Breast fellows Talk Part 1

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Dr. Joel Aronowitz, is a prominent Los Angeles cosmetic surgeon in practice for over twenty years. The office suite is located adjacent to the highly regarded Cedars Sinai Medical Center. Dr. Aronowitz is a graduate of the Accelerated MD program at prestigious Baylor College of Medicine in Texas where he performed his General and Plastic Surgery residency training. Dr. Aronowitz is certified as a diplomate of the American Board of Plastic Surgery and is a member of the American Society of Plastic Surgeons, the American Society of Bariatric Plastic Surgeons, and California Society of Plastic Surgeons. He is affiliated with the USC School of Medicine as a Clinical Assistant Professor of Plastic Surgery. For more information visit www.aronowitzmd.com

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  • Use of keyhole for benign disease
  • Breast fellows Talk Part 1

    1. 1. BREAST INCISIONS a history, basic science and technique of The New Standard of Care Joel A. Aronowitz, MD Division of Plastic Surgery Cedars Sinai Medical Center Los Angeles, CA Conflict of Interest Disclosure: Nothing to disclose
    2. 2. Mastectomy incision concepts <ul><li>Skin and breast tissue are distinct tissues resection of skin must be oncologically justified. </li></ul><ul><li>Principles of incision placement, skin tailoring are well estab. </li></ul><ul><li>Preservation or improvement of natural breast appearance improves QOL dramatically, is compatible with effective oncologic surgery. </li></ul><ul><li>Multidisciplinary approach is Standard of Care, </li></ul><ul><li>work with a Plastic Surgeon. </li></ul>
    3. 3. General anesthesia opens modern era in surgery, Halstead attempts cure with radical surgery
    4. 4. “ Breast cancer wars” Crile vs Halstead the modified radical mastectomy emerges Transverse incision with elliptical skin excision is established
    5. 5. Open Biopsy and Lumpectomy Incisions Concentric circles & Langer’s Lines
    6. 6. Advances in Reconstructive Surgery <ul><li>Keyhole Pattern skin tailoring the breast (Wise,1956) </li></ul><ul><li>Breast implant (Gerow, Cronin 1962) </li></ul><ul><li>Myocutaneous Flaps (Emory,1980’s </li></ul>
    7. 7. before after Oncologic breast incisions and reconstruction, c.1990’s
    8. 8. before After bilateral mastectomy TRAM reconstruction Courtesy J. Anderson, COH Nat’l Med.Ctr The New Standard of Care 1. Low threshold use of needle biopsy 2. Incisions planned with 1st principles 3. Skin resection justified oncologically 4. Multidisciplinary approach
    9. 9. Skin envelope… breast shape/appearance Breast tissue… volume and malignancy <ul><li>Pubertal breast bud grows, skin expands according to Law of LaPlace, see below… </li></ul><ul><li>Breast tissue in non discrete lobules </li></ul><ul><li>Breast tissue separated from skin by 0.5 cm (97%) </li></ul><ul><li>Areola contains no ductal tissue </li></ul><ul><li>No ducts in areola </li></ul>
    10. 10. LaPlace predicts breast shape Breast diameter is > in lower pole therefore the skin below the nipple is under greater tension and stretches the most. Nipple decent with the breast.
    11. 11. Chest shape may influence breast shape; pectus deformity
    12. 12. Cause of the tubular breast <ul><li>Inner quadrant tightness causes a deficiency of skin toward the midline and sometimes a “Cross-eyed” look to the nipples. </li></ul><ul><li>A mild case may just show a pouty or “herniated” areola. </li></ul><ul><li>A very tight mesenchymal layer may inhibit breast growth so much that size is affected. </li></ul>
    13. 13. The Flattening Effect of Excising Transverse Ellipse of Breast Skin <ul><li>Initial biopsy left upper outer quadrant leads to excision of otherwise uninvolved skin at mastectomy. Note flat breast shape. </li></ul>
    14. 14. Typical Skin Envelope after Transverse Mastectomy
    15. 15. Law of LaPlace and breast shape <ul><li>Larger diameter = </li></ul><ul><li>more skin tension = </li></ul><ul><li>greater skin stretch = </li></ul><ul><li>more skin = </li></ul><ul><li>More breast ptosis! </li></ul>
