Hello Dr. Bermant,
Can you please comment on how thin is the average areola? What thickness is the dermis plus the small areola muscle? When you remove the gland to what thickness do you cut the areola? 0.25", 0.1", ...?
Thank you,
Kevin
Thickness of skin varies throughout the normal body and varies from individual to individual. Being "thick skinned" is more than just an expression, some people just have a differences like that. Medical problems and medications can make the skin thinner or thicker over time. The stimulation of that just under the areola muscle can also change the thickness of the tissue (this is how muscle contraction works making the areola smaller and flatter). You can see the effect of muscle thickness changing as you flex your pectoral muscles (or for that matter almost any muscle).
So I first infiltrate a numbing solution just under this muscle layer to increase comfort (the infiltrating tumescent cannula does not reach this layer between gland and areola structures), and help separate the structures for dissection. This numbing layer also helps relax / paralyze the muscle for a more consistent surgical sculpture. I then identify the structures visually though my magnified loupes for the best most accurate sculpture. This is a monster advantage of starting the surgery at the edge of the areola. This identification and targeting the gland first was a hallmark of my Dynamic Technique that I had discovered by my careful analysis of pictures before and after surgery. The flexing views as well as the later videos demonstrated the advantages of targeting the gland first as well. The analysis also was critical in evaluating the many failures I was seeing from other surgeons during my revision surgery.
That means that I start out the dissection and dividing not by thickness, but by direct visual observation. You can actually see the difference between this muscle layer and the white of gland or yellow of fat. I let the thickness of gland left behind get a little thicker at the anatomic nipple. Coring out the nipple is a mistake unless you are trying to decrease the diameter and change the shape of this structure. However, this is a trivial amount of gland left there. The goal is to leave a flat nipple areola complex that then has a natural protruding central nipple above this flat structure. It is neat looking at the removed gland tissues at the end of surgery. In some cases, you can see the pointed shape of the gland I have removed that was contributing to the contour of that component of the body. I am not talking about just a gland duct connection to the central nipple. I am describing a gland extending well beyond the areola in many cases having a shape to the gland that reflects on the shape of the surface. You can see the guess of gland extent on my map of each patient before surgery and then the removed tissue on the chest at the end. We try to put the outer gland upward for this picture.
The resulting thickness of skin, dermis, and muscle does vary greatly from patient to patient. It can sometimes vary from one side to the other. In some patients the remaining tissue is tough and strong, in others it is thin and fine requiring the utmost is patience and delicacy in protection from making a hole through it during the dissection. So it is the anatomy that I am trying to preserve and define, not just by measurement of thickness.
It is this cast gland shape that is one common cause of the residual puffy nipple deformity I have documented and described on the patients coming to me for help for their revision surgery.
Hope this helps,
Michael Bermant, M.D.
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