Reconstructive

BREAST RECONSTRUCTION

Breast reconstruction aims to correct the sequelae caused by breast cancer surgery (mastectomy) and coadjutant treatments (radiotherapy), by reconstructing woman’s breast, and giving the appearance of the original one. In addition to the lost breast, the nipple and the areola are also reconstructed. In this way, the patient will recover not only an important part of her anatomy but also identity as a woman.

Daily gestures such as hugging, dressing, or looking in a mirror can be negatively affected. This is why we understand breast reconstruction as a process for the patient to recover her self-esteem, improve her quality of life, and feel “complete” again.

Breast reconstruction can be performed during the same operation in which the breast is removed (immediate reconstruction), or in a second surgical time after the mastectomy (delayed reconstruction).

There are different methods:

The method with tissue expanders consists of placing a device with a valve under the skin, where saline is introduced once a week for several weeks, until filling the expander. Therefore, the skin of the breast progressively achieves the desired volume. At this time, it will be replaced by a definitive prosthesis.

• The wide dorsal flap method consists of using the skin and a large back muscle to reconstruct the breast on the same side. This technique can be associated with the use of prosthesis if the breast to be reconstructed is large, or lipofilling if the breast is small.
• The method with microvascular flaps consists of a transplant of tissues from one area of ​​the body to another. It is usually the technique of choice, since it provides more natural and long-lasting results. As general rule, two techniques are used:
  • DIEAP technique: the breast is reconstructed with the excessive abdominal dermal-fat tissue. Apart from reconstructing the breast, the abdominal contour of the patient is also improved.
  • PAP or TUG technique: the breast is reconstructed with excessive abdominal dermal-fat tissue from the inner thigh. It is indicated for patients who do not have enough tissue at the abdominal level.

In both techniques it is necessary to have a team of well-trained microsurgeons. Surgery involves the transplant of a tissue from one area of ​​the body to another, requiring the ‘splice’ or anastomosis of a small-sized artery and vein, which is performed with the help of a microscope.

The procedure is performed under general anesthesia, the scars are hidden in discrete areas, and the patient will be discharged between 1 and 6 days after the surgery, depending on the technique used.

FACIAL RECONSTRUCTION

There are many situations in which a plastic surgeon faces complicated facial defects, especially in case of large tumor resections, traumas, and congenital malformations.

The reconstructive surgery presents a double objective: On the one hand, returning the functionality, and on the other hand, restoring the normal morphology of the face. The first one has great impact on the daily life of the patient, whereas the second one has emotional impact.

There are different situations we can find, including:

• FACIAL PARALYSIS: Generally, when a facial paralysis has not been recovered within a year (despite intensive rehabilitative treatment), its effect is considered permanent. This is the appropriate time to propose the facial paralysis surgery. Some procedures that can be performed are aimed at recovering the ocular closure, correcting facial asymmetry (improving speech), improving nasal ventilation, and recovering facial expression, such as smiling. There are different types of procedures (from static procedures to dynamic restorations). Your plastic surgeon will explain you the different reconstructive options according to your case.

The first step is to define if the paralysis is reversible or irreversible. If it is reversible, the patient will be derived, for management, to rehabilitation specialists, and will be evaluated annually to assess the recovery. If it is irreversible, complete or incomplete paralysis is determined by clinical and electromyography techniques, and then the surgical treatment will be conducted according to the case:

1. Complete unilateral facial paralysis: A cross graft of the sural nerve to the contralateral facial nerve is performed, and the free muscle flap is then transferred (gracilis muscle or serratus major muscle) in 2 times. The doctor can evaluate doing the procedure in a single intervention or with another variant.
2. Full bilateral facial paralysis or Möbius syndrome: The free muscle flap (gracilis muscle) is transferred and attached to the trigeminal nerve (masseter). The second surgery is performed after 3 months (contralateral side).
3. Incomplete unilateral facial paralysis: It consists of a cross graft from the sural nerve to the contralateral facial nerve.
4. Complementary procedures depending on the need: mini-temporal flap, facelift, blepharoplasty, palpebral suspension, etc.

Finally, the specialized rehabilitation is an essential part of an appropriate treatment. This consists in facial mimic exercises with biofeedback, i.e. a set of exercises initially indicated and taught by specialists, and subsequently practiced by the patient in front of the mirror during an extended period of time.

• MOUTH AND LIPS: It occurs especially in cases of important tumor resections or traumas. The restoration of this area is complex, and the surgical techniques range from small local plasties to microsurgery. Your plastic surgeon will explain you the different options in each case.
• NOSE: from simple to complex defects of the total thickness that affect several anatomical subunits. Depending on the type of defect, more than one surgery and subsequent refinements may be required in order to achieve an optimal result.
• CRANIOFACIAL SURGERY: it reconstructs congenital malformations of the cranium and the face, and soft tissues.
• FACIAL FRACTURES: mainly due to traffic accidents and aggressions. The facial bones can suffer complex fractures requiring treatment. A correct approach and a good reduction of fractures with plates and screws are necessary to ensure the good occlusion of the teeth, the correct ocular mobility and vision, and restore the facial anatomy with the minimum possible sequelae.
• EYELIDS: A good palpebral reconstruction is very important in cases of tumor resections (mainly skin cancer), always preserving the function while maintaining the aesthetics.