    16. 16. How Transverse Incision Results in Typical Superior Pole Fullness
    17. 17. Periareolar incision ok for implant placement even if areola small <ul><li>Rx; 300 cc smooth silicone, retromammary prosthesis </li></ul>
    18. 18. Incision Placement periareolar or IM crease incision
    19. 19. Operative Technique Cancer bearing breast tissue removed, not skin. Blunt retractors, no sharp rakes on skin flaps.
    20. 20. A Segway slide…
    21. 21. The WISE Pattern an essential guide to breast incisions <ul><li>The Wise pattern was introduced in 1956 </li></ul><ul><li>Gold Standard for tailoring the skin of the female breast </li></ul><ul><li>Method of transposing the nipple varies (superior, inferior pedicles) </li></ul><ul><li>Skin tailoring may use all or only a portion of full incision, ie, periareolar (donut), vertical (lollipop), full keyhole (inverted T) </li></ul>
    22. 22. Keyhole vs Transverse
    23. 23. Breast cancer surgery in the modern era <ul><li>Advent of anesthesia </li></ul><ul><li>Trend toward earlier detection </li></ul><ul><li>Halsted vs Crile; “Breast Wars” </li></ul><ul><li>Keyhole concept to tailor breast skin (Wise, ‘56) </li></ul><ul><li>Silicone implant introduced, ‘62 </li></ul><ul><li>Rise of lay advocacy groups, 70’s </li></ul><ul><li>Myocut., free flaps refined, 80’s </li></ul><ul><li>Disconnect between GS and PS </li></ul><ul><li>Demand for better cosmetic results: Today </li></ul>
    24. 24. -A Guide to Breast Incisions- Lumpectomy and Open Biopsy <ul><ul><li>Needle biopsy liberally, open biopsy infrequently. </li></ul></ul><ul><ul><li>Periareolar incisions are generally good. </li></ul></ul><ul><ul><li>Inframmamary crease incision ok if breast is ptotic </li></ul></ul><ul><ul><li>Safe Zone: within the Keyhole Pattern </li></ul></ul><ul><ul><li>Never Zone: above and medial to nipple/areola </li></ul></ul><ul><ul><li>Anticipate future surgery and respect blood supply </li></ul></ul><ul><ul><li>Involve a Plastic Surgeon and validate patient’s concern for natural breast appearance </li></ul></ul>
    25. 25. Incision placement in the ptotic breast <ul><li>Incisions to remove breast tissue should be placed within this Keyhole pattern </li></ul><ul><li>A continuum; </li></ul><ul><ul><li>Periareolar </li></ul></ul><ul><ul><li>Lollipop </li></ul></ul><ul><ul><li>“ L” shape </li></ul></ul><ul><ul><li>Full Inverted “T” </li></ul></ul>X X O
    26. 26. Tailoring redundant skin in male vs female breast
    27. 27. Pre op markings <ul><li>Preoperative markings usually made by Plastic surg </li></ul>
    28. 28. Basics of Keyhole Pattern <ul><li>De-epithelialize central pedicle, dermis left intact </li></ul><ul><li>Central pedicle not needed if nipple sacrificed </li></ul>
    29. 29. Central pedicle isolated <ul><li>Central pedicle carries nipple superiorly or inferiorly </li></ul><ul><li>Medial and lateral flap breast tissue removed </li></ul><ul><li>Central pedicle not preserved w/ mastec. </li></ul>
    30. 30. Lateral flap resection
    31. 31. Tailor tacking closure <ul><li>Pedicle w/ nipple transposed </li></ul><ul><li>Medial and Lateral flaps rotated toward T </li></ul><ul><li>Ready for final skin trimming </li></ul>
    32. 32. Keyhole inverted “T” scar <ul><li>Nipple-IM= 5-6 cm </li></ul><ul><li>Nipple-SN> 22 cm </li></ul>
    33. 33. The WISE Pattern an essential guide to breast incisions <ul><li>Small breasts- periareolar or inframammary crease </li></ul><ul><li>Large ptotic breasts- Periareolar or inframammary crease </li></ul><ul><li>Method of transposing the nipple varies (superior, inferior pedicles) </li></ul><ul><li>Skin tailoring may use all or only a portion of full incision, ie, periareolar (donut), vertical (lollipop), full keyhole (inverted T) </li></ul>
    34. 34. Mastectomy after breast reduction Right; post lumpectomy, XRT Left; asymmetry, hypertrophy <ul><li>RX: Rt tissue rearrangement via periareolar incision, excision ant. Axillary fold fat </li></ul><ul><li>Left symmetrizing breast reduction. Pathology; LEFT breast DCIS </li></ul>
    35. 35. Mastectomy after breast reduction
    36. 36. Wise pattern after mastectomy

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