Hypoplastic Breast Research Articles

A spectrum of TP63-related disorders with eight affected individuals in five unrelated families

TP63-related disdorders broadly involve varying combinations of ectodermal dysplasia (sparse hair, hypohydrosis, tooth abnormalities, nail dysplasia), cleft lip/palate, acromelic malformation, split-hand/foot malformation/syndactyly, ankyloblepharon filiforme adnatum, lacrimal duct obstruction, hypopigmentation, and hypoplastic breasts and/or nipples. TP63-related disorders are associated with heterozygous pathogenic variants in TP63 and include seven overlapping phenotypes; Ankyloblepharon‐ectodermal defects‐cleft lip/palate syndrome (AEC), Ectrodactyly‐ectodermal dysplasia‐cleft lip/palate syndrome 3 (EEC3), Limb‐mammary syndrome (LMS), Acro‐dermo‐ungual‐lacrimal‐tooth syndrome (ADULT), Rapp–Hodgkin syndrome (RHS), Split-hand/foot malformation 4 (SHFM4), and Orofacial cleft 8. We report on five unrelated families with 8 affected individuals in which the probands presented with varying combinations of ectodermal dysplasia, cleft lip/palate, split-hand/foot malformation, lacrimal duct obstruction, and ankyloblepharon filiforme adnatum. The clinical diagnosis involved AEC syndrome (2 patients), EEC3 syndrome (2 patients), and a yet hitherto unclassified TP63-related disorder. Sanger sequence analysis of the TP63 gene was performed revealing five different variants among which four were novel and three were de novo. The identificated TP63 variants co-segregated with the other affected individuals in the families. The abnormalities of ectoderm derived structures including hair, nails, sweat glands, and teeth should alert the physician to the possibility of TP63-related disorders particularly in the presence of orofacial clefting.

A Simple and Effective Intraoperative Technique for Correction of Severe Congenital Breast Asymmetry.

One severe type of congenital breast asymmetry, with a hypoplastic breast on one side and a hyperplastic breast on the other side, has been recognized in the author's practice. Although breast augmentation, mastopexy, and breast reduction used separately or in combination are the most common procedures performed to correct congenital asymmetrical breasts, an effective approach for the correction of such a congenital breast asymmetry has not been established in the literature. In this article, a simple and effective intraoperative approach is described for correction of severe congenital breast asymmetry. Breast augmentation with an implant for the hypoplastic side and mastopexy or small breast reduction for the hyperplastic side were performed. Symmetry was achieved intraoperatively by an implant for breast augmentation on the hypoplastic side and mastopexy or small reduction, determined by a tailor-tacking technique, on the hyperplastic side. In the past 2 years, a total of 4 patients with severe congenital breast asymmetry was operated on by the author with this established approach. All patients were pleased about their symmetry and cosmetic outcome without any surgical complications. The resulted breast scars are minimal and well tolerated by patients. No revision or subsequent surgery has even been needed during follow-op. Correction of severe congenital breast asymmetry is not an easy task and can be difficult. This simple and effective intraoperative approach provides a relatively easy and logical way as a 1-stage procedure for this subgroup of patients with symmetrical and cosmetically pleasing outcome.

Postburn breast reconstruction: a scoping review.

