia DC	-	Anti-inflammatory Healing Immunostimulant ^* Contraindicated in the preoperative period
Black sage	Varronia curassavica Jacq.	3g	Anti-inflammatory
St. John’s wort	Hypericum perforatum	-	^* Contraindicated in the preoperative period
Anise	Pimpinella anisum L.	-	Antioxidant Cytoprotective
Espinheira santa	Maytenus ilicifolia Maytenus aquifolia Mart	2-6g	Analgesic Anti-inflammatory Antioxidant Antiulcerogenic Healing Detoxification
Devil’s claw	Harpagophytum procumbens D.C.	600-6000 mg	Anti-inflammatory Antioxidant
Ginger	Zingiber officinale Roscoe	1-2g	Anti-inflammatory Antioxidant Spasmodic
Ginkgo biloba	Ginkgo biloba	-	^* Contraindicated in the preoperative period
True ginseng	Panax ginseng	-	Antioxidant Pharmacological effects on the immune, endocrine, and nervous systems Improves chemical stress Improves the functions of the cellular membrane Reduces muscle damage and inflammation ^* Contraindicated in the preoperative period
Siberian ginseng	Acanthopanax senticosus	-	Anti-inflammatory
American witch-hazel	Hamamelis virginiana	3-6g	Skin and mucous membranes anti-inflammatory
Peppermint	Mentha piperita	-	Antimutagenic Antioxidant Anti-inflammatory DNA repair
Macela	Achyrocline satureioides	1,5g	Anti-inflammatory
Yarrow	Achillea millefolium	1-2g	Anti-inflammatory
Bitter melon	Mormodica charantia L.	-	Healing
Pau-ferro	Caesalpinia ferrea	7,5g	Healing
Black pepper	Piper nigrum	-	Antioxidant Anti-inflammatory
Stonebreaker	Phyllanthus niruri L.	10g	Diuretic
Golden root	Rodhiola rosea	-	Antioxidante
Pomegranate	Punica granatum L.	6g	Anti-inflammatory
White willow	Salix alba	400 mg-3 g 60-120 mg salicin	Anti-inflammatory
Sage	Salvia officinalis	-	Anti-inflammatory
Broadleaf plantain	Platago major L	6-9g	Anti-inflammatory
Cat’s claw	Uncaria tomentosa	600-900mg	Anti-inflammatory Antioxidant Immune regulation Vasodilator
Sweet broom	Scoparia dulcis	1-3 mL dye	Antioxidant Anti-inflammatory Glycemic control ^* Synergy with Silybum marianus L.

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E-mail: rbcp@cirurgiaplastica.org.br

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[1] Corresponding author: Camile Laís Rocha Rua Luiz Altemburg Sênior, 90 - Escola Agrícola - Blumenau, Santa Catarina, Brazil, Zip code: 89031-300, E-mail: camile.rocha@hotmail.com