I'm Rick Zenowitz, I'm an Associate Plastic Surgeon professor here at Brown University. Been here 25 years. Have done some weird things in plastic surgery. People used to call me a fringe character, but I think that almost everything that I've done now has been at least acknowledged as having some sense. And I think you'll make some sense out of this operation. This is very different from things that you've been taught. So the first part of it is you're introducing an implant through the abdomen. So how many mommy makeovers do you do a year? How many mommy makeovers do you think you're going to do in your career? Well, if you're an average plastic surgeon, it's going to be a lot. Because that's the population that is the least cared for and the most deserving of regeneration of the breasts and the tummy. And usually they go together. If you think about it, when a woman goes through pregnancy, they end up with a diastasis recti, they end up with stretch marks, they end up with loose skin, often with fat as well. But the breasts take a beating too. The breasts often have involutional ptosis, so they sag. Sometimes they just become floppy because they've lost volume. So what this operation does, and it's called TABA, transabdominal breast augmentation, is take the biggest root that you could possibly put an implant through with the least amount of skin touch, insert the breast implants under the muscle, or above if you choose to, but I think under the muscle is generally the better way, and end up with a capsule contracture rate that is the lowest reported ever. We fortunately just had our paper accepted by the White Journal, and it's less than 1%. It's about .8%, .78 I believe. Why is that? Well, because it's a no-touch technique. You're putting the implant in through the abdominal opening, so there's no contact at all with skin. And number two, the pocket from the breast is draining into the abdomen, so there's no chance of collection of seroma or hematoma around the implant. So we strongly believe that that's what's contributing to it. I think that it gives you more power over the inframammary fold than any other technique available. The series that we're presenting is 114 patients. Trust me, there are patients that you have seen in your office many times because the collective has a little bit of everything. So today's patient is a professional, wanted to be a little smaller than I thought would be ideal for her, but still turned out to be, I think, a reasonable size for her. And she chose saline implants. Now we use about 95% silicone today, but in the early days when silicone wasn't as available, I was certainly using a lot of saline, and saline works beautifully. Today we had a little snafu with the fill mechanism, but it was all straightened out. You'll see it. I'm also going to have the gentleman include an inset of putting an implant in with a shaped implant via the conventional technique and show you how easy it is. It is an easy operation. We all know how to do tram flap surgery, where you make a tunnel through the abdomen up into the breast. It's not much different. It's very straightforward. And if you see today, and if you don't think it's very straightforward, I'd be very surprised. We have a bilateral grade cetosis. So here is the inframammary fold. You can see that in that position, the nipple is actually below the inframammary fold when she is in a standing position. So she needs a full mastopexy. The way that we're starting is we want to mark the vertical axis of the nipple areolar complex. If you notice her chest, interestingly, though there is a slope here, she has a bit of an excavatum here, which bodes favorably for the implants once they're in. It tends to keep them more in the middle, and hence, even though she's a belly sleeper, her breasts have not gone that far south or laterally. So what we're going to do is there's two ways to put implants in my gestalt in trying to preserve the maximum blood supply to the nipple areolar complex, which is the synacron known for this operation. We need to have good blood supply to avoid nipple areolar necrosis, which is the devastating or the most devastating complication that can happen after this kind of operation. So historically, I have been known to do a transaxillary approach, which completely obviates any disruption of the blood supply. But I think in this woman, we can, through a relatively small incision here with a Keller funnel, put our implants in and not disturb the breast tissue very much. So we're going to go with that route because she prefers it. So what we're going to do right now is only plain local to the nipple areolar complex, and then we're going to do intercostal neuroblocks. So we're going to go T2 to T7. We're going to do the medial row here, a little bit in the inferior portion as well. And Dr. Pinero is going to help us with his experts, ketamine, propofol, drip, and all adjuncts. Okay, thank you. Let's start. Also want to get the pectoralis major muscle. So we go in, we transfix, hit the rib right there. I'm hitting it, and then I'm going to go above this one because that's going to be T2. So I can possibly get a little bit of T1 and then T2. Beata, can I please have some more? This is Beata Sochocka, our head nurse. She's phenomenal. Couldn't do it without her. Dr. Steven Pinero, Dr. Bill Abination, our chief resident. And Paola, our scrub tech from Dominican Republic. So why are we doing this? Yes, we are not doing general anesthesia, but think about it just for a second. And I do this on every breast case. I want you to know that. If we can stem the blood flow, which is dominant through the intercostals, we can ostensibly decrease our rate of hemorrhage internally, so leading to negligible hematoma rates, which I can promise you I have, and anybody that does this will