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Seme Protocolos051115.Pages PROTOCOLOS DE PRÁCTICA CLÍNICA EN MEDICINA ESTÉTICA FEBRERO 2016 COMITÉ EDITORIAL Dra. Petra Mª Vega López. Presidenta de la SEME. Dra. Pilar Rodrigo Anoro. Presidenta de Honor de la SEME. Dra. Paloma Tejero. Socia de Honor de la SEME. Dr. Juan Antonio López López-Pitalúa. Vicepresidente 1º de la SEME. Dr. Fernando García Monforte. Vicepresidente 2º de la SEME. Dr. Manuel Sánchez Sánchez. Tesorero de la SEME. SOCIEDAD ESPAÑOLA DE MEDICINA ESTETICA Ronda General Mitre, 210.08006 Barcelona. E-mail [email protected] 3ª Edición Febrero de 2016 Dirección editorial: Dr. Antoni Baena Coordinación editorial: Mónica Rivero > página 3 > página 4 PRESENTACIÓN Los Protocolos de Práctica Clínica en Medicina Estetica son una iniciativa de la Sociedad Española de Medicina Estética, publicados por primera vez en febrero de 2008, ampliados, revisados y actualizados en febrero de 2015. Los objetivos de los mismos son: • Homogeneizar los criterios de la práctica clínica: las nomenclaturas, las clasificaciones y los tratamientos. • Aplicar la medicina basada en la evidencia. • Dotar a la Medicina Estética de una herramienta que mejore la seguridad del paciente y que facilite la actuación del profesional. Es la primera iniciativa internacional de este tipo en Medicina Estética y a través de estos protocolos la SEME quiere ofrecer al médico y a la sociedad la posibilidad de: • Facilitar el Desarrollo Profesional Continuo en beneficio de los ciudadanos. • Ofrecer una herramienta médico-legal que proteja al ciudadano y facilite la labor del profesional. • Ser una guía de actuación que fomente la buena práctica médica y que minimice los efectos adversos. > página 5 MARZO 2015 > página 6 ÍNDICE 1. Sobrepeso y Obesidad .....................................................8 2. Adiposidad Localizada ....................................................15 3. Celulitis .....................................................................27 4. Elastosis Cutánea .........................................................35 5. Estrías .......................................................................45 6. Insuficiencias venosas, Varices y Edemas .............................51 7. Toxina Butolínica ..........................................................57 8. Acné .........................................................................71 9. Alteraciones Circulatorias Cutáneas Faciales .........................79 10. Hirsutismo ...............................................................105 11. Materiales de Relleno Inyectables ...................................125 12. Discromías. Alteraciones de la Pigmentación ......................141 13.Alopecia ..................................................................153 14.Envejecimiento y Longevidad .........................................159 > página 7 1.Sobrepeso y Obesidad REVISORES Dra. Pilar Rodrigo Anoro (Coord.) Dra. Susana Monereo Presidenta de Honor de la SEME. Barcelona. Jefe de la Sección de Endocrinología y Nutriciónu del Hospital Universitario de Getafe. Madrid. Sociedad Española para el Estudio de la Obesidad (SEEDO). AUTORES Dra. Carmen Fernández Dr. José R. Cabo Soler Directora de la Clínica Fitland. La Coruña. Catedrático de la Facultad de Medicina. Sociedad Española para el Estudio de la Obesidad Universidad de Valencia. Director Médico del (SEEDO). Master en Medicina Estética de la Universidad de [email protected] y [email protected] las Islas Baleares. [email protected] Dra. Concha Fuentes Herreros Directora del Centro de Medicina Estética de la Dra. Concha Fuentes. Madrid. [email protected] Avalado por: > página 8 > Sobrepeso y obesidad SOBREPESO Y OBESIDAD La obesidad es una enfermedad crónica Diabetes Mellitus, cáncer de origen multifactorial en la que pueden estar epitelial). implicados: • Antecedentes personales (enfermedad • Factores neuroendocrinos (neuropeptidos metabólica asociada, fármacos iatrogénicos, hipotalámicos junto con factores HTA). gastrointestinales). • Evolución del sobrepeso u obesidad (edad • Factores implicados en la termogénesis de inicio, causas desencadenantes…). inducida por nutrientes y hormonas. • Historia dietética (registro alimenticio, • Papel endocrino y paracrino del adipocito. número de comidas al día, tiempo dedicado • Hormonas implicadas en la regulación de la a la comida, lugar en el que se come, adiposidad (insulina, esteroides, hábitos compulsivos, picoteo, preferencias glucocorticoides). alimentarias, trastornos del • Variaciones de la actividad metabólica de comportamiento alimentario…). los enzimas implicados en la síntesis de líquidos, oxidación de substratos o EXPLORACIÓN FÍSICA almacenamiento de triglicéridos. • Flora intestinal. Los obesos presentan un Mediante la exploración física se diagnosticará predominio