Nipple sparing mastectomy with a de-epithelialized derma-fat flap (modified Spira technique) and direct-to implant reconstruction

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del Amo, Ismael Gil Romea, María Pilar Val-Carreres Rivera, Ramón Sousa Domínguez, Antonio Tomás Güemes Sánchez" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Marta" "apellidos" => "Allué Cabañuz" "email" => array:1 [ 0 => "martitaallue@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Maria Dolores" "apellidos" => "Arribas del Amo" ] 2 => array:2 [ "nombre" => "Ismael" "apellidos" => "Gil Romea" ] 3 => array:2 [ "nombre" => "María Pilar" "apellidos" => "Val-Carreres Rivera" ] 4 => array:2 [ "nombre" => "Ramón" "apellidos" => "Sousa Domínguez" ] 5 => array:2 [ "nombre" => "Antonio Tomás" "apellidos" => "Güemes Sánchez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Mama, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Mastectomía preservadora de piel con colgajo dermograso desepitelizado (técnica de Spira modificada) y reconstrucción mediante implante directo" ] ] "resumenGrafico" => array:2 [ "original" => 1 "multimedia" => array:5 [ "identificador" => "fig0015" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 718 "Ancho" => 1333 "Tamanyo" => 146058 ] ] ] ] "textoCompleto" => "IntroductionIn 1977, Spira described skin-sparing mastectomy using a lower dermal fat flap.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Using this technique, which is classified as a Carlson type IV skin-sparing mastectomy, it is possible to remove all the glandular tissue, a small portion of skin and all the retroareolar tissue.It is usually a technique intended for medium or large breasts with a minimal degree of ptosis. To be able to perform this technique and achieve satisfactory cosmetic results, it is essential for the nipple-areola complex (NAC) to reach at least the level of the inframammary fold.In this technique, the NAC is removed and refined to be later grafted onto the newly created breast mound. Although Spira did not describe complications in this initial experience other than capsular contracture,<a class="elsevierStyleCrossRef" href="#bib0005">1</a> recent studies have found general complication rates of around 20%, especially necrosis of the NAC with possible graft loss.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>The main advantage of this technique is that it allows us to perform the reconstruction in a single surgery, accommodating the definitive implant in a partially retromuscular position, covered by the dermal fat flap below. This avoids the need to use acellular dermal matrix and achieves favorable cosmetic results,<a class="elsevierStyleCrossRef" href="#bib0015">3</a> while remaining an oncologically safe<a class="elsevierStyleCrossRef" href="#bib0020">4</a> and efficient<a class="elsevierStyleCrossRef" href="#bib0025">5</a> technique.While skin-sparing mastectomy is widely validated as a therapeutic and not just prophylactic mastectomy,<a class="elsevierStyleCrossRef" href="#bib0030">6</a> preservation of the PAC continues to generate controversy,<a class="elsevierStyleCrossRef" href="#bib0035">7</a> mainly regarding recurrence.The objective of this study is to analyze postoperative complications, cosmetic sequelae, causes of reoperation, and oncological results of skin-sparing mastectomy with a dermal fat flap.MethodsPatient selectionOur study included patients who underwent skin-sparing mastectomy with a de-epithelialized dermal fat flap (modified Spira technique) and direct-to-implant reconstruction, treated consecutively over a 15-year period (2003–2018) by a single breast unit. A retrospective observational analysis was carried out.The following clinical conditions were included:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•Patients with de novo breast carcinoma.</li><li class="elsevierStyleListItem" id="lsti0010">•Patients previously treated for breast cancer with conservative surgery who have recurrence or affected margins and opt for mastectomy instead of re-excision.</li><li class="elsevierStyleListItem" id="lsti0015">•Contralateral prophylactic mastectomy in patients with breast cancer (due to risk factors, patient choice, or for symmetry).</li><li class="elsevierStyleListItem" id="lsti0020">•Bilateral prophylactic mastectomy in patients with BRCA 1/2 mutations or high risk due to family history without demonstrated mutation.</li><li class="elsevierStyleListItem" id="lsti0025">•Patients with a minimal degree of ptosis (it is essential for the NAC to at least reach the level of the submammary fold).</li></ul>The following cases were excluded:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030">•Inflammatory breast carcinoma</li><li class="elsevierStyleListItem" id="lsti0035">•Two-stage breast reconstruction</li><li class="elsevierStyleListItem" id="lsti0040">•Patients with distant metastases at diagnosis, since direct-to-implant reconstruction was not performed.</li><li class="elsevierStyleListItem" id="lsti0045">•Patients with small breasts or without ptosis (other techniques were performed).</li></ul>Surgical technique and cancer treatmentPlanning phaseSurgical planning is carried out with the patients in the standing position. First, the skin is marked with an inverted V pattern; the submammary fold is projected on the breast midline 5 cm from the NAC, from which two vertical branches are drawn, trying to make them as closed as possible to preserve the greatest skin coverage. From there, horizontal branches are drawn towards the inframammary groove (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Mastectomy phaseThe procedure is performed with the patient in a semi-sitting position. First, the NAC is released, but we do not remove it until the end of the operation (in order to decrease the ischemia time of the free graft). Then, we de-epithelialize the dermal fat flap in the lower pole of the breast. Excision of the mammary gland is completed, preserving thin flaps of skin according to the pattern that we had designed and respecting a minimum thickness of 1 cm. We remove the NAC, keeping it in gauze moistened with saline solution, and we create the dermal flap. Lastly, the axillary breast tissue is removed, and the pectoralis major muscle is released from the pectoralis minor and its attachments in the thoracic wall to later cover the implant. We also divide the pectoralis major muscle from its medial attachments at the sternum (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).Reconstructive phaseReconstruction is completed in a single stage by placing a silicone implant with an anatomical profile, which is double covered by the de-epithelialized dermal fat flap sutured to the pectoralis major muscle. The volume of the implant depends on the volume of breast tissue extracted and the configuration of the affected and contralateral breasts, so each case is personalized. Finally, the skin is closed, following the pattern made, first the vertical branches over the projection of the submammary fold along the midline. We look for the area of maximum projection on the mound created as a new breast to mark the area where we will attach the free NAC graft. At this time, we confirm its viability by visual examination, and the absence of retroareolar tissue involvement is confirmed by intraoperative biopsy. After de-epithelializing the marked area and making small perforations in the graft, we suture the PAC using interrupted 4−0 non-absorbable monofilament stitches and place a knotted gauze pressing on the graft, which will remain in place for one week. We place two suction drains, one in the implant chamber and the other subcutaneous, which are removed when the discharge is less than 30 cc, often on an outpatient basis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>The administration of chemotherapy (CT) or radiotherapy (RT) followed our hospital’s clinical practice guidelines at the time of treatment.Study variablesThe study variables were divided into four groups:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0050">•Complications: the presence of cutaneous necrosis, specifically necrosis of the NAC, which was defined as partial (possible to recover) or total (required surgical excision with secondary reconstruction); maintained seroma, infection, or hematoma.