31 year old 3 children likes proportion best in padded brassiere 34 B or slightly bigger. Patient 5′ 11″ tall and 140 lb. now 34A. Exam revealed “adolescent” shaped breasts (I.e. entire breast below nipple all the way to the chest was visible without a fold). Patient brought models’ pictures to show desired proportion that was duplicated at Dr. Pertsch’s office with a stretchy brassiere and sizer implants. At surgery under general anesthesia via a periareolar approach smooth saline implants were placed under pectoralis major muscle. To improve her asymmetry 270 cc mid-range profile implants were used on both sides but filled to 300 cc on the right and 275 cc on the left. After her surgery her breasts were very soft as implants moved away from the examining fingers. Implant itself was barely perceptible. All nipple and skin sensation remained normal. She was very pleased with her appearance and results. Although she had worn sizes, 36B, 36 C and 34 C the 36C fit the best. “After” pictures taken 1 year 2 weeks after surgery.
40 yr. old with two sons now 14 & 17 yrs., each breast-fed for 1 yr.
Exam: 5’4” 122 lb. 34A pseudoptosis L slightly larger.
Breast augmentation was performed via infra-mammary incision, sub-pectoral (under muscle/dual plane) implant location, intravenous sedation then local by Dr Pertsch (no anesthesiologist present). Round smooth saline mid of the range intermediate profile 330 cc implants filled with 355cc on the right side and to 350cc on the left to improve slight asymmetry. Very happy afterwards. “No one can tell I’ve had augmentation”. 36C fits best as 36B and 34 is a little tight.
Exam revealed implants easily move in their pockets giving very natural feeling soft breasts. Sensation had been reduced early after but was now almost normal and improving. She notes her right breast changes shape slightly during sex due to chest muscle activity. Post op photos taken 2 yrs. 5 mos. after when she came back for another non-breast procedure now 43 yr. 5’4” 123 lb. 36C. Her R side implant was replaced after deflation 6.5 years after initial surgery.
25 year old teacher was a 34B 5’6” 135 lb. had breast augmentation sub-muscular (dual plane) through axillary (armpit) incision under general anesthesia. Smooth round saline intermediate profile implants 425 cc filled to 450 cc on the right and only 425 cc on the slightly larger left side.
Very happy with her 36 C very soft breasts with mobile implants barely detectable on the underside her breasts. She had liposuction performed at the same time as her augmentation. She was so happy with her inner, outer thigh and hip liposuction she came back 3 years later to have more areas of liposuction.
After photos taken 11 years 9 mos. after surgery now 37 year old 36 C 5’ 6” 142 lb. no children. She feared her 10 year old implants should be replaced. In fact, there is no need to have additional surgery unless the implant has broken or further change in breast size or shape is desired.
30 yr. old, son 3.5 yrs. old, before surgery 5’ 6” 130 lb. 34A
She underwent breast augmentation via periareolar incision, under muscle (dual plane meaning under the big pectoralis major muscle but over the thin muscles lower most part of the breast). Smooth saline implants filed to 350 cc on the right and 345 cc on the left to account for slight asymmetry.
After surgery she was 36 B except in Ralph Lauren brassieres where she was 36 C. “Pretty perfect position. I’m surprised at how natural they look and feel. Nice cleavage not too little or too much.”
After views were taken 11 years after surgery when she came back to see Dr. Pertsch about an abdominoplasty. Still 130 lb. no longer wears a brassiere. Exam reveal near invisible periareolar incisions, full sensation, very moveable implants give breast a soft, very natural look and feel. Photos show patient squeezing lower breast to show how freely implant slides within its capsule to give a soft natural feel and look standing or laying down.
At Dr. Pertsch’s office ask to see more photos of this patient comparing results 6 months after surgery and then 11 years after surgery. These show progressively more natural appearance with time. Also views with and without animation (i.e. photos taken during pectoralis muscle contraction)
Breast Augmentation with Lift
23 year with 4-year-old son had met two of my previous patients. Happy with her breast before her pregnancy but now sagging. Wants to be “restored’ better in bathing suit, look better naked without bra and wants a lift because of the sagging. Exam 5’ 4 ½” 128 lb. now 34C although can wear a 34 B+ a B is too small. Exam revealed grade II ptosis (drooping where the nipple hung below the fold under the breast) and diffuse pale stretch marks.
