Plastics

Vanderbilt University, Nashville, TN - B.A., European History (High honors in History), Minor Degree in Studio Art, Magna Cum Laude (1988 – 1992)
Tulane University Medical School, New Orleans, LA, Doctor of Medicine (1992 – 1996)
Categorical Surgical Resident - New York Presbyterian Hospital, Weill-Cornell Medical Center, Department of Surgery, New York, NY (1996 – 1998)
Research Fellow - Massachusetts General Hospital, Harvard Medical School, Department of Surgery, Boston, MA (1998 – 2001)
Categorical Surgical Resident - New York Presbyterian Hospital, Weill-Cornell Medical Center, Department of Surgery, New York, NY (2001 – 2003)
Chief Resident and Clinical Instructor in General Surgery - New York Presbyterian Hospital, Weill-Cornell Medical Center, Department of Surgery, New York, NY (2003 – 2004)
Resident in Plastic and Reconstructive Surgery - University of Texas, Southwestern Medical Center, Department of Plastic and Reconstructive Surgery, Dallas, TX (2004 – 2006)

Mathes Publications Link

Skin closure 3-0, 4-0 monocryl. Does not “cross midline of the patient or breast” with closing sutures.
For dressings he uses steri-strips and mastisol and he puts the mastisol right on the incisions.

Sutures: for incision use 3-0 and 4-0 monocryl. Stab incisions for liposuction or fat grafting closed with 5-0 fast gut
Dressings: Bra with ABD pads, Binder with ABD pads, Mastasol (NOT benzoin) and steri strips over incisions, steri strip over stab incisions. No need to wrap/compress liposuction sites. Okay for DERMABOND® PRINEO® Skin Closure System.
Equipment: Uses silk tie with two mosquitos for measuring symmetry. 5 staplers.
Markings: Standard breast markings. Mark midline by sternal notch and introits.
Prep: Chloraprep

Ties a 3-0 nylon suture the the internal medial and lateral walls of the umbilicus and leaves long tails (this is both to assist in incising and later orienting the umbilicus. Pull up on the 2 sutures and mark a small circle around the umbilicus for incision. Incise down to subQ tissue and stop. He likes to divide the inferior pannus in half and extend it up to the umbilicus incision then get around the stalk while holding the panniculus skin flaps in the other hand. When closing the abdomen pull the 2 sutures on the umbilicus out through the inferior incision. Before completely closing the incision, find the umbilical stalk and make a mark on the overlying skin. Cut out a 2x1cm circle and pull the sutures through, making sure orientation is good. Secure umbilicus with interrupted 3-0 monocryl and ½ buried 4-0 horizontal mattress sutures as needed. Dermabond. (Mathes will also sometimes do an inferior flap incision for the new umbilicus location. It looks like an upside-down shield.)

Intraoperative antibiotics. Antibiotics for home
Sutures: 3-0 PDS for TE and alloderm, 3-0 monocryl deep dermal, 4-0 monocryl subcuticutlar, mastisol and steris
If going pre-pectoral, make sure that there are 2 pieces of alloderm in the room per side.

Pre-Pec- 2 pieces of alloderm sew into IMF and circumferentially at Breast “SFS” dont really sew into muscle Horizontal mattress sutures to secure alloderm, make sure expander is as low as can go the lower the better. Sew alloderm in first superior and inferior than place TE secure inferior and lateral and if can get medial as well. then sew both alloderms together. Place drain. Close

Placing the alloderm at the edge at the sternal edge of the pectoralis muscle may be a good option for Dr. Mathes' cases. Remember that the alloderm should be placed at the, at the IMF and the breast surgeon will violate the IMF on a regular basis. So you should be actually sewing the alloderm to the top of the flap, not to the chest wall.

Places central tab at the breast meridian.
Only sews in 2 tabs for the TE.

Intraoperative antibiotics. No antibiotics for home.
Sutures: 3-0 vicryl for capsule, 3-0 monocryl deep dermal, 4-0 monocryl subcuticutlar

Intraoperative antibiotics. 1 week of Keflex for home.
Close stab incisions with 5-0 fast gut. Steri strip dressing.

MAKE SURE THE BED IS A REFLEX BED… not a chair bed.

“Mark midline once patient is on table but BEFORE prepping If no CT scan, make sure you doppler out perforators BEFORE prepping” - Make sure there is at least 1 perforator on each side of midline. No need to doppler out all of them.
He spends a good amount of time measuring and making sure his abdominal marking elipse is even on each side. An old trick of his is to use the paper that the gloves come in to transfer the marks to the other side as a tracer.

