This patient is a young women, under thirty years of age who’s had one pregnancy, but that one pregnancy, because she breast fed, left her with an enormous excess of skin for the volume of her breast. When you look at a breast that you believe to look its best. We know the distance from the sternal notch, which is where the collar bones join in the middle of the body to the nipple, somewhere between twenty to twenty-two – no more than twenty-three centimeters. Her distance from her sternal notch to her nipple was well over thirty centimeters, I think it was thirty-three or thirty-four centimeters. So we moved her nipple twelve centimeters or so from where it was, to where it will be. Prior to surgery we’ve seen the patient at least twice, oftentimes more. We reviewed risks and benefits and all the potential complications, and gone through a very extensive educational process for the patient, regarding her particular specific procedure.

“Knock-knock.”

“Come in.”

“May we come in?”

“Yea.”

On the day of surgery we see her in the preoperative holding area, where any last minute questions are addressed, and I usually have the patient stand up with the nurse in attendance, and I go through the markings and exact measurements and drawings that need to be done, in order to guide us during the operative procedure. Once I make those measurements, draw the mid-line, find the midclavicular line, drop the breast meridian, measure where the new nipple’s going to be – and this is an interesting process to determine where will the new nipple be. The mid-humerus, the mid-upper arm, can correlate to where the new nipple areolar position should be – that’s one method. But their shoulder’s back, feet together, head… lift their arms straight up to the sky, straight up to the ceiling, and that gives us an indication, compared to where the nipple position was, with the arms at their sides, to where it’s going to be. Then I estimate where those two positions are, and then measure it with are previously mentioned, and it almost always comes out to be exactly where it’s supposed to be.

Then what I do, at this point, is inject the area with local anesthesia that’s long-lasting, in conjunction with a vasoconstricting agent, this gives us an opportunity to then have a patient free of pain upon awakening, and also give us a minimal bleeding during surgery. I usually interact with the woman preoperatively to determine how large areola, which is the brown skin around the nipple, she would like to have.

“We’re using’a fifty millimeter diameter.”

So we have a variety of areolar templates that we use to give us a perfect circular areolar dimension and incision sight, and what I like to do is make a circumareolar incision to basically embed, engrave that sight. Now it’s done. We made a commitment at that point, that’s our new areolar size. Once the circular areolar incision is made, then I follow the template and I mark that distance of where that new triangulation point will be, and once we make the incisions for the right and left medial lateral limbs, and then carry the incision along the inframammary sight, we are now committed to the new breast shape. At this point it doesn’t look like much, but once we proceed the skin excision, and then we can bring those three points together. There’s the medial and lateral junction of the upper and lower limbs of the incision sight which then will be joined the midline meridian and the bottom of the breast and the inframammary crease, that will then give us the new shape. Once the extra skin has been removed, and we’ve done the triangulation stich, we’ve brought the medial limb to the lateral limb, and joined it to the inframammary crease, that gives us the new shape. Now are job is to close these incisions. We have the bottom lateral portion of the T, we have the bottom medial portion of the T – we close that. Then the vertical component. Then the last thing is to exteriorize the nipple areolar complex – that’s the next-to-last step. So if there’s any need for a final adjustment, this is our last chance to adjust the final position of the nipple areolar complex as it appears on the new breast mound. Putting sutures through the skin surface can potentially leave suture marks. What we do is use deep sutures to take the, remove the tension from the final skin closure, those are all absorbable sutures. Once that’s done, then we augment that closure and further remove tension on the incision with steri strips – most all plastic surgeons use steri strips. The goal of all surgical wound closures is to optimize the body’s own mechanism to heal it closed.

After surgery it’s very important to follow all of our post-surgical instructions. One of them is to get a good rest. We want you to stay in bed and minimize your activity so as not to strain wound healing process in place for your normal body, for your body. The normal wound healing functions of your body can be enhanced by you, as the patient, reducing the stress that you place on them by following your post-surgical orders. Take your pain medications only as needed, take your antibiotics, get good rest, eat normally, make sure all your bodily functions are working properly, and most of all be very aware of the fact that you have had surgery and embrace that, and not reject that, and not think that – not be in denial over the fact that you’ve had an operative procedure.

Postoperatively what I see for her is a commitment to living longer, her quality of life, I’m sure will improve because she will glean a newer renewed outlook on her anatomy, and it’s amazing what improved appearance does to people’s behavior and their feelings about themselves. So we know factually that patients who feel better about how they look, feel better about themselves in general.

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