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| Dr. Joel Aronowitz |
Breast Cancer Surgery:
One and Done Nipple Sparing Mastectomy and Lift
Dr. Joel Aronowitz: Hi everyone, and welcome to another Aronowitzland video!
This is a
wonderful young woman who presented to me with breast cancer. She actually had
two breast cancers in her left breast and no breast cancer in the right breast.
She has a young family and she rejected the treatment that was recommended,
which was a traditional mastectomy and chemotherapy beforehand.
So you'll
watch the surgery, you'll see the surgery that she chose, which is a nipple
sparing mastectomy. This is an operation which all of the breast tissue is
removed in one step. In one operation, the skin, including the nipple and
areola are preserved. The volume of the breast is replaced with an implant. The
implant can then be removed later and replaced with fat, which is our plan for
Tiffany. And then the opposite breast, in her case, she decided to go ahead and
treat with just a lift in order to match the breast better. So hope you enjoy
watching the technical side of the surgery and meeting this wonderful woman
who's very kind to share her story with us. So here we go.
Dr. Joel Aronowitz: Elevating the flap and separating the breast tissue below down
here from the skin flap up here.
Doctor: Okay,
go.
Dr.
Joel Aronowitz: So here's
the little jelly bean like lymph node. And you can see that it has a bluish
cast to it. And that's because the dye that's been placed has found its way to
the lymph node. And we're taking that node as a sentinel node, which we'll
explain later. But basically, theoretically, the breast cancer which is up here
will drain to that lymph node and that will be the first place that the breast
cancer metastasizes to if it's going to. So that'll give us a good indication
of the prognosis and also the need for further treatment.
So here's
our breast. We've begun this operation the same way we would for a mastectomy
or a breast reduction. We've created a pedicle here, an inferior pedicle. We've
dissected the lateral flap. We've dissected a medial flap and we've dissected
it superiorly. The breast cancer in this patient is right here and it's
relatively close to the skin. So we're going to have to be close to the skin
from the under surface to have a good margin.
And I want
to show you here a couple of things. One is we've injected dye for the -- let's
see, for the sentinel node. And if you can get in here, Lena, you can see the
lymphatic channel with dye in it going up and down right here. If you zoom in a
little bit, you can probably see it well. And then we're dissecting between
this fatty tissue subcutaneously and this white tissue below. And in this area,
there's a very good demarcation between the breast tissue and the subcutaneous
fat. So we have skin, we have fat, and then we have breast tissue. And that
difference is not always very apparent in this case, in this particular area of
the breast, it is so I wanted to show that to you.
And
ultimately what we're going to do is remove this whole breast tissue. But we're
going to leave the skin envelope intact here so that we can refill the volume
of the breast with, in this case an implant and ultimately with her own fat. So
that's a nipple sparing mastectomy. Here's our nipple areola complex and
ultimately we're going to carry the blood supply to this nipple areola complex
on a very thin, narrow pedicle based on the perforating vessels. We have these
intercostal vessels between each rib and they give off little perforators like
the sprinkler system in your lawn. And we're going to try to capture at least
two or three of those so that those perforating vessels off of the intercostals
will be able to supply blood supply reliably to the nipple areola complex. So
hope that makes the operation a little more understandable. And we are going to
carry on.
All right,
so here we are and we can see the breast. And do you want to show us the flap?
It's been dissected. So we've separated here the breast tissue from the skin.
So the skin is being held up. And then so here is the pedicle supporting the nipple
areola complex. We're going to take off the skin below the nipple. Do you want
to show us how that's separate -- so that's separate and apart from the rest of
the breast, which we're just about to take off. And then below is the
pectoralis muscle here.
Now we have
the nipple areola complex carried on its own pedicle from inferior. We have the
breast tissue above and the breast cancer. Do you want to show us where the
breast cancer is so the viewers can't really tell that it is hard, but there's
a hard lump right there. Hard lump right there. That is, that's going to be the
cancer. And we'll show that to you when we remove it.
So stay
tuned and we'll show you how we put this breast back together again.
Doctor: Long
stitch, lateral, double stitch – [Crosstalk]
Dr. Joel Aronowitz: And then you can take a photo, if you don't mind. So you can't see
it. But the tumor is palpable right here in a couple of other areas. And right
now we're marking the specimen.
Doctor: This
was adjacent to the pectoralis major muscle.
Dr. Joel Aronowitz: Oh, so this is below.
Doctor: And
this was the skin. [Crosstalk]
Dr. Joel Aronowitz: But that's still a very nice, very nice dissection.
Doctor: I'm
just going to put the nipples kind of being but there really is no nipple in
there.