have, because you're basically truncating all of the bad bleeders. So you want to get this medial row as well, because as we well know, the intercostals are on both sides. Lastly, we know that plain xylocaine is a smooth muscle relaxant, right? So we're going to increase blood flow to the nipple areola complex by using it, not hurt it, actually increase it at the same time as causing some analgesia, right? That analgesia would be incredibly important post-operatively, too, because she'll require much less narcotic, less nausea. Precisely. Less anesthetic intraoperatively. Okay. So we don't want to go anywhere into the actual axial blood supply of the nipple-relar complex, right? That's good. I think I'm good. Did you get all yours? And then I got this. I got that for you. Oh, I got that, too. Okay. We're good. Thank you. Can I just make one quick point? So these actual accessory marks you see right here, this is what I do for everybody is the pinch test. You take a pinch, and then you mark on either side of the opposite side of your gloved hand, and that's going to be a relative indicator about where you're going to need to do your tailor tacking. So the tailor tacking, you'll see after we put the implant in, will begin roughly in that zone, and it's incredibly satisfying how frequently it is dead on. So I strongly encourage you, and it's a stout pinch. Apologize to the patient that you're pinching them, and then make your marks on either side of the fingers. When we look at this size right here, to me, generally, a 38 works great, 38, that's 34. So we take a 38, we'll tie it down to a 34. One of the things that works for me is, ooh, ooh, I need to get rid of that. There was a spudge on the floor, there was a lot of milk that came out. So what I like to do, because if you twist the nipple areola complex, you can kill it. So why do that? So we mark the periphery with north, south, east, west meridians with methylene blue. That way it goes back anatomically, there's no twisting, and it just works out, it's beautiful. So always pull away from you as you cut, and see the bevel that I'm using? The bevel will give you as much dermis as you need. Look at the perfect dermis right here. There's no scalloping, there's none of that cellophane tape that you have to sew to. So you have beautiful dermis left. Always do this. Let's go to the other side. I can still see my mark, I can see my mark, yep, 38. It's actually pretty good. Okay, so methylene blue. Really want to make sure you pull evenly because this is this everything for giving you a good result pull away from even honey with your That's it pull And when I'm operating with residents, I always sweat them doing this part I I don't sweat anymore with that Bella because she's got it really down nicely You got a pull while you're cutting Because counter tensions everything with precision You Can you see Okay, let's let him take a look see where we are Okay. So now let's go. No, let's cut a little bit more a little bit more with the knife Your knife just a little bit more and then we'll and then we'll use our neck You want to we want to free that dermis up all the way around before we use a bovie? Free it up real good And right at the base here at six o'clock Okay Okay, so now now now here's here's what happens we need to translocate that nipple in a superior direction So it's a it's a it's a look becomes a local advancement flap right release So what Bell is gonna do is gonna burn the outside We're going to use the bovie and burn the outside because that's going to be discarded get stay away from the nipple areola complex Keep on that bevel. Keep the bevel bevel bevel That way we're preserving blood supply, right? This is what allows us to move the nipple areola complex Several centimeters without creating undue tension on it I Just had a little bit to go and then I need the bovie as well So always out to the side release on a bevel Be Careful because sometimes there's enough blood you can slip and then you could really ding it. You don't want to ding this this is your lifeboat And you don't want a hole in the raft, okay bovie What do I have? Okay, good. All right. So now look at what look look what we've got in the way of a Freedom degrees of freedom. I was explained to Bella before she's actually got a pretty tight inframammary fold and That means that we're generally going to put some implant below it And if we don't have to cut it, wouldn't that be nice? So we're gonna have to tighten a little bit here. So we're just gonna release this part right here But We're going to create a small opening here, please our army-navy Bell's gonna do the same thing on her side And we're going to just create a small opening and use a Keller funnel and get that's it. Thank you for that I'm Going straight down. Okay, how can you hold this for me honey? I'll take that Thank you for the lights And I'm going down You Might want my help. So maybe just wait a second. I'm right on the muscle Another army-navy And believe it or not folks, but we're already where we need to be I Can we open up the first implant, please We open up the first implant So I have a nice sub pectoral plane here She's chosen a generous implant What we use for sizing and in my practice for about the last eight years have been mentor sizers, which are incredibly Excellent in a bra patients get an immediate feel for what it will look like Unfortunately, they feel a lot of weight. So a lot of times they translate that in their own You know their Mental picture of the implant as being these heavy things that I don't like. So what we've introduced is Vectra and Vectra is It's the it's the gold bullet or silver bullet for Determining implant size and predictability. It's been verified by a number of well-controlled studies and In my hands, I think it delivers an exceptional