Lumpectomy and Sentinel Lymph Node Biopsy Using Lumicell System for Intraoperative Detection of Residual Cancer

CHAPTER 1

So, pre-op, this is a woman with a palpable breast cancer, and she agreed to be in our study, where we're trying to find ways to detect residual tumor during the first operation and not leave any tumor behind, and not have to do second surgeries. The key things of this is she was injected with a dye before she got to the operating room, that was going - the lume 015 dye, that becomes activated to a fluorescent form in areas where there's tumor. The things you saw us do that were using this imaging device, uh, covering things with a towel, turning the lights on and off, that was all part of the protocol. Other than that, it was quite a standard lumpectomy, where the idea was to take out her tumor, uh, with a margin of normal-appearing tissue around it. Uh, her tumor was palpable, so I was able to use touch to put my hand on the tumor and cut about 1 cm or 1.5 cm all the way around. We did that as the first step in the surgery, took the tumor out after we made the incision, exposed it circumferentially to make that easier. Once the main specimen was out, we actually imaged it in the operating room. We had put metallic markers on, so we would be able to orient the specimen on the X-ray image relative to where the tumor was in the patient. And that picture showed us that the lesion was pretty well centered in the lumpectomy specimen I took out, and it looked like there was grossly clear tissue all the way around. I then went back and did the standard of care here at MGH, which is taking comprehensive shaved margins of the entire cavity. That's taking a thin shave of tissue from the cavity that's the left after that first lumpectomy has been removed. Uh, we do that because randomized studies have shown that that cuts the re-excision rate in half, and that makes up for any trauma to the specimen that can make a margin look positive when it actually isn't. It also is more precise for orienting where any part - positive margins might be, as compared to just using marking stitches or paint on the original specimen. After we did that, we did the protocol part of the study, which is where I introduce the Lumicell probe into the cavity. We got the patient's baseline measurements, just looking all around first at 6 surfaces of the cavity. And then after that, the machine algorithms calculated what that patient's threshold was for normal versus tumor, and I then went back and systematically looked at the cavity, with the machine applying the threshold. There was one spot in the deep margin where there was some fluorescent signal, that had me take a second margin in that area and after that, that area looked clean. I then resumed the normal part of the procedure, which was I did some cosmetic work lifting the breast tissue off the muscle, so I could mobilize it in a local advancement flap to get a better closure cosmetically. That was done, I stopped all the bleeding with a cautery, packed the incision, and then on to part 2 of the surgery, which is taking out the lymph nodes under the arm to see if there's been any spread of tumor to the underarm lymph nodes. For that, there was the second incision placed in the underarm. We then went deeper through the fatty tissue, the superficial tissues in the axilla, until we found the fascia, and at that point, went through the fascia, and after that, pretty quickly could visualize the lymph node that was producing the radioactive signal. We excised that, and counted it. And once that was out, there weren't any other suspicious nodes by palpation, or nothing that had a radioactive signal, and we got nice hemostasis there. We then imaged the lymph node with our Lumicell device, and there was one small area where there was some fluorescent signal, and we'll see what that turns out to be. Once all the specimens have been removed like that, then we put on our cosmetic surgeon hat, and try to do things to close the incision so it will look nice afterward. We also think about patient comfort, and inject a lot of long-acting local anesthetic. That's Marcaine, uh, bupivacaine 0.25%, into the incisions. And that local anesthetic makes it so at least half of my patients say they never took any pain medicine afterward. And most of the rest can get by with Tylenol or Ibuprofen, so we can minimize narcotic utilization with that. After that was done, we put some marking clips into the breast incision. These will show up on subsequent X-rays and radiation planning CT scans, and they will help the radiation oncologist aim the radiation precisely around the space where the lumpectomy took place. And then for subsequent mammograms, it will help everyone see, this is where the tumor was, and we look more carefully at that area for any signs of recurrence in the future. After we did that, we closed both incisions with some cosmetic techniques. Closed the skin with subcuticular closure, so there's no sutures on the outside. It makes it cosmetically nicer, and it's nice for the patient to not have to come back for suture removal. And then we put on waterproof dressings. She woke up quite nicely, and was able to tell us she really had very little pain as she was waking up.