Postburn breast deformities pose functional and aesthetic concerns for burn patients, particularly when injury occurs before puberty, as normal breast development may be hindered. Postburn breast reconstruction aims at restoration of native anatomic features, as well as re-establishment of symmetry. The objectives of this scoping review are to map the literature on scar management and breast reconstruction, highlighting strategies that are particular to postburn deformities, as well as to establish optimal timing principles. A comprehensive search of the English literature across MEDLINE and EMBASE databases, including the grey literature, was conducted. Literature of all study designs were eligible, provided it discussed the treatment of postburn breast deformities. A total of 64 studies were included. The most common study design was case series (58%) followed by retrospective cohorts (28%). Scar contracture release with split thickness skin grafts (26%) and various techniques for nipple-areola reconstruction (22%) were the most common reconstructive procedures. Scar contracture releases predominate when there is normal breast development under a contracted skin envelope, and should be performed as soon as breast mound development is restricted. Surgical techniques widely used for postmastectomy reconstruction are required for patients with amastia or hypoplastic breasts. Given the heterogeneity of defects, availability of donor sites, and patient preference, no standardized guideline is available. Surgeons should combine basic scar management principles with postmastectomy techniques, adapting the surgical approach to features that are particular to thermally injured patients, as well as taking into account ideal timing considerations. Breast deformities secondary to burn scars pose functional and aesthetic concerns for burn patients, particularly when injury occurs before puberty, as normal breast development may be hindered. Postburn breast reconstruction aims at restoration of native anatomic features, as well as re-establishment of symmetry. This literature review aimed at summarizing the available techniques to treat postburn breast deformities, as well as establishing optimal timing guidelines, given these issues may occur at any phase of breast development. When there is breast development under a scarred skin envelope, treatment entails scar contracture release and should be recommended as soon as the diagnosis is established, in order to allow the breast to further develop in an unrestricted manner. When there is absence of breast tissue, surgical techniques widely utilized for breast cancer reconstruction are warranted, and should be delayed until no further breast development is expected. Given the heterogeneity of deformities, availability of donor sites, and patience preference, no standardized guideline is available. Treatment options include several surgical techniques, in addition to non-surgical scar management, and timing considerations must take into account the patient's developmental phase and psychosocial wellness.

Familial cleft tongue caused by a unique translation initiation codon variant in TP63

Variants in transcription factor p63 have been linked to several autosomal dominantly inherited malformation syndromes. These disorders show overlapping phenotypic characteristics with various combinations of the following features: ectodermal dysplasia, split-hand/foot malformation/syndactyly, lacrimal duct obstruction, hypoplastic breasts and/or nipples, ankyloblepharon filiforme adnatum, hypospadias and cleft lip/palate. We describe a family with six individuals presenting with a striking novel phenotype characterized by a furrowed or cleft tongue, a narrow face, reddish hair, freckles and various foot deformities. Whole-exome sequencing (WES) identified a novel heterozygous variant, c.3G>T, in TP63 affecting the translation initiation codon (p.1Met?). Sanger sequencing confirmed dominant inheritance of this unique variant in all six affected family members. In summary, our findings indicate that heterozygous variants in TP63 affecting the first translation initiation codon result in a novel phenotype dominated by a cleft tongue, expanding the complex genotypic and phenotypic spectrum of TP63-associated disorders.

Becker\u2019s nevus syndrome: a case report\xa0

BackgroundBecker’s nevus syndrome is a syndrome characterized by the presence of a Becker’s nevus with ipsilateral breast hypoplasia or hypoplastic defects of the muscle, skin, or skeleton. The nevus usually consists of a circumscribed, unilateral, irregularly shaped hyperpigmented macule, commonly occurring around the anterior upper trunk, with/without hypertrichosis and/or acneiform lesions. This rare syndrome has not been reported in our locality to the best of our knowledge.Case presentationWe report the case of a 15-year-old Igbo female patient who presented to our pediatric endocrinology clinic, University of Nigeria Teaching Hospital, Enugu, with complaints of asymmetry of the breasts and hyperpigmented macules on the side. Based on her symptoms, diagnosis of Becker’s nevus syndrome was made. The diagnosis of Becker’s nevus syndrome is mostly clinical, based on the presence of a Becker’s nevus with ipsilateral breast hypoplasia or hypoplastic defects of the muscle, skin, or skeleton. In our patient, there was a Becker’s nevus with ipsilateral breast hypoplasia. This syndrome, belonging to the class of epidermal nevus syndromes, is very rare, and is usually benign. She was placed on spironolactone tablets 50 mg daily, which have been associated with an improvement in the size of the hypoplastic breast, and her fears were allayed.ConclusionThis syndrome has not been reported in our locality to the best of our knowledge and, therefore, has a propensity for misdiagnosis by clinicians because of its rarity. We therefore report this to create awareness among clinicians regarding this condition that is associated with much psychosocial trauma among patients, and that can be easily managed with oral spironolactone.