In office sizing with a brassiere and sizer implants showed her preference for 450 cc implants was consistent with the photos she brought demonstrated her ideal outcome. Surgery with the “short scar” breast lift (mastopexy) with sub muscular 450 cc moderate profile textured silicone implants.
Initially there was excessive fullness of the upper breast reduced with stretching exercises by the patient and a breast strap over a 4-week period. Post operative photos 3 months after her surgery. Nipple and skin sensation intact. Very happy with outcome and 34 DD size. She has referred two friends to the office. Pink incision color fades and other slight irregularities typically settle within 12-36 months after breast lift surgery.
Breast Implant Deflation
Patient 26 year old wanted a fuller breast size in proportion to her body. She was 5’6” 145 lb. 34 -36 B before her surgery.
Breast augmentation under pectoralis major muscle via periareolar incisions using smooth round saline implants 420cc minimum fill volume filled to 450cc on each side, intermediate profile. IV local anesthesia by surgeon. Post op bra size 36D very soft and mobile.
She had 2 children and gained weight to 200 pounds during the second pregnancy 2 years before these after photos. She had no problem breast feeding her children after her breast augmentation procedure with periareolar incisions. Breast were very soft and implants difficult to detect as they moved very easily with the lightest touch within a large pocket.
After pictures 9 years 10 months after surgery when she returned to the office feeling the R breast had become softer and smaller starting about 2 previously but had not gotten any smaller. Exam 5’4” 135 lb. 36 C or D brassiere confirmed R side significantly smaller (~75 cc = 5 Tablespoons) Most likely the R side developed the smallest pinhole leak. As there is minimal pressure on this implant as very lax skin, capsule and very mobile implant, implant did not deflate all the way. She has elected to replace both as she is just within the manufacturers 10-year warrantee period. She restored original implant size plus 30cc (2 tablespoons) more volume to each side. photos not yet available.
45 year old was cup size B in high school-> size C early 20’s-> remained size D after first child-> remained size DDD after 2nd childbirth -> measured 32G 3 years ago. She has neck and back pain, and pain between her shoulder blades. There was pain at the base of her neck as well as pain in her shoulders R worse than L. her back always felt as though it needed to ‘crack”.
Before surgery exam consistent with 5’1” height and 143 lbs weight and brassiere size 32G. Grade II ptosis on both sides. R side was larger than L. Preoperative estimation of tissue to be removed 500-550 Gms on larger R and 450-500 Gms on smaller L. Insurance paid for surgery to reduce symptoms.
Surgery consisted of the “short scar” vertical technique. On the right 573 Gms was resected and 100 cc of liposuction contouring of the outer breast and to reduce chest wall fullness next to the breast totaled 673 Gms removed. On the Left 476 Gms of breast tissue was surgically removed and 100 cc of liposuction from the outer breast and lateral chest wall for a total of 576 Gms removed totally 2 ¾ pounds removed.
After surgery she had complete relief of her back, neck shoulder blade and shoulder discomfort. Her old brassiere under wires hurt even though the cup is real loose. Her current 36C brassiere is too loose. She thinks a 32 or 34C will fit best but is going to be sized for the best fit. She has some numbness remaining on the left side but realizes it takes up to 2 years for it sensation to maximally improve.
After photos taken only 3 ½ months after surgery. Scars will continue to improve for another 2 years and in most cases become pale thin barely perceptible lines. She now weighs 130 Lbs.
She very happy she had it done and very happy with the result.
Patient happy with size C+ but after two childbirths had atrophied to A+. She underwent surgery with another doctor: breast augmentation with limited breast lift. Saline implants were placed under pectoralis muscle R 250 cc and L 300 cc.
Only 2.5 years later she presented to Dr. Pertsch noting the implants seemed too high and her breast tissue seemed to be sliding off the implants. She had undergone only a limited “circumareolar” or so called “donut” mastopexy by the other surgeon and the breast drooping had reoccurred quickly. Exam consistent with 5’5 ½” 130 lb. 34C size now age 39 yrs. Pre-op photos reveal breast tissue sagging off of implants that were relatively high on the chest.