CHAPTER 2

So, I'm going to just mark where the sentinel node signal is. So, it's right there. So, this is where we'll do our node surgery. And we've used only the radioactive dye because the blue dyes don't - aren't compatible with the Lumicell dye. Okay, so that's that. And I've also checked to see there's nothing in the supraclav or internal mammary. Okay, we can shut the probe off. And now we're going to see - You can see there's a little dimpling in the skin. So now, we're going to feel where the tumor is in this position. And it's really right under there. There's the little needle injection site, here. So, the tumor's right here, and what I like to do is mark the boundaries of what I feel, with her breast sitting here. So, that shows me where I should put the incision. So, I'll put - And, uh, actually, I think it looks a little better if I make the incision here as opposed to trying to tunnel from here, because I'll be able to use some tissue from the side to help close things. So, we'll do something like that. And then for here we'll make an incision something like this. When you're discussing the procedure, do you give them the option of doing... No, I, uh... It's - sometimes if they have worried about cosmetics, I'll describe things, but I think her cosmetic result is actually - can be better here with what I'm going to do. Okay?

CHAPTER 3

So, here's our incision. We'll use 2 Adsons next. So here's the same thing we did before, I'm going deep enough that I can get the Bovie in without burning the skin. Knife down. And so, we'll have you pick up opposite me here. I usually cut here to get started, and then come back with coag. And it feels to me like this is fairly superficial, um, so we're going to raise relatively thin flaps here. Okay, let's regrab here. Okay, good, and you let go there. And then here I'm just going to look and see if there's anything that needs to be buzzed here, okay. Then we feel again. You can feel that we're not right at the tumor yet. So now, pick up opposite, and take a real big bite, not just the skin. Good. And let's have the - let go now. Now let's have the, um, skin hooks. So, if you feel gently down here, you'll feel that the tumor's over here. Okay? I'll give you these back. So, now we're going to raise some flaps here. And here, I'm staying parallel to the skin. Can I have the suction? Where do we put this one? Nora, could you hold this one? Okay, good, and come over here. Okay, good, and let's come back over here again. Just leave that one in. And could you reach in front of me and hold that one? Let's have 2 baby abdominals. So, put your hand in, you can feel where the lump is there, and we're kind of coming around the sides of it. Okay, so let's do this, we'll put this one here. This one here. Put that a little deeper. There, good. Thanks. So here, I'm going to have you angle things a little bit - Good, that gives me just a little extra room to work around the retractor here. Suction. Good, now we're going to put you here. And we're trying to get these about 90 degrees apart. And I have my finger on the lump. And I'm going about the width of my finger, which is about 1 cm, 1.5 cm beyond the lesion. Relax on that a little. Good. Okay, there. And now here. And not too - not too hard. And Nora, relax just a little more. Perfect. And I'm watching what I'm cutting here, so, if anything looks like tumor, as opposed to regular breast tissue, I'll take that into account. Okay, now we're going to scoot over here. Here. And then, do you have some, um, clips ready for us? Put this a little deeper - Yeah, take the clip applier in your right hand. We're not quite ready for you to do that yet, but soon we will, so I'll put this here and here. I'm going to put you a little deeper there, now. So I - see, I'm keeping tension on this stuff here. And then I feel where I can come under it. And this side right here, if you can put the clip applier on, and put 3 clips, 1, 2, 3, kind of grabbing this edge perpendicular. Really perpendicular, like that. Either reach your hand around or do that, okay? Good, good. And then right there. Good. And right - I'll move it right there, good. Okay, good. Now, let's have you put that down for Nora for a minute, and then I'm going to have you now grab this one here. Not quite - not quite so much pull - good. And have the suction ready, Nora. So here, I'm coming - Let me win the tug-of-war to lift this side toward me a little more. Okay, now right here, and here. Suction. Okay, take those out for a minute, both those retractors out. Okay, so here's our specimen. Again, let's take another clip and put it right here, marking the superior part of it. Good. Now, let's see if we're - And I think that you can hold off on the rest of that for a minute. So, now... So, now I'm feeling the tumor front and back, here. And I'm going to do this, good. And not too much pull. Here, let me - Sorry? You mind if I turn on the Lumicell light? Yeah, I think I'll be fine. Yeah, just make... So here, this is just normal-looking yellow fat. And this specimen is a pretty good cylinder. Okay, good.