Versatility of Pectoralis Major High Splitting Technique in Breast Augmentation

Breast augmentation is one of the most common aestheticprocedures required by plastic surgery female patients, andone of the most effective procedures changing their physical,psychological and social status as well. Certain problemswould be corrected by breast augmentation as well such asamastia, hypoplastic breast, asymmetry, and age-relatedchanges. To obtain an Ideal breast augmentation, there aresome objectives that have to be fulfilled: The position of thenipples must be in the most projecting part of the breasts. Theimplant must be non-visible and non-palpable underneath theskin envelope. And the lower pole of the breast should beadequately filled than the upper pole. Thirty patients wereincluded in this study using pectoralis major high splittingtechnique for the purpose of performing breast augmentationover the period of 5 years from February 2013 to November2018. Follow-up period for each case was at least 6 monthsfor the aesthetic outcome and patient satisfaction. Patientssatisfaction was extremely high and there were no evidencesfor capsular contracture or abrupt demarcation of the implantunder breasts skin. In conclusion performing breast augmentationusing pectoralis major high splitting technique is ofgreat value in giving a three-dimensional improvement in thecontinuously changing soft tissue dynamics of the breast, alsodecreases morbidity of the procedure and raises satisfactionand favorability of patients toward breast augmentation.

Hand Pattern Based on Second-to-Fourth Digit Ratio: Its Relationship to Sex, Body Mass Index, and Physical Activity.

Background:The second-to-fourth digit ratio is measured by dividing the length of the index finger by the length of the ring finger. A ratio <1 means that the ring finger is longer; this is known as the male pattern or “A” pattern. A ratio >1 means that the index finger is longer; this is known as the female pattern or “C” pattern. When both fingers are equal in length (ratio = 1), the pattern is labeled as “B” pattern; this may be seen in both sexes. None of the previously reported studies on this topic were reported in the plastic or hand surgery literature. Our aim is to increase the awareness of plastic and hand surgeons to these types of hand patterns and to correlate such patterns to sex, body mass index (BMI), and physical activity in a group of healthy medical students and interns.Methods:We conducted a cross-sectional study on 160 healthy medical students/interns. There were 82 females and 78 males between the ages of 20 and 30. A male pattern (pattern A) was defined as pattern A in both hands or pattern A in one hand and pattern B in the other hand. A female pattern (pattern C) was defined as pattern C in both hands or pattern C in one hand and pattern B in the other hand. The correlation between hand pattern and sex, BMI, and physical activity was done using the chi-square test and Fisher’s exact test. A P value of <0.05 was considered statistically significant.Results:Five participants (3.1%) had pattern B in both hands. Another 15 participants (9.4%) had a male pattern in one hand and a female pattern in the other hand. Both of these groups were excluded from the statistical analysis. Pattern A was significantly higher in males, and pattern C was significantly higher in females (P < 0.001). BMI and physical activity did not significantly affect the hand pattern in males. However, the correlations between hand pattern and both BMI and physical activity were significant in females (P = 0.005 for BMI) (P = 0.042 for physical activity).Conclusions:About 12.5% of the study group did not fit into a male or female pattern. In the remaining 87.5% of the participants, sex correlated with hand pattern. BMI and physical activity significantly affected the hand pattern in females. We believe that our study will encourage plastic surgeons to further investigate the correlation of different hands patterns to other variables of interest in plastic surgery such as masculine facial anthropometric values, hypoplastic breasts, gynecomastia, and lipodystrophy.

The Use of a Retromammary Adipofascial Flap in Breast Augmentation for Patients with Thin Soft Tissue.

In patients with a thin soft tissue breast envelope, lower pole implant palpability is a postoperative sequela that concerns patients. Anatomically, the lower aspect of the breast near the inframammary fold lacks sufficient soft tissue to cover the breast implant after augmentation. A transareolar incision was made, and subcutaneous dissection was performed. The dissection first proceeded caudally to the lower aspect to the breast parenchyma. The dissection then changed direction and moved cephalad to the mid breast or nipple region. The fatty tissue and pectoralis muscle fascia were cut transversely at this level, and the dissection was reversed caudally in a subfascial plane to the new inframammary fold region. This maneuver created a retromammary adipofascial flap. A total of 368 breast augmentations were performed in 184 patients. Breast implants were inserted in the subfascial plane in 40 patients (21.7%) and in the subpectoral-subfascial plane in 144 patients (78.3%). A total of 368 breast implants were inserted, including 140 smooth cohesive silicone implants (38.0%), 2 textured round implants (0.5%), and 226 anatomic-type implants (61.5%). A cadaveric dissection revealed that a retromammary adipofascial flap measuring 3-4mm in thickness can be acquired. Capsular contracture occurred in six breasts (1.7%). During breast augmentation, an inferiorly based retromammary adipofascial flap can be created to help cover the lower pole of the breast from implant palpability. This is helpful especially in patients with thin skin, hypoplastic breasts, or constricted breasts. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Bilateral breast reconstruction and pectus excavatum correction: a case and review of the literature

