I am Arthur Salivian, a plastic surgeon who is practicing at St. Joseph's Hospital in Orange, California. For the past few years, I and Dr. Harness have been working on the nipple-sparing mastectomy procedure and today we're going to be emphasizing the team approach to nipple-sparing mastectomy. I'm Jay Harness. I am a full-time breast surgeon in Orange, California at St. Joseph's Hospital. Our interest in nipple-sparing mastectomy fits in with an interest in the oncoplastic approach to breast cancer patients. Oncoplastic approach is a term coined in Europe which means that we're not only emphasizing the cancer surgery but also the plastic surgery outcome. I've been focused on nipple-sparing mastectomies for around seven and a half years. I've chosen an inframammary approach and will emphasize today making thicker skin flaps which we believe gives us greater flexibility in the reconstructive process and will also emphasize today some of the subtle techniques of what we're doing particularly in the region of the cancer itself. This is a 48-year-old patient who has undergone a previous bilateral silicone augmentation and who has been demonstrated in the upper inner quadrant of her right breast to have an approximately 5-centimeter area of in situ breast cancer. We've marked out the skin in the area where we need to thin the subcutaneous fat. Now we're in the process of marking out some other areas of enhancement noted on the breast MRI examination. We've drawn an elliptical incision at the bottom, in other words, in order to remove the old incision from the augmentation. Here we're placing a piece of tegaderm over where we marked the skin in order to preserve it. Our approach to a patient like this now is to do the prophylactic side first which is what we're going to demonstrate, marking out both an axillary incision which allows us to have access to the tail of the breast and to make sure that's resected as well as doing any sentinel lymph node biopsies. The inframammary incision is generally in the neighborhood of 12 to 14 centimeters. In this case, it's being marked out as an ellipse in order to resect some of the skin in the old scar. We work as a team with both myself and the plastic surgeon, Dr. Salabian, simultaneously operating. The areas have been generously infiltrated with local anesthesia and you can see now the dissection on my part is in the tail region, freeing up the breast from the pectoralis major muscle which is a key component that we'll discuss later. Also, as can be seen now, cutting down through the inframammary incision, incising the capsule and the silicone implant will then be removed from and below from the inframammary incision. Following this, we begin the dissection of the axillary tail by dissecting along the anterior mammary fascia, also known as the superficial layer of the superficial fascia. In any mastectomy, it's really critical that the axillary tail region be completely excised. We have found that curved Mayo scissors bluntly dissecting along the plane and then cutting the individual Cooper's ligaments is the way to go. We're now going to demonstrate the same process through the inframammary incision, again identifying this anterior mammary fascia as it's known in ultrasound books and also in the anatomy books known as the superficial layer of the superficial fascia. We're trying to preserve all of the subcutaneous fat. Here is a long Cooper's ligament that it's important that it be divided at the top of the Cooper's ligament, in other words, not to leave any glandular tissue behind. This is a combination dissection with the curved Mayo scissors, as well as my colleague bluntly dissecting along this plane with the backside of a DeBakey's forceps. You can see how we're carefully preserving all of the subcutaneous fat and in the area of a cancer, we thin that subcutaneous fat out as we demonstrated by previously marking a known area of cancer. This is a somewhat tedious dissection. This is now in the region of the areola where we no longer have any subcutaneous fat and what we have is basically the underside of the areola, the dermis, if you will, of the areola, finding the base of the nipple and dividing the base of the nipple and we always save a deep biopsy for permanent pathology of the base of the nipple. We also mark this area with a silk suture to assist our pathology colleagues so they know exactly where we divided the base of the nipple. Once then we get beyond, we then dissect further. In this particular case because of our prior augmentation, we're now freeing up a capsule and pectoralis major muscle from the cephalad portion on the underside of the breast just beyond the nipple areola complex. Normally we would have freed up the breast completely from the pectoralis muscle as an important initial part. Here you can see some resection of the capsule, the cut edge of the pectoralis muscle. We're now continuing the dissection along the same anterior mammary fascia doing exactly the same technique that we did below and completing the dissection as we head up with a standard dissection approach heading up to underneath the clavicle. The planes of the dissection are identical to any normal mastectomy dissection planes. Again you can see the curved scissors dissecting along dividing individual's Cooper's ligaments. We'll have a nice view here of the underside of the breast and we will further dissect the breast off of the pectoralis muscle as we complete the upper portion of the dissection. The breast is now out completely. The breast is then sent to the pathologist for evaluation. Here we've chosen a 350cc tissue expander. This particular mentor expander has three fixation tabs for anchoring the implant in place. The location of the medial tab is first marked on the skin at the external border keeping the lower border of the expander at the inframammary fold. The contralateral side is also marked for symmetry. The medial tab is sutured to the pectoralis fascia with a two monocle suture. Implant fixation permanently defines the lower border of the pocket. We have not used a cellular dermal matrix for lower fold definition. In this patient the expander is being placed pre-pectorally rather than in the sub-pectoral space. The thick breast skin flap allows creating a pre-pectoral pocket for the future permanent implant without causing skin rippling. We feel that a pre-pectoral permanent implant gives the breast a better shape, particularly in patients who have had post-mastectomy radiation therapy. This shows the fixation of the lower tab. The expander is then filled with 180cc of saline solution. We tend to under-expand the skin rather than over-expand it to allow greater skin shrinkage, particularly in thoracic breasts. Our average post-op fill is once. This shows the final closure, which is usually done with a single layer of three or monocle dermal sutures. When we started these procedures, the nipple-sparing mastectomy, we were limiting our patient choice to those patients who had small breasts. And then we found out with our technique, which is basically an inframammary approach to nipple-sparing mastectomy, that we could extend our indications to medium-sized breasts and even large breasts. And the fact that we were using thick flaps allowed us to do the same procedure for women who had large breasts.

nipple-sparing mastectomies

oncoplastic techniques

inframammary approach

breast reconstruction

radiation therapy