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| Dr. Joel Aronowitz |
Dr. Joel Aronowitz: "Okay, this morning we're going to do a breast reduction. This is a very common operation in plastic surgery. There are as many breast reductions done as augmentations, which is hard to believe, but it's true. And a woman who has breasts that are excessively large suffers from some real problems in life. You want to tell us, Rita, some of the problems?"
Rita: "Yes, back pain, neck pain, lower back, inability to run, free."
Dr. Joel Aronowitz: "So the modern breast reduction operation that we, almost all plastic surgeons, do today is based on a publication by a surgeon in Houston named Wise, W-I-S-C, back in the 50s. And the components of that operation are basically to tailor the skin using a keyhole pattern, which I'm going to show you, and carrying the nipple on a pedicle so that it can be left attached to the breast but moved, much like you would move a button up and down on a blouse or a shirt and bring it through a different hole in the shirt. The same principle we use with the nipple, only the nipple has to remain attached. So first I'm going to mark some landmarks, so we'll make a little dot here at the sternal notch, and then I'm going to mark approximately where I think the nipple belongs, which is at the level of the fold, so I'm going to feel with my hand underneath your breast where the fold is roughly, so her inframammary fold is roughly right here. And you can't really tell, you can't feel in the video, but I can, how heavy these breasts are. The other thing I'm going to do at this stage is take a look at her chest, that the breasts are sitting on, to get an idea of the asymmetry, and then look at the breast, where does the breast begin exactly, where is the fold beginning, so that I have an idea of the asymmetry I'm dealing with, the size also, you can see there's a little difference in the size. So the next thing I'm going to mark then is going to be a line, thank you, a line that the nipple is going to fall along, so I'm just going to use this tape measure and drape it around her neck and across the nipple area, and then along this line is where the nipple is going to be lying, so they don't get too far, I don't want to make the nipple too far toward the sternum and I don't want to make it too far outside. So now, I know the nipple is going to be somewhere along here, probably around there, but I'm going to take a second measurement that's going to tell me that I'm in the ballpark here, so I've marked her 24 centimeters here from the sternal notch to my meridian line there, that's going to be about right there, so we'll check that again because I can stretch this out quite a bit one way or the other, I'm not careful. That breast is lower or my mark is lower?"
Rita: "No, no, I have another kind of mark, the actual breast."
Dr. Joel Aronowitz: "Okay, so now we've marked the location of the nipple here or the top of the areola, if I squeeze these breasts together, you can see I'm pretty symmetrical there, and that's a good hint that I'm in the ballpark because you can't go strictly by measurements because your shoulders are different, one side is a little different than the other, so we want to really, it's not that the markings are perfect, it's that they look perfect. Okay, so now I'm going to mark, I want to basically just get a feel for the final product here, if you will, so I want to leave you with a reasonable size breast. I'm going to check my measurements here. Okay, so we're going to go from the sternal notch down to the nipple or the top of the areola. One, two, three, four. Okay, and then we're going to drop our vertical limb of our keyhole, and your areola here is a little bit on the big side, we're going to try to get all of that out, but when there is a little bit of areola left on either side, then that will show up in the vertical scar as a little brownish area, and sometimes that's just unavoidable. Now this measurement is also important from the bottom of the areola, it's going to be in the neighborhood of five to six centimeters, and because it's a little stretched, I'm going to mark a little bit on the long side, so I have a little extra, and then again I can do my little trick here to compare. That marks my opposite limb. So there's the keyhole, and let's just explain this. So basically what we've done is we've created a pattern for our skin brassiere, so it's the bra made out of the skin, and we've found the new location for the nipple, which belongs up here, which is basically the nipple belongs at the level of where her fold is, and then once I know where the nipple belongs, then everything else comes from that. So this skin on either side, we'll call this flap A, and this flap B, and here's the nipple. These two points will come together, will come together, this will come together, and that will be my smaller, more improved breast, and then everything below all of this will be sent to pathology for the pathologist to write a report on, and you won't have to be troubled with it, and then the breasts you'll be left with will be smaller and perkier there. Same thing over here. And we need to reduce this side more, especially out here we've got that extra. So let's just check these measurements one more time, and then we'll get you to surgery. We're about to start the right breast, the larger breast. Here's where the nipple is going to come out. Here is going to be the vertical limb. I'm going to make the areola much smaller, and then I'm going to discard the rest of the breast tissue that's excessive. So first thing is to create a smaller areola, and I'm going to do that by using the little cookie cutter pattern and reduce the size of this areola to about 42 to 44 millimeters. And then I'm going to take just the top layers of the skin off, and you can see underneath the white layer underneath this layer. Jasmine, do you know what layer this is, the white layer?