CHAPTER 4

And let's have one more, uh - the clip applier. And then, um, Connor, are you ready to, uh, start painting this? Okay. Got some gloves on. And you can take that retractor out. Sure, I can do that. So, everything here is still sterile? Yes. And which is the anterior? It's blue? Anterior is blue, right. So, as part of this protocol, we're inking the specimen as soon as it comes out of the patient to help more precisely identify the orientation before the fatty tissue deforms. Okay. So Connor, I'm going to put this down here, and - I think you can see there are 3 clips here. That's going to be, uh, medial. Superior, okay, I'll let you work on that.

CHAPTER 5

Okay, so now, what we'll do is we'll get hemostasis. We were just getting that out quickly. And so, we'll do this. Um, oh, you can let go of that, thank you. Good. And then we'll have you hold that. And we'll just see where the bleeder is, here. One of these. Next time I'm going to do this on coag, it's a lot drier. But not always. Can I get a little squirt of irrigation? Okay, now, let's move over here. And you're going to hold those both yourself. Okay, relax on those a little, good. Okay, good, thank you. This is just to make sure there's nothing oozing here that we need to deal with now.

CHAPTER 6

Okay, that looks pretty good. So now, we look at the cavity we have here. And you can see and feel, there's - space there. Um, and then we're going to take our shave marg - Could you just see if you can get that fat out of there? And then we're going to move this here. And we'll take our shaves first. And Connor, do you want us to initialize after the shaves? Initialize after the shaves. After the shaves, okay. And we're going to make - lateral and anterior will be together. And then we'll have a deep, also. Okay, so, for this part we'll take, um, rat tooth. Perfect. So, our routine here is to take shaved margins that, this now will make up for any, um - uh, I'll make you start like this first - start up for any trauma to the specimen that happens in handling it that creates a crack that the ink can go down into that would make a margin look positive that wasn't. And there's some data that if you take shaves like this, it cuts the positive margin rate in a randomized trial from 40% to 20%. So, it's useful, but it means we have to take more tissue than we otherwise would like to. Okay, now we're going to come here. I'll have you do that. Um, how about another, um, clip, please? This looks like a little vessel here that's probably part of what was oozing before. And we'll have you - I think you did this before, you'll mark the margin that's facing up. Oh, actually, there's another piece here. Okay, pull less on this one, so I can see this spot here. Put this one here. And then I'm going to move these here, just to see if there's anything still bleeding, or if this is all just leftover. Looks like it is, okay. And then you're going to hold like this. And then, um, Connor, were you going to put that specimen in the, um, BioVision when we're done? Okay, good, and then we'll take some down here for deep. Okay, and then why don't you go start marking those and Nora and I can get this last one and dry up a little bit. This little anterior one, when you put it down, I think it flipped. Oh, it doesn't matter, that's not going to get marked. Yeah. Okay, so this piece we're just going to throw in here, but you're going to mark that, the side that's up. Okay, good, and then I'll come here. Excellent. Let me just look - I'm going to move these a little closer together there, good. So, there's still some deep tissue remaining there. Okay, let's irrigate just a little bit more. Actually, if you - and if you put that down, you know, I have one thing I want to buzz first. I'll put you there.

CHAPTER 7

Here's our tumor. And you can see the - I think the ink is marking a little, but you see it's in - it looks like the margins are grossly clean. So yeah, we'll have the lights down now.

