Historical Case Report: 45 Years of the First Plastic Surgery in Morbid Obese in Brazil and Their Weight Loss

Before the 70s, in Brazil, each city had its morbidly obese, considered as the “excessive fats”, in very small numbers if we compare it with the current percentage. There was no classification of the degree of obesity by the body mass index (BMI) as we have today. By chance, on a Saturday in June 1975, at the Outpatient Clinic of the 23rd Infirmary of Santa Casa da Misericordia Hospital in Rio de Janeiro, arrived the patient I. S., 41 years old, 1.70 m tall, supported by her two children, weighing 210 kg in weight body. Knowing that bariatric surgery only appeared in the 1980s, before that, patients with morbid obesity were left to their own devices, with hypertension and diabetes. The patient I. S. was hospitalized for 3 years in our Plastic Surgery Service, having received nutritional monitoring, had sporadic discharges and undergone 9 reparative plastic surgeries. She was discharged weighing 71 kg, with self-esteem recovered and happy to start a new life, without hypertension and diabetes.


Introduction
This manuscript will serve to guide future doctors who will be able to deepen their studies on this disease called OBESITY. After 45 years of the first plastic  They are considered disabled (Medeiros, 2018) [4] in some tasks and cannot exercise their rights equally to the slender. In the case reported, we admitted for philanthropic reasons, even without future planning. The patient said: "Doctor, you saw me, be the mechanic, I'm in the workshop". On the following Monday, with the authorization of Prof. Xavier Lopes, we started to create a nutritional and surgical protocol to attend to her. We are very grateful to our head nurse, the Dominican Sister Lúcia Sezures, who was the right hand in this period. One day, she said: "Doctor, don't worry, the food here is so bad that the patient will lose weight anyway". I had already finished my 2-year residency in general surgery and was in the second year of plastic surgery. We idealize performing body relief surgeries concomitantly with weight loss using protein and vitamin supplements every 6 hours [5]. The largest surgical piece excised was the breasts with 32 kg. All laboratory tests of the patient, upon admission, were altered, including blood pressure and blood glucose, 170 × 110 mmHg and 210 mg/dL, respectively. Although obese, she had a 34% hematocrit.
We felt compelled to remember in honor of the courageous team that helped us at a time when everything was new and undergoinga learning stage. Anes

Material
45 years ago, it was not usual to document the pre and postoperative surgeries. If there was any kind of lawsuit, which was rare, black and white photos were accepted. At that time, we used the old "slides"-slides (sheets) of an image projector presentation. Even so, we are amazed to have kept and organized, at least, the main results of the reparative surgeries that, today, I call "body relief".
After some Plastic Surgery Services rejected the lady I. S.'s case, I took courage and made a plan that I thought was more adapted to what I knew. A careful pre-operative, which I follow to this day, and the most important: to not put the patient's life at risk. Nutrition was controlled with protein and vitamin supplements [6]. After she lost 20 kg in 6 months, we checked her laboratory exams, which would allow us to start surgery. All results were already within normal limits. We decided to do only one body part at a time, a technique recommended until today [7]. Then, in the 6th month, we marked the extirpation of the larger part, the breasts (Figure 2), which had two layers of tissue, skin and subcutaneous cell, never seen before in professional life. After 4 hours of procedure, we ended with the removal of 18 kg of the right breast and 14 kg of the left breast, making a total of 32 kg of breast pieces. We can observe the reduction of the layers seen on the back (Figure 3 and Figure 4). Some photos were not found or we did not think it was due to the impossibility of identification due to the number of overlapping layers. The preoperative and postoperative periods Modern Plastic Surgery   Modern Plastic Surgery went smoothly, having been assisted by 4 surgeons and 3 anesthetists. After 6 months, we studied and performed the second surgical intervention, the first to remove the abdomen. When we put the patient on the table, the anesthetist said: "Dr. José Humberto, the belly fell to the sides of the table". Thus, we concluded that, as it was relief surgery, but not yet described in the literature, we decided to make the longitudinal surgical incision, which started in the armpit and ended near the pelvic region ( Figures 5-7). At the end of this surgical time, she had her only cardiac arrest for 3 years, which was soon reversed. Six months later, we performed the second repair of the breasts and, with an interval of 3 months, we performed the second abdominal repair, with a transverse incision. Also in the 2nd year of hospitalization, we underwent surgery on the thighs and the pubic mound ( Figure 8 and Figure 9). In the last six months of the 3rd year of hospitalization, we performed the last surgeries to decrease the diameter of the arms ( Figure 10 and Figure 11). For the purpose of comparing pre and postoperative periods, at the end of the 3 years, we show the result ( Figure 12 and Figure 13). The patient arrived weighing 210 kg and was discharged with 71 kg. She arrived wearing a giant dress, which fit 4 people inside (Figure 14), and was discharged wearing "jeans" and mid-heel shoes [8]. It is worth remembering that, at that time, we did not have a bibliographic review that would assist us in choosing the technique. For this reason, we chose linear incisions with the intention of "body relief" [9] [10] for the patient.

Discussion
Perhaps today, after the bodily relief of the breasts, I would recommend bariatric surgery, even though I know that weight loss depends on a great psychological preparation, because when they are slowly monitored they are more advantageous. We have already published several articles on the subject, but even so, there is a large population increase at the moment. Recalling this case report will serve to open doors for more publications and awaken young doctors to this specialty that covers cases like this, which, one day, will be considered public health. Saying that there is nothing to do is an easy solution. It was difficult to face the case, with no future perspective and uncertain results. Even today, after 45 years, we still consider it a complicated case, but one that could not be ignored in view of the patient's age and the psychological severity she was experiencing. We always respect different or even contrary opinions. Today, perhaps, the postoperative results could be more acceptable; however what we achieved was the best for that moment or that time.
In this reported case, we had to develop a solution taking into account the pa-

Conclusion
As professionals and as human beings, we are very happy to see the result of this reported case. Monitoring and being part of this process, from the arrival of patient I. S., weighing 210 kg, carried by relatives, until being discharged, wearing jeans and 71 kg is the real payment for the well being provided to her. Seeing a person suffering from hypertension, arriving with 310 mg/dL of blood glucose and blood pressure 170 × 110 mmHg, leaving the hospital with 90 mg/dL of blood glucose and 130 × 80 mmHg of blood pressure is the best final balance we could have obtained, giving us the certainty, it was worth it! At that time, we still did not have the collaboration of bariatric surgery or liposuction (1980) [12].
The doors will always be open for us to evolve and, certainly, with the appearance of many new techniques for improvements in all specialties. It is important to remember that 9 surgical acts were performed, without bariatric and without liposuction, which would have contributed a lot. The best gratitude was to witness the degree of joy, satisfaction of the patient and the social inclusion that we felt during the ultimate discharge.