So, one of the common wisdoms of the performance of mastectomies is to have thinner flaps. I think most of us as general surgeons were trained to do that. The difficulty with thinner flaps, certainly from the plastic surgery perspective, is that I think it adds potential complications to the first and second stage reconstructions. I've been focused on thicker flaps for well over a decade. And as I have looked at my results, some of which are published and most are not, we've seen no greater increase in recurrence with either a standard skin-sparing mastectomy or with our nipple-sparing mastectomies. So that from the plastic surgery perspective, having thicker flaps is good. From an oncologic perspective, I find no downside to having thicker flaps and frankly only more benefits in lower complication rates. On the right side, which is the tumor side, an ellipse of skin will be deacetylized to shorten the lower pole of the breast and prevent the nipple areola from riding up high. This now again demonstrates the axillary dissection on the treatment side of the patient, nicely demonstrating the anterior mammary fascia, bluntly dissecting with the scissors and then cutting the individual Cooper's ligaments. This is a nice demonstration of the importance of removing the axillary tail. We've already performed a sentinel lymph node biopsy through this same incision. This now again demonstrates the underside of the areola on the treatment side and how we're about to divide the base of the nipple, mark it with a silk suture, and then take a rather deep biopsy into the base of the nipple for permanent pathology. Pathologists prefer to have this done as a permanent biopsy and not as a frozen section. Further dissection now of the breast as we demonstrated on the prophylactic side, completing the dissection. Here the expander is being fixed in place, starting with the medial suture, which is placed at a pre-marked location. The medial fixation is then followed by the suture placed through the lower fixation tab, and this is anchored to the rectus fascia. Laterally, the suture anchors the tab to the serratus anterior fascia. The same fill volume is used on the right side. And the final closure is done with a trio of monoclodermal sutures. This shows the final result with one drain placed in each side and exteriorized at the lateral edge of the suture line. This patient is undergoing a second stage implant exchange approximately three months after the initial mastectomy. The expander has been filled with 240 cc of saline solution during the first stage. Because of the large areola, which was approximately 6 centimeters in diameter, the subcutaneous areolar breast tissue was not thinned out at the time of the initial mastectomy to minimize the chances of nipple loss. The residual subareolar tissue will now be removed by Dr. Harness. This patient was quite unusual in that she had such a very large areola. This is a 39-year-old patient who had DCIS or margins were negative at her original surgery. What we see demonstrated here is a very large area of residual subareolar breast tissue that's being carefully dissected off, basically the subdermal area. We've learned in these procedures how critical it is that we not leave any visible breast tissue behind in any of these patients. A meticulous dissection is always done on the subareolar side of any of our nipple-sparing mastectomies. And as can be seen here, this is a really large area. And as Dr. Slavian has already indicated, we were concerned about the vascular viability of such a large areola had we removed this tissue originally. Therefore doing this as a delayed procedure at this time we felt was not a problem. And the actual eventual permanent pathology demonstrated this was just additional benign breast tissue. The area was quite large as can be seen in this dissection. So we defer taking the biopsy, permanent biopsy, of the nipple until the time of the second stage reconstruction. Ink is used to mark the new outer cut surface. So in case there was residual cancer there, the pathologist would know that. This demonstrates nicely a biopsy of the base of the nipple. Here the peripheral capsulotum is being done. In addition to the peripheral incision, radial incisions are made. And if need be, these radial incisions are joined to crosshatch the capsule, giving it a cobblestone appearance. We do not perform a capsulectomy. Now a 450cc sizer is being placed in the pre-pectoral space to assess the shape and the contour of the breast. Any irregularities are corrected by additional capsulotomies to smoothen out the skin. It is important to have both sizers in place before deciding on the final implant size as additional corrections may be needed. Going back to the patient's other size, we're again demonstrating the resection of residual breast tissue left on the underside of the areola. In nipple-sparing mastectomies, one of the concerns has been what are the odds of recurrence actually in the nipple itself long-term. If you look at the published literature, the odds of that is far less than 1% down in the neighborhood of around 0.6%. Critical to this, however, is the fact that you cannot leave any residual breast tissue that we can see behind. And here shows the demonstration of that. In addition to the peripheral capsulotomy, a central capsulotomy is being performed. This is done to smoothen out the periphery of the areola and prevent a step-off along its margin. Here you can see the short radial incisions being made circumferentially, as well as cross-hatching of the capsule for a smoother transition. A 525 cc silicone gel implant is inserted in the pre-pectoral pocket. We routinely drain these wounds and this shows the final single layer closure of the skin. On the right side and before the final closure, scarring along the skin margin was noted causing the skin edge to invert. A capsulotomy is being done here to release the contracted margins and evert the skin edge. This is the final closure on the right side and the final result with a light dressing. It has been a pleasure of sharing our team approach today and we hope that this has been a productive session and that you've learned something from our team approach effort. You know in many settings the breast surgeon does his or her thing first and the plastic surgeon comes in subsequently to do the first stage reconstruction. We've learned that working simultaneously together is truly a team approach. We really complement and help each other and I hope you've picked up on those kinds of subtleties as you've reviewed today's technical sharing with you of our approach to nipple

thicker flaps

mastectomy reconstruction

nipple-sparing

sentinel lymph node biopsy

breast and plastic surgery collaboration