We're now here in the operating room, and we've prepared for now our spare mammoplasty. A couple preliminaries that we always try to address are the preparation of the patient. So the arms have been wrapped with towels and then acrylics roll and placed at slightly less than 90 degrees out from the side so that we can sit the patient up during surgery and assess the results of our operation, make any manipulations that we might need to make. And as well, we've prepped the patient so that the tops of the shoulders can be seen, and this will allow us to make certain that the shoulder level is anatomic for her. In other words, it's at its normal posture when she stands, and we can determine that when we look at the photo that we have on our screen. And so with that in mind then, we're now going to prepare for making our incisions, and we use a diluted solution of local with epinephrine at this point so that when the areas are deeply epithelialized, we won't be dealing with a lot of troublesome bleeding from the deeply epithelialized surfaces. This just makes the operation cleaner and a little bit easier to concentrate on the aesthetic aspect of it, in other words, the shaping of the breast without a lot of dermal bleeding clouding your vision, so to speak. So as we apply our local here, one of the visualizations that we're making as we apply this is that we'd like to put the local in where the skin's going to be deeply epithelialized, and basically we determine that from our marks. So we're going to be making a periureal incision here, and this is the skin that will be deeply epithelialized. And you'll see as we get going here where the strategy is going to be to make a small dermal shelf around the periphery of our periureal pattern, and that's ultimately where our purse string stitch is going to be applied. And today we'll be using a technique called the interlocking Teflon suture, or the interlocking technique to control the dimensions and the shape of this opening. So we begin to prepare for that now even as we are putting in the local. Now after having dealt with the periureal defect, we know that the vertical extension is going to have a shape something like a canted tornado here along the inferior pole. This is where the tissue is going to be brought together. So to prepare for that deeply epithelialization, we'll also go ahead and inject along what is likely to be our line of deeply epithelialization on the inferior pole of the breast, and we'll determine the exact dimensions of this area later on once the breast has actually been reduced and we can see exactly the shape that we want to create. One of the other tenets here while we're just injecting this material, this local, is that we're going to want to make certain that the inframammary fold is not violated as we do our dissection. So the fold is here now and it will be here when the operation is done. By being able to rely on the position of that fold, it allows us to make decisions with regards to the shape of the breast with confidence knowing that we won't be dealing with one of the tenets of bottoming out, which is migration of breast parenchyma below that fold. By incising scarpus fascia along the fold, basically what you end up doing is cutting a zone of attachment for the breast. That's essentially what the inframammary fold represents, is a zone of attachment. It's passively formed as the breast develops, and by cutting that zone of attachment, you allow the parenchyma to drift inferiorly, even below the line of the incision, so that the inframammary fold that forms goes below the incision, stay in your standard WISE pattern inferior pedicle. So we desperately want to try to avoid that complication, and we can do that fairly easily just by the way that we manage the fold. And we'll do that most definitely today, and that eliminates one of the major complications and causes of patient dissatisfaction after breast reduction, which is bottoming out, and it really creates a very happy circumstance for us as far as providing consistent results. We've gone ahead and injected our tissues, and now we're ready to prepare for making our incisions. And one of the incisions that we'll want to make accurately is an incision around the areola. So, for instance, we would not want to make an incision on a flaccid areola, measuring it, say, at 40 millimeters, and then do the operation, because what'll happen is a purse-string stitch will pull on that very elastic areolar skin, and it could easily stretch to 50 millimeters. And the mistaken assumption would be that the purse-string stitch spread over time, and basically it spread because you didn't make the proper incision at the beginning of the case. So whenever we make incisions in the areola, we try to do it with the areola under maximal stretch. So go ahead and lift that right up. And by doing that, we put on a breast tourniquet. Okay, go ahead and reach around and grab that with the... And this is just a very easy way to go about doing this. And so now, we'll put a little dot right on the tip of the nipple. You can see that right there. And now we'll use this multidiameter nipple marker. And today, this is a fairly average breast reduction. We're gonna estimate about 500 grams or so off each side. We'll use a 40 millimeter areolar mark. So we'll position this right on the middle of the nipple, like that. And so there's our areolar incision. So we'll use a 40 millimeter areolar diameter today, and then we'll perform the rest of the procedure. Okay, now, once the areolar diameter is set, we'll go ahead and make our incisions. And then our outer periareolar incision. Inherent in the spheromammoplasty is an intraoperative placation of the inferior skin envelope, and this is perhaps the most difficult part of the operation to learn for novice surgeons, because it's something that not a lot of us have done very frequently. However, I will say this, if you become adept at managing that circumvertical pattern, you will truly become a powerful breast surgeon, because that circumvertical maneuver will be applicable to nearly every other aspect of your practice, ranging from mastopexy to augmentation mastopexy to revisional breast surgery to management of excessive skin envelopes and breast reconstruction. You will use that concept in nearly every circumstance, and becoming adept at that will certainly enhance results that you can obtain in your practice. As far as the areolar incision is concerned here, we'll get through the dermis here just a little bit more aggressively than the other incisions. It gives us just a little bit more room to close at the end.

spare mammoplasty

precise incision

local anesthesia

inframammary fold

circumvertical maneuvers