Only remove A FEW staples if you think there is venous congestion. Hematoma should be handled in OR

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, placed in supine position. Bilateral sequential compression devices were placed and patient was given intravenous antibiotics and pressure points were padded. Surgical timeout was performed.   We marked on the left side for a Wise-type breast reduction. We first began by incising around the nipple using the 42 mm nipple sizer. We then incised our incision markings, we then proceeded to elevate the medial and lateral skin and tissue flaps, deepithelialized the inferior central pedicle. Once we had completed that, we then resected the lateral aspect of the tissue. We then lifted up the superior flap, removed some tissue superiorly and laterally. We then divided the inferior pedicle and noted good blood supply. We then stapled into position after irrigating. We then closed with deep 3-0 Monocryl and running 4-0 Monocryl. Sara Douglass was critical for retraction during the excision of the tissue and performed the majority of the suturing of the breast while I was able to work on the other side. We then marked the nipple position with a 38 mm nipple sizer, surrounded it, deepithelialized it, a cruciate incision, brought the nipples, sewn in with deep 3-0 Monocryl and running 4-0 Monocryl. It was pink and viable. Mastisol and dressings were applied to that area.   On the flap side, we elevated the flap superiorly about 8 cm, and resected approximately 1 cm of the mastectomy flap where it interfaced with the DIEP skin. There were some areas of firmness on the outside that when we elevated we found no evidence of fat necrosis on the flap. It appeared that this was scar in the chest wall. After we had elevated the mastectomy flap and excised the mastectomy skin we sat the patient up and noted that the lateral side was flat and that there was significant scarring. We then dissected laterally and opened up all the areas of scar in the area of the lateral chest. We placed a 15 french drain and secured it with a 3'0 Nylon. The flap was then stapled to the mastectomy flap.   We then performed fat grafting to the upper pole and lateral area using 50 mL of fat, which we had processed by liposuctioning of the lateral flanks using the Revolve system. We then excised an 8 cm area of her lateral scar. The scar was excised with subcutaneous tissue and fat. We then lifted superior and inferior skin flaps and then closed with deep 3-0 Monocryl and running 4-0 Monocryl. Mastisol and Steri-Strip dressings were applied. The patient was then extubated and brought to recovery in stable condition. I was present for all portions of this case. The flap was pink and viable at the end of the case as was the nipple on the reduction side.  

The patient was brought into the operating room and placed in the supine position. All bony prominences were padded and the SCDs were on and functioning prior to the induction of anesthesia. All lines were obtained and secured and the patient was intubated and sedated as per protocol. The patient received preoperative antibiotics prior to surgical incision. A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion.    I was the co-surgeon for this free flap due to the complexity and difficulty in DIEP dissection, history of radiation, and need for advanced microsurgical expertise.  This operation qualifies for the S code due to the above reasons.     The assistance of Sara Douglas, PAC was required as there was no senior plastic surgery resident available for the entire case.   We utilized a two team approach. I exposed the mammary vessels.   Initially, the breast footprint was created by raising the mastectomy flaps full thickness above the alloderm. We then removed the intact tissue expander. Finally we removed the capsule. We then identified the 3rd rib costal cartilage and the pectoralis muscle was split longitudinally to access it.  The perichondrium was scored and elevated circumferentially.  The entire costal cartilage was removed.  We then split the posterior perichondrium and elevated it off the IM vessels.  The IMA was evident beneath a thick layer of scar and was dissected free for the entire interspace.  We then proceeded to dissect out the IMV. A laterally based sensory nerve was identified and preserved. the connector and then the nerve alllograft was then sutured to the nerve with a 8-0 nylon suture.  Dissection was carried to the cephalad rib.  The artery was at least 3 mm and the vein was 3 mm.     During this time we began the flap elevation portion of the operation by making the superior incision.  This was carried to the xiphoid and costal margin.  The patient was flexed and the lower incision line was confirmed.  We then made lower abdominal incision. This was carried down to the SFS layer and the SIEV's were identified and dissected for 6cm. The flap dissection was then carried down to the rectus fascia.   We then elevated the flap from lateral to medial starting on the left side . The lateral row had 2 perforators.  An oval incision was made around the umbilicus and carried down to the fascia. We then began the dissection on the from medial to lateral. There were 2 medial row perforators that were identified. These were all smaller on the left and we then dissected on the right where she had a large medial row perforator and smaller lateral row. We transected the lateral row and decided to base the flap off the medial row due to the size and quality. The remaining perforators were clamped with atraumatic clamps.  The SPY imaging device was brought into the field and the patient received ICG as per manufacturers guidelines.  The flap perfused well based off the perforators and there was no clinical evidence of venous or arterial compromise. The flap perfused across the abdomen on the single perforator into zone 4 and the less perfused part was identified and marked and excised after a second spy run was performed with all of the other perforators ligated but the large medial row on the right side.    We then split the fascia above the cephalad perforator and around the remaining perforators. A complex intramuscular dissection was then performed to the pedicle. This dissection took greater than 50% longer than a TRAM or MS TRAM due to the muscle splitting and preservation and the complex intramuscular course of the pedicle.  This added an additional 2 hours to each side.  The remaining perforators were then clipped and divided and the remainder of the dissection was then performed.   We then brought the flap to the contralateral chest and secured it to the chest wall. The IMA vessels and DIEP pedicle vessels were then prepared under the microscope.  We then used a 3 mm flow coupler for the vein and a 9-0 nylon suture for the arterial anastomosis. The flap was well perfused with a doppler signal in the pedicle and on the skin.  A sensory nerve on the flap was then anastomosed to the nerve allograft using the nerve connector and a 8-0 nylon suture. The flap was then inset after we had de-epithelialized the portion of the buried flap. We excised some of the skin as it was damaged by radiation and made both superior and inferior darts to open the skin flaps. A 15 blake drain was then placed and the flap inset with 3-0 and then 4-0 moncryl sutures.   The rectus fascia defect was then closed with buried 0 prolene in an interrupted figure of eight fashion. Two 15 blake drains were then placed. All drains were secured with 3-0 nylons and a biopatch. The skin was then closed with a 3-0 monocryl for the deep dermal layer. The skin was closed with 4-0 running subcuticular suture. The umbilicus was then incised on the abdominal wall the the umbilical stalk delivered. The umbilicus was then inset with 4-0 monocryl deep dermal sutures. The skin was then dressed with dermabond and the patient was placed into an abdominal binder.   At the time of extubation and transfer to recovery she had a doppler signal on the skin and flow coupler. 