prediction of what what the patient can expect. I Need some triple antibiotics Okay Let's do yours Then we'll do it all then we'll do it all clean. Okay, so Yeah, precisely. That's good. That's good. That's good. So take the book take the sucker in your hand and Use that to displace the tissues while it's sucking now, let's go down straight Good see the gland So let's stay away from the blood supply Let's try to go more more towards the inframammary fold because we need to thin those tissues out Anyway, I'm just talking about leaving some parenchyma. Think about a mastectomy If you have a good healthy mastectomy flap with a little fat on the back of it, it's perfect, right? So in this case, you want to leave just a little bit of that because we're gonna take up that fold right there And if I'm pulling up It's much like the table we just did We're pulling the pectoralis major muscle off of the chest wall There's no way that you could possibly go into The the parenchyma of the lung because we haven't even seen muscle yet Okay, you're doing great I want to just reverse these good So there's muscle And go straight down you're perfect Okay ready Get right through that muscle layer now right there. See it see it. Oh, yeah Perfect. Now could you put your finger in there and I think you will find that you'll be on the ribcage Go right through Okay, are you in? Oh, yeah, perfect. Perfect. Okay. So now I I'm Exploring my pocket. It's a 485. So I know you're gonna have a little bit of a hard time I'm gonna have a little bit of a hard time. I'm gonna have a little bit of a hard time My pocket that's a 485 so I I know that the approximate base dimension of that is going to be It's around 13 centimeters plus and and I need that much space But I don't want to over dissect laterally at all I want this implant to be occupying a medial part of the breast so medial and a little bit inferior because this part right here if you look at it, it's beautiful breast and Nipple is not too high right now So we want to expand that and take advantage of some of this We're all familiar with the connotation of dual plane Can I have a deeper please? So I need to release a little bit of muscle Yet just so that it is not going to interfere later on one more And if you could please hold right here Paul Good hold that right there. I'll take the sucker So in in the in the fashion of the dual plane, I'm going to release hold right that I'm going to release some of the pectoralis major muscle right here Which will allow the implant to sit where it belongs Rather than being artificially pushed up by the muscle Oh Can I have an army-navy so I can show this let's hold this right here like there, okay And again, my muscle release has been medial I Just had a few little losers here that I want to make sure are all Completely dry hold that right there So What happens sometimes when we're giving ketamine is the patients get a little hyper salivate salivatory and That's what dr. Pinero is dealing with right now. So we have to suck them out I Think I'm good. I would like to put just a sponge in there while you hold that right there I'm just gonna pack that on while we work on Bella's side. Can I have a long force it? Doesn't seem to be losing at all, but let's just do a little bit of that while we're working on her side. Okay good All right, that's feel Very nice. So you got to do the same thing You're in good shape all the way around but if you feel Let's show that let's show that let's show it right with the camera here. So here is Here is our muscle Here's our pectorals major muscle muscle look over a second. Here's our pectorals major muscle right here And I'm gonna get under it and there it is right there, okay So so now Bella is going to release it. I'm gonna hold it take the sucker in your hand And Bella's just gonna release it right here ready watch Look and use bogey Can you see it opening up is it opening up can you see it? Um, let's get I Want to get it so you can see it because there's the mud. There's the edge of the muscle She's gonna really release some more right here Perfect. Yes. Yes Excellent. Okay good Let's do a Little bit more right there see it right there. Yes, right there the base right there the base to leg Beautiful more More get all that muscle. They're still there. See that right? Yeah right there Okay, I think that's not bad Little bit right there see right there still on the chat show A Little bit right there see right there still on the chat chest wall right in the chest wall hold this Paula Right here this stuff. This stuff is still binding us to the chest wall Okay, so it comes up and it goes away Perfect excellent. Okay. Now I want to do a little bit this way as well Hold this right there Okay, I'll Hold this I Would take the paper off first The middle paper the middle paper Okay, good hold just hold this right there hold this let go of that hold this you don't need the paper just hold it Right here, Ovi Okay, so move over this way so they can see So that if you pull it pulls so they could see can you see this right here? I'm freeing up this part of the pectoralis major muscle I Saw it Can you come in can you come into the pocket let's pull back so they can come Keep can you can you get into that pocket right now? That's why a head cam would be so much better Ovi Looks good now, isn't it? Okay, okay show them Your head's in the way your head's in the way. Yeah another Deaver Your head is still hitting the camera move Can you see it right there Okay, so let's throw some triple antibiotics in there There's nothing bleeding there triple antibiotics. Okay, go wash it go wash your hands Leave it it's fine. You don't need Yeah, exactly I Think people get get this I think people get this part of the operation pretty easily. It's a it's the rest of it And that's all gonna be external