Dr Pertsch performed a complete breast lift on both. A small amount of breast tissue was removed to during glandular reshaping to give a longer lasting result. 36 gms of tissue were removed from R and 57 gms removed from the L. The R breast seemed slightly larger before this surgery so 25 cc of saline was added to L breast implant to improve symmetry. Original implants (only 2 years old) were placed in a slightly lower position on the chest wall (an inferior capsulectomy allowed implants to settle). Photos taken 2 years and 4 months after Dr. Pertsch’s surgery. 5’5 ½” 135 lb. 36C (almost D) but happier with improved shape. Breast felt very soft as implants remained very mobile within their pocket.
Breast augmentation revision: 4’11” 120 lb. 34C lady after augmentation elsewhere 9 years prior. Breast augmentation sub muscular with saline PIP breast implants.
L side was noted to be deflating in the shower after going for a run days prior to consultation. (“PIP” pre-filled saline implants from France or Poly Implant Prosthesis implant shells were high temperature vulcanized that made them softer but more abrasive. They are now are known to deflate much more frequently. The FDA took them off the US market May 2000. Current saline manufacturing uses room temperature vulcanization techniques so the shell lasts much longer.)
She wished a little smaller breast volume than the 325 cc originally placed on each side. A natural look was desired so no breast lift was performed. Silicone implants were selected. Intermediate profile was chosen consistent with her breast measurements. Her original breast tissue was palpated to be larger on the now deflated L side. 225 cc smooth gel implant was selected for the slightly smaller R breast and 200 cc gel for the slightly larger L. Post op photos taken 3 months after her surgery. She “loved it” and is “really happy” with her smaller size and ongoing “natural” appearance. She could still wear many of her 34C brassieres although some 34C now too loose. She noticed her nipple sensitivity had increased.
Breast Revision (Strattice ACD)
23 y.o. underwent TUBA (Trans Umbilical Breast Augmentation) implants 550 cc saline filled smooth surface moderate profile implants placed on each side by another surgeon. The left side deflated the next day and was replaced. Over time the implants “bottomed out” i.e. the lower part of the breast tissue stretched out allowing the implants to settle too far. When she laid down her breasts “disappeared” sliding off to her sides. There was diffuse rippling.
Her goals were:
- “Wants breast to look amazing!”
- “Reduce rippling inner and under her breasts”
- “Lifted “playboy status” higher look”
- “Feels weighed down by drooping breasts”
- “Reduce weird upper inner shape”
Exam 2 years after her initial surgery 5’5” 110 lb. 32D confirmed diffuse rippling as she was razor thin with only 1/8” of tissue covering the implants. The implants had settled too low so the nipple/areola looked too high on the breast mound. The implants did slide too far off to the sides when she laid down. She thought the implants were placed under the muscle but they were actually on top of the pectoralis muscle. Right side was a little larger than the left.
Plan and surgery:
- Although removing saline filled implants and replacing with silicone filled implants reduces rippling she did not feel comfortable using gel implants.
- Place implants under pectoralis muscle to give more natural inner/upper breast shape and minimize rippling.
- Use high profile 460 cc saline implants filled to maximum 550 cc to improve shape, minimize implant folding/rippling, and maximize implant projection to 6.9 cm.
- Place capsule tightening sutures to reshape the stretched out implant pocket and correct the bottoming out and sideward slide.
- Use Strattice ACD (Acellular Dermis) to support the implant in the new higher position, add more tissue to cover the lower part of the implant to minimize rippling, minimize breast motion (“animation effects”) in the new sub muscular location, and minimize chance of settling too far again.
- Access via periareolar incision, general anesthesia used.
- Old saline implants removed had volume on R 586 cc and L 535 cc accounting for her asymmetry.
- She noticed her arms no long touched the sides of her breasts even as she walked from the operating room to the recovery room.
- She is really happy with the outcome and has received many complements about her breasts.
- Size 32 D fits well although often wears Frederick’s 34 D shelf bra.
- After photos taken at 5.5 months after surgery.
20 year old wanted to “be normal”. Main concern was to even out, fuller and same size on each side noting R now bigger than left. Just wants “perky and normal like a 20 year old”. Patient never dated after a first boyfriend made fun of her physique.
Exam: Tuberous breasts where most breast tissue herniated into large areola (flat colored breast skin) and not spread out normally over the chest. 5’ 8” 130 lb. 32 B or C with L side stuffed. Timid demeanor.
Asymmetry: Size and shape differences.