The patient was brought into the operating room and placed in the supine position. All bony prominences were padded and the SCDs were on and functioning prior to the induction of anesthesia. All lines were obtained and secured and the patient was intubated and sedated as per protocol. The patient received preoperative antibiotics prior to surgical incision. A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion.   At the time that I was called into the OR, the mastectomy had been completed. The axilla was noted to be fibrotic. I then injected the hand and upper arm with ICG and the SPY imaging device was brought into the field. There was a trace of contrast uptake in the axilla.   I then brought the operating microscope into the field. The area that illuminated was dissected and several small lymphatic vessels were dissected. They were noted to appear fibrosed and I then divided one - it did not have a functional lumen. At this point, I decided that this reflected the status of her lymphatics and we stopped further dissection. The lymphatic was clipped as a precaution.

The patient was brought to the OR and placed in the supine position. Bilateral sequential compression devices were placed, the patient was given intravenous antibiotics, and pressure points were padded. Surgical timeout was performed.   Dr. Ahrendt did her bilateral skin-sparing mastectomies and axillary node dissection. When she was complete, we then entered the operating room. We first achieved hemostasis with electrocautery, and then lifted up a submuscular subpectoral flap all the way to her fold. We were able to preserve tissue. We then raised a lateral serratus fascial flap, incising the edge of the fascia near the lateral border of the pectoralis muscle, dissecting through, and including a small amount of the serratus muscle at the most inferior portion of the flap. We then took a 475 mL tissue expander, deflated it, placed it, and it was sewn in the lateral aspect with 3-0 PDS. We then were able to close the pectoralis flap to the serratus fascia flap with 3-0 PDS. We then placed a 15-French round Blake drain, which was sewn in with 3-0 nylon. We then placed 120 mL sterilely into the tissue expander, and then closed the skin with deep 3-0 Monocryl and running 4-0 Monocryl. We then did the same surgery on the right side, again lifting up the serratus fascial flap, dissecting it off at the insertion near the muscle interface with the pectoralis minor muscle, then preserving a thin fascial flap with a small amount of serratus muscle at the very distal portion. We then lifted up our subpectoral flap, dissecting it all the way to the IMF. We were able to preserve some subcutaneous fat and tissue in order to not need to use any human acellular dermal matrix. We then irrigated, placed a 475 mL deflated tissue expander, and secured the lateral tab. Then with a 3-0 PDS, closed the serratus fascia flap to the pectoralis muscle. Irrigated. They had already placed a drain in the axilla. We placed another drain to drain the mastectomy flap area, sewn in with a 3-0 nylon as it was on the other side. Irrigated. Stapled closed. We then did SPY angiography, which demonstrated excellent perfusion of both flaps. Then, closed with deep 3-0 Monocryl and running 4-0 Monocryl. Mastisol and Steri-Strips were applied. Dressings were applied. The patient tolerated the procedure and left the operating room in stable condition. I was present for all portions of the case.

