Video Transcript

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Dr. Delgado: If you look at the pictures that he has the nipples are lateral which means out towards the arm and down low. they’re not medial they’re not up high but they’re out to the side. So they also come across here and it usually the nipple usually bisects around where this comes in it comes in about here. So I’m going to put a dot here and I’m gonna put it about three centimeters above our fold which is about here. So so we’re about 13 and a half centimeters over we’re about three centimeters from here close who are our peck. so this is a starting point. This is a full-thickness skin graft so we took the old nipple off the same way I’m taking this skin off. So I’ve got the circle I made the circle and took it off with the same diameter of the circle and I’m making the same diameter I’m taking off this skin. Now it’s important that the skin under here is bleeding because that’s the blood flow. It’s important that this blood flow works into the nipple that I’m going to put on. And so what we’re going to do is take this off leave as much of the dermis which is the deeper tissue in place which carries the most blood flow in the skin you can see it just oozing and that’s what we want to see. So I’m taking this off keeping the dermis which is a deep layer of the skin intact and is rich in blood flow. So this is the old nipple here right here and we want to thin it out some because it was too thick it won’t take that well and this is pretty thick anyway. So he’ll probably have a little bit of like healing issues here but it’s just very very thick and the blood flow takes a while to kind of grow in but it will be fine. it will be perfectly fine. so I’m getting this down to the dermis and I’m going to staple this on. yeah and then I’m going to sew it maybe have a poor oh. I’m gonna sew it on so you can see it and then we’ll sit him up again and you can kind of see the finished product. So to have this take as a graph it has to basically be in really good contact with the skin so we have a tie-over bolster that you’ll see. You notice how the nipples are white because it’s got no blood flow to them now. As soon as that the blood supply grows in and you see the blood it’s gonna grow into the area in a turn pink. Usually, it is gonna take about a week to ten days. we see that it’s sewn on now we’ll do the same to the other side this wash this off for a while. Let’s set him up and take a good look so we see that we have a nice incision that is pretty symmetrical on both sides and in terms of the orientation. If we see our peck outline on both sides a little bit more swelling here. We see our nipple area which is his nipple that’s made smaller and it’s out laterally. Pectoralis comes across here and it’s about three centimeters up from here. The only other thing I’m contemplating is is is this area here and I think I’m going to go ahead and do something there. And the sutures for a tie-over bolster because this graph has to be in very close contact with that dermis underneath so the blood supply can grow into it if it moves around it will break its contact so that’s what we don’t want. One of the other issues with a free nipple graph which is the proper term for it, it does not have sensations so that’s one of the disadvantages is that it does not have sensations. To have the sensation you have to basically leave a bulk of tissue underneath it for its blood supply and then it would not be as flat because it would leave a mound it would have to have a significant mound there so most everyone goes for having it flat. And so this full-thickness skin graph will allow that to happen because it does not need to carry a bulk of tissue for its blood flow. Okay, okay. So that’s gonna hold our graph in place very, very nicely it’s toned down around the entire area and then this bolster is holding it down in place also. I usually never have to do this but in his case, he would have had that little dog or nipple there and I think I don’t think it would have gone down significantly enough. So you see how it dips down now as opposed to it pilling up so it’s gonna end up having a nicer contour there. I think this is going to end up being more aesthetic for him it’s just a scar I get worried about crossing this region. But I’ve put an AV into it so it’s not a straight line tissue tends to scar worse and contract worse when it’s in a straight line when this is in a zigzag line it breaks it up. And if we can clean this off everything off really well please explain here okay good all right okay.

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