</li><li class="elsevierStyleListItem" id="lsti0055">•Reoperations: during the first month, they were considered ‘postoperative complications’; after the first month, they were ‘cosmetic sequelae’.</li><li class="elsevierStyleListItem" id="lsti0060">•Cosmetic sequelae: include periprosthetic capsular contracture, implant rupture, prosthetic extrusion, and skin folds.</li><li class="elsevierStyleListItem" id="lsti0065">•Oncological results: locoregional recurrence was defined as the appearance of a new tumor in the ipsilateral chest wall (subcutaneous tissue and pectoral muscle) or recurrence in the ipsilateral axilla, supraclavicular lymph nodes, internal or infraclavicular mammary chains. Exclusively cutaneous recurrence was considered separately for the analysis. Distant recurrence (metastasis) was defined as any recurrence in all other areas not included in locoregional recurrence.</li></ul>Statistical analysisWe conducted a descriptive analysis of the variables under study. For qualitative variables, relative and absolute frequencies are provided. For quantitative variables, mean and standard deviation are given. The SPSS 22.0 for Windows statistical program (SPSS Ibérica, Madrid, Spain) was used for the analysis.This study complies with the ethical principles of the Declaration of Helsinki and was approved by the hospital ethics committee.ResultsDescription of the seriesDuring the study period, 247 skin-sparing mastectomies were performed using the Spira technique, with immediate reconstruction in 139 patients. Of the total, 216 were bilateral (87.4%) and 31 unilateral (12.5%). Also, 121 therapeutic mastectomies (49%) were conducted (71 as treatment for de novo cancer [28.7%] and 50 mastectomies in breasts with previous conservative surgery [20.2%]) and 126 prophylactic mastectomies (51%) (92 prophylactic contralateral mastectomies in patients with breast cancer [37.2%] and 34 risk-reducing mastectomies in patients at risk [13.7%]). Comorbidities are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Post-mastectomy, 28% of patients received adjuvant RT, while 24.7% had previously received RT and 47.1% of the operated breasts were not radiated. Sixty-two patients required adjuvant CT (44.6%), 27 had received neoadjuvant CT (19.4%) and 50 did not receive chemotherapy treatment either before or after surgery (35.9%).Adjuvant CT was administered a mean of 47.3 days after the procedure (SD 29.8) (range 13–147). In five cases (5/62; 8%), it was postponed more than the 90 days that are defined by consensus as ‘delay’, motivated in two cases by postoperative infection and in one by maintained seroma. The median follow-up was 81 months (SD 52.42).ComplicationsThe overall complication rate was 16.2% (40/247), and skin necrosis was the most frequent (13/247 [5.3%]). There were only five cases of necrosis of the NAC after free graft (2%), and eight patients required reoperation in the short-term postoperative period (five cases due to bleeding and three due to infection, these being the patients who later presented extrusion of the prosthesis that required reoperations in the long term) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Cosmetic sequelaeThe rate of cosmetic sequelae was 17.4% (43/247), and grade III/IV periprosthetic capsular contracture was the most frequent cause of reoperation in the long term (28/247 [11.3%]). Out of the total number of patients who presented capsular contracture, 11 had received adjuvant RT (11/28 [39.3%]) (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). Reoperation for sequelae was performed with a mean of 4.7 years (SD ± 4.96) after the intervention.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Oncological resultsOut of the 121 therapeutic mastectomies, the overall recurrence rate was 14% (17/121), with 0.8% skin recurrence, 3.3% locoregional recurrence, and 9.9% distant metastases. No recurrence was observed in the NAC.Eight patients died (6.6%). Mean disease-free survival (DFS) was 5.08 years (SD 4.35), and mean overall survival (OS) was 5.78 years (SD 4.73). The DFS and OS rates were 92.6% and 93.3% respectively. The percentages by subgroups are shown in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>DiscussionDue to the increase in the detection of cancers in earlier stages, the need for skin preservation techniques has increased in recent decades in the same way as prophylactic contralateral mastectomy in patients with unilateral cancer due to patient demand.<a class="elsevierStyleCrossRefs" href="#bib0040">8,9</a> In addition, patients demand satisfactory cosmetic results and choose breast reconstruction in a single surgery, when possible.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> Therefore, we often find ourselves in the need to perform bilateral mastectomies, preserving the skin and the NAC, followed by the placement of a definitive implant, all in the same surgery. The Spira technique perfectly meets all these needs and is ideal for patients with medium or large breasts and a certain degree of ptosis.<a class="elsevierStyleCrossRefs" href="#bib0055">11,12</a>Unlike what happens with subcutaneous mastectomy in small breasts, obtaining optimal results in this type of breasts is more difficult and requires repositioning the NAC and reducing the skin coverage. The technique, which is not without risks, can compromise wound healing and the viability of the NAC, which could lead to skin necrosis with exposure of the implant, extrusion of the implant and failed reconstruction.<a class="elsevierStyleCrossRefs" href="#bib0065">13,14</a> Two mechanisms have been proposed to explain these healing/perfusion problems: first, dermal flaps that are too long; and second, flaps that are too thin, which endangers their vascularization through the subdermal plexus.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>In our experience, we found an incidence of cutaneous necrosis of 5.3%, an NAC necrosis rate of 2%, and the need for reoperation due to extrusion of the prosthesis in three patients (1.2%). These rates are lower than those reported in other series, such as the King et al. study, with 10% skin necrosis.<a class="elsevierStyleCrossRef" href="#bib0080">16</a>Several studies have also demonstrated that the average local recurrence rate after skin-sparing mastectomies is no different whether the NAC is preserved or not (3.9% vs. 3.25%, respectively).<a class="elsevierStyleCrossRef" href="#bib0085">17</a> Furthermore, there is evidence that combining these techniques with immediate reconstruction does not significantly delay the administration of adjuvant therapy.