Now the breast implant is going to be placed underneath this which is going to make it bigger and its going to do the opposite of reducing the breast so we are kinda using two different approaches here when we combine a breast lift and an implant. A breast lift reduces the skin enveloped an implant expands the skin envelope so there’s a fine balance here. Personally I like to do the breast lift first and then place the implant at the end. I will trim the skin if necessary to achieve my final result.

I am back – I have done a slight reduction on this left side – we’re pretty close – there’s still a little bit of difference and I think it has to do as much with position and the overall difference in the natural breast. Volume wise I think we’re pretty close. I took off about the equivalent of two implants which is a decent amount – she certainly could have elected to just use two different implants and not do this and that is usually the most common approach to doing this.

I’ve done the breast lift – base width here is a little wider than this one – position wise it will equal out, vertical height on this is longer than here and all these little things add up – her chest is different between one side and the other and these are significant issues that come into play when we perform surgery because most patients don’t even realize that they are different – until we start looking at and evaluating their breasts, so its important that I spend a lot of time discussing all these nuances with patients so there are no surprises.

So we’re here in surgery and both sides are done enough actually in the process of creating a pocket under the muscle – the muscle lays on the chest and I virtually always go under this because it allows a little bit more protection over the implant. So here’s that main muscle to the chest and I’ve actually started to dissect it and when I go underneath here you can actually start to see the ribs and the pocket – so that’s the pocket that I’m going to create and where to put the implant in will be done with them.

Alright we are back. The sizers are placed on both sides, they are temporary implants to allow me to get close. We have got 100 cc’s in this sizer here which I think is a very nice breast – its a full B Cup and obviously she wants to be more of a C Cup so we are going to be put in another 50, that’s 150, here’s 200, heres’s 250, and this is going to be close to 270. So as we increase the volume we round out the breast, we get more fullness up here and actually starts to distort the natural appearance in the breast and bigger is not always better. A lot of women like this look but it clearly is not a natural look. I’ll also is fighting against this portion of the breast and in her particular case Ive had to release down here just to make sure that I can make this fold as low as this one. This is our implant Ive got a 270 here – it’s a silicone implant silicone gel wonderful devices and I think that for her it’s going to be a nice. Its going to match her base width and so we are just going to go ahead and insert this relatively straightforward to put in – good — perfect… Ive got some anesthetic medicine – Ive got the implant over here – the implant over here – you got to see it inserted we’re gonna go ahead and close and then we’ll update you one more time.

Alright so what Ive done here is Ive internally closed everything and the final closure in this we call a circum- vertical breast lift this does not have the upside down T so that’s not what we want but when we do this I can take the sharp needle and go all the way around with this per minute stitch call gore-tex and what that allows me to do is that. And this is beautiful and there is a little bit gathering here this almost always goes away but this permanent stitch tends to keep the areola from widening up again the other thing I’d like to show you is that here’s the areola and nipple you can see this is where skin used to be and I just kind of peeled of the outer layer of skin and kept all this attached this has never been removed nipples nice and pink and there’s nothing about this that is at all concerning and so they keep their sensation and they keep their the whole nipple and we don’t disconnect it and so what this is basically done the lift occurs by removing the excess skin above the level of the nipple and this ends up moving up and so when we do that that’s how that looks and you can see this sides been done over here and that’s the final look at we trim that extra skin and bring it through and we will be done.

Alright welcome back to the end of the case we are done and we all agree she looks really really good Ive used dissolving stitches for everything all the incisions are sealed with a topical adhesive so the patients can take the dressings off the next day – they can shower the next day they wear a support bra – for 5 to 6 weeks – I see them at one week, six weeks, six months a year, I like to follow up with my patients. And everything is healthy. These minor gathers virtually disappear as the months go by. Implant height it looks good. The volume symmetry is I think very good Ive expanded the lower pull of this breast a little bit to match this one. Nipple height looks good. So I think that’s it’ll be exciting to see her back as the weeks and months go by. So thank you for being with us”