you an interesting patient who has previously had a breast uplift with a periareolar mastopexy

and a PIP implant. She is worried about her PIP implants so I'm going to exchange those.

Also her areolas widened quite a lot so I'm going to show you how I reduce that. Reducing

the areola, leaving a permanent stitch around the implant.

In this operation, number one I'm going to be removing this scar. She's got a long, wide

scar. Let's just measure it. It's six and a half centimetres which is really longer

than you would normally get for breast implants. I'm going to revise that. Then, you can see

how her nipple is stretched? She said initially it was much narrower, but with time it tends

to stretch so I'm going to remove all this area here, this nipple area here, then I'm

going to bring the skin in to here.

Then I'm going to put a permanent prolene stitch, which is going to to be permanently

buried, around like a purse string so that will stop anything from widening. The nipple

will stay nice and narrow. I think if you're doing an areola reduction you have to put

that prolene in or else, unfortunately, the areola does tend to stretch over time.

So the first stage anyway is to go and see what the PIP implant looks like.

I've just gone down to the implant here. I don't know whether you can see. Can you see

all this silicone here? We quite often see that. Can you see all that free silicon just

coming out? That's the gel bleed and that's basically the silicone oozing out of the implant

because of the porous layers. Can you see that there?

Camera Operator: Can see it coming down.

Adrian: Yeah all this silicone. There is quite a lot lying around in this patient. I mean,

we've seen this a couple of time, today even, all that free silicone.

I'll just suck the rest of it out. Can you put the sucker on please? And a Langenbeck

[sounds like 02:12] please. Great. Can you see it all coming out? It normally tends to

go to the lowest part of the breast when the patient's standing. When you're standing it

will be down here and when you're lying it tends to go down mostly to this area because

that's gravity.

Quite interestingly, you can see the muscle, see the implant under the muscle. I don't

know whether you can see there. That's the muscle. This surgeon put this implant under

muscle and hasn't actually released the muscle very much. See how the muscle's still contracted

there. When that happens sometimes the implants lie very high. Which hasn't happened in this

case. Also, can you see that the implant ends there? That's the inner aspect of the implant

just there, where my sucker is, there. Can you see that? Really, it's far too narrow

for her and giving her no cleavage. It's going far too far out the sides.

Overall, I wouldn't give many marks out of ten for this original operation really. Number

one, all this is stretched. Number two, the implants are too far away. Number three the

scar is too long. Anyway, there you go.

We're just going to remove the implant now. There you go. It's intact but as we always

see with these 350 high profile, you can see all of this gel bleed and so basically, because

the implants were made without the protective layer, the silicone gel can ooze through.

It hasn't got the fluoride [sounds like 04:07] layer, so the silicone is... it's not sealed

for this internal silicone. What happens is silicone leaches through and then because

of gravity, the bit that empties is the top bit here. A lot of patients that I'm seeing

say, "I've lost a lot of volume at the top here." You see why. The top's empty because

the silicon that was in there is now, I just sucked it out. You can see why patients become

more heavy at the bottom and less full at the top when really, what they would like,

is a fuller appearance at the top.

The other thing about this implant I would say, is that it's gone down a little bit too

low. This should be where the fold is, the pocket implant shouldn't be able to go any

lower than that. But look, see if I put my finger in, can you see? The pocket is far

too low. It goes down to here. I'm going to sew that pocket down because what's happening

with our lady feels that her implants have gone down. Not only has it lost volume at

the top but it's sitting below the fold. A lot of surgeons would stitch that fold down

so that the implant sits there with the fold and the crease rather than down there, which

is not where it should sit. The further down the implant goes, the further that way, the

less fullness you get here which is where you want it.

I've stitched the fold back so you see my finger can't physically go back any lower

because that's where I've sewn the fold. So the next layer is putting our implant in.

Now I've corrected the fold by internal stitching so you see, I don't know whether you can see

the implant can't go any lower than the fold. Whereas it was down here.

The next stage is to check my markings here. For this we use, people call it the cookie

cutter. It's a nipple marker essentially. What we do is just mark the roundness. You

can see how well it matches my marks. We do it as just a double check. You have it on

the inner circle, the outer circle, or the inner or outer one there. This is the narrowest

one. I tend to use the narrowest one because I think most patients want slightly narrower

nipples in my experience. The areola, so you can tell we have it one that one, sometimes

on that one, sometimes on that one, sometimes on that one. It just depends on the size of

the areola the people want.

My next stage will be to remove this area of skin here. Remove the top layer of skin,

from that sort of doughnut area. That bit to that bit, that point to that point, that

point to that point, and that point to that point. So I sew the 12 to the 12, the three

o'clock to the three o'clock, six to the six o'clock, nine o'clock to the nine o'clock,

then two stitches in between. The will bring everything down and I'll show you how it looks

at that stage.

You see now, I've stitched each of the four quadrants to each of the areas and I'm going

to bring these areas in. I'll show you that in a second. You have to use a special stitch

technique to get it to sit down properly. It's a secret that I tell all the trainees

but I--if they come to watch me I'll tell them how to do it and I'll show you.

This is, with everything stitched in, this the end of the little stitches here and then

I've got a prolene in there. These little pleats settle down. They take a few months

to go down but there is a permanent prolene here so that circle can't widen. The nipple

cannot get much bigger than that.

Just remove this implant here and you can see, again, we've got deflation of the top

of the implant, a lot of silicone gel bleed on both sides. The bleeding blood vessel,

that will stop in a second. Can you see the lack of fill in that lower part of the breast

and all that gel bleed? Pretty typical PIP implant, that's the sort of appearance we're

seeing a lot with the bulk of the silicone implant being [inaudible 08:33].

Going to cookie cutter the nipple, we call this a cookie cutter, because it's supposed

to look like a cookie cutter. This is just to check my marks around the areola which

I think are quite good there. Then I'm going to remove all the tissue between this mark

and this mark all the way around.

The end of the procedure so I'll just show you the nipple on that side is elevated and

this is the nipple on the left side which I reduced significantly, as you can see. The

white area is the adrenaline affecting the skin which will wear off in about an hour

or so. I think we've got a better bust size, better cleavage, higher on this side, and

smaller areola, which is rounder on this side, when the pleating effect settles down.

The implants on both sides, this is the right one. As you can see, when it's removed the

gel bleed all dries up. You can see how flat they get in their upper part. I don't whether

you can see that actually but see how it deflated the implants get in their upper portion because

of the gel bleed. We think that basically the PIPs are lacking that protective layer

which lets the gel come through. You can see, this is how it would be sitting inside a person,

you can see how much deflation you get in that top part. That's the lot number 350 ccs,

28508. We got the same lot number on the left so that's good to have the same lot number.

It means they were made on the same day, same batch, anyway. And then, I don't know whether

you can see that again. So we've got the same issue here with the implant deflating and

I think that's what happens over time. Also, you get this flattened area at the top, here.

Flattened rim which is prone to buckling, rippling, and folding and then you get a fracture

in it. Overall, pretty average condition for a PIP I think in this lady. Typical gel bleed

and deflation in the upper pole.