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> Our series supports these data, with 0.8% skin recurrence, 3.3% locoregional recurrence, and no case of recurrence in the NAC. Furthermore, we only observed a significant delay (greater than 90 days) in the administration of adjuvant chemotherapy in five cases, two due to postoperative infection and one due to a maintained seroma.Although this study has a considerable number of cases and a long follow-up period, it presents limitations because it is a retrospective analysis of the experience from a single institution, so the results cannot be generalized.In conclusion, skin-sparing mastectomy with de-epithelialized dermal fat flap and direct-to-implant reconstruction is a safe option that offers good cosmetic and oncological results in the treatment and prophylaxis of breast cancer for patients with moderate to large ptotic breasts.FundingThis study has received no funding.Conflict of interestsThe authors have no conflict of interests to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1481428" "titulo" => "Graphical abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:3 [ "identificador" => "xres1481430" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0010" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusion" ] ] ] 2 => array:2 [ "identificador" => "xpalclavsec1348990" "titulo" => "Keywords" ] 3 => array:3 [ "identificador" => "xres1481429" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Conclusión" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec1348989" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 6 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patient selection" ] 1 => array:3 [ "identificador" => "sec0020" "titulo" => "Surgical technique and cancer treatment" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Planning phase" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Mastectomy phase" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Reconstructive phase" ] ] ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Study variables" ] 3 => array:2 [ "identificador" => "sec0045" "titulo" => "Statistical analysis" ] ] ] 7 => array:3 [ "identificador" => "sec0050" "titulo" => "Results" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Description of the series" ] 1 => array:2 [ "identificador" => "sec0060" "titulo" => "Complications" ] 2 => array:2 [ "identificador" => "sec0065" "titulo" => "Cosmetic sequelae" ] 3 => array:2 [ "identificador" => "sec0070" "titulo" => "Oncological results" ] ] ] 8 => array:2 [ "identificador" => "sec0075" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0080" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0085" "titulo" => "Conflict of interests" ] 11 => array:2 [ "identificador" => "xack519731" "titulo" => "Acknowledgements" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-04-07" "fechaAceptado" => "2020-04-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1348990" "palabras" => array:5 [ 0 => "Nipple sparing mastectomy" 1 => "Immediate breast reconstruction" 2 => "Spira technique" 3 => "Complications" 4 => "Sequelae" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1348989" "palabras" => array:5 [ 0 => "Mastectomía preservadora de piel y pezón" 1 => "Reconstrucción inmediata" 2 => "Técnica de Spira" 3 => "Complicaciones" 4 => "Secuelas" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionSpira technique is a type of nipple-sparing mastectomy that allows immediate reconstruction (IBR), ideal for ptotic breasts. Although, controversy persists regarding oncological results in breast cancer. The aim is to analyze complications, cosmetic outcomes, causes of reoperation and oncological results. MethodsRetrospective observational analysis of patients undergone surgery during 2003–2018 in our center. Study population is based on patients with breast carcinoma or undergoing prophylactic mastectomy due to high-risk, in which a skin-sparing mastectomy with a de-epithelialized derma-fat flap (modified Spira technique) and direct to implant reconstruction was performed. Short and long-term complications, sequelae, tumor recurrence and survival rates are analyzed. ResultsA total of 247 mastectomies with immediate reconstruction in 139 patients, 216 bilateral (87.4%) and 31 unilateral (12.5%) were performed. 121 therapeutic (49%) and 126 prophylactic (51%). Median follow-up 81 months. Complications were observed in 16.2%; skin necrosis 5.3% and 5 cases of NAC necrosis (2%). Reoperation rate due to cosmetic sequelae was 17.4% (capsular contracture was the most frequent,11.3%) and a 39.3% of these patients have received RT. Recurrence of 14% (0.8% skin, 3.3% locoregional and 9.9% metastatic), 8 patients died (6.6%). Rates of FSD and OS were 92.6% and 93.3% respectively. ConclusionSpira mastectomy is a safe option and provides good cosmetic and oncologic results as breast cancer treatment and prophylaxis in moderate-large ptotic breasts." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0010" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa técnica de Spira es un tipo de mastectomía preservadora de piel que permite la reconstrucción inmediata (RMI), ideal en mamas ptósicas. Si bien, persiste controversia sobre resultados oncológicos en el cáncer de mama. El objetivo es analizar complicaciones, secuelas cosméticas, causas de reintervención y resultados oncológicos. MétodosEstudio observacional retrospectivo de pacientes intervenidas durante 2003–2018 en nuestro centro. La población de estudio la constituyen pacientes con carcinoma de mama o sometidas a mastectomía profiláctica por alto riesgo, en las que se realizó una mastectomía preservadora de piel con colgajo dermograso desepitelizado (técnica de Spira modificada) y reconstrucción mediante implante directo. Se analiza la presencia de complicaciones precoces y tardías, secuelas, recidiva tumoral y supervivencia. ResultadosSe realizaron 247 mastectomías con reconstrucción en 139 pacientes, 216 bilaterales (87,4%) y 31 unilaterales (12,5%); 121 terapéuticas (49%) y 126 profilácticas (51%). La mediana de seguimiento fue de 81 meses. Se observaron complicaciones en un 16,2%; necrosis cutánea en 5,3% y cinco casos de necrosis del CAP (2%). La tasa de reintervención por secuelas cosméticas fue del 17,4% (la más frecuente fue contractura capsular 11,3%) y, de ellas, el 39,3% recibieron RT. La tasa de recidiva fue del 14% (0,8% cutánea, 3,3% locorregional y 9,9% a distancia). Ocho pacientes fallecieron (6,6%). La SLE y SG fue del 92,6% y 93,3% a cinco años. ConclusiónLa técnica de Spira constituye una opción segura y ofrece buenos resultados cosméticos y oncológicos como tratamiento y profilaxis de cáncer de mama en mamas ptósicas de moderado a gran tamaño." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Allué Cabañuz M, Arribas del Amo MD, Gil Romea I, Val-Carreres Rivera MP, Sousa Domínguez R, Güemes Sánchez AT. Mastectomía preservadora de piel con colgajo dermograso desepitelizado (técnica de Spira modificada) y reconstrucción mediante implante directo. Cir Esp. 2021;99:215–221." ] ] "multimedia" => array:7 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 763 "Ancho" => 1500 "Tamanyo" => 242349 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Mastectomy phase: a) Marking the pattern; b) Inclusion of the biopsy scar within the area to be resected; c) De-epithelization of the area that will be the lower dermal fat flap; d) Excision and preservation of the NAC; e) Mastectomy releasing adhesions to the muscle; f) Result after complete excision of the gland." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 744 "Ancho" => 1500 "Tamanyo" => 171117 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Reconstruction phase: a) Placement of the implant that will be covered by the pectoralis major muscle (upper 2/3), sutured to the dermal fat flap (covering the lower 1/3); b) Marking the area for the new NAC once sutured to the skin pattern; c) Free NAC graft in its new position; d) Result after seven days; e) Result after one year; frontal view; f) Result after one year; lateral view." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Population characteristics \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N 247 (%)<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Indication for mastectomy</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Therapeutic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">121 (49) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">For de novo cancer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">71 (28.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">After previous breast-conserving surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 (20.