CHAPTER 8

So we'll start initializing now. And I'm going to cover the area with a towel just to make it even darker on the inside. Okay, so this is deep. I have that. Okay, this is - uh, lateral. Okay, this is inferior. Okay. This is, uh, medial. Have that one, thank you. And, do you need superior still? Or are you - Uh, yes, superior. Superior. Superior. Have that one. Okay, and anterior will be skin, I don't know if you want that or not. We can take that? Okay. So here is, um, anterior. And you can make a note that that is skin. Okay. Do you want me to take another anterior picture? Yes, it was also pretty dark. Okay, so that may be the reason. So maybe we'll use a different surface for that one. Okay, we'll try that for anter - hold on. So that's anterior now. Okay, alright. So, you'll let us know. For the serious - Okay. So, let's do, um - I'll just look around like this first, and see what we see. So now, I'm trying to systematically run the probe over all of the surfaces of the cavity here. And I want to go fast enough that it feels efficient, but slowly enough that I feel like I'm not missing anything. And I'm looking for red signal on the, uh, screen there. Okay, and then let's do some with the thyroid pole so I'm sure I'm getting a more sys - I'm not missing anything in the folds, though I haven't seen anything light up yet. So, we're trying to use something that will hold each surface still without taking up a lot of space. These are called thyroid poles. Or thyroid pulls, people call them, but I guess the technical name is pole. And so you can see there's a little piece of fuzz. I mean, it's a camera as well as a fluorescent detector, so if we had stitches on the specimen... Okay, good, so let's move this one here. This one here. And we keep covering this, because you see, you get the shine-through, um, the light's strong enough. Okay, good. And then we're going to scoot a little here. And here, and then you - It's hard to keep track of where you are with this, so I'm just experimenting with different ways that we don't lose track of where we are. Good, and then we'll come here. Nora, could you grab that one? Okay, good. And then over here. And over here. So, the area where the retractors are is holding things very nicely. Still, I'm going to move this one here. Good, and Nora, I'm going to actually pull you back the other way a little bit. Good. And a little less tension on that one. Okay, good, and then we're going to come like this. I'll have you switch hands. You can let go of the other one if you need to. Okay, here. Trying to reproduce those little things. Let's come over here. And here. Okay, so that's deep. I'll take a - I'm going to take a shave here. Let's have a, uh, tooth. Okay, and I'll have you do this. Could I have a baby abdominal, Nora, that you'll hold? Could you hold that? And can we get the lights back on, please? Thank you. So this is going to be called a therapeutic shave deep. Stitches final margin. Same surface. There's a fix. So this will be, um, lateral. And that's actually getting some shine-through, and still looks nice and negative. Here's superior. Here is medial. And I'm going to move this one here. Good, and this one's going to be over this way. Good, I'm going to shift this one up here. And this is now inferior. And this is the same general area where anterior came before. Would you stitch this? And then - and then after you stitch it, we'll have you flip it over and take a picture of the non-stitched side, just by gently holding this against the specimen.

CHAPTER 9

Okay, so I'm going to mobilize the tissue a little bit now, just for cosmetic purposes. I'm going to shift you over here. Is that my patient snoring? No. Okay, good, so I'm going to put a sponge in there. And can I see if you can try to rescue some of that fat? I'll hold on to this for a minute. Okay, I'll give you this back, good. Oh, actually, let's leave it right on here. Just because it's a little kinder on the tissue, on the smooth stuff. So now, we'll have to - Let's push that light away. And then, you're going to have that gently touch there. You want to be as perpendicular - so it's really quite on there and then we'll cover that. Um, so we're ready for that non... Okay, good, all right. And then Nora can take that. And are you - do you want to image the node, you said, too? Okay. So we'll just keep this tucked under here, and we're really careful that we don't do anything that, you know, cuts the cover. It has to have the special kind of image surface, but we have to not pull on any of that. Okay. So now, we're ready to do the - the node.

