 Good morning everyone. Dr. Sol here in Beverly Hills. We have a very special patient. She's a VIP. She's super nice, beautiful, everything. She's here to visit us today. We've done some work today. We're going to do some other stuff. So let's take a look at her and see what we're going to do. So she has breast implants in. They're 660 implants. At every stage of life, people have different ideas. People are in different ways. Different things look good. But she's slimmed down. She looks spectacular, curvy. Her implants now make her top heavy. So what we want to do right now is we want to balance her top with the rest of her. So in order to do that, we're going to remove the implants and put in smaller ones. We're going to go somewhere between 345 and 405 silicone under the muscle. And what we're going to also do is do a breast lift. There's excess skin, especially going from 660 down to 345 to 400. We're reducing by about 40 to 40 to 45 percent. Not quite 50 percent. It's a good reduction. So what's going to happen is the envelope is going to be too much for the content. She has good breast tissue right here. Look at that. She has good breast tissue. She told me she developed that over time. So, man, you know, she was smaller, thinner. Now she has more breast tissue. We don't have to use as big as an implant. We're going to use a smaller implant. And as I always say, it's like a origami. You've seen my points here. These are going to come together. These are going to come together. These are going to come together. So we're going to give it, I want to give her a more roundish look to her breast. She's very full here, but it kind of looks like more squarish. Want to make it rounder for her. And, you know, the implants are so big for her right now. You can see there's like, there's almost touching each other, which also has its own issue of skin on skin, which is you get, you get moisture in between. You can get infections in between and stuff. Skin is never meant to be on skin causes trouble. So we're going to fix all that for her. It's going to be spectacular. In addition, we're going to do some work on her arms and get these arms smaller. Again, just fit her back to what she looks like in her body. The breasts look too big for her. Makes her look top-heavy. We're going to correct that. Make the arms smaller. She's going to be fantabulized today. Stay tuned. Good morning, everyone. So you guys have seen the cookie cutter. They call it a cookie cutter because it looks like a cookie. And it's a very round, circular instrument. We put it right around the areola to the exact size we want. So this is a 42 millimeter, which is aesthetically pleasing areola. We're going to put the nipple right in the middle of it. We just put it on there, screw it on, boom, boom, boom. And it leaves an imprint of across where to cut. Perfect. So next thing we do is we're going to go over our line. Now, the nipple does not get detached from the blood supply below. It's always attached. People say, oh dude, take off my nipple and place it on. No, it needs to be attached in order for it to have the blood supply. So it never gets detached. It's always attached or else it would die or it would be a nipple graft and you would have no sensation. So it is completely attached, but through magical moves and moves up to where we want it to go. So going through, we're going through here through the side and I'm going to take out the implant, which is ruptured. So that poses a little bit of a concern. You can see it's ruptured. There it is. I'm going to try to clean it up as best as possible and get it out of there. So here we are. I'm actually taking out the implant. Look at this. It's just through this suction device. Look at this. We're just taking out the ruptured. You can see it's totally ruptured implant. We're taking it out. I'm going to wrap it up in this. This turned from an easy case to a very more complex case because she had a ruptured implant. So what we had to do is we went in there and cleared out the implant. We took out the posterior wall, anterior wall. There's the pectoralis major muscle. This is the posterior wall. This is the ribs. This very thin sheet is what's between the chest cavity and the lungs. So we have to be very careful. It's very tedious work, but we were able to get it off. We cleaned it out. We're going to wash it out more, but it's important to get as much as the silicone out as possible. This is one reason where the implant company says they're good for 10 years. After that you should get an MRI or replace it. Another thing is this is when someone comes in and says, I already have an implant. It's easy for you to just take it out and place another one in. No, because it could turn into a very complex case if you have a ruptured implant, as in this case. But we were able to clear it out. Look all nice and beefy red tissue. We're going to clean it out more. The next step is going to be we're going to start our mastopex. Let's hit her up. So here we are. We sat her up. We took out the implant. We took out the silicone everywhere. So I'm looking at the areola being right here and the nipple would be right in the middle. And we went down to a 360 so it'll still give her a full C small D breast. And you can see how the skin is nice and tight. And it's much rounder rather than rectangular and squarish like that. I think she's going to like it. I think it looks nice. And the other thing is her skin isn't touching with each other to cause her to have an infection with skin sores. I think this is a very nice size for her. This is 360. Literally half the size that she had before. She was 660. This is a 360. Look at the proponent up here. Look at how high it is. This is going to look much more natural for her. So again we use the cookie cutter to get a perfect circle. Then we are going to go around the circle delicate. We don't want to go too