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prophylactic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">126 (51) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prophylactic contralateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">92 (37.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prophylactic bilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34 (13.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">47.4 ± 9.2 yrs \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Comorbidities</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type 2 DM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (6.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BMI > 30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (4.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Active smoker \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 (7.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tumor stage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">N 121 (%)<a class="elsevierStyleCrossRef" href="#tblfn0010">**</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">DCis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (7.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">58 (47.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29 (23.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 (20.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Radiotherapy (therapeutic mastectomies) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">N 121 (%)<a class="elsevierStyleCrossRef" href="#tblfn0010">**</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57 (47.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anterior \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 (24.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adjuvant \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34 (28) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chemotherapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">N 139 patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 (35.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Neoadjuvant \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 (19.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adjuvant (post-mastectomy) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62 (44.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2548892.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "Rates determined by number of breasts, except comorbidities and chemotherapy, which was determined by number of patients." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "**" "nota" => "Rates reported for the total of therapeutic mastectomies." ] ] ] "descripcion" => array:1 [ "en" => "Patient characteristics." ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Complications \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">40 (16.2%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Skin necrosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 (5.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Seroma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (2.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (2.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hematoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (4.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Necrosis NAC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (2.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reoperation in the first month \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (3.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2548895.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Complications." ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cosmetic sequelae \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">43 (17.4%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Capsular contracture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28 (11.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Implant rupture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (3.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Extrusion of prosthesis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (1.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reconstruction NAC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (0.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Skin folds \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (0.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2548893.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Causes for reoperation in the long-term due to cosmetic sequelae." ] ] 5 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="7" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Oncologic results in therapeutic mastectomies</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Skin recurrence,n (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Locoregional recurrence,n (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Distant recurrence,n (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Exitus, n (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No recurrence (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total therapeutic mastectomies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">121 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (0.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (3.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 (9.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (6.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">96 (79.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">De novo cancer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1(1.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (4.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (9.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (4.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57 (80.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">DCis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (50) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Invasive carcinoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (4.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (8.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (2.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">55 (82.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Previously treated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39 (78) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">DCis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (20) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (20) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (60) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Invasive carcinoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (2.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (8.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (8.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36 (80) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2548894.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Oncologic results in therapeutic cases." ] ] 6 => array:5 [ "identificador" => "fig0015" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 718 "Ancho" => 1333 "Tamanyo" => 146058 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Subcutaneous mastectomy in the large ptotic breast" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M. 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Nipple sparing mastectomy with a de-epithelialized derma-fat flap (modified Spira technique) and direct-to implant reconstruction

Mastectomía preservadora de piel con colgajo dermograso desepitelizado (técnica de Spira modificada) y reconstrucción mediante implante directo

Marta Allué Cabañuz

Corresponding author

martitaallue@hotmail.com

Corresponding author.