CHAPTER 10

So, let's have a 10 blade. Thank you. And then we'll go to the 2 Adsons. Okay, and knife down, 2 Adsons. So you'll pick up opposite me here. And here we're going to go - get a real good bite on that. A little bigger bite. Perfect. And we'll come down here. So, because we're filming this, this is one of the bloodiest ones I'll have this month. Of course. Of course. And now take it right out - right opposite me here, on that stuff right there. Okay, so now we're going to grab in the fat. So, if you can rotate your pickups 90 degrees so you're in that fat - perfect. Nice big bite. So, we have to go all through this subcu fat. Okay, and, see what we have oozing here. And so, what I do is, I get it down like this. Okay, and then take that out. Take your finger, and you're going to gently sweep like this, lengthwise along the incision. Just - yeah, and you're trying to gently bluntly dissect there. And usually it will get you right down to the fascia. And our node is this way, so you don't need to go too much back that way, just sort of in that direction. Okay, let's have a baby abdominal. And usually, in a younger person, the fascia will be intact, which is what we have here. And, uh, the nodes can move around in the fat, so your retractor and my finger are holding the fat so it's not going to go anywhere. So then we move this around, until we get the - the hottest signal we can. Right there. Then I put this down, and then... You can maybe rotate that probe. And then I'm going to poke through the fat right there. In fact, I'm going to need the Bovie for this one. The Bovie, yeah. Because this is still... Could you point that away from her? That's good. This is a low node, and there's a little bit of axillary breast tissue here that I'm cutting through. Okay, so then I'll put this in like that, and then I'll take the probe again. So, right there. So then, I just keep going deeper wherever that signal is. And there, I'm now through this fascial layer and down into that lipoma-like fat here. And sometimes I can feel the node. But I think, in this case, I can't quite yet, so I'm going to put you in like that. So now we're seeing that. But every time we go through a layer, the node can move. So now, it's right there. And we didn't use any blue dye, so we'll be looking for the node by its being a mauve color against the yellow - fat, or something I can feel. Now, there's a little bit of mauve right there. I don't know if you can see, right there, it's a little different color. Let's see if that's it. And then we see if we can pull it up into view. And there it is. Spread it just a little. Good. And see, I like to grab it with the Schnidt so it's held like a sling between the two. Maybe this one can even come a little - a little more. You see, there's really not anything attached to it, so as you fiddle with it, sometimes it dissects itself somewhat free. Okay, so now we're going to confirm that's the node. Good, so that's it. And then, could you take the clip applier in your - if you can, with one - left hand hold the retractor, and right hand this, what we'll do is I'll have you, um, put a clip right here and then I'll cut between that and the node. Good. Clip and release, good. And then we'll work our way around the node. Some things I can do a little blunt. Okay, put a clip right about here, straight down. Straight down, coming from above, yeah. Oh, let me show you, I want it to be right about there. Yeah, try that. And anything that looks like it could - Now there's a little vessel right there, if you could clip that maybe back about here. Perfect. And you're clipping it like this, because you - if this is the vessel, you're likely to get it. And if it's at an angle, you might - if it's thicker than you think, you might - or if there's a vein, artery, nerve... And now here, as we have this mostly out, I'm going to use the probe again, and confirm that this is in fact our node and that there's not another one behind it. It doesn't look like there is, good. Okay, and how about right on that little bundle, right there. And let's put one more, just for fun, because they're fun to use. I like the clip applier, myself. And now relax a little on your retractor. Good, and see how that widens the space there. So, with a small incision, if you pull in one direction, you lose view somewhere else. So, would you come and do the honors, and, uh, the count this node, down below? And then they're going to want us to image it also, so why don't you count it first. Okay. And this is a spare, I think. Can we do a count, please? Please. 1411, good. And then, um, while you're - And then let me take the probe and now I just look around inside, and then the other thing I was doing while you were counting was feeling to make sure there were no palpable nodes, because one of the ways you can get a false negative node is the sentinel node is negative, but the former sentinel node has been replaced by tumor, and the dye doesn't get to it. That all looks good. Okay, we can shut the probe off. And then - yep, and then I think we'll - yep. And let's image on... I always like imaging on this stuff. Yep, 1411. And then you can use this to shield the... I don't know if that's dark enough. And then you want to actually roll it over and image the other side. Can we do that? So we get the opposite side of the node. So we're not seeing any glow, so that's good. Looks like there's something towards the top of it. It's really, really small. Okay, so let's, um, which - Let's rotate, yeah, rotate around, and see if we can see, while you're looking, if there's any - So right there. So, there's a small thing there. All right, I have that saved. Okay, so we'll see. All right, so we'll send that for the regular permanent section. Um, if you put your finger in here, um, you can feel the fascia down there. So that's the clavipectoral fascia. And we're going to try to put a stitch in that when we close this.