After Dr. Arruda completed her case, we prepped and draped the abdomen and chest and thighs as per usual. We made sure all pressure points had been previously padded. She already had a Foley catheter placed. We then proceeded to perform tumescence of her inner and outer thighs, and performed with tumescent of 1 liter of lactated Ringer, 1 ampule of epinephrine, and 20 mg of lidocaine. We were able to get approximately 250 mL of fat into the Revolve system, which then allowed us to get approximately 110 mL of viable fat. We then proceeded to layer this fat, make 2 stab incisions in the breast reconstruction, and allow this to layer the fat in the upper pole and lateral areas where she had some noticeable loss of contour. We did 55 mL of fat per side. Once this was complete, we closed the area with 5-0 fast and Dermabond. The donor sites were closed with 5-0 fast.   We then turned our attention to the abdominal incision, which was measured at 45 cm. We excised 45 cm x approximately 5 cm at its maximum width to lower her scar and give her a better contour. This area was then excised. We then elevated her abdominal flap again up to the umbilicus, and then at the area over the left side of the DIP site. We went all the way to the costal margin. We then proceeded to imbricate and do a plication of her left fascia using interrupted 0 silks. Once this was complete, we irrigated. We then placed a 15-French round Blake drain, which was sewn in with 3-0 nylon. We then stapled and closed with deep 3-0 Monocryl and running 4-0 Monocryl, Mastisol, and Steri-Strips for a length of 45 cm. Dressings were applied. The patient was then extubated and brought to the recovery room in stable condition. I was present for all portions of our case.

  We then turned our attention to the nipple reconstruction, which we had marked at 31 cm. We then drew out a Tennessee-type flap, excised around the edges of the Tennessee flap, preserved the dermis and subdermal plexus as well as some flap fat in order to give it some projection. We then folded these areas and closed the donor site with deep 3-0 Monocryl and running 4-0 Monocryl for the lateral portion. The nipple reconstruction itself was constructed by sewing the ends together with 5-0 Monocryl. Once this was completed and showed pink and viable nipple reconstruction, we then put Dermabond on that area. We then applied Steri-Strips. Dressings were applied. The patient was then extubated and brought to the recovery room in stable condition.  

The patient was brought to the operating room, placed in supine position. Bilateral sequential devices were placed, and patient was given intravenous antibiotics and pressure points were padded. Surgical timeout was performed. I first began by injecting 20 mL of 0.25% Marcaine with epinephrine into the drawn out lower abdominal incision. We then made a 16 cm incision and then lifted up a skin flap superiorly, which measured approximately 6 cm in width. We then tailor tacked this and cut off the excess skin, then closed with deep 3-0 Monocryl and running 4-0 Monocryl. Mastisol and Steri-Strips were applied.   We then turned our attention to the breast, first doing a periareolar mastopexy on both sides using the larger nipple sizer and then doing a 1 cm excision of skin circumareolar. This was all deepithelialized. SPY angiography for intraoperative assessment and perfusion was done and demonstrated good perfusion of the nipples bilaterally. We then deepithelialized this area and then were able to close with deep 3-0 Monocryl and running 4-0 Monocryl, doing a periareolar mastopexy bilaterally. Mastisol and Steri-Strips were applied. We did do SPY angiography at several stages to demonstrate good perfusion, both when we did simple stapling and also when had deepithelialize and stapled. Once this was complete, we then excised our old incisions for the placement of bilateral tissue expanders, removed the bilateral tissue expanders to the minor capsulotomy. We then tried the 400 mL SSF Natrelle implants bilaterally, which gave good form and quality. We then irrigated. Hemostasis with electrocautery. We then changed our gloves. We used a Keller funnel and placed both implants with a no-touch technique. We then closed the capsule with 3-0 Vicryl and deep 3-0 Monocryl and running 4-0 Monocryl. Mastisol and Steri-Strips were applied. Dressings were applied. The patient tolerated the procedure and left the operating room in stable condition. I was present for all portions of the case.

The patient was brought to the operating room, placed in supine position. Bilateral sequential devices were placed, and patient was given intravenous antibiotics. All pressure points were padded. Surgical timeout was performed. We had marked her for a Wise-type pattern breast reduction. We first began by using the larger areola sizer, 45 mm, marking the areolas, then incising around the areolas, then deepithelializing on each side central medial pedicle. We then began our dissection, first making our medial flaps, then the lateral flaps, then removing a large amount of lateral tissue on each side and then dissecting our superior flap, trying to get them even approximately 1 to 2 cm. Then removing the superior tissue bilaterally and then removing additional tissue until we removed approximately 472 grams on the left and 412 grams on the right. We then irrigated, stapled closed, and noted that we had good symmetry. We then closed with deep 3-0 Monocryl and running 4-0 Monocryl. We then brought the nipples out using a 38 mm sizer, deepithelialized in a cruciate incision, brought it out and deep 3-0 Monocryl and running 4-0 Monocryl, Mastisol and Steri-Strips. Dressings were applied. We placed the 15-French round Blake drains, which were sewn in with 3-0 nylon. The patient tolerated the procedure and left the operating room in stable condition.