, Maria Dolores Arribas del Amo, Ismael Gil Romea, María Pilar Val-Carreres Rivera, Ramón Sousa Domínguez, Antonio Tomás Güemes Sánchez

Unidad de Mama, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain

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    "titulo" => "Nipple sparing mastectomy with a de-epithelialized derma-fat flap &#40;modified Spira technique&#41; and direct-to implant reconstruction"
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        "titulo" => "Mastectom&#237;a preservadora de piel con colgajo dermograso desepitelizado &#40;t&#233;cnica de Spira modificada&#41; y reconstrucci&#243;n mediante implante directo"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In 1977&#44; Spira described skin-sparing mastectomy using a lower dermal fat flap&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Using this technique&#44; which is classified as a Carlson type IV skin-sparing mastectomy&#44; it is possible to remove all the glandular tissue&#44; a small portion of skin and all the retroareolar tissue&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">It is usually a technique intended for medium or large breasts with a minimal degree of ptosis&#46; To be able to perform this technique and achieve satisfactory cosmetic results&#44; it is essential for the nipple-areola complex &#40;NAC&#41; to reach at least the level of the inframammary fold&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In this technique&#44; the NAC is removed and refined to be later grafted onto the newly created breast mound&#46; Although Spira did not describe complications in this initial experience other than capsular contracture&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> recent studies have found general complication rates of around 20&#37;&#44; especially necrosis of the NAC with possible graft loss&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The main advantage of this technique is that it allows us to perform the reconstruction in a single surgery&#44; accommodating the definitive implant in a partially retromuscular position&#44; covered by the dermal fat flap below&#46; This avoids the need to use acellular dermal matrix and achieves favorable cosmetic results&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> while remaining an oncologically safe<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and efficient<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> technique&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">While skin-sparing mastectomy is widely validated as a therapeutic and not just prophylactic mastectomy&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> preservation of the PAC continues to generate controversy&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> mainly regarding recurrence&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The objective of this study is to analyze postoperative complications&#44; cosmetic sequelae&#44; causes of reoperation&#44; and oncological results of skin-sparing mastectomy with a dermal fat flap&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patient selection</span><p id="par0035" class="elsevierStylePara elsevierViewall">Our study included patients who underwent skin-sparing mastectomy with a de-epithelialized dermal fat flap &#40;modified Spira technique&#41; and direct-to-implant reconstruction&#44; treated consecutively over a 15-year period &#40;2003&#8211;2018&#41; by a single breast unit&#46; A retrospective observational analysis was carried out&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The following clinical conditions were included&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Patients with <span class="elsevierStyleItalic">de novo</span> breast carcinoma&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Patients previously treated for breast cancer with conservative surgery who have recurrence or affected margins and opt for mastectomy instead of re-excision&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Contralateral prophylactic mastectomy in patients with breast cancer &#40;due to risk factors&#44; patient choice&#44; or for symmetry&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Bilateral prophylactic mastectomy in patients with BRCA 1&#47;2 mutations or high risk due to family history without demonstrated mutation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Patients with a minimal degree of ptosis &#40;it is essential for the NAC to at least reach the level of the submammary fold&#41;&#46;</p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">The following cases were excluded&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Inflammatory breast carcinoma</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Two-stage breast reconstruction</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Patients with distant metastases at diagnosis&#44; since direct-to-implant reconstruction was not performed&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Patients with small breasts or without ptosis &#40;other techniques were performed&#41;&#46;</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Surgical technique and cancer treatment</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Planning phase</span><p id="par0095" class="elsevierStylePara elsevierViewall">Surgical planning is carried out with the patients in the standing position&#46; First&#44; the skin is marked with an inverted V pattern&#59; the submammary fold is projected on the breast midline 5&#8239;cm from the NAC&#44; from which two vertical branches are drawn&#44; trying to make them as closed as possible to preserve the greatest skin coverage&#46; From there&#44; horizontal branches are drawn towards the inframammary groove &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Mastectomy phase</span><p id="par0100" class="elsevierStylePara elsevierViewall">The procedure is performed with the patient in a semi-sitting position&#46; First&#44; the NAC is released&#44; but we do not remove it until the end of the operation &#40;in order to decrease the ischemia time of the free graft&#41;&#46; Then&#44; we de-epithelialize the dermal fat flap in the lower pole of the breast&#46; Excision of the mammary gland is completed&#44; preserving thin flaps of skin according to the pattern that we had designed and respecting a minimum thickness of 1&#8239;cm&#46; We remove the NAC&#44; keeping it in gauze moistened with saline solution&#44; and we create the dermal flap&#46; Lastly&#44; the axillary breast tissue is removed&#44; and the pectoralis major muscle is released from the pectoralis minor and its attachments in the thoracic wall to later cover the implant&#46; We also divide the pectoralis major muscle from its medial attachments at the sternum &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Reconstructive phase</span><p id="par0105" class="elsevierStylePara elsevierViewall">Reconstruction is completed in a single stage by placing a silicone implant with an anatomical profile&#44; which is double covered by the de-epithelialized dermal fat flap sutured to the pectoralis major muscle&#46; The volume of the implant depends on the volume of breast tissue extracted and the configuration of the affected and contralateral breasts&#44; so each case is personalized&#46; Finally&#44; the skin is closed&#44; following the pattern made&#44; first the vertical branches over the projection of the submammary fold along the midline&#46; We look for the area of maximum projection on the mound created as a new breast to mark the area where we will attach the free NAC graft&#46; At this time&#44; we confirm its viability by visual examination&#44; and the absence of retroareolar tissue involvement is confirmed by intraoperative biopsy&#46; After de-epithelializing the marked area and making small perforations in the graft&#44; we suture the PAC using interrupted 4&#8722;0 non-absorbable monofilament stitches and place a knotted gauze pressing on the graft&#44; which will remain in place