CHAPTER 11

Okay, so let's have some irrigation. So, put this in slowly enough that I can keep up. And you want to get it down into that space, good. Just keep going, yeah. As long as it's not overflowing. Good. You can go a little faster than that, good. Looks like we're doing a good job here, good. And what's coming out is nice and clear, so now that that fill up, good, and then I'm going to just put my finger in here and swish it around a little bit. And that's still pretty watery, so I don't think there's anything bleeding there. Okay, good, and now we're going to do the same thing here. Put that in there. Okay, and you just go right - sort of aiming it all the way around here. And I like this because this is the only part that can burn, and if you're in a small incision, it's - you're less likely to get the burn marks on the edges. Okay, good. Okay, so let's have some Marcaine, please. I'll take a long, um, needle to start with. And so, I'm going to first put this in with the, um - to get along the chest wall, here. Okay, and I'll take this. So... And here there are potentially some vessels big enough to inject into, so I'm actually pulling back a little bit as I do this. Good, relax on that a little bit. So I'm giving local here on the, uh, deep aspect of where we were working and the, uh, chest wall or rib side. So, you won't have to do any of that. You can work on the skin. Okay, and then we'll take a short needle. I'll have you start coming in the side like this. And I'll take - let me have a short one also, and I can just show you. I'm going to do the same thing over here where you're going, just in that subcutaneous tissue, and you have at least 10 cc to use there. So, imagine you're getting 1 cm, 1.5 cm of local all around that skin edge. And then, when you've done that, you'll use whatever is left, and you can have some more if you need it, to get that fat between the skin and the fascia. I'll take the one bigger... Okay, more. We're going to keep using it all up with short needles. You're going to hold this like this, and you want to get - I've done everything below this hole here, but all this deeper fat here, you can do that, and then you'll also want to move this retractor, so you're getting behind where the retractor is, okay? So, you can have up to 10 cc, but if it's leaking, I can use it in the incision in the breast. Okay, I'll take some more. And I think you'll probably get about 5 cc in there, I would guess. That medial area toward the ribs is important, because that's where the nerves come out from between the ribs, so you want to be sure that's - that space under your retractor gets nicely numbed. In these spaces, there isn't any vessel that's big enough to inject into, so you don't have to draw back. Is that it? Pretty well saturated? Okay, I'll take what's left. Perfect. Okay, and then we'll have you maybe just take a sponge and blot that skin edge in the axilla and make sure that's okay. I think I'll take one more look with the retractor. Okay, needle back. Okay, that looks good. So let me - why don't you you hold that for a minute. Let me take that one deep stitch here while we have this view. So, I'm going to take a bite that's way down in here. And just close up that fascia here that we see. So I'll bite from there to there. And then after this, we're going to, um, put the clips in the breast with the clip applier. Okay good, so now what we're going to do is, you're going to... We have that hole in the breast. We're going to put clips at 12, 6, 3, 9, and one deep. Just to - so when they do their CT scan for radiation planning they can see where the cavity is, even if it's healed a bit. So, we'll have you start here, and I'd like you to go halfway between the chest wall and the skin. So, you'll take a little bite, maybe there, good. And remember you want - Actually, don't go and grab on that stuff. Grab maybe over here, on that. Good. And then go parallel to your bite, not - good. Okay, good, now here. 6 o'clock. Perfect. And then over here. Maybe around there. A little deeper, where my fingertip is, yeah. Good. And, um, as you're lifting things up with your pickups, you don't want to go this way, you want to go parallel to the pickups, because the tips get buried, and sometimes it gets caught on the clip. Okay, and then you have one up here at 12 o'clock, so, somewhere about there. Good. And then one on this deep stuff, say right about there. Okay, good. You'll take a bite that goes from here to here, and then tie it. She'll hold that for you. I'll take this. And then this is going to be your suture scissor, in here. So, she got 60 of 0.25% Marcaine plain. And Nora, I think she might need to take that out. It's such a small incision, it'll close a little easier if you have that. Um, not right now, no, but I probably will need you