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| Dr. Joel Aronowitz |
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 in 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 I hope you enjoy watching the technical side of the surgery and meeting this wonderful woman who is very kind to share her story with us. So here we go. Elevating the flap and separating the breast tissue below down here from the skin flap up here. So here's the little jelly bean-like lymph node, and you can see 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 would 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 mastopexy or 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 undersurface to have a good margin. And I want to show you here a couple of things. One is we've injected dye 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, 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, 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 blood supply reliably to the nipple areola complex. So I hope that makes the operation a little more understandable, and we are going to carry on.
Alrighty, 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, I mean, if you could, yeah. So here's 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 breast, which we're just about to take off. And then below is the pectoralis muscle here. So now we have the nipple areola complex carried on its own pedicle from the 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, and we'll show you how this, we put this breast back together again.
Long stitch, lateral, double stitch nipple. And then you can take a photo if you don't mind.
So you can't see it, but there, the tumor is palpable right here in a couple of other areas, and right now we're marking the specimen. This was adjacent to the pectoralis major muscle. Oh, this is below. And this was the skin. Okay, but that's still a very nice, very nice. I'm just going to put the nipples in this area, but there really is no nipple.
I think it's, it should be right there. 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. The specimen, you can see a little of the dye is left over here. We've marked the specimen at 12 o'clock 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 there's 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. You can be felt. You can't really, can't really see it, but you 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 our, hopefully all 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 the patient is a good candidate for.
Alright, 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 breast 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 mastopexy 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 removed. And it's taking up that space. Now we've 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 stalk, 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. And so 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 a little protector 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 shots in surgery, and how that's done, and put in an implant, and then eventually, we'll replace that with your own fat—your back grafting—and give it an implant altogether.
So what do you have to say to women who have breast cancer, and what advice would you give them?
I think too deeply to come up with something in two seconds. Do your research. I know, do your research. Do your research, and be an advocate for your own health. You know, you could be in control of your own destiny, and you have choices. You have the right to direct your own medical care, and don't be bullied into some decision. Take your time with this, and make a 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 with 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 mastopexy 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 develop breast cancer or a suspicious mass in the breast, you won't be afraid that it is necessarily disfiguring, or that you can be treated and have a very natural, beautiful appearance, without an effective treatment of this terrible disease. And then, meanwhile, I'll try to get my hair under control. More later from Aronowitzland." - Dr. Joel Aronowitz
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