 Good morning, everyone. We're ready for our second case. This is much more complex than the first case. The first case is our bread and butter breast dog put in the implant. We all, everyone is happy. This is a mastopexy. What is a mastopexy? Mastopexy is when we lift the nipples up. Now this young lady, believe it or not, she's in her 40s. She looks spectacular. She has three kids and she just told me she's going to become a grandma, which I don't believe. Her skin is impeccable. She has great skin, no stretch marks or anything like that. I mentioned that to you is because I'm going to take the fat out of the abdomen and we're going to utilize it in the breast. Let's see what we're going to do for her breast. Number one, she had the Benelli breast lift. That's the one day advertise that's a scarless breast lift. This is what happens 10 years down the line after a scarless breast lift. What happens is that the areola, which should be this small, stretches and livens and encompasses more than 50% of your breast. That's another teaching point. This is our teaching point for this case. Beware. When you get the Benelli, eventually your areola will go from this size to this size. That's what happened for this young lady is because the skin tension pulls the areola and widens it. I talked extensively with her and explained to her what we're going to do for her. The nipple areola is here. We're going to center it in here. Unfortunately, she doesn't have enough skin for me to take out everything. Watch when I take out everything, how we see these tension lines. We're going to do as best as we can to remove as much as the areola to give her the best result. The other thing is she has implants and she had them from 2000. She has a cap so long this side. You can see it's a little bit harder. This side is still pretty soft, but in this day and age, we have a lot of patients that are moving away from implants and going to fat. What we're going to do, as I said, is we're going to utilize her fat, put it up there. I'm going to do a little extra for her today. I'm going to do some etching, give her some abdominal muscles. I hope she likes it. That's my present to her and we're going to put in as much of the fat as possible up top. Right here to give her the volume up top and not on the bottom because eventually gravity pulls everything down. As I say, it's like an origami. This goes to this, this goes to this, and it's going to look like that. Nice and beautiful, full on top. She wants a D cup. I'm going to do my best to get her up to a D, but I said at least a C, probably a D, but again, it's fat transfer. It's not implant. I'm taking live tissue from the abdomen. We take it out. It's dead technically and we transplant it to the chest. We have to be cautious that we don't put too much in at once because if we do, the center of it can't get blood or oxygen and it'll die anyways. It takes the judgment of the surgeon to do the best possible. But again, this is what happens with the scarless breastlet. I know a lot of my colleague surgeons advertise it and a lot of people go for it, but eventually your areola, look at how big that areola is. It's the size of an orange, so be cautious out there. Thank you so much and we're going to get it started and fantabilize this young lady and get her ready, bikini ready for the summer. I just want you guys to appreciate the areola as it's expanded. Normally the normal areola is about four to five centimeters. This areola is 10 by 11 centimeters and you can see how the line of tension has just expanded the areola because the tissue is thinned out and the way it was put together, which is called a benelli lift or a purse string lift, what happens is over time it just goes wider, wider, wider till it encompasses more than 50% of the breast. So geometrically it's impossible for me to remove everything and put it without leaving some of the red tissue. I told this to the patient and she was agreeable, so we're going to start the case. So I want you guys to see this. This is also a capsule, but this is a thin capsule. This is a capsule. Anytime any foreign body, foreign object goes in the body, the body forms a capsule, but sometimes the capsule becomes solidified and calcified and when it becomes calcified is when we get issues like the other breasts where it becomes tight and it becomes sensitive and it's painful. Here you can see it's soft, it's malleable, it's not impinging on anything, but on the other side it's harder because it's thicker, but again another teaching point. Anytime any foreign object goes into the body, you will form a capsule around it. It depends if the capsule becomes calcified or not. Patients with the implants that are textured that are removing them are going to surgeons and some of our colleagues are charging an enormous amount of money to get, take an end block resection. What is end block? It basically means taking out the whole implant and a capsule together as I'm doing right now. So we're, this is the rib, you could see I'm just peeling it off the rib for her. So this is called an end block resection and as long as it's safe you could do it, but sometimes it gets so thinned out that it's not worth the risk of taking it out and block. But here so far it's coming around smoothly so we're doing it. So look at this permanent suture that they used to put it together. It was, it's a circular suture, but it doesn't hold. It expands. It's not enough to hold the skin together. You see it's permanent, but here it is. I'm going to take it out right now. See part of it is there too. We're going to pull out this, here's some more of it. See that suture? So here we are. We removed the implant. We removed the capsule. I have a tailor tacked. This is what I imagined what she would look like with her breasts more conforming to her body. And we're going to act a fat we're going to take from the abdomen up top to give her more fullness. So it's not going to be laying on her stomach. It's going to be up higher. Her nipple position is going to be in the right place, right at midline. I think it'll look very nice. So we're going to get started. Stay tuned. So I want you guys to see this little like an octopus kind of thing like with the legs is the permanent suture they used previously. So we're just going to try to just gently just bring it out. It's a permanent suture you could see, but it's just totally out of place. It was circular now. It's like an octopus, like with legs coming all the way down here. So you could see it really expands and doesn't work. So here we are. Look at this. This is the suture. You see how I pull it out? There it is. Look at a permanent suture, but did not work again. Here we are. We're using the cookie cutter to put an imprint on a circular device, which we imprint on it. That's why it's called a cookie. And then we could get a nice circle just like we did on the other side. So we dig it in and boom. Look at that beautiful circle. Yay. Here's an inside view of a chest. This right here, these diagonal fibers are the pectoralis major muscle. You see how it fasciculates? Here is the capsule. You could see how it's integrated. It was under the muscle, the implant, and you could see the capsule. This sheer thing is the capsule right there we're taking out. Her capsule was pretty thin. It surprised me, but look at, I'm peeling off and keeping her muscle fibers. That's just good technique. You could just rip them off, but you don't want to. You want to leave as much behind of the natural tissue as possible. So you're just, you just start dissecting and leaving as much of it back as possible. So here we are. This is the posterior aspect of the capsule. I'm just trying to get all of it out, but this is where caution comes in because it could be thin. Right here, we have intercostal muscles, ribs, and you know, the underneath that is the lung. So you don't, you have, you want to be very careful. Look at how sheer this is. You don't want to go, you don't want to go too deep here. Caution, caution, caution. So here we have it. We have a superior pedicle. So the blood flow actually to the ariola nipple is coming from a superior pedicle through these coming in, remaining viability of the nipple and ariola. This is going to get wider. So what now we're going to do is like origami. We're going to put all this together and form a breast. It looks like an explosion, but really this was meant to happen. But this is what end block resection of a implant includes the removal of the posterior capsule from the ribs. So here we are. We're getting the fat from the abdomen to transfer to the breast. So look at that golden yellow fat. It's all nice and yellow, golden, no blood. That's amazing. So here are the implants we took out. They were very small. They're about 240cc. So here she had two small implants. This is the extra skin we took out. You can see from each side. We took out the capsule. There's the capsule. We took it out. Instead of the 240cc implants, I added about 500cc of fat in each breast. And now we just got to sit and wait for the angiogenesis to start and give oxygen and nutrition to the new fat.