Jasmine: “The dermis.”
Dr. Joel Aronowitz: “Jasmine, I'm so proud of you. Yes, that's the dermis. And what's the main protein of the dermis?
Jasmine: “Is it collagen?”
Dr. Joel Aronowitz: “It is collagen. It is collagen. And if you'd be kind enough to just put your hand flat here and hold a little tension like that, and let me give you a little hint about, you can see that white dermis that Jasmine identified correctly. So if you're going to answer, answer like you really know it, and because if you're going to be wrong, you're going to be wrong, and if you're wrong, you're going to be wrong all along, instead of that you were guessing, you know?
Jasmine: “Right.”
Dr. Joel Aronowitz: “No, right. Just keep slipping down there. Do you know why this is, this pigmented skin around the nipple is called the areola?”
Jasmine: “No, I don't.”
Dr. Joel Aronowitz: “This means colorful circle.”
Jasmine: “Oh.”
Dr. Joel Aronowitz: “And it's distinguished by the, from the other skin of the breast because there's, there are little glands in it that make it some little nopally appearing things under the skin that are oil creating glands called Montgomery glands, and some people have more of them than others. And then also by virtue of the layer of muscle that's in that, under, underneath that layer, hold like that please, just flat. Yeah, just give me a warning. De-epithelialized most of what we need to, and you can see how the, here's the nipple, it's going to be carried on this stock to place it up in its new location. So the next step is going to be to dissect our new, our medial here and our lateral pedicles. So let's make these incisions. This last bit of skin off. Thank you. It would be to dissect underneath here and the same on the lateral part in order to create a pedicle.
So we're going to go down to the chest wall here and then we're going to head straight up so that we can identify this. Thank you. Identify the plane between the breast and the muscle underneath. Jasmine, you're on a roll. What is the muscle that the superior part of the breast sits on? There's a big one, a small one, the major and the minor, so mostly the majors. See, and if the muscles have an origin and an insertion, the origin of the pectoralis major is going to be what? Where does it originate from? The muscle itself? Yeah. I'm not sure. Well, it's right here. You can see it. And it's, if you put your finger there, you'll feel where it's originating from. What is that?”
Jasmine: “Yeah, the rib. So it's coming from the media from a little bit on the sternum and the ribs.”
Dr. Joel Aronowitz: “So it's originating on a bone and it's going to insert by means of a tendon onto a bone. So it's got to originate on a bone always because it needs something solid. There is a muscle that originates on a tendon and ends on a tendon and that's one of the muscles that gives a spine motor control of the, of our fingers and it's called a lumbar muscle. Have you ever heard of that?”
Jasmine: “I don't know. Yeah, so that's a nice little pimp question.”
Dr. Joel Aronowitz: “For when you're in a position to quiz people, it should be sooner than you think and that's the lumbar muscle and they do this. And it doesn't originate on the bone? No, it begins on a tendon and ends on a tendon. So that's a great little quiz question because every other muscle has got to be. You can see it contracting when I cauterize one of the little bleeders there. So here are the fibers and that you can, the direction of the fibers will also help you identify muscles when you're in surgery or trying to identify what's what because you can see where it's coming from and where it's going to. All right, let's talk about breast tissue. Jasmine, can you name some of these different tissues within the breast? What is this white tissue?”
Jasmine: “Those are the ducts. This is a combination of ducts and glands and the fibrous network-”
Dr. Joel Aronowitz: “-that supports it. And when you feel a woman's breast and you feel hard, fibrous kind of tissue, that's what you're feeling. And then this tissue is what? That's the fat. That's the fat. And when you feel a woman's breast, especially a woman who hasn't had children and it's nice and soft and kind of squishy, that's the adipose tissue within the breast. And then here's, let's see, can you see this structure? Thank you. Going straight up like this, kind of bluish. What is that, Jasmine?”
Jasmine: “That's the vein.”