later. Okay, good. And then we're going to look at what we have here. So, we want this to all line up really smoothly here. Okay, good. So, um, can you do that, Nora? I'm going to put one in for you to tie here. Um, actually, why don't I use your suture. I'll just take that and leave my - I'll use my needle driver. So here, we want you to take one up here and I'll do the one down here that's a little more awkward. So, these are going to be buried bites that you're going to take not a lot of the fat. You really just want the dermis, here. And you want this to go - line up right about the there. And then these are the ones you tie really tight. Okay. So, 3 good, tight knots. And for these, you can't - because we're trying to tighten the skin, you can't press on the skin, so you're tightening them, like, with the 2 ends of the suture parallel to the skin. Perfect. And real tight. And you want to try to keep the skin tented up between bite 1 and bite 2. Those are perfect. And then you're going to do one at this end. You don't want it to close too the end, because you want to leave yourself a little room for putting your 4-0 knot in, so instead of putting it here, you're going to put it maybe about here. And see how this is trying to roll up, like this? You correct that by taking the bite here, and then going a little farther down on this side so it'll sit like that. Okay? So we're always - about - 45% of breast cancers are in the upper outer quadrant, so that's why we're always bumping into each other when we're trying to tie these. Think we still save a little time by working together. So, you try to take a bite that reaches back. See, the one thing that, um - there's a little more gapping here than down here. And so, some of that's how the bite's placed. So, um, we can have you try to take the bite really... So, pick that up, and enter perpendicular to the skin. Good. A little more superficial. Even more superficial. Good. Good. And you feel how you're digging in - you're in the dermis, so that's giving a lot of drag, and so that will tie tighter and better. So that looks good. Thank you. And here, over here, I'm using - I mobilized the tissue on the underlying muscle, and I'm pulling the pieces in so she won't have a hole here that can collapse on itself. Okay, good. And really, 3 knots is enough. So, really tight on each of those. Good. Good, and then we're going to run a 4-0 on that. Do you need another? Uh, no, I think he's ready for 4-0. Needle back. I'll take another 3-0. And so for this, um, you're going to have to sew this way, because - so you can keep your hand on that side. So, you're going to start with a, um - I'll just demo with this. You're going to start here with a bite that comes deep to superficial and stays a little on the deep side. Just one bite. And then you're going to tie a knot there. Three good knots. And you only need - This doesn't have to be very long, because you're just going to sew back the other way with no knot. So why don't you start that? And I'm going to give you this for light, your light. So, pretty close to the apex, there. And this is just to stay in the fat, this is just to anchor it. Good. But it has to be big enough it's not going to fall out. That's a little thin, I think. Um, third plea - uh, actually, we need some quarter, and some third. And let's see how much length you need. Where's the needle? Yeah. So where's the nee - oh, not even that much. You really need only about 2.5 times the length of your incision, so that's probably more than enough. Good and tight. And then you'll cut the tail. Really short, yeah. And then, your goal now - And, uh, Nora, I think we might need your finger. So, could you - she's going to hold it like this for you. Good. And so, your next bite, you want to pick up on the skin edge again, on this side. And you're going to go deep to your knot and come up superficial to it. And that will really dunk that knot. But not - no no, not this way, this - perpendicular like this. Yeah, so you're going straight below it, coming straight up in that superficial, above the knot. See, that's below the knot, still. So here, you want to- Let me help you a little here. So pull on that for a minute, on the cord. So, you want to pick up like this, really right at the edge, and that way you're making a little space superficial to the knot. There you go. And then those knots that you do that to won't spit. Okay, and then you want to go straight across. And I'd - uh, you want the, um, you want your stitch to not go too far here, you want it to really close this hole, so you actually want your needle to enter way down here, really close to the apex. And these are bites, make it like a deep dermal. Good, and you can feel that drag when you're in the right place. Even a little - a little deeper, um, parallel to the