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      Unificación de subunidades estéticas de la mama en reconstrucción autóloga postmastectomia Translated title: Unification of the aesthetic subunits of the breast in postmastectomy authologous reconstruction

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          Abstract

          La restauración de la mama es un componente esencial en el tratamiento curativo del cáncer tras la mastectomía, ya que una cicatriz o una reconstrucción con malos resultados estéticos se traducen para la mujer en un recordatorio constante de la enfermedad. Para la reconstrucción de mama planteamos un modelo según subunidades estéticas, ya que en ella se encuentran distintos componentes y diferentes distribuciones de volúmenes que caracterizan a cada mama en particular según el hábito corporal de la paciente. Nuestro objetivo es no ver la mama como un montículo único, sino compuesto por distintas subunidades que pueden ser restauradas con un adecuado posicionamiento de los colgajos autólogos. Realizamos un total de 32 reconstrucciones mamarias con colgajos basados en el abdomen para la restauración e integración de sus subunidades estéticas, ya que los colgajos abdominales brindan la ventaja de poder ser moldeados según las necesidades, particularidad que no ofrecen los materiales aloplásticos, y así poder lograr una transición suave de la mama a la pared torácica. La reconstrucción del complejo areola pezón y los procedimientos de simetrización de la mama sana como reducción o mastopexia, los efectuamos 6 meses después del procedimiento inicial, utilizando las mismas subunidades para valorar el resultado así como para mejorar las zonas de continuidad mediante la aplicación de lipoinyección grasa o revisión de cicatrices. De las 32 reconstrucciones autólogas realizadas, 28 obtuvieron un adecuado contorno del colgajo, continuidad con la pared torácica, y un adecuado posicionamiento del surco submamario, con buena simetría de la mama contralateral. En 4 reconstrucciones no logramos la adecuada unificación de las subunidades: en 2 hubo una apariencia del colgajo en parche, y en 2 quedó un posicionamiento muy bajo del nuevo surco submamario. El enfoque del principio de subunidades propuesto para la reconstrucción mamaria puede utilizarse con eficacia en la planificación preoperatoria y en la segunda etapa de la reconstrucción mamaria para obtener una mejor simetrización, con resultados estéticos superiores, con un adecuado posicionamiento del colgajo, distribución del volumen, colocación y dirección de las incisiones, y lograr así como resultado la unificación de las subunidades en su conjunto, con una alta satisfacción de la paciente y del cirujano.

          Translated abstract

          The restoration of the breast is an essential component in the curative treatment of cancer after mastectomy, as a scar or reconstruction with a poor cosmetic outcome translates into constant reminder of the disease. We propose a model of aesthetic subunits of the breast for mammary reconstruction, since the breast itself has different volume distribution that are characteristic of each patients body habitus, and avoiding in the reconstruction a single focal point in the perfectible breast. A total of 32 abdominally base flap reconstructions were performed for the restoration and integration of the subunits, as the abdominal flaps offers the advantage of being molded according to need, a characteristic not met by the use of alloplastic materials, for soft transition of the chest wall to the observer. The reconstruction of the nipple areola complex, procedures for symmetrization of healthy native breast, such as reduction or mastopexy, were performed 6 months after the initial procedure, where we can use the same subunits to assess the outcome and improve areas of continuity with lipoinjection application of fat or scar revision. Twenty-eight of the reconstructions, had a good contour of the flap in continuity with the chest wall, and proper positioning of the breast groove with good symmetry with the contralateral breast. Four reconstructions failed to unifiy the subunits of the breast, 2 of them with an appearance of patch flap, and 2 with a low positioning of the new inframamary fold. The proposed subunit principle approach to breast reconstruction may be used effectively in preoperative planning and second staged procedures, to obtain superior aesthetic outcomes in breast reconstruction, with a good flap positioning, volume distribution and incision placement and direction, having as a result the unification of the subunits as a whole.

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          Most cited references24

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          Oncoplastic breast surgery: indications, techniques and perspectives.

          Breast-conservation surgery (BCS) is established as a safe option for most women with early breast cancer. Recently, advances in oncoplastic techniques have reduced surgical trauma and thus are capable of preserving the breast form and quality of life. In spite of the most BCS defects can be managed with primary closure, the aesthetic outcome may be unpredictable. Oncoplastic reconstruction may begin at the time of BCS (immediate), weeks (delayed-immediate) or months to years afterwards (delayed). With immediate reconstruction, the surgical process is smooth, since both procedures can be associated in one operative setting. Additionally, it permits wider excision of the tumor, with a superior mean volume of the specimen and potentially reducing the incidence of margin involvement. The oncoplastic techniques are related to volume displacement or replacement procedures including local flaps, latissimus dorsi myocutaneous flap and reduction mammaplasty/masthopexy. Regardless of the fact that there is no consensus concerning the best approach, the criteria are determined by the surgeon's experience and the size of the defect in relation to the size of the remaining breast. On the basis of our 15-year experience, it is possible to identify trends in types of breast defects and to develop an algorithm for immediate BCS reconstruction on the basis of the initial breast volume, the extent/location of glandular tissue ressection and the remaining available breast tissue. The main advantages of the technique utilized should include reproducibility, low interference with the oncologic treatment and long-term results. Surgical planning should include the patients's preferences, and chiefly addressing individual reconstructive requirements, enabling each patient to receive an individual "custom-made" reconstruction.
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            Surgery of the Breast: Principles and Art

            DC Hammond (1998)
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              Improving outcomes in autologous breast reconstruction.

              Autologous breast reconstruction can often provide a more aesthetic outcome than other options for breast reconstruction because breast volume and shape can be extensively modified based on individual need, the texture of the reconstructed breast is a closer match to the native breast, and complications such as capsular contracture are avoided. However, with these benefits come the potential for complications unique to autologous tissue transfer. While overall complications are low, there are ways to maximize operative success and minimize the risk of complications. Deep inferior epigastric artery perforator (DIEP) flaps, the current mainstay in choice of autologous reconstruction, provide generally good outcomes. However, improvements in outcomes can still be achieved with a better understanding of individual anatomy. Perforator size, location, intramuscular and subcutaneous course, and association with motor nerves are all factors that can significantly affect operative technique, length of operation, and operative outcomes. With significant variation between individuals, preoperative imaging has become an essential element of DIEP flap surgery. Computed tomography angiography (CTA) is currently the gold standard but evolving techniques such as magnetic resonance angiography (MRA) and image-guided stereotaxy are rapidly contributing to improved outcomes.
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                Author and article information

                Contributors
                Role: ND
                Role: ND
                Role: ND
                Journal
                cpil
                Cirugía Plástica Ibero-Latinoamericana
                Cir. plást. iberolatinoam.
                Sociedad Española de Cirugía Plástica, Reparadora y Estética (SECPRE)
                0376-7892
                December 2015
                : 41
                : 4
                : 373-384
                Affiliations
                [1 ] Hospital Militar Escuela Dr.Alejandro Dávila Bolaños Nicaragua
                [2 ] Hospital Militar Escuela Dr.Alejandro Dávila Bolaños
                Article
                S0376-78922015000400004
                9140c7d1-ef65-446f-b0a5-c11f9ce11de7

                http://creativecommons.org/licenses/by/4.0/

                History
                Categories
                SURGERY

                Surgery
                Aesthetic subunits of the breast,Breast reconstruction,Abdominally based flaps,Subunidades estéticas de la mama,Reconstrucción mamaria,Colgajos abdominales autólogos

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