Dr. Joel Aronowitz: “That's a vein and it's coursing from down here on the muscle, the pectoralis muscle, up into the breast tissue and the nerve, the nerves going to the skin of the breast and the nipple of the breast are doing the same thing. So here we have a mixture of tissues that constitutes a breast. And the naughty one here, the one that causes us the most grief in life, is the ductal tissue. And why is that the tissue that's most problematic? That's where cancer cells can grow. That's where most breast cancers come from, the ducts. And the ducts all coalesce into about 12 to 15 little tubes or bigger ducts and they come out through the nipple here. And that's what delivers milk and other secretions to the nipple are those ducts. So that ductal structures are where most breast cancers come from. Okay, so let's take a look at what we have here. Here's our breast. I've taken the skin off in the lower part here inside the keyhole. I've carried the nipple areola here on a pedicle on a stalk coming up from below. And then I have a medial or inner pillar and a lateral or outer pillar. So now I'm going to the excess tissue here from the inside. I'm going to preserve the pedicle. I'm going to remove a lot of this excess tissue from the lateral breast here. And then we're going to move the nipple areola up to this new location that we've marked previously. Let's take a look at where we are at this point. So we're finished taking out most of the breast tissue and trimming the skin. And I've put some tailor tacking staples in so that I can make sure that my measurements are correct and that I've got everything in the ballpark. So here's the nipple in its new location. And here's my vertical limb. I've trimmed off the extra skin. I've taken out a lot of the excess breast tissue. And now it's going to be a matter of just tailoring this down to make it neater and a little bit perkier. And then I'm going to take out all these staples. I'm going to do that right now. And from this point, we can go inside again, wash everything out, make sure there's no to correct little asymmetries and inconsistencies. And then do the final closure. So now just to review, here's our nipple, pedicle coming from inferiorly to hold the blood supply to the nipple areola. So you can see that's free and then that allows me to move the nipple wherever I need to. And then here's my medial limb, medial flap, and here's my lateral flap. And I've left a little extra breast tissue here and I think we'll trim that because you may have noticed when I had that close, it was a little bulging out here "So I've got a little excess breast tissue, which is fine. It's always better to have a little extra at the end that I can trim rather than have not enough. So there's the breast with most of the dissection done, the excess breast tissue removed. And now we just have to figure out how to put it all back together again. You think you can help me with that, Jasmine? Yep. Okay, good. We'll do it. Okay, so let's review where we are now. We have partially closed up the skin. Here's our vertical limb where we brought those two pieces together along the inframammary fold and then we brought the nipple out through its own little new opening. And we can see the nipple has a nice blood supply, good color, which means it's still well vascularized after all that moving around. So now we'll just finish closing her up. We've weighed the specimen so we know how much we've removed from this side and we have a good estimate what we need to remove from the other side. So almost done with side one. Stay tuned. I'll show you more. So we're all done, Lina. All done.
So here's our post-op. Just getting the stearage strips on and I've caught a bit of breast tissue there that has been removed. And that will be a breast reduction. Thank you, Lina. You're welcome. More later from Aronowitzland. Yeah, okey-dokey. So now you're post-op two weeks after a breast reduction and do you want to tell us why you had a breast reduction and what your experience is?
Lina: “Excessive pain in my back, shoulders, under the breast, a lot of sweating, a lot of rash, and oh my god, you guys all have to come to this doctor. He's the best. Thank you. But you know, I think maybe people would like to know why you would want to have your breasts reduced and how much pain there is afterward, how much recovery there is afterward, that sort of thing. I would say in a scale of one to ten, turns of pain, two. Literally, right after the surgery, I was obviously unable to walk as well only because I was dizzy. But I literally came home, I finished the surgery at two, came home at two thirty, slept till three thirty, woke up as if I never had a surgery. And my husband thought I was crazy because I already wanted to start moving around. But very easy surgery.”
Dr. Joel Aronowitz: “Did you take narcotic pain pills very much?”
Lina: “Only once. I took it right after the surgery so I could, you know, so I could go sleep for a while. And I woke up, I was totally fine.”
Dr. Joel Aronowitz: “It was great. And that's my experience with most women. Ancinella is maybe one or two days, they might take a pill or two of narcotic. And then the scars here go around the areola, down and then underneath kind of an upside down T and there's still a little scab on there since you're only a couple of weeks. And then how far out they go to the side depends on how far the fold goes. And you can see there's a little gathering there which is very typical to try to keep the scar from going too far out to the back. And the same on the inside. I'm just going to lift here a little bit. You can see it's a little gathered there which will flatten out after a few days, maybe three or four weeks. And that way we don't have the scar go straight across. We don't want the scar to go across the sternum and it will be a thick scar and look terrible. So thank you for sharing that with us. Appreciate it."