skin, and be sure you pull it nice and tight after each bite. That's what makes it watertight. I'm happy to say I could forget that I had this camera on my head. So, that's good. Of course, Max couldn't quite forget, since I'm poking him with it. We do these tests with the GoPros on. Do you, yeah? It's kind of weird at first, but then you forget. Yeah. It's like when you first have to wear gloves and masks and all that other stuff. And then when you get to the end, you're going to sew back the other way. You might want to blot, um, so you can see the skin edges better. And I'll get out of your way, so you can have your hand on this side of things. And you want to go as far into the apex as you can. I'm going to need one more of these. I'll just put that... So, let's see. So you're up there, so you're ready to start coming down the other way. So you can - You want to come down here, or can you lean from where you are? Yeah, come on down. Yeah, come on down. So, maybe 2 more stitches down the other way. And that makes it so the end of the stitch is woven back and forth in an area where it's not under any tension, so it doesn't unravel. But before you turn the corner - is this your first stitch coming back the other way? So be sure you've tightened it as much as you can the other direction before you tighten it here, because once you pull this one tight, you can't tighten the original part. Okay, real tight, good. And now, just maybe 1 or 2 bites more. One's probably enough. And then we'll have you bury it. Okay, good. And then, before you - Let me just - And so, the test we use here is, does it budge? And not much. Why don't you take one more bite and then bury it. And be sure you pull it real tight. And then you want to go straight in to the incision, and come out a little farther along, so you leave an end dangling inside, but you haven't made another cut in the skin. So actually, for this, um, can I make a suggestion here? So - excuse me a second here. So, you want to have your - it to be forehand, so you want to go straight down in with it like this, and then come out along here, so it's doing that. And what can help you with that is you pull this up first, and you use your pickups right here and then you're going to dive straight in between the pieces, between the skin edges, yeah, good. Good. And then come out somewhere down here. Good, and then just cut it off flush with the skin there. Okay, good, so we'll give that back to Nora. Yeah, I'm - this is my last stitch before I do the 4-0. And I'm actually on skin, so... You can count this as a second count. Okay, good, so we'll let them count, and then while I'm closing this incision, you can wand from the other side. That's nice. A nice closure there. Nora, I'm going to give you this, and take the 4-0, please. Thank you. Are we all set with the counts? Yep. Then can we wand? Okay. So, and here's this, uh, 3-0 back again. And I think we could use, um, we can use 1 medium and 1 small Tegaderm for the closure. Thank you. And this is where we're, um, deliberately - So here's what I was talking about. At first when I, after I turn the corner, I pull it really tight, yeah. And this is where we deliberately try to have it everted a little bit, so that ends up making the scar look nicer in the long run, even though it looks a little funny the first couple of weeks. Okay, so you can go ahead and, um, just clean up that. And just pat it dry, then I can put the actual dressings on while you're doing the orders. Nothing special for her? No, so she - and she has her script already filled at home, so you don't have to write a script. And you say, in the instructions, you say breast sheet, um, with exercises. And that will have everything she needs. And you'll see her before discharge? Uh, yes.

CHAPTER 12

For anyone who's, uh, thinking of - who's participating in our Lumicell trial, the key elements that I was doing then was I was being sure that the, the probe, which has a smooth glass face, was touching the walls of the cavity, the tissue inside the patient, very closely, that there wasn't a gap or air. I was trying to be a systematic as possible, covering all the surface area with the probe. And I was using something called thyroid poles, which are very narrow retractors, that hold the cavity smooth and stiff so I can cover it all without any folds of the tissue getting in the way. Um, the other key element is that it is a light-detecting protocol, and probe, so we dim the room lights, we take the spotlights off the field, and we actually cover the area of skin around the probe with a towel to try to avoid any light contamination getting into the cavity. Those are probably the main things if you're using the Lumicell tool - being systematic, being sure you have good contact, and shielding the field from any excess light.