for one week&#46; We place two suction drains&#44; one in the implant chamber and the other subcutaneous&#44; which are removed when the discharge is less than 30 cc&#44; often on an outpatient basis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">The administration of chemotherapy &#40;CT&#41; or radiotherapy &#40;RT&#41; followed our hospital&#8217;s clinical practice guidelines at the time of treatment&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Study variables</span><p id="par0115" class="elsevierStylePara elsevierViewall">The study variables were divided into four groups&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Complications&#58; the presence of cutaneous necrosis&#44; specifically necrosis of the NAC&#44; which was defined as partial &#40;possible to recover&#41; or total &#40;required surgical excision with secondary reconstruction&#41;&#59; maintained seroma&#44; infection&#44; or hematoma&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0125" class="elsevierStylePara elsevierViewall">Reoperations&#58; during the first month&#44; they were considered &#8216;postoperative complications&#8217;&#59; after the first month&#44; they were &#8216;cosmetic sequelae&#8217;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Cosmetic sequelae&#58; include periprosthetic capsular contracture&#44; implant rupture&#44; prosthetic extrusion&#44; and skin folds&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Oncological results&#58; locoregional recurrence was defined as the appearance of a new tumor in the ipsilateral chest wall &#40;subcutaneous tissue and pectoral muscle&#41; or recurrence in the ipsilateral axilla&#44; supraclavicular lymph nodes&#44; internal or infraclavicular mammary chains&#46; Exclusively cutaneous recurrence was considered separately for the analysis&#46; Distant recurrence &#40;metastasis&#41; was defined as any recurrence in all other areas not included in locoregional recurrence&#46;</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Statistical analysis</span><p id="par0140" class="elsevierStylePara elsevierViewall">We conducted a descriptive analysis of the variables under study&#46; For qualitative variables&#44; relative and absolute frequencies are provided&#46; For quantitative variables&#44; mean and standard deviation are given&#46; The SPSS 22&#46;0 for Windows statistical program &#40;SPSS Ib&#233;rica&#44; Madrid&#44; Spain&#41; was used for the analysis&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">This study complies with the ethical principles of the Declaration of Helsinki and was approved by the hospital ethics committee&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Results</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Description of the series</span><p id="par0150" class="elsevierStylePara elsevierViewall">During the study period&#44; 247 skin-sparing mastectomies were performed using the Spira technique&#44; with immediate reconstruction in 139 patients&#46; Of the total&#44; 216 were bilateral &#40;87&#46;4&#37;&#41; and 31 unilateral &#40;12&#46;5&#37;&#41;&#46; Also&#44; 121 therapeutic mastectomies &#40;49&#37;&#41; were conducted &#40;71 as treatment for <span class="elsevierStyleItalic">de novo</span> cancer &#91;28&#46;7&#37;&#93; and 50 mastectomies in breasts with previous conservative surgery &#91;20&#46;2&#37;&#93;&#41; and 126 prophylactic mastectomies &#40;51&#37;&#41; &#40;92 prophylactic contralateral mastectomies in patients with breast cancer &#91;37&#46;2&#37;&#93; and 34 risk-reducing mastectomies in patients at risk &#91;13&#46;7&#37;&#93;&#41;&#46; Comorbidities are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">Post-mastectomy&#44; 28&#37; of patients received adjuvant RT&#44; while 24&#46;7&#37; had previously received RT and 47&#46;1&#37; of the operated breasts were not radiated&#46; Sixty-two patients required adjuvant CT &#40;44&#46;6&#37;&#41;&#44; 27 had received neoadjuvant CT &#40;19&#46;4&#37;&#41; and 50 did not receive chemotherapy treatment either before or after surgery &#40;35&#46;9&#37;&#41;&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Adjuvant CT was administered a mean of 47&#46;3 days after the procedure &#40;SD 29&#46;8&#41; &#40;range 13&#8211;147&#41;&#46; In five cases &#40;5&#47;62&#59; 8&#37;&#41;&#44; it was postponed more than the 90 days that are defined by consensus as &#8216;delay&#8217;&#44; motivated in two cases by postoperative infection and in one by maintained seroma&#46; The median follow-up was 81 months &#40;SD 52&#46;42&#41;&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Complications</span><p id="par0165" class="elsevierStylePara elsevierViewall">The overall complication rate was 16&#46;2&#37; &#40;40&#47;247&#41;&#44; and skin necrosis was the most frequent &#40;13&#47;247 &#91;5&#46;3&#37;&#93;&#41;&#46; There were only five cases of necrosis of the NAC after free graft &#40;2&#37;&#41;&#44; and eight patients required reoperation in the short-term postoperative period &#40;five cases due to bleeding and three due to infection&#44; these being the patients who later presented extrusion of the prosthesis that required reoperations in the long term&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Cosmetic sequelae</span><p id="par0170" class="elsevierStylePara elsevierViewall">The rate of cosmetic sequelae was 17&#46;4&#37; &#40;43&#47;247&#41;&#44; and grade III&#47;IV periprosthetic capsular contracture was the most frequent cause of reoperation in the long term &#40;28&#47;247 &#91;11&#46;3&#37;&#93;&#41;&#46; Out of the total number of patients who presented capsular contracture&#44; 11 had received adjuvant RT &#40;11&#47;28 &#91;39&#46;3&#37;&#93;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Reoperation for sequelae was performed with a mean of 4&#46;7 years &#40;SD&#8239;&#177;&#8239;4&#46;96&#41; after the intervention&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Oncological results</span><p id="par0175" class="elsevierStylePara elsevierViewall">Out of the 121 therapeutic mastectomies&#44; the overall recurrence rate was 14&#37; &#40;17&#47;121&#41;&#44; with 0&#46;8&#37; skin recurrence&#44; 3&#46;3&#37; locoregional recurrence&#44; and 9&#46;9&#37; distant metastases&#46; No recurrence was observed in the NAC&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Eight patients died &#40;6&#46;6&#37;&#41;&#46; Mean disease-free survival &#40;DFS&#41; was 5&#46;08 years &#40;SD 4&#46;35&#41;&#44; and mean overall survival &#40;OS&#41; was 5&#46;78 years &#40;SD 4&#46;73&#41;&#46; The DFS and OS rates were 92&#46;6&#37; and 93&#46;3&#37; respectively&#46; The percentages by subgroups are shown in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Discussion</span><p id="par0185" class="elsevierStylePara elsevierViewall">Due to the increase in the detection of cancers in earlier stages&#44; the need for skin preservation techniques has increased in recent decades in the same way as prophylactic contralateral mastectomy in patients with unilateral cancer due to patient demand&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> In addition&#44; patients demand satisfactory cosmetic results and choose breast reconstruction in a single surgery&#44; when possible&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Therefore&#44; we often find ourselves in the need to perform bilateral mastectomies&#44; preserving the skin and the NAC&#44; followed by the placement of a definitive implant&#44; all in the same surgery&#46; The Spira technique perfectly meets all these needs and is ideal for patients with medium or large breasts and a certain degree of ptosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Unlike what happens with subcutaneous mastectomy in small breasts&#44; obtaining optimal results in this type of breasts is more difficult and requires repositioning the NAC and reducing the skin coverage&#46; The technique&#44; which is not without risks&#44; can compromise wound healing and the viability of the NAC&#44; which