Pectus excavatum is a chest wall malformation characterized by anterior chest wall depression. It is often associated with hypoplastic breasts, sternal rotation, and consequent breast asymmetry. We present here the case of a 52-year-old female with pectus excavatum, a bilateral nipple-sparing mastectomy for breast cancer, and immediate autologous breast reconstruction using bilateral deep inferior epigastric perforator flaps. To correct reconstructed breast deformities and pectus excavatum depression and to enhance breast volume to treat hypoplastic breasts, three sessions of Brava-assisted fat grafting were performed. These postoperative courses were uneventful and without any complications. The patient was satisfied with the final esthetic results. There are only two case reports to perform bilateral breast reconstruction and surgical correction of pectus excavatum, which were used with both pedicle musculocutaneous flap and breast implant, with or without a sternal implant. In this study, we discuss indications and surgical options for bilateral breast reconstruction, pectus excavatum, and breast augmentation. Level of Evidence: Level V, therapeutic study.

Rare Case of Ulnar-Mammary-Like Syndrome With Left Ventricular Tachycardia and Lack of TBX3 Mutation.

“Heart–hand” type syndromes represent a group of rare congenital conditions that combine cardiac pathology (structural defect or arrhythmic disorder) and limb abnormality. Significant clinical variability and genetic heterogeneity typical for such syndromes complicate correct diagnosis, prognosis, and appropriate genetic counseling of the affected families. By now, only single genes have been unambiguously determined as a genetic cause of heart–hand syndromes and phenotypically similar conditions. In the present study, we report on a 25-year-old Russian female patient with a clinical picture resembling ulnar-mammary syndrome (UMS). Principal clinical manifestations included heart septal fibrosis and non-sustained left ventricular tachycardia combined with fifth finger camptodactyly, hypoplastic breast, abnormal teeth, and mental retardation. Target Sanger sequencing and array-based comparative genome hybridization confirmed the lack of pathogenic mutations and large-scale deletions in TBX3 (12q24.21), the only gene known to be associated with UMS cases to date. Based on the results of whole-exome sequencing, 14 potential candidate variants were identified. Among them, a novel missense variant in SYNM gene (exon 1, c.173C > T, p.A58V), encoding intermediate filament protein synemin was characterized. Until the present, no association between SYNM mutations and congenital clinical syndromes has been reported. At the same time, taking into account synemin tissue-specific expression profiles and available data on abnormal knock-out mice phenotypes, we propose SYNM as a candidate gene contributing to the UMS-like phenotype. Further comprehensive functional studies are required to evaluate possible involvement of SYNM in genesis of complex heart-limb pathology.

Treatment of congenital unilateral hypoplastic breast anomalies using autologous fat grafting: A study of 11 consecutive patients

During the period 2008-2013, 11 women were treated with autologous fat grafting for unilateral congenital breast hypoplasia comprising both tuberous breast and micromastia. No correction of the contralateral breast was done at evaluation. Patients were treated median one time, and they had their inter-breast volume difference reduced from median 175 to 50 ml. Patients showed overall high degree of satisfaction with the treatment, but they were less satisfied when addressing size and shape separately. The median follow-up time was 13 months, and the achieved breast volume sustained throughout the follow-up period.