Jasmine: “Is it collagen?”
Dr. Joel Aronowitz: “It is collagen. It is collagen. And if you'd be kind enough to just put your hand flat here and hold a little tension like that, and let me give you a little hint about, you can see that white dermis that Jasmine identified correctly. So if you're going to answer, answer like you really know it, and because if you're going to be wrong, you're going to be wrong, and if you're wrong, you're going to be wrong all along, instead of that you were guessing, you know?
Jasmine: “Right.”
Dr. Joel Aronowitz: “No, right. Just keep slipping down there. Do you know why this is, this pigmented skin around the nipple is called the areola?”
Jasmine: “No, I don't.”
Dr. Joel Aronowitz: “This means colorful circle.”
Jasmine: “Oh.”
Dr. Joel Aronowitz: “And it's distinguished by the, from the other skin of the breast because there's, there are little glands in it that make it some little nopally appearing things under the skin that are oil creating glands called Montgomery glands, and some people have more of them than others. And then also by virtue of the layer of muscle that's in that, under, underneath that layer, hold like that please, just flat. Yeah, just give me a warning. De-epithelialized most of what we need to, and you can see how the, here's the nipple, it's going to be carried on this stock to place it up in its new location. So the next step is going to be to dissect our new, our medial here and our lateral pedicles. So let's make these incisions. This last bit of skin off. Thank you. It would be to dissect underneath here and the same on the lateral part in order to create a pedicle.
So we're going to go down to the chest wall here and then we're going to head straight up so that we can identify this. Thank you. Identify the plane between the breast and the muscle underneath. Jasmine, you're on a roll. What is the muscle that the superior part of the breast sits on? There's a big one, a small one, the major and the minor, so mostly the majors. See, and if the muscles have an origin and an insertion, the origin of the pectoralis major is going to be what? Where does it originate from? The muscle itself? Yeah. I'm not sure. Well, it's right here. You can see it. And it's, if you put your finger there, you'll feel where it's originating from. What is that?”
Jasmine: “Yeah, the rib. So it's coming from the media from a little bit on the sternum and the ribs.”
Dr. Joel Aronowitz: “So it's originating on a bone and it's going to insert by means of a tendon onto a bone. So it's got to originate on a bone always because it needs something solid. There is a muscle that originates on a tendon and ends on a tendon and that's one of the muscles that gives a spine motor control of the, of our fingers and it's called a lumbar muscle. Have you ever heard of that?”
Jasmine: “I don't know. Yeah, so that's a nice little pimp question.”
Dr. Joel Aronowitz: “For when you're in a position to quiz people, it should be sooner than you think and that's the lumbar muscle and they do this. And it doesn't originate on the bone? No, it begins on a tendon and ends on a tendon. So that's a great little quiz question because every other muscle has got to be. You can see it contracting when I cauterize one of the little bleeders there. So here are the fibers and that you can, the direction of the fibers will also help you identify muscles when you're in surgery or trying to identify what's what because you can see where it's coming from and where it's going to. All right, let's talk about breast tissue. Jasmine, can you name some of these different tissues within the breast? What is this white tissue?”
Jasmine: “Those are the ducts. This is a combination of ducts and glands and the fibrous network-”
Dr. Joel Aronowitz: “-that supports it. And when you feel a woman's breast and you feel hard, fibrous kind of tissue, that's what you're feeling. And then this tissue is what? That's the fat. That's the fat. And when you feel a woman's breast, especially a woman who hasn't had children and it's nice and soft and kind of squishy, that's the adipose tissue within the breast. And then here's, let's see, can you see this structure? Thank you. Going straight up like this, kind of bluish. What is that, Jasmine?”
Jasmine: “That's the vein.”
