Are you taking the pith?

Mr A has finished the fruit sculptures he promised me, but we had a misunderstanding. I was expecting a sculpture with incisions in the skin of the orange to show how they open the breast up to remove the tissue. However, last night he texted me two photographs of oranges to help explain more clearly how an areola is created during skin-sparing mastectomy and latissimus dorsi reconstruction.


This is the perfect strategy for beginners as far as I'm concerned. Think of the educational possibilities the surgeon and the orange could provide me with! I'm far less squeamish about seeing the peel shaved off an orange vs. the epidermis shaved off somebody's back muscle, although I do hope to get around to watching the latter sooner or later. In the meantime, I have commissioned the artist to make me a skin envelope out of an orange for a future date.


So, how is an areola made again? An ellipse is drawn on the patient's back, near the centre of the LD muscle. The surgeon cuts along the dotted lines, and separates the muscle underneath from all of the skin except that of the ellipse. Mr A says to consider the white tissue as LD muscle and the orange as the ellipse of skin remaining on the back. The circle, marked in the middle, is the future areola. 

Fig. 1.

The LD muscle is then swung under the armpit, ellipse of skin still in place, and brought around to the front of the body to form the basis of the new breast. The skin around the areola-to-be is carefully trimmed: skin has two layers, and in order to maximise the volume in the new breast, the surgeon wants to leave as much behind as he can. But he can't bury the epidermis, because it wouldn't heal. So he shaves the superficial layer of skin around the circle, the top layer called the epidermis, and leaves the dermis, the second layer, behind.

Fig. 2.

The muscle (the white tissue in the picture, remember?) is set in the skin envelope (the breast is ready to be refilled after having had the inside removed). The shaved bit of the ellipse is buried along with the muscle, so that only a circle of skin is left exposed: the new areola. I believe it's at this point that the surgeon reaches for his sewing kit, so stay tuned for your how-to guide on suturing skills: specifically, how to neatly sew an areola.