I Think people get get this part of the operation pretty easily. It's a it's the rest of it, and that's all gonna be external That's fine, that's good These are moderate profile plus right? These are SRM SRM perfect good. Okay, so you take that out squirt it all good We're doing great actually what time is your flight Smart no, you're so smart Hey Paul, I need your help you need a Deaver get a Deaver Get it you get it deep. Okay here we go Okay, you hold that one you hold that no, I got this I get this I get this you just hold that one Okay, ready, hey you ready Yeah You're good, you're good you're good just squeeze it in Boom Now how fantastic is that? It's so amazing. It's the best ever. Okay, so your hands are clean Actually, it looks pretty perfect right here. You just need to release a little bit with your finger right there Can I see these let's just make sure I'm good and See how small that hole was that we used it was beautiful Okay, I am Hold this right here, Bobby You don't don't you rock the ship No problem, buddy, okay triples Okay, can you hold this for me? Can you hold this for me? Yeah, okay. Hold that I need some wash Okay, perfect Okay, so these are both the same size, right Okay, let's see how big this one is Let's have some triples Beautiful, okay. Hold on you take this one. Okay good Sweet Awesome Well, all I can tell you is if you can come up with a better system than this it's worth a Nobel Prize because that is Unbelievable. Look at it Okay. So now we're gonna close. I want a little bit more triple antibiotics And we're gonna just gonna close look at the size of these holes guys. I Mean, can I have can I have something to measure this? The tissues are a little bit elastic, of course but but seriously For maybe maybe four centimeters and they stretch to five and we got those in beautifully, okay, let's have to a monocle So if you look Right now I'm still Right there a little bit tight, but it's gonna be perfect. Once we close This side I still think I'm a little tight right there. I'm gonna open mine a little bit You can start closing yours Bell Meaning meaning my my my release of the pectorals major muscle has not been complete enough Paula please hold this for me And I can see it can we can we can we look at with the camera So if you look If you look right here You See my implant You see the implant and you see the pectorals major muscle right there Can we see that? Can we see the implant and see the pe- and the peck? Okay, good. Paul, hold that right there. And, um, ribbon. Okay, and bovie. Suction. Okay, now when we look, do you see the difference? Look at the difference. It's fixed, right? Okay, I'm good. Two on monocle, please. Um, can I have a regular forcep? So, some people might call this Texas or California-style mastopexy because we're using a huge implant. I didn't choose the implant, honestly, I didn't. And you know, I think Rhode Island tends to be sometimes a larger choice state, but we just did a case and she chose a very diminutive implant. So it takes all comers. All I can say is, if you are looking for an optimization procedure, clearly a larger implant within reason helps. Can you do me a favor and close that? Oh yeah, with a 2-0 or a 3-0? 2-0. Because the only thing we're going to be taking out after that is skin, right? I made the point to Bella early on that the tendency sometimes might be to make a big long incision when you're contemplating a circumvertical mastopexy and just going ahead making your full lollipop and all the way down. But that would have ruined, in this case, a situation where you're only going to need a small scar. The rest of this is all beautiful, healthy tissue which is recruited from the abdomen. Okay, everyone's ready? Yeah. All right. We're going to put another one. Let's just do that and let's just do our circle vertical. Okay. Single hook. Now, there are multiple varieties of tailored tacks that have been promulgated over the years. Did you put one in there? No, no, because that's going to be closed with staples. So here, we want to start above the current nipple areolar complex. No, give that to her. Give that to her. I'll take another regular forcep. Regular forcep. I have one. I need one more. Thank you. OK, good. So just pre-cock. Now, you remember what I had marked before. So I'm getting close to those ones that I had marked before. And I knew that it was going to end at some point. So pretty close, right? When we're finally done here, those marks, they're in the ballpark always. OK, good. So let's do yours. And when you use a bigger implant, obviously they don't need to be as aggressive, which is the case here. Okay, good. Alright, now... Marking pen... Okay, let's have, um... We want to try to get rid of all the older reel. That's one of the precepts of doing a good mastopexy. You can't always do it, but you have to try. So, that's why we're doing this. Alright, now... Lastly... This is one of those cases where... Stapler... She has not had... As much... As much of a cone creation... Simply because of the shape of her breasts. They weren't as long as some breasts are. But, when you're recreating the cone, the vertex is always right here in the center, near the nipple or reel complex. So, what I like to do here is to add something that takes up the slack of the extra skin here. So, what we do is we put in a purse string suture. Okay... Mine doesn't need it as much as Bella's, so my circle will be smaller. Okay, single. I'll take a two-oh. That's good to forcep. And then, when we tie it, tying it is... First of all, can you see from the top here? We still have a vestige of the older reel here. So, it's going to help us to get rid of some of that. That's another of the benefits. But, it's going to help us to control that central projection. If you like Hershey's Kisses types of