could lead to skin necrosis with exposure of the implant&#44; extrusion of the implant and failed reconstruction&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a> Two mechanisms have been proposed to explain these healing&#47;perfusion problems&#58; first&#44; dermal flaps that are too long&#59; and second&#44; flaps that are too thin&#44; which endangers their vascularization through the subdermal plexus&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">In our experience&#44; we found an incidence of cutaneous necrosis of 5&#46;3&#37;&#44; an NAC necrosis rate of 2&#37;&#44; and the need for reoperation due to extrusion of the prosthesis in three patients &#40;1&#46;2&#37;&#41;&#46; These rates are lower than those reported in other series&#44; such as the King et al&#46; study&#44; with 10&#37; skin necrosis&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Several studies have also demonstrated that the average local recurrence rate after skin-sparing mastectomies is no different whether the NAC is preserved or not &#40;3&#46;9&#37; vs&#46; 3&#46;25&#37;&#44; respectively&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Furthermore&#44; there is evidence that combining these techniques with immediate reconstruction does not significantly delay the administration of adjuvant therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Our series supports these data&#44; with 0&#46;8&#37; skin recurrence&#44; 3&#46;3&#37; locoregional recurrence&#44; and no case of recurrence in the NAC&#46; Furthermore&#44; we only observed a significant delay &#40;greater than 90 days&#41; in the administration of adjuvant chemotherapy in five cases&#44; two due to postoperative infection and one due to a maintained seroma&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Although this study has a considerable number of cases and a long follow-up period&#44; it presents limitations because it is a retrospective analysis of the experience from a single institution&#44; so the results cannot be generalized&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">In conclusion&#44; skin-sparing mastectomy with de-epithelialized dermal fat flap and direct-to-implant reconstruction is a safe option that offers good cosmetic and oncological results in the treatment and prophylaxis of breast cancer for patients with moderate to large ptotic breasts&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Funding</span><p id="par0215" class="elsevierStylePara elsevierViewall">This study has received no funding&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflict of interests</span><p id="par0220" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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    "fechaRecibido" => "2020-04-07"
    "fechaAceptado" => "2020-04-24"
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            0 => "Nipple sparing mastectomy"
            1 => "Immediate breast reconstruction"
            2 => "Spira technique"
            3 => "Complications"
            4 => "Sequelae"
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          "palabras" => array:5 [
            0 => "Mastectom&#237;a preservadora de piel y pez&#243;n"
            1 => "Reconstrucci&#243;n inmediata"
            2 => "T&#233;cnica de Spira"
            3 => "Complicaciones"
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Spira technique is a type of nipple-sparing mastectomy that allows immediate reconstruction &#40;IBR&#41;&#44; ideal for ptotic breasts&#46; Although&#44; controversy persists regarding oncological results in breast cancer&#46; The aim is to analyze complications&#44; cosmetic outcomes&#44; causes of reoperation and oncological results&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Retrospective observational analysis of patients undergone surgery during 2003&#8211;2018 in our center&#46; Study population is based on patients with breast carcinoma or undergoing prophylactic mastectomy due to high-risk&#44; in which a skin-sparing mastectomy with a de-epithelialized derma-fat flap &#40;modified Spira technique&#41; and direct to implant reconstruction was performed&#46; Short and long-term complications&#44; sequelae&#44; tumor recurrence and survival rates are analyzed&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">A total of 247 mastectomies with immediate reconstruction in 139 patients&#44; 216 bilateral &#40;87&#46;4&#37;&#41; and 31 unilateral &#40;12&#46;5&#37;&#41; were performed&#46; 121 therapeutic &#40;49&#37;&#41; and 126 prophylactic &#40;51&#37;&#41;&#46; Median follow-up 81 months&#46; Complications were observed in 16&#46;2&#37;&#59; skin necrosis 5&#46;3&#37; and 5 cases of NAC necrosis &#40;2&#37;&#41;&#46; Reoperation rate due to cosmetic sequelae was 17&#46;4&#37; &#40;capsular contracture was the most frequent&#44;11&#46;3&#37;&#41; and a 39&#46;3&#37; of these patients have received RT&#46; Recurrence of 14&#37; &#40;0&#46;8&#37; skin&#44; 3&#46;3&#37; locoregional and 9&#46;9&#37; metastatic&#41;&#44; 8 patients died &#40;6&#46;6&#37;&#41;&#46; Rates of FSD and OS were 92&#46;6&#37; and 93&#46;3&#37; respectively&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusion</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Spira mastectomy is a safe option and provides good cosmetic and oncologic results as breast cancer treatment and prophylaxis in moderate-large ptotic breasts&#46;</p></span>"
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            "titulo" => "Introduction"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">La t&#233;cnica de Spira es un tipo de mastectom&#237;a preservadora de piel que permite la reconstrucci&#243;n inmediata &#40;RMI&#41;&#44; ideal en mamas pt&#243;sicas&#46; Si bien&#44; persiste controversia sobre resultados oncol&#243;gicos en el c&#225;ncer de mama&#46; El objetivo es analizar complicaciones&#44; secuelas cosm&#233;ticas&#44; causas de reintervenci&#243;n y resultados oncol&#243;gicos&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">M&#233;todos</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional retrospectivo de pacientes intervenidas durante 2003&#8211;2018 en nuestro centro&#46; La poblaci&#243;n de estudio la constituyen pacientes con carcinoma de mama o sometidas a mastectom&#237;a profil&#225;ctica por alto riesgo&#44; en las que se realiz&#243; una mastectom&#237;a preservadora de piel con colgajo dermograso desepitelizado &#40;t&#233;cnica de Spira modificada&#41; y reconstrucci&#243;n mediante implante directo&#46; Se analiza la presencia de complicaciones precoces y tard&#237;as&#44; secuelas&#44; recidiva tumoral y supervivencia&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Se realizaron 247 mastectom&#237;as con reconstrucci&#243;n en 139 pacientes&#44; 216 bilaterales &#40;87&#44;4&#37;&#41; y 31 unilaterales &#40;12&#44;5&#37;&#41;&#59; 121 terap&#233;uticas &#40;49&#37;&#41; y 126 profil&#225;cticas &#40;51&#37;&#41;&#46; La mediana de seguimiento fue de 81 meses&#46; Se observaron complicaciones en un 16&#44;2&#37;&#59; necrosis cut&#225;nea en 5&#44;3&#37; y cinco casos de necrosis del CAP &#40;2&#37;&#41;&#46; La tasa de reintervenci&#243;n por secuelas cosm&#233;ticas fue del 17&#44;4&#37; &#40;la m&#225;s frecuente fue contractura capsular 11&#44;3&#37;&#41; y&#44; de ellas&#44; el 39&#44;3&#37; recibieron RT&#46; La tasa de recidiva fue del 14&#37; &#40;0&#44;8&#37; cut&#225;nea&#44; 3&#44;3&#37; locorregional y 9&#44;9&#37; a distancia&#41;&#46; Ocho pacientes fallecieron &#40;6&#44;6&#37;&#41;&#46; La SLE y SG fue del 92&#44;6&#37; y 93&#44;3&#37; a cinco a&#241;os&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusi&#243;n</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">La t&#233;cnica de Spira constituye una opci&#243;n segura y ofrece buenos resultados cosm&#233;ticos y oncol&#243;gicos como tratamiento y profilaxis de c&#225;ncer de mama en mamas pt&#243;sicas de moderado a gran tama&#241;o&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; Allu&#233; Caba&#241;uz M&#44; Arribas del Amo MD&#44; Gil Romea I&#44; Val-Carreres Rivera MP&#44; Sousa Dom&#237;nguez R&#44; G&#252;emes S&#225;nchez AT&#46; Mastectom&#237;a preservadora de piel con colgajo dermograso desepitelizado &#40;t&#233;cnica de Spira modificada&#41; y reconstrucci&#243;n mediante implante directo&#46; Cir Esp&#46; 2021&#59;99&#58;215&#8211;221&#46;</p>"