Right side ~ 30 cc larger and Grade II ptosis (nipple below level of fold under breast).
Left side Pseudo-ptosis (“false” drooping: nipple above the level of the fold under breast but, from front view, cannot see breast all the way under to where it joins chest wall).
- Allow areola to be flatter: remove breast tissue from deep behind areola 55 grams right and 32 grams left to improve symmetry
- Allow breast tissue to flatten: breast glandular reshaping by release tissue radially from inside so it would relax and spread over larger area.
- Normalize proportion: Subpectoralis muscle “dual plane” breast augmentation with gel high profile 616 gel implants
- Reshape skin removing excess areola and skin near areola to give even more normal breast shape: mastopexy breast lift) with incision around areola and vertically down.
- Initially breast had a very flattened appearance below areola “In a T shirt there is no underside to my left breast!”
- 10.5 months after surgery: Now 21 yrs. 5’ 8” 144 lb. 34 D scars red and still stretching out. R nipple remained flat when stimulated and had less sensation. “OK to show photos to patients in the office”
- 2 yr. 9.5 mo. after surgery photos taken: 23 yrs. 5’8” 125 lb. 32 or 34DD fit best. Sensation normalized and tissue relaxation had further improved breast shape. “OK to show photos on the internet”
- “Thrilled, steady boyfriend and normal life.”
- Before she left she insisted I see her fully dressed eye catching, head turning, statuesque 5’8” 125 lb. in 4” heels and short, black, form fitting dress. I marveled again at the unleashed psyche after figure flaw improvement.
42 y.o. 5’5 ½” 135 lb. with daughters age 3 and 10 yr.
The covering over her stomach (abdominal) muscles (the fascia) was stretched by her two pregnancies. Despite sit-ups she always had to “hold her stomach in”. Abdomen bulged above the top of her jeans. Skin laxity about her abdomen prevented performing just liposuction.
Tummy tuck surgery (full abdominoplasty) removed all skin and fat from just above her pubic area to just above the belly button (navel). The covering over the muscle was tightened (fascial plication) to give a firmer flatter abdomen. Abdominal skin and fat removed weighed 1 lb. 12 oz (788 gm.). She also underwent liposuction to her hips, inner & outer thigh, knee, and upper arm at the same time.
After pictures taken 5 yr. 5 mo. after surgery now 140 lb.
Although she had undergone breast augmentation with Dr. Pertsch 8 years before her abdominoplasty and liposuction she felt the abdominoplasty was the best thing she ever did for herself. Jeans fit and looked much better.
After liposuction thigh shape improvement is maintained despite 20 lb. weight gain. 30 year old single mother of 9 yr. old daughter and 5 1/2 yr. old son. She is 5’8” high and her weight as fluctuated between 110 to 130 but even at her lowest she still had fullness of her inner and outer thighs, excess fat just below her buttock crease in the upper thigh, and hips. Her skin tone was very good to support liposuction.
At surgery 1400 cc of fat was removed (just over 3 lb.). About 200 cc from each hip, 360 cc from each outer thigh and back of her thigh, and 150 cc from each inner thigh. Fluid was evenly put into her tissues while under anesthesia to maximize fat removal. Patient gained 20 lb. to 150 lb. when after surgery photos taken 2 yrs. 7.5 months after her procedure. Despite gaining 20 lb. her post operative photographs show her shape remains improved after surgery. i.e. the figure faults about the thighs remain improved. Weight gained after a liposuction procedure is more evenly distributed than a similar weight gain before liposuction.
She “Loved the lipo” and “best thing she’s ever done, great result”.
48 yr. old 5’4” 123 lb. had 2 C-section scars from childbirths. She elected a “mini” abdominoplasty or “mini-tuck” that removed some skin and fat from the lower abdomen (about half of the amount that would be removed during a full abdominoplasty). This provides some tightening of the abdomen skin but also allows for aggressive abdominal liposuction at the same surgery.
Mini-abdominoplasty specimen 305 gms + abdominal liposuction 175 cc. 34A and had undergone 2 R breast biopsies reducing R breast volume. Breast Augmentation was also performed at the same surgery: periareolar, sub pectoralis, patient chose 270 cc smooth round saline implants filled to 270 cc on the left and 300 cc on the right to improve symmetry.
Post op photos 5.5 months after surgery After photos were taken just before a