deep. We just want to go bring through the skin and not get the tissue below it. It's attached still and it gets its nutrient oxygen and blood flow from below. So we're going to start this one. We're going to make the low incision anticipating that this side of the implant will be ruptured. So we'll see. Hopefully it's not. But since the other one was I wouldn't be surprised if this one is too. So here we are. We're opening up the breast. We went from an incision down low. You can see that the light is hitting right there. That blue stuff is actually the gel. It's a very thin capsule. So I'm trying to keep it intact so the gel spillage won't be all over. I'm suspecting she does have a capsule because it bubbles. There's different bubbles here. So I believe that she has a rupture but it's contained within this small shell. And we're going to it's a very sheer shell and we're going to try to keep it intact. It hasn't calcified so it's very thin. I wish it would have been calcified. Then it would give us a thicker shell and it would make our job easier. So here we are. Look this is the top of the capsule, the implant. I've dissected all the way as high as we could go this way. So now we're going down below. We're peeling it off the rib cage. This is some of my colleagues advertised taking out the implant with the capsule and everything for people that have the implants that cause cancer. So that's how they're doing it. They're taking out the whole thing, taking it out from the posterior anterior, taking it, taking out the shell. But this is a smooth implant so we're not worried about cancer. It's the textured implant so we're not dealing with that but we're still being cautious because we want to keep it as clean as possible. So you know this is a very thin layer we're going through so we're working very very cautiously as we move up and peel the implant off the rib cage. Remember we have the ribs and the flora right underneath us so we continue to be very slow, meticulous and cautious. So everyone that has an implant forms a capsule. Even if it's soft you have this capsule. Sometimes it's sheer, sometimes it's calcified. But look at how we're trying to take it. It's called inside shoe capsule removal. The posterior wall is intact, the lateral is intact, superior, medial. All the implant is encapsulated and it restricts it from moving. You see how it's adhered? So when someone has an implant which is a capsular contracture it's stuck in a place. This is what's happening. This capsule is a body's reaction to a foreign object and it encapsulates it and sometimes this capsule becomes hard. Sometimes it's soft but that's what's called a capsular contracture. We're still going on. You can see the implant it's still intact. We got a little poke in there but this is under the pectoralis. Look at this is the pectoralis muscle. Over time it thins out. So we're still trying to take out the implant and block all in one piece as much as possible. I know we got a couple of small little holes in but we want to save as much of the muscle as possible so that when we put in the new implant it will be submuscular under the muscle. But just so you guys know whenever you go in bigger implant you just make everything else smaller because the pressure of the implant on the fat and the muscle just makes it thinner. This is the pectoralis muscle now. This thin thing here, this is it. So I'm trying to save all of it using you know precise dissection making it as smooth as possible. So look at it. We almost have the whole implant out. This is the pec minor. Look it's stuck like Velcro. Look at that as I'm pulling it back. This is the superior aspect of the implant all the way to the top. The clavicle. We're peeling it off very cautiously. Again this is incredible. I'm sure you haven't seen many of these cases like this because this is pretty hard for stuck down. So you can see the whole implant is right in this capsule. We're taking it out in one big piece. This is how we started. We lifted this up. We brought this out. We lifted it off the chest wall. You can see as I'm lifting it very cautiously. Look it's almost all of it is released. This is nice dissection. It takes a little bit longer but it's worth it for the patient to get a better result is to have this capsule all out like we have done today. Here is the final step of the release of the capsule there. Boom. We got it all nicely out. That's incredible. I love it. So right now what I'm going to do is I'm going to make this pocket smaller. The implant was so wide that her implant was going to the side. So what I'm doing is I'm suturing the lateral aspect and closing it down so the implant will stay centered in her chest rather than fall in the side when she sleeps. So look at how I closed the pocket here. So now it's the implant cannot go to the side. It's nicely sutured. Look at the suture line. It's sutured from the inside so the implant will lay right where it should in the middle of her chest. Not going laterally. This is different than a totally different case than a breast dog. Usually we're going through a small hole through a funnel. Today I just changed my gloves, brand new gloves. The implant is in betadine and triple antibiotics and we make sure it's twisted and surely in there and slide it all the way in. Bam. Look at that. And we'll put some antibiotic on it. Beautiful. So we've done our dissection. The breast looks wide open but look at with one stitch how powerful this stitch is. It forms into a cone. It brings the breast together. Look how beautiful that is now. Okay so we're done. So you can see that she has nicer space between her implants. She has lateral full. It doesn't the implants don't fall all the way down and they're not hanging on her skin. You can actually see her torso. So we're done. We changed it down from 660 to 365. We did a mastopexy and we'll see her back in the office tomorrow.