de bacteris fimicurtes con a los pacientes con obesidad secundaria: mayor capacidad para la digestión de • Exploración física general. polisacáridos y de obtención de energía, así • Exploración física específica (peso, talla, como producción de sustancias IMC, perímetro de cintura). Estos proinflamatorias. parámetros nos ayudaran a diagnosticar si el sobrepeso u obesidad es de origen En cuanto a la prevalencia, en la edad infantil central. y juvenil es del 18,4%. Entre los adultos asciende al 22,9% siendo más frecuente en los Exploraciones complementarias varones. El sobrepeso afecta al 40% de la • Analítica general (hemograma, población siendo igualmente más prevalente monograma, glucemia basal, perfil en varones. La prevalencia de obesidad lipídico, perfil renal y hepático). abdominal es muy elevada alcanzando el • Analítica específica (Hba1c glicosilada, 36,1%, llegando al 62% en las mujeres a partir sobre carga oral de glucosa, de los 65 años. microalbuminuria). • Ecografía abdominal (descartará la La finalidad de esta revisión es establecer un presencia de esteatosis hepática, litiasis protocolo de actuación sencillo, manejable y biliar y ovarios poliquísticos). consensuado. Estos objetivos consisten en • Estudio del sueño (si existe síndrome de identificar y evaluar a la persona con apnea del sueño). sobrepeso y obesidad y establecer los • Pruebas funcionales respiratorias (en parámetros de diagnóstico y tratamiento. casos de insuficiencia respiratoria) . • Ecocardiograma. VALORACIÓN CLASIFICACIÓN Realizaremos una historia clínica completa: Utilizaremos el IMC para la clasificación del • Antecedentes familiares relacionados con sobrepeso y la obesidad y el índice de cintura la obesidad (sobrepeso y obesidad, para valorar la distribución de la grasa enfermedad cardiovascular prematura, corporal y su riesgo metabólico. > página 9 > Sobrepeso y obesidad La obesidad se caracteriza por el exceso de se debe insistir en un cambio en el estilo grasa corporal y para su evaluación se utiliza de vida y del comportamiento el índice de masa corporal (IMC=Kg/m2): alimentario, una alimentación saludable, • IMC>25=sobrepeso. un aumento del ejercicio físico y vigilar • IMC>30=obesidad. y cuidar el sueño. Pueden ser útiles los En la población infantil se considera sobrepeso controles médicos periódicos. En el caso al 85% del percentil de las tablas de Cole, y de presentar comorbilidades asociadas a obesidad al 95% del percentil. la obesidad se debe actuar igual qu een pacientes con obesidad. El sobrepeso con distribución central de grasa corporal se considera cuando el perímetro de C. Obesidad grado I (IMC=30–34,9) cintura es mayor de 94 cm en varones y 80 cm Generalmente asociada a Diabetes en mujeres. La obesidad central se considera Mellitus Tipo2, a dislipemias y a la HTA. cuando el perímetro de cintura es superior a Se recomienda terapia intensiva para 102 cm en varones. conseguir cambio de estilo de vida y de comportamiento alimentario. Higien del Actualmente la presencia de comorbilidades sueño. Además de la dieta hipocalórica, asociadas es un factor más importante que el o modificada en macronutrientes, el propio IMC. Así, pacientes con comorbilidades aumento de la actividad física y el deben considerarse obesos a todos los efectos tratamiento farmacológico de las a partir de un IMC≥25 kg/m2. comorbilidades asociadas, es necesario emplear fármacos específicos para el Los mejores indicadores del factor de riesgo tratamiento de la obesidad. El control cardiovascular son: médico debe ser riguroso y periódico. El • Perímetro de la cintura objetivo, en este caso, es lograr una • Índice cintura/altura: pérdida del 10% del peso inicial para que • ≥0,53 en varones disminuya el riesgo cardiovascular. • ≥0,51 en mujeres D.Obesidad grado II (IMC=35–39,9) CRITERIOS DE INTERVENCIÓN Se acompaña de una alta comorbilidad. TERAPÉUTICA El objetivo es conseguir la pérdida de un Los factores a tener en cuenta son: 10% del peso inicial. Si no se consigue en • Edad. seis meses remitiremos al paciente a una • IMC. unidad hospitalaria especializada para • Distribución de la grasa corporal. plantear dieta de muy bajo contenido • Existencia de comorbilidades. calórico y/o cirugía bariátrica. Según el IMC: E. Obesidad grado III (IMC=40–49,9) y A. Normopeso (IMC=18,5–24,9) Obesidad grado IV (IMC>50) No será necesaria la intervención A. Implica una gravedad cardiovascular excepto si existen antecedentes de importante. El tratamiento de elección obesidad, aumento de 5Kg en el último es la cirugía bariátrica. año, distribución abdominal de la grasa corporal o presencia de factores de TRATAMIENTO riesgo cardiovasculares asociados. Se aplicaran medidas preventivas sobre la El objetivo principal es conseguir una alimentación saludable y fomentar la disminución
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