Dr. Joel Aronowitz: “That's a vein and it's coursing from down here on the muscle, the pectoralis muscle, up into the breast tissue and the nerve, the nerves going to the skin of the breast and the nipple of the breast are doing the same thing. So here we have a mixture of tissues that constitutes a breast. And the naughty one here, the one that causes us the most grief in life, is the ductal tissue. And why is that the tissue that's most problematic? That's where cancer cells can grow. That's where most breast cancers come from, the ducts. And the ducts all coalesce into about 12 to 15 little tubes or bigger ducts and they come out through the nipple here. And that's what delivers milk and other secretions to the nipple are those ducts. So that ductal structures are where most breast cancers come from. Okay, so let's take a look at what we have here. Here's our breast. I've taken the skin off in the lower part here inside the keyhole. I've carried the nipple areola here on a pedicle on a stalk coming up from below. And then I have a medial or inner pillar and a lateral or outer pillar. So now I'm going to the excess tissue here from the inside. I'm going to preserve the pedicle. I'm going to remove a lot of this excess tissue from the lateral breast here. And then we're going to move the nipple areola up to this new location that we've marked previously. Let's take a look at where we are at this point. So we're finished taking out most of the breast tissue and trimming the skin. And I've put some tailor tacking staples in so that I can make sure that my measurements are correct and that I've got everything in the ballpark. So here's the nipple in its new location. And here's my vertical limb. I've trimmed off the extra skin. I've taken out a lot of the excess breast tissue. And now it's going to be a matter of just tailoring this down to make it neater and a little bit perkier. And then I'm going to take out all these staples. I'm going to do that right now. And from this point, we can go inside again, wash everything out, make sure there's no to correct little asymmetries and inconsistencies. And then do the final closure. So now just to review, here's our nipple, pedicle coming from inferiorly to hold the blood supply to the nipple areola. So you can see that's free and then that allows me to move the nipple wherever I need to. And then here's my medial limb, medial flap, and here's my lateral flap. And I've left a little extra breast tissue here and I think we'll trim that because you may have noticed when I had that close, it was a little bulging out here "So I've got a little excess breast tissue, which is fine. It's always better to have a little extra at the end that I can trim rather than have not enough. So there's the breast with most of the dissection done, the excess breast tissue removed. And now we just have to figure out how to put it all back together again. You think you can help me with that, Jasmine? Yep. Okay, good. We'll do it. Okay, so let's review where we are now. We have partially closed up the skin. Here's our vertical limb where we brought those two pieces together along the inframammary fold and then we brought the nipple out through its own little new opening. And we can see the nipple has a nice blood supply, good color, which means it's still well vascularized after all that moving around. So now we'll just finish closing her up. We've weighed the specimen so we know how much we've removed from this side and we have a good estimate what we need to remove from the other side. So almost done with side one. Stay tuned. I'll show you more. So we're all done, Lina. All done.
So here's our post-op. Just getting the stearage strips on and I've caught a bit of breast tissue there that has been removed. And that will be a breast reduction. Thank you, Lina. You're welcome. More later from Aronowitzland. Yeah, okey-dokey. So now you're post-op two weeks after a breast reduction and do you want to tell us why you had a breast reduction and what your experience is?
Lina: “Excessive pain in my back, shoulders, under the breast, a lot of sweating, a lot of rash, and oh my god, you guys all have to come to this doctor. He's the best. Thank you. But you know, I think maybe people would like to know why you would want to have your breasts reduced and how much pain there is afterward, how much recovery there is afterward, that sort of thing. I would say in a scale of one to ten, turns of pain, two. Literally, right after the surgery, I was obviously unable to walk as well only because I was dizzy. But I literally came home, I finished the surgery at two, came home at two thirty, slept till three thirty, woke up as if I never had a surgery. And my husband thought I was crazy because I already wanted to start moving around. But very easy surgery.”
Dr. Joel Aronowitz: “Did you take narcotic pain pills very much?”
Lina: “Only once. I took it right after the surgery so I could, you know, so I could go sleep for a while. And I woke up, I was totally fine.”
Dr. Joel Aronowitz: “It was great. And that's my experience with most women. Ancinella is maybe one or two days, they might take a pill or two of narcotic. And then the scars here go around the areola, down and then underneath kind of an upside down T and there's still a little scab on there since you're only a couple of weeks. And then how far out they go to the side depends on how far the fold goes. And you can see there's a little gathering there which is very typical to try to keep the scar from going too far out to the back. And the same on the inside. I'm just going to lift here a little bit. You can see it's a little gathered there which will flatten out after a few days, maybe three or four weeks. And that way we don't have the scar go straight across. We don't want the scar to go across the sternum and it will be a thick scar and look terrible. So thank you for sharing that with us. Appreciate it."
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