RECONSTRUCTION OF A LOWER LIMB

There are many situations in which the performance of a repairing plastic surgeon is required for solving problems in a limb. These include traumas, infections, systemic diseases (such as atherosclerosis or diabetes mellitus) or tumor resections that may expose important anatomical structures such as blood vessels, nerves, tendons or bone.

In the most severe situations, the extremities could be amputated. For this reason, it is important applying the knowledge and adequate techniques that allow the conservation and functionality of the affected limb.

There are different techniques for using:

• Skin grafts: it consists of a skin transplant (dermis and epidermis) from a receptor area to the area of ​​the defect. It is only possible in situations where the recipient is well vascularized. The grafts cannot be placed on tendons or bone.
• Flaps: it consists of vascularized tissue transfers; thus they do not depend on the recipient bed. They can be fasciocutaneous, muscular, fascial, osseous, compound etc.
  • Pediculates: they maintain the native vascularity.
  • Free: the artery and vein that nourish the flap are sectioned and reconnected in the receiving area. A specific surgical instrument is necessary to make these flats, as well as a microscope and very fine sutures.

The current level of anatomical and physiological knowledge allows us designing flaps able to avoid the sacrifice or reduction in functionality of the donor area and planning detailed surgeries, which mean high success rates.

SCARS

Scar reconstruction surgery aims to minimize a scar, making it imperceptible and unified in tone and texture with the surrounding skin.

Hypertrophic scar and keloids are pathologies or skin disorders that occur after surgery, burn, inflammation or any type of skin trauma.

Hypertrophic scar is a fibrous lesion developed inside the borders of a wound. Nevertheless, keloid scar is a lesion with tumor appearance, red-pink or purple color that develops over the borders of a wound.

Both old and new scars can be treated with scar reconstruction surgery.

There are two types of available treatments:

• Non-surgical: It is performed by different techniques depending on the characteristics of the scar. These include, among others, topical gels, injectable treatments such as triamcinolone or fillers, laser or dermabrasion.
• Surgical: In cases of large, depressed scars, retractable cicatricial flanges, sequelae of burns, etc. The use of local plasties, grafts, flaps, expanders, radiotherapy may be necessary.

One or another treatment will be chosen depending on the time of evolution, the origin of the scar, the characteristics of your skin, etc. It will require several months to achieve the final result.

SEX REASSIGNMENT SURGERY

Sex reassignment surgery responds to a need that has recently increased, thanks to normalization and social awareness. It aims to reconcile the biological sex of the patient with the one that feels like own, achieving thanks to the surgical intervention and the support of the pharmacological treatment.

The joint assessment of the doctor with the patient is of great importance because these are complex and multidisciplinary processes that require the most qualified medical personnel. In addition to the plastic surgeon, different health professionals from other areas also participate.

The process of sex reassignment surgery (or gender confirmation surgery) can be: transmasculine or transfeminine.

• Female sexual reassignment surgery:

It is performed in people who were born with a male biological sex but have a female sexual identity.

The surgical process carried out to achieve this is called vaginoplasty or feminizing genioplasty and can be done by two different techniques.

The technique of penile inversion is a process by which the skin of the penis and scrotum are used to replicate a vagina, and part of the glans is used to form the clitoris. It allows replicating a vagina with an adequate depth to maintain full sexual relations.

Vaginoplasty with colon is another technique, in which part of the colon is used to build the vagina.

Transfeminine cosmetic surgeries are usually performed to complete the process, in the body (liposculpture, mammoplasty, etc.) and in the facial area (softening of facial features through surgeries such as mentoplasty, rhinoplasty, etc.).

• Male sexual reassignment surgery:

This intervention is performed on patients who were born with a female biological sex but have a male sexual identity.

Metaidoioplasty and phalloplasty are two surgical techniques for male sexual reassignment aimed at creating external genitalia according to their gender.

Metaidoplasty is a surgical intervention through which the construction of the penis is carried out from the clitoris, which has been hypertrophied by means of hormonal treatment. A small penis with partial functionality is achieved, since sexual penetration cannot be carried out with it.

Through the technique of phalloplasty or free flap technique, a penis of anatomical dimensions can be obtained. To achieve this, tissue from other parts of the body is required, usually skin and forearm fat are obtained (radial flap), and less frequently from other areas, such as the abdomen or thigh. In this case a tactile and erogenous sensibility is achieved, being able to achieve the erection with the help of an implantable prosthesis, thus allowing the sexual penetration.