P351 Mammary fibromatosis in a young woman with ipsilateral hypoplastic breast

P351 Mammary fibromatosis in a young woman with ipsilateral hypoplastic breast

Evidence-Based Evaluation Technique to Assess Augmentation Mammaplasty Results: A Simple Method to Objectively Analyze Mammary Symmetry and Position

Despite the great variety of mammaplasty techniques, outcome assessment remains a challenging issue. The authors devised an objective method to evaluate mammary symmetry based on statistical analysis of objective manual breast measurements and validated the method by applying it to results of a randomized controlled trial on the correction of breast asymmetry. Sixty consecutive patients with hypoplastic breasts and small-volume asymmetry were enrolled in the study and randomly assigned to 1 of 2 groups. One group received a fixed-volume implant in 1 breast and an adjustable-volume implant in the other. The other group received 2 fixed-volume implants of different sizes. The differences in specific breast and chest measurements, obtained before surgery and during follow-up, were analyzed statistically with the Wilcoxon signed rank test. Correction of the asymmetry resulted in the reduction of the differences between left and right values for each specific breast measurement. Placement of an adjustable implant on 1 side yielded better symmetry than placement of 2 fixed-volume prostheses of different sizes. Patient and physician satisfaction was high for both groups. This objective analysis of clinical parameters enables comparing results for different patients in large clinical trials and for the same patient at different follow-up periods. 3.

The Use of Lipofilling to Treat Congenital Hypoplastic Breast Anomalies

Treatment options for congenital hypoplastic breast anomalies are often open, including radial scoring, parenchymal flaps, and insertion of expanders and implants. Drawbacks of open techniques involve scarring, the use of drains, and inpatient stays. The use of lipofilling to treat breast deformities is increasing, as more research is completed in this area. We report a retrospective study of 10 patients below the age of 20 following autologous fat transfer between January 1, 2003 and January 1, 2004. (2 Poland syndrome, 3 bilateral tuberous breast, and 5 unilateral micromastia). Age, cup size, the number of sessions, time interval between each session, volumes injected, and complications were recorded. Postoperative mammography, ultrasonography, and MRI were assessed by a specialized radiologist. Patients answered a questionnaire 1 year after the procedure. Mean follow-up was 68 months (60-77 months) and mean age was 17.5 years (15-20 years). Mean number of fat injection sessions was 2 (1-4) and mean volume injected 285 mL per breast (200-500 mL). The time interval between each session was 5 months (3-6 months). Cup size remained unchanged after at least 5 years of follow-up. One case underwent a contralateral breast reduction. The cosmetic results considered satisfactory in almost all the patients after 1 year of follow-up. None of our patients complained of scars or defects at the donor site. All breasts imaging were normal except 1 patient with oil cysts. Our preliminary results using lipofilling to treat young patients with breast hypoplasia with lipofilling are very encouraging. The authors believe it is an alternative of choice for the correction of the young woman's breast deformities if the avoidance of scarring is preferred.

Fat Grafting in a Patient with a Poland Syndrome Variant

When a patient has a problem with asymmetry physicians strive to correct it to the best of their abilities. Many patients ask for a perfect or almost perfect result; however, some patients are pleased with a small correction to their problem. Here is an illustrative case of such a patient with hypo-plastic breast anomaly—a variant of Poland syndrome—who requested fat grafting to the affected breast.

Correction of Pectus Excavatum With Breast Hypoplasia Using Simultaneous Pectus Bar Procedure and Augmentation Mammoplasty

Most women with asymmetric pectus excavatum suffer from hypoplastic breasts. Hence, aesthetic correction of pectus excavatum has to address thoracic wall deformity, breast hypoplasia, and asymmetry.In retrospective series, 21 patients with a diagnosis of pectus excavatum with hypoplastic breasts were corrected using the pectus bar procedure and subpectoral augmentation mammoplasty. Results were assessed by analyzing prospectively collected data and calculating pectus indices from computed tomographic scans. At 12 months postoperatively, cosmetic evaluations were performed by the patients and by an independent, board-certified plastic surgeon using score from 0 (very poor) to 4 (very good).Cosmetic results evaluated by plastic surgeon were good (3.33 ± 0.03) and patient satisfaction was high (3.52 ± 0.03). Furthermore, indices of pectus excavatum were corrected to near normal.The authors consider that the pectus bar procedure with subpectoral augmentation mammoplasty is useful for the aesthetic correction of pectus excavatum with hypoplastic breasts.

Augmentation mastopexy: maximal reduction and stable implant coverage using four flaps.