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            "imagen" => "gr1.jpeg"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Mastectomy phase&#58; a&#41; Marking the pattern&#59; b&#41; Inclusion of the biopsy scar within the area to be resected&#59; c&#41; De-epithelization of the area that will be the lower dermal fat flap&#59; d&#41; Excision and preservation of the NAC&#59; e&#41; Mastectomy releasing adhesions to the muscle&#59; f&#41; Result after complete excision of the gland&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Reconstruction phase&#58; a&#41; Placement of the implant that will be covered by the pectoralis major muscle &#40;upper 2&#47;3&#41;&#44; sutured to the dermal fat flap &#40;covering the lower 1&#47;3&#41;&#59; b&#41; Marking the area for the new NAC once sutured to the skin pattern&#59; c&#41; Free NAC graft in its new position&#59; d&#41; Result after seven days&#59; e&#41; Result after one year&#59; frontal view&#59; f&#41; Result after one year&#59; lateral view&#46;</p>"
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Population characteristics&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N 247 &#40;&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Indication for mastectomy</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Therapeutic&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">121 &#40;49&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>For <span class="elsevierStyleItalic">de novo</span> cancer&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71 &#40;28&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>After previous breast-conserving surgery&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50 &#40;20&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Prophylactic&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">126 &#40;51&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Prophylactic contralateral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">92 &#40;37&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Prophylactic bilateral&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34 &#40;13&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mean age&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">47&#46;4&#8239;&#177;&#8239;9&#46;2 yrs&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Type 2 DM&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;6&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>BMI &#62; 30&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6 &#40;4&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Active smoker&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;7&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Tumor stage</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N 121 &#40;&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010">&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>DCis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;7&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58 &#40;47&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29 &#40;23&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;20&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Radiotherapy &#40;therapeutic mastectomies&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N 121 &#40;&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010">&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57 &#40;47&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Anterior&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30 &#40;24&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Adjuvant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34 &#40;28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Chemotherapy</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N 139 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50 &#40;35&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Neoadjuvant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27 &#40;19&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Adjuvant &#40;post-mastectomy&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#40;44&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            0 => array:3 [
              "identificador" => "tblfn0005"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Rates determined by number of breasts&#44; except comorbidities and chemotherapy&#44; which was determined by number of patients&#46;</p>"
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              "etiqueta" => "&#42;&#42;"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Rates reported for the total of therapeutic mastectomies&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Patient characteristics&#46;</p>"
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            "identificador" => "at0020"
            "detalle" => "Table "
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            0 => array:2 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Complications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">40 &#40;16&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Skin necrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;5&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Seroma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;2&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;2&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hematoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;4&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Necrosis NAC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;2&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reoperation in the first month&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;3&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Complications&#46;</p>"
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        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0025"
            "detalle" => "Table "
            "rol" => "short"
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cosmetic sequelae&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">43 &#40;17&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Capsular contracture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 &#40;11&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Implant rupture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;3&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Extrusion of prosthesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;1&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reconstruction NAC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;0&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Skin folds&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;0&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0030"
            "detalle" => "Table "
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Oncologic results in therapeutic mastectomies</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
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        "texto" => "<p id="par0225" class="elsevierStylePara elsevierViewall">The authors would like to thank the Breast Unit at the Hospital Cl&#237;nico Universitario Lozano Blesa de Zaragoza&#44; including surgeons&#44; nursing staff and patients&#46;</p>"
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Article information

ISSN: 21735077
Original language: English

DOI:10.1016/j.cireng.2021.02.011

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2024 October	81	13	94
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2024 July	39	9	48
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