Breast Lift and Implant Exchange Part 2

This is part two of a breast implant exchange with breast implant repositioned from above the muscle to below the muscle.

I'm demonstrating the pectoralis muscle, which you can see right here. You can appreciate that it is a relatively loose muscle. It is not densely adherent to the chest, and that's because this muscle has been designed to glide. The retractor is actually in what we call the subglandular plane, and it's above the muscle. So an implant, when it's placed in the subglandular plane, it's actually above the muscle.

The majority of the implants I place are below the muscle, and you can get a sense here that the device that I'm using is called a suction, and that suction device I'm using to demonstrate the two different pockets. There's a pocket above the muscle, and a pocket below. I just put my finger in the pocket that's below the muscle, but I have not really created it yet. So at this point, I'm going to create a submuscular pocket, and that will allow me to move her implant from being above the muscle to below the muscle.

Now I'll place this retractor below the muscle, and now I will create a submuscular, or below the muscle, pocket. The overwhelming majority of breast augmentation surgery as well as secondary surgery that I do, I place the implants below the muscle. Now, I also use a much smaller incision. If this was a primary augmentation, her entire incision would be about the width of that retractor, which is the gold-handled device which I'm holding in my left hand. So it's a much smaller incision. One of the benefits of this particular surgery is that you really get to see the muscle and how it comes up, and that's because this patient had a much larger incision done by the other surgeon.

At this point, we have created two pockets. One above the muscle and one below the muscle, and now I'm putting the implant in below the muscle. The pocket that was above the muscle was actually created by the other surgeon, and I had to take out the scar tissue pocket, which was demonstrated in part one of this video.

I've actually sewn down the pocket above the muscle, so the only pocket she has that's easily accessible is below the muscle. You can kind of see how big of an incision that was that the other surgeon had used. Because the incision's so big, this silicone gel implant goes in very, very easily. Again, these implants are now above the muscle. You can tell she's going to have a breast lift like we talked about in the first part where I've taken away some of the redundant skin.

What I have done at this point, and what you are seeing, is I've gone ahead and closed the wound under her breast on the left side. That's going to allow me to assess this breast for shape. I have not done that on the right side. So now I'm using a stapler to determine how much skin I need to take out, and how high I want to raise the nipple. Most of these marks are all made before surgery with the patient standing, and for the most part those marks are very reliable and very predictable. In some instances, I will make adjustments based upon what I find on the operating table or [interoperably 00:03:49].

You can kind of see now we've made her areola a lot smaller, which is what she wanted. Her breast is coming together very nicely, and fortunately for her it doesn't look like she'll need a vertical scar or a scar from the areola going down to her chest. She's only going to have one new scar created from me, and that's going to the scar around her areola. The other scar that I used to do part one of her surgery was actually created by the initial surgeon who did her subglandular breast augmentation. That scar is still going to be there, but I've made it thinner, and I certainly haven't made it any bigger. It should be a thinner scar, and hopefully not get any pigment in it.

At this point, I'm pretty happy with the shape of that breast, so I don't think she needs any more skin taken out. I will go ahead and close that wound a little bit temporarily with staples just to make sure that I'm happy with how it looks, and I am. At this point, I will try and reshape the right breast to match. What you see at this point, for diagram purposes, is the right breast wound had not been closed. You could tell how big of a gap there was on that right side, and how much lower the implant sat.

For demonstration purposes, I'm showing you the final layer of this wound closure, which is a running layer. Again, this woman is from out of the country, so she'll have no sutures to take out, and even this final layer will be done in such a way that she won't have to have any sutures taken out when she returns home.

At this point we're going to go ahead and do her breast lift. I felt like in addition to the redundant areola that I took out in part one, that the right nipple areola complex had to go a little bit higher. So I'm taking out even more skin on this right side. I've just cut the skin, and I'm going to go ahead and cut out that extra skin by deepithelialization. I'm going to lift up that skin and take out the extra skin, leaving the dermis down, at which point I'll start to close the wound.

You can tell that her nipple is still attached to her breast. I haven't affected its blood supply or the innervation to it. Now in a sequential fashion, very similar to using a clock, I will go from 12 o'clock and close that wound, which is what you're seeing here, and then I'll go to 6 o'clock, and then 3 o'clock, then 9 o'clock. Then I'll go to all the different times of the clock to bring the wound together in a sequential fashion. This is done all with dissolvable sutures, and you can see here that she's not under any tension, so this wound should heal very well. It really shouldn't widen much at all, and she should have a lovely result.

We're using time lapse photography here so that you can get a sense of how it goes. The breast will be wiped off, and it will be dried. Again, on this side she did not need the vertical incision. She'll have Steri-Strips on. When I do these surgeries, I like the Steri-Strips to stay on for about a month, and that really helps the wound heal well and prevents her from getting thickened scars.

If you'd like to see her results, or results similar to hers, please visit my website.