A single-stage operation to correct ptotic and hypoplastic breasts would appear to be a very appealing option for both surgeons and patients. However, this procedure is the most often litigated in aesthetic surgery because of its frequent complications. Our goal in this article is to report our experience with a four-flap technique for implant coverage in maximum reduction mastopexy with prosthesis. From January 2011 to March 2013, a total of 41 patients with Regnault grade II or grade III ptosis with no hypertrophy underwent primary bilateral augmentation mastopexy. Our technique includes an inverted-T mastopexy and a thin, well-vascularized, inferior dermoglandular flap to cover the inferior pole of the implant. Retrospective data collection revealed a mean patient age of 37.5 years. Thirty-nine patients were treated with round cohesive silicone gel implants and two with anatomical cohesive gel implants. The mean implant volume was 280 cc and mean follow-up time was 14 months. The following complications were observed in declining frequency: four suture dehiscences, two hematomas, one capsular contracture, one implant malposition, and one poor scarring. A satisfaction questionnaire revealed very high satisfaction in 23 patients (56.09 %), high satisfaction in 12 (29.26 %), moderate satisfaction in four (9.75 %), and low satisfaction in two (4.87 %). Our results demonstrated a low complication rate (21.9 %) and low reoperation rate (12.1 %) with our technique and make us confident in recommending this technique for grade II and grade III ptosis. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266 .

Hypoplastic Breast Anomalies in the Female Adolescent Breast

Hypoplastic breast anomalies remain a reconstructive challenge. In this article, the authors review the spectrum of nonsyndromic breast hypoplasia in the adolescent girl, namely idiopathic breast hypoplasia and tuberous breast deformity. Challenges specific to this population include (1) identifying the ideal timing for surgery, (2) choosing the optimal reconstructive method while taking into consideration ongoing changes in the female body (e.g., future pregnancy), and (3) considering the use of a two-stage reconstructive approach to gradually expand the skin envelope. A comprehensive review of surgical techniques that address these conditions is provided, taking into account the evolution and the most recent advances in surgical techniques.

Congenital Linear Becker’s Nevus, with Underlying Breast Hypoplasia that Spontaneously Corrected during Pregnancy: Role of Androgen Receptors

Becker’s nevus is a pigmented cutaneous hamartoma that is normally localized to the upper torso. It is more commonly found in adolescent males and may form part of the Becker’s nevus syndrome, in association with other features which may include overlying hypertrichosis, chest wall, breast or limb hypoplasia and scoliosis. Congenital and linear lesions have been reported but are very rare. We describe here a case of a congenital, linear nevus with histological features diagnostic of a Becker’s nevus, with associated underlying breast hypoplasia. We confirm increased androgen receptors within her nevus and consequently, when our patient became pregnant, her relative antiandrogen profile enabled physiological enlargement of the previously hypoplastic breast beneath this nevus

Complicação pós-implante mamário na síndrome de Poland

A síndrome de Poland é descrita como ausência do músculo peitoral maior, associada a deformidade das mãos, como sindactilias variáveis, ausência de falanges médias, fusão dos ossos do carpo ou encurtamento do antebraço. Pode haver variação na extensão do comprometimento torácico, desde o sunken chest, termo utilizado para as depressões torácicas associadas a displasia esquelética em geral, até a ausência das porções anteriores das costelas ou cartilagens costais. Em geral, o complexo areolopapilar é posicionado mais superiormente nos homens e nas mulheres a mama é hipoplásica. É relatado o caso de paciente portadora de síndrome de Poland, com 32 anos de idade, que procurou nosso ambulatório de residentes com o desejo de melhorar a aparência do tórax e da mama. Foi realizada intervenção cirúrgica sete anos antes, com implante de prótese mamária de silicone, no intuito de amenizar a deformidade torácica característica. Após avaliação, optou-se pela troca da prótese. No intraoperatório, observou-se área de reabsorção osteocartilaginosa com cerca de 4 cm de diâmetro, em região de articulação costocondral. Após a cirurgia, a paciente evoluiu conforme o esperado. Foi realizada investigação ampla da deformidade encontrada e a paciente avaliada foi encaminhada ao cirurgião torácico. A reabsorção óssea regional anterior no hemitórax esquerdo pode ser um achado cirúrgico e representar diminuição da proteção cardíaca, tornando necessária maior atenção para os casos de substituição de prótese mamária, com realização de exame de imagem específico, como tomografia computadorizada, com o objetivo de minimizar o risco cirúrgico.