Now that we've debrided our pedicle away, I think there's a little extra tissue right here that we can remove just to sculpt the pedicle, but we definitely don't want to go so deep that we injure the septum, and we can't actually see the septum fairly well in this case. We'll be able to show that here in just a second, but I'm just going to debride a little bit more tissue off here. Now the internal breast septum is a key anatomic landmark in the breast. You can see it most commonly coming from above like this, but you can also see it coming from below in a vertical mammoplasty when this tissue here is cleaned out. You can see the same septum, and here it is right here. If I move this, if you zoom in on this, can you see this is the cephalic leaf of the septum, and as I move that back and forth, you can see the vascular network underneath, and this is a vascular network that comes up in the septum of the breast. As the breast develops, the upper layer of the breast, the upper soft tissue layer, and the lower soft tissue layer expand up like this, and there's a cleft that develops in between, and this is what the breast septum is, and you can see it very nicely right here. Another manifestation of it, as you can see, as I pull on the pedicle, you can see how this upper leaf is densely attached to the pectoralis major right there, like that, and there's actually a space right here that I can just bluntly put my finger in, and I've just kind of worked my finger under that septum coming all the way over here medially, and there is the breast septum right there. It's very important to leave that intact because it provides an additional blood supply to your nipple and areola via your inferior pedicle, which can provide a nice safety boat, lifeboat, to preserve the blood supply, so the breast septum is a key element in all inferior pedicle techniques. I'm just going to debride a little bit more tissue off this lateral pedicle out here. It seems just a little bit full yet. I'd really like to create a sculpted pedicle, if I can. So what I do at this point is I look at the pedicle, and I try to make certain that it's evenly dissected in all parameters, like so, and so now our pedicle will fit nicely into our periurelar defect. Now, one word about the inframammary fold. Because the breast septum is attached, this cannot migrate inferiorly. It's attached, a zone of attachment right there. As well, the inframammary fold has not been violated there. All of that remains attached, and laterally as well. Even though this has been cleaned out, the inframammary fold has not been violated. So that means that the inframammary fold position cannot change as a result of the surgical manipulations that we've performed. Now, we have cut the internal support structure of the breast, the Cooper's ligaments as it were, and so post-operatively this tissue can relax, and the skin can stretch a bit, but we won't lose the position of our fold. And that's a key element of this operation. So at this point, I think what we'll do is apply our vertical segment and show how the shaping of the breast occurs at this point. So after the breast is irrigated, we'll get in here and try to be certain that we've got absolute hemostasis. Hemostasis. So thin to start with, and then thicker. Thin to start with, and then thicker. Somewhat thinner out laterally, all the way down to our mark, and then the inframammary fold completely intact with our septum intact and good blood supply to the nipple and the areola. And so that's a very successful debridement and flap creation. Now in some patients, we would at this point undermine the upper flap and undermine the medial flap and suture those tissues up to try to create more upper pull fullness. This patient does not need that as a modification in her technique. So when we get ready to shape this, what we'll do is we'll be able to look at that even though we've made some incisions. So now to apply the vertical segment are a couple maneuvers that are helpful. By taking a clamp and putting it on the inferior pedicle and pulling upwards, what you end up creating are two small redundancies, laterally and medially, and this is where you want to engage the tissues to apply what we call the key staple. And that key staple sets the pattern. Once that key staple is in place, you can apply a hemostat to that deepothelialized edge like this. Okay, now let go. And by pulling upwards, you can almost see where the dog ear needs to come out. The dog ear is basically the unequal length incision along the vertical segment of the breast so that the lateral segment will be slightly longer than the medial segment. So as that's lifted up, you can see where that breast wants to fold in order to shape itself. Notice that it does not come straight down to the inframammary fold. It actually jays out just a little bit. And that's one of the key concepts of what we do as far as shaping the breast is concerned. Managing this vertical segment is a slightly different process than your classic vertical mammoplasty because the incision jays out along the breast like this. So as we pull that together, I'll just put a couple of orientation dots on here, and that'll give us a head start as to where to put our staples. And so now we'll basically tailor staple this breast together like so. And this is essentially an on-table sculpting of the breast shape. We tailor tack this tissue together along the inferior pole of the breast down to the inframammary pole until the shape of the breast is aesthetic. And this is one of the key maneuvers in all of breast surgery. The circumvertical pattern is one of the most powerful methods of management of the breast that there is. And becoming adept at performing this maneuver that we just did will go a long way towards increasing an individual surgeon's ability to shape the breast. So it actually looks pretty good right there at this point. I think that's going to be a nice gathering together of these redundant tissues. Now if we needed to, we could re-tighten this again over the top if we didn't do it aggressively enough. If it was too tight, we could certainly take a couple staples out and put them back in a little less vigorously. But overall, I think this is going to be a nice reshaping of that inferior pole. So now we'll tailor staple in our areola and we'll sit the patient up and see just exactly what we've been able to accomplish as far as creating an aesthetic breast shape by insetting this inferior pedicle into our periareolar defect. So like this. We've now placed the patient upright so that we can evaluate the shape of the breast and it appears to be a fairly reasonable reduction as far as the volume of the breast is concerned. Also, you can see how much the breast is lifted as compared to the opposite side. But it does appear that I could tighten this inferior pole just a bit more. And so this is done basically as a sculpting maneuver, gathering the tissues together and stapling them just a little bit more vigorously like this. And this is really one of the unique features of this operation is that there's a fair bit of on-table adjustment which is performed which will allow you to shape the breast to create the aesthetic results you're looking for. And a lot of that stems from the fact that the fold will not be violated. So with that in mind then I think we've been able to identify the vertical segment that needs to be dealt with to shape this breast. One point that we'll emphasize is right in this area here. We could probably clean that out just a little bit more vigorously to try to create a more circular fold right in that area. That should give us a very nice shape to that breast. As a result of our reduction. So overall I think we're in a pretty good position here to achieve a very nice result. So what we'll do now is layer down and mark our vertical segment. So now we're back flat and what we're going to do is identify the segment here that needs to be dealt with as far as taking out our vertical segment. So we just mark the edges of our placation and we'll put some orientation marks on that will help us put this breast back together once the staples are out. Like this. And so now as the staples come out this is sometimes useful to visualize how the breast comes apart and then goes back together. So there's our periureal defect. Now one point I'll make at this time is that notice that as a result of the pulling together of the vertical segment what at one point was a fairly impressive periureal diameter is now just a very manageable diameter hardly really any challenge at all. So the interlocking technique will very nicely control this inequity between the incision around the areola and the periureal incision. That's kind of a unique feature of the circumvertical pattern. And so now as these staples come out, you'll be able to see how the skin flaps fall away. And we'll see the shape of the vertical segment that needs to be dealt with. Okay, hold that right there. Okay, give me a scalpel and a marking pen. Thanks. Okay, go ahead and hold this right here. So now you can see that our inferior pedicle is right here. So this is where the blood supply is coming in to our nipple and areola. So we'll take that mark and we'll deepithelialize this portion right here. That means that our lateral mark is out here. And so this is the lateral portion of our pattern. And again, we just curve this right out along the fold, which is right there. We don't want to go down into here. We want to violate that space. And then our medial mark is here like this. And so now that identifies really the pattern that we're trying to deal with. So we'll make an initial mark incision like this, and then we'll just come right down our lateral portion. We'll make another little nick like this right at right angles to the perireolar pattern so that we can find it easily. And then we'll come down along our medial pattern. And then, like this.

breast reshaping

pedicle sculpting

inframammary fold

debridement

hemostasis