central breast mounds, then you just don't tie this as tight. It's especially useful in breast reconstruction, where you have to sometimes markedly change the symmetry. That's a little tight. Let's get a little bit less than that. Okay, let's see. I like it. Perfect. So, clearly, you have your nipple-areola complex underneath. Be kind to it. You don't want to strangulate it. Always be aware of it. What could happen is you could tie this really tightly and then go down and do an abdominoplasty and leave this strangulated for a few hours and come back to something that was not so healthy. So, be careful. Always be cognizant of blood supply. I'm sorry. Alright, could we please sit her up now? Thank you, buddy. So, the thing that is not done enough in breast surgery is sitting the patient up. Perfect. That's good. Okay. Now, the first thing to notice is we've got a shoulder discrepancy here. And that throws the whole cant of the body off. So, we've got to raise the shoulders so that they're the same height. Can we walk now, please? You don't want to create visual obstacles. So, you could get an optical illusion just by having a drape that goes in the wrong direction. So, you want to make sure that those are relatively straight and not throwing your eye off. Wash. Peroxide. Now, these are some big breasts. There's no question about it. And as a result, big breasts require more prophylaxis. You have to emphasize to the patient that you cannot be sleeping directly on these breasts or they are going to deform quickly. And you want to wear a bra 24-7. I have all of my patients wear a very good supportive racer back bra that gives them support like this and holds them in that position while they're at rest. Okay. This shoulder is still down. Okay. Can you just get that head straight for me? Thank you, buddy. Okay. It's still lower. Yeah. I was wondering... I'm going to just try it. Okay, ready? It's not too... It's still like a half an inch lower. Can you get it any higher? I don't want it to disconnect. Oh, good. Okay. And head straight? Okay, good. All right. Stapler. So we're going to get the lower pull. Perfect. Isn't that funny? Okay, good. All right. Let's have cookie cutters. I'm going to... What I'm going to do now is I'm just going to... I'm going to insert the nipple areola complex into this and close it so it doesn't distract us. Okay. All right, Bella, help me out now. How's the shape? How's the shape? Okay, can we mark the nipples the way they are? Okay, let's go with a 34. Yes, I will do yours first. Can I mark it right where it is? Yeah. Can I ask you... I want to ask you to go back behind the camera and get right in the middle. So this is what we do on everybody. We need a team because... It might be more lateral, just like a millimeter or two. Okay. Can I have an alcohol swab, please? If you have more than one eye, you will pick up more discrepancies. I think three is generally... Three people with good eyes, you're never going to get too far off the mark. Okay. Okay. I like that. You like that? Can I match that now? Yeah. So... I'd rather have it a little tiny bit lower than higher. Yeah. I think if... Well, then, another one can go lower, too. It can? Okay, so let me go a little bit lower with this one. Just tell me about if this is okay. Beata? No, it's... Yeah, so if I bring this one down... If I bring this one down... Okay. Hang with me. Okay, I got it. It's good. Okay, how is it now? I like that one better than... Okay, so am I lowering this? Just a tiny, tiny bit. Okay, good. Alcohol, please. Can I also have a stapler? You still like it? I like that. Good. Okay, good. Beata, help me. I need another stapler. Okay, so help me here. Good, so I can go down. Is it medial and lateral? Okay, so I want to come a little tiny bit more medial and down. All right, so let me take a look. Excuse me, please. I'll get by it. Good. Yeah, I think the right one is too medial. Yeah, I agree. Okay, and we need to liposuction a little bit on the side. It's kind of wide. Okay, I need a right glove also, please. Right glove. Okay. Not your fault, Jeff. Okay. Alcohol. Can you go back there and make sure this gets done right? So, just look. I want to lipo this. See how that's going to help? See how this is going to help by taking away some of this bulk? Don't you think? Yes. Yes, okay. Right, okay. So I'm going to go more laterally. Well, with your hand there, you're pulling it down slightly. Okay. Okay, Jeff, let me squeeze by, please, buddy. Okay. It's not off by much. Okay. Slightly up. Equal up the other one. But is that shoulder still kind of good? Okay, I am, I actually am happy with it. Okay, we can go back. Let me sneak by you, buddy. Okay. Okay. Let's do two masks. Siri, a big scissor. Okay. Eleven blade. Okay. One more. Oh! This is awesome! Mm-hmm. So why am I doing this if I'm not going to do fat grafting? Why would I be doing this? No, I'm going to do a little bit of fat grafting. A little bit, not a lot, don't worry. Yeah, that's good right there. Otherwise, I mean, I think we're good, don't you? Okay, let's do a little bit right under here, too. Because we're going to... Yeah, exactly. Because you see, once we do that, we'd like to get more of a fold right there. So the next thing is, Paula, we'll use a 10 blade, and we're going to do a little... Oh, here, too? Yeah, right there, on both of those chub areas. They tend to... The blood supply over the rib cage right there is pretty good, interestingly. Okay, good. All set, you can take that. All right. Here's the next step. The cardinal steps for this is... For this area right here, is... To make... A suture that is not going to deform once you release the cone that you've created. So look what we're doing here. We're making a little box cut. And Belle's going to put this together with a 3-0 monocryl. And that's a key suture. It just holds everything in position while you do the rest. So I've cut away the right angles. I've got two corners here to put together. Not this. This is going to be a discard. But see what she's got right here? This and this. Put that together. Boom. And I do the same thing. I promise you, if you do this, this will change your results dramatically. If you adhere to these principles. So see right here? I've made my cut. I'm pulling across the midline. And then I'm making a cut right in the midline. So it's a circumvertical, right? I want that to be right in the middle. And I discard that chunk. Same thing on the other side. Look. Pull right to the middle. Cut overlapping that so it's absolutely symmetrical. And then you put the two corners together. Thank you. Now she's going to take out just all these sutures here and staples. Z, do we want to re-mark this blue? Yes, yes, yes, yes. As soon as we get all that stuff out, we'll do that. Okay, here we go. Cut on the knot. Beautiful. Okay, so you see what she's got? It's really pretty close to a perfect circle. There are going to be times when you may have more nipple areola complex pigment than you want left. And so you have to adjust it. If you look right here, believe it or not, we still have some left right here in the midline. Now she's got a pretty faint areola. I don't think it's going to be a real problem for her. What I do in those circumstances is bleach them. I use trichloroacetic acid, and I use that at one-month intervals for about three times, and that will lighten it so that it will go away. But now see how perfect this is? She's made it perfect. She's going to cut a perfect circle. I'm going to help her. You go on your side. One thing I've found when I'm operating with anybody, including residents, it is helpful to be able to do things together. I made her circle a little tiny bit wider on this side because I felt it needed it. Bovee. And then we always use Gore-Tex sutures. Someday there will be something better than Gore-Tex. And it might be there, and I don't know about it. But it's actually very malleable. It's well tolerated. The problem is it gets infected because it's a braided suture, and it harbors specialty staff very well. So once it gets infected, you can't sterilize it. You have to take it out. But what you can do is leave it in long enough and just treat the patient. They can stay subclinical for several months until you've developed enough scar tissue, and then it forms a dam around it, which is a little bit more impervious to dilatation. All right, I'm going to mark this. Could I have a marker? And then Bella can help me. So think about what we're doing right here. It's just trying to make it as perfect as it can be. Ten blade to her. Okay. If you have two good surgeons working together, it's a symphony. It makes your life so happy. It doesn't always happen. So you see what we're doing. We again have to be cognizant that Mr. Nipple is underneath there, right? Mr. Nipple areola or Mrs. is still under there, and we have to be very cautious of it. So look, make sure you see it and get rid of any attaching tissues and don't hurt it. Okay, good. Beautiful. Okay, so can you see? I mean, I'll be honest with you. John and Jeff came here. We didn't know that we were going to be able to do this case. And I think they brought their lucky charms with them because we got a great symmetrical case. When you get a symmetrical case, it makes it so much easier, right? Look at the difference. Now, look it for both of us. Look at our circles. They're mirror images almost, right? Okay, Gore-Tex. As I said, harbors bacteria. Keep it from getting contaminated right from the get-go. Deep suture is better than superficial because this thing gets easily contaminated by surface bacteria if it's really close to the superficial dermis. So put in the deep dermis. What? The scissors? Oh. I have something that I call a spar suture that my residents have been trying to write up for 10 years now. It's been presented nationally. It's one of the best things ever. And all it is is one of these done to balance out irregular areola. So you can do the same thing and balance out one side without cutting the nipple. So all you do is make little tiny perforations. Here's your needle. Can I please have a smooth needle driver? And I have at least one gynecomastia patient. And we did this to him. It was an absolute home run. So he had big areola. Now he's got normal-sized male areola. And it's been, like, five years. And just with sutures. Okay, so this is one of the problems with the fragility of Gore-Tex. We use 3-0 because it seems to be the best. Can we have the 34 cookie cutter? So we originally cut these at 38. We're tying down to 34. What I like to do here is to do – sorry, my hand is still a little bit weak from an injury – is to get this tied down to a 34. You want to eliminate all the tension on your closure. So if you look at this now, it's probably a 36 in diameter because I'm not getting it absolutely all the way in. But that takes two millimeters of tension off of the areola. And that's going to be enough. Awesome, thank you very much. You're all set, Paul. I will need a left glove. Uh-huh. Cut, please. And leave a little tail. Shorter, shorter. Shorter, shorter, shorter, shorter. Good. Even shorter than that. Want that off? Yeah. So if you leave these too long, they will definitely spit. And may I have the other left glove? Thank you. Buddy, can you just pull that off and throw it right in there for me? It's not contaminated. Just throw it right in there. Thank you. Thank you. 34. Yeah, let me help you. Okay. No, it's a 30. Can I have a needle driver? Okay, now hold that. That's it. Just stop right there. Good. Okay, good. And don't over tighten. That's good enough. Perfect, beautiful. One more. Awesome. Okay, so you can see what we've got there. We're going to go now with north, south, east, west meridians. The rest of it is pretty slam dunk. We don't have to do anything to the inframammary folds per se. It's just as ideal as it can get. Okay, let's have two 50 nylons, please. Here's a nice forcep for you. Thank you. And we are officially smoking. Smoking? Yeah, we're smoking. In time? Yeah. Maybe another hour. No, less, half hour at the most. Maybe 15 minutes if we're... No. No. Well, I'm an impaired physician right now, but I'll try to get there. That implies something different for your profession than mine. So once again, I can't emphasize enough avoiding twisting. So you see, we'll put these exactly where they want to sit. So if they're just a little bit off of the true meridians of north, south, east, and west, so what? Just get the axis so that it is not twisted on its pedicle. Cut, please. For the record, I have tried 3-0 running quill, and it hasn't been bad. And it really speeds things up. But you saw how irregular these looked a few minutes ago, right? Look how they're shaping up now. 5-0 monocryl, please. That's 6-0 nylon. 5-0 monocryl, please. Two of those. Purple if you've got it. Yeah, but that's not. That's nylon. That's OK. We'll use it for the nipple. I'll get the 5-0 monocryl also, please. Cut. Thanks for watching! Can I take, uh, six hours? Beep. Beep. Beep. Beep. Thank you for watching! Dry? Dry, yeah, I got it, thanks, awesome, thank you. I don't think so. No, no, it's like liposculpture and liposuction. I mean, it's like, you know, there's semantics. I mean, some people want to add some braggadocio to their. Exactly, it's a euphemism. Okay, I will take, Mark, no I'm good, knife. And a bovie. And a bovie. To a monocle. To a monocle. Alright. Alright. Needle down. You're just right in the middle. Alright. Snap, please. Guard that, please. Alright. Isn't it funny how, when you lie her down, how short this looks? Yeah. It's crazy. Still can't even figure that out. Okay, marking pen. So I try to not go a little bit as wide as the marks. Okay. Here's yours. Can I have a ten? Okay. Because this is like crazy good skin. This is like, you don't get any better fricking chances than this. You know, seriously. Cool. Two more to go. Can I have a knife, please? Or a sharp scissor? Something like that? Okay. You bastard. Oh, there we go. Good. Got it. Mm-hmm. Can I get a monocle also, please? Okay. See, I still got a tiny bit of lipo to do. Is that going to be like a, should I do it now? Yeah. Why don't we do it now? Okay. Cut. Here, lipo. Okay, who's going to collect it? You're going to collect it in the... Good. Oh, that's so small. Come on. Do you have anything? Give it to me. Give it to me if you don't have anything else. Uh, excuse me? Okay. Is it coming? Oh, yeah. Here it comes. Sorry, Val. Go ahead, get a bite in there. Oh, you can go. No, get a good bite. Get a good bite. And then while you're trying, I'll do it. These are going to be USDA grade one. Why am I doing this? Okay, so this, this is right here. This is the area that will make any abdomen look better. By sucking out this median trough right here, it gives you fake abs. So, and it lasts for a lifetime. So on all of my reconstructions, on all my abdominoplasties, I tried to do it on that woman today, but she was too thin. So watch this. Watch the difference when I'm done with this. You can see how it's just starting to collapse right there. And once it does, it looks beautiful. And it looks beautiful when you're standing sideways. Because it just, it's a focal point of the abdomen. It's an Adonis kind of thing. Or Minerva, or, who's Adonis? Aphrodite, Aphrodite. Wow. It's how Bella likes to look in the summer. And Beata. And Paula. And Heather. Every woman wants to look like this. Get that, get that nice curve here. So I think you can see it already happening there. How much have we got? Not much either. I don't know why. I'm going to get... Okay, so I'm going to come up here and get a little bit of this chub right here. So the price to pay is zero in this area for the average person. Because this is what everybody has a little bit. They could spare right there. Now here, you could see it when we were before. She just had a wider area right here at the base of this breast. So I want to get that. Okay. I'm giving you a hard time, I know, sweetie. I'm sorry. Okay. Alright, how are we doing? Cast some triples? Bella, just do a little bit right here for your record book. Okay. See right here you need a little bit more. I'll take a 3L. Forcep. Okay. Yeah, it's really easy. Down low? No, no, just try to get as much... There's a little bit left of yours, a little bit left here of mine. Mm-hmm. 10 minutes, 10 minutes and we'll be done. Unless you can come up with something else. Oh, this isn't on. Here it is. Do we have 509 allowance? Yes we do. Okay. Caught. Okay, let's see. How much have we got? We got enough, we got enough. Looks great. Just get, see right here? Yeah. See if you can get a little bit of that. You know what? Maybe you can come from here. Yes, you can get that. We'll take a 509. Mm-hmm. Sharp scissor. So right here I still have a little remnant areola. And I can afford to take it, so I'm taking it. That's good. Good, thank you. Mm-hmm. Okay, we're ready. Process please. Should I get a finer needle driver please? Peace. Can you sit her up? So what I'm going to do, John has put a roll here, because you see, it's actually pretty deep and we just maintain it there while it sets in place and it will be deeper than it looks right now. Okay, where am I going to put this now? Right there, right? What do you think? A little bit right there? Come on. Right here? Right here. Oh, Jesus. How much do I have? You have... That looks good. Okay, let's see. Any recommendations, boys? Can I have a wash? Please, peroxide. A wash of peroxide, please. First of all, do they look okay? I think right there. Right there? Okay. Here. Oh. Oh. I already did left, right, and she's doing left, so that'll be 10 each so far. But she's slower than shit, so I don't know how long it's gonna take her. Oh, she's good. She's good. How was it? That's a man cough right there. That sounds like somebody that... Sounds like something that Jeff would do in the morning. Oh. Okay, 20 and 10. So far. I'm gonna put some more on Bella's side. Oh. Okay, that was on her, so it's 20 and 20. I don't know. I think they look pretty damn good, don't they? Yeah. Yeah, I think we're just gonna stop. You can go down. Go down. 20 and 20. Oh, that is a nasty sound. That sounds like... That sounds like... Like... Okay, peroxide, let's wash it up really good, put the dressings on so we can get some final pictures. Do you like it better with drapes on or off? Drapes on or off? Actually they're pretty clean, the drapes are pretty clean. Okay, final pictures? Should we sit her up? a little bit a little bit higher Steve perfect good oh sorry sorry sorry yes thank you Gorgeous. Beautiful. Okay, so now we're going to tape. Tape, tape. Because the tape is important. Mask us all. So, tape to shape, scissors, yes, dressing pearls, these are very important because they work for weeks and you've got to be aware of them, so like this one right here, I have a suture that's a deep suture in here and you can see how it's pulling down a little bit on my closure at the top right here, so anchor this and pull up, done, fixed, okay, that's what you've got to do, if you do this you can reshape anything because it's, what's the word for plastic, plasticos, it means to take form or to shape, well that's what we can do by molding and when we don't mold enough, you know, Gary Rogers and the guys that do cranial molding, they finally paid attention that sleeping on your skull is what deforms heads, well that's what deforms breasts, it's Newton's second law, force equals mass times acceleration, people are lying on these things all day long, they're wearing the worst kinds of clothes, sometimes they wear bras that just flatten and smoosh them, it's the wrong thing, you need to be able to shape the breasts, I swear I've been preaching it for 25 years and it's, I think it's going to take hold now, okay, Stevie, we can go back now, let's have our, we need some midline ones now and then I need some metapor, so the metapor is really important because metapor or methix or hypofix, any of those very hypoallergenic types of, yeah, let's put, can we put one strip on the center first, oh not, yeah, not too, yeah, oh before, before we do that, can I have a big, a big teggy, so this is going to go here, another molding principle, I need a big, big, big teggy, and a starry strip, could you put one right on there, oh yeah, that's what I was doing, Help me, help me sweetie. Here, grab this side. Push down, and that causes this to indent, and it's a positive indent. We want it. Okay, where's my, this is, this is what makes all the difference in the world for, for calcium treatment patients that don't pay attention to you. This, this will actually prevent bad scarring, because if you put it across the wound and negate the forces, for, unfortunately, the closer you get to the center on this, it really is crappy and stuck together, but it's great tape. So, we want to tape across the wound. See what, I'm taping across it, I'm also slowing down the inflammatory phase of healing, because all the inflammatory products have a hard time getting into the wound and pooling, because we've compressed it. And lastly, the nipple areolar complex, if we protect it, then we take all the tension off of the closure. And you don't need a bra. So, you know, they showed that wearing a bra increases your capsule contracture rate by 2% if you wear it in the first two weeks. That's the meta-analysis, that's what it shows. So, I don't do it. And why is that? I, I don't know. I think it may be because it probably can pool fluids more easily, but this works like a bra. Does it what? Is this a typical? I use that on everybody, 100%. No, I know you do. Oh. It is a typical. No, no. It's not. It is with, it is with my residents. Yes. Yes. Okay, that's, that's good. Oh, and in one piece and we're good. Okay, perfect. Thank you guys. It was awesome. So, we finished our tablet today and all I can tell you is I was ecstatic with how everything went. This was a patient who is extremely thin, probably has about, at the most, a centimeter of fat behind her abdominal skin flap. We did our very best to leave a little bit of fat on the fascia afterwards to try and decrease the chance of seroma formation. I think her implants were, by and large, a nice choice for her and I think she's going to be very happy with those. You're going to see a difference with this technique over virtually every other abdominoplasty technique because we close the old umbilical site as a little straight line in the lower abdomen rather than create a big, high, horizontal scar that is unsightly and can't be hidden in any beach wear. So, that's the big difference. It went exceedingly well. I will show you the post-ops and you'll have a good idea about just how nicely this can turn out. And I encourage you to look at the article, which has actually been published in the book on body contouring by Peter Rubin et al. But it will be published, presumably in the next six months, in the White Journal. Thank you. www.ottobock.com

Dr. Rick Zenowitz

plastic surgeon

Brown University

transabdominal breast augmentation

TABA

breast implants

capsule contracture

surgical technique

mastopexy

nipple-areolar complex

no-touch technique

neuroblocks

Keller funnel

aesthetic outcomes

post-operative care