Dr. Joel Aronowitz: I think it should be right there.
Doctor: Correct.
It's the top of the only because you think anatomically they could figure it
out. But they'd like to be helped as much as they can.
Dr. Joel
Aronowitz: Breath specimen, you can see a
little of the dye is left over here. We've marked the specimen at 12:00 at
where the nipple was. So the nipple was overlying here and then below this is
where the breast was taken off. The chest wall and you can see there's a
natural nice plane taking off the chest wall. And the dissection of the breast
from the subcutaneous tissue more superficially is done very cleanly here.
And in the
case of this patient there was a very well demarcated plane, which there isn't
always. So this is the breast tissue. The breast cancer can be felt, you can't
really see it, but might be able to see this little bulge right here. And what
I'm holding is really pretty hard and there's another one over here.
So we'll
send this off to pathology and let them bisect the specimen and tell us that
hopefully all of our margins are clear and then they'll do chemical analysis to
tell us more about the nature of the cancer so that the oncologists know what
type of treatment patient is a good candidate for.
Right, so
now we have removed the breast tissue here's, the muscle, the pectoralis
muscle, the breast tissue from inside all the way around has been removed and
we just have the nipple and areola carried on a very thin stalk. So I'm going
to next take off the skin from this pedicle and then that pedicle is going to
get buried and the breasts will be closed with an upside down T or Y's pattern
like this. And the nipple will come out right here through its new location.
And this is going to be a very similar operation to a mastectomy or breast
reduction except that in those operations we're not taking out virtually all
the breast tissue.
Well, now we
have our drain in place. We have an implant. You can see the outline of the
implant here as I move it around. And if we look carefully up in here, you can
see the edge of the implant right here. So the implant is roughly the same size
as the breast tissue that we remove and it's taking up that space. Now we
brought the flaps together and we're going to bring right here where we have
this little extra tissue. We're going to make a circle here, take it out and
bring the nipple out just as you would a button. It's connected to that stock
so it has a blood supply and sometimes even a reasonably good nerve supply. So
that'll be our mastectomy and immediate reconstruction. And I'll show you what
the final result looks like here in a few minutes.
So now we're
all done. This is the breast with breast cancer we've removed the breast and
inside is the implant here you can see me pushing the implant a little bit.
Here's our incision where we took the sentinel node. Here's our drain tube
which drains into this little reservoir. And then on the opposite side we have
the same upside down T incision and that's to do the lift. And we can see that
the blood supply to the nipple has good brisk refill, pretty good on this side
as well. We're happy with the blood supply, we're happy with the volume. And
the pathology was all good, showing no additional cancer.
We'll wait
for the permanent section, but all breast cancer removed, as far as we can
tell. Reconstruction done, breast symmetrical, and that is a one and done
mastectomy and reconstruction. So here's where you had the sentinel node
removed and we put little protectors on the nipple. But you have your nipple areola
you have a scar that goes down and under like an upside down t on both sides.
So this
side, we just did a lift and we didn't replace the breast tissue. And here we
took out all the breast tissue and we'll show you some shots in surgery of how
that's done and put in an implant. And then eventually we'll replace that with
your own fat through fat grafting and get rid of the implant altogether. So
what do you have to say to women who have a breast cancer and what advice would
you give them?
Speaker: I
think too deeply to come up with something in 2 seconds. I know. Do your
research.
Dr. Joel Aronowitz: And be an advocate for your own health. You can be in control of
your own destiny.
Speaker: Absolutely.
You have choices.
Dr. Joel Aronowitz: You have choices and you have the right to direct your own medical
care. And don't be bullied as to some decision. Take your time with this and
make decision on your time with that.
Well, I hope
you enjoyed watching that video and meeting Tiffany. The lesson here is that
women should be empowered to choose the kind of treatment that's best for them.
They should be presented the choices for the problem, in this case, breast
cancer. What are the pros and cons of each approach and then allowed and
supported to choose the treatment that's best for their individual case, in
this case, a nipple sparing mastectomy to treat the two breast cancers.
She also had
a sentinel node, that is the lymph node removed from the opposite breast. In
her case, the pathology was all very good, the margins were all clear and the
sentinel node was negative. She also had a lift or a mastectomy on the opposite
side. And now at a later date, we will replace the implant probably with fat
grafting, which will be another video.
So I hope
you enjoyed this and learned a little something from it. And maybe if you or a
loved one develops a breast cancer or a suspicious mass in the breast, you
won't be afraid that it is necessarily disfiguring, but you can be treated and
have very natural, beautiful appearance without and an effective treatment of
this terrible disease. And then meanwhile, I'll try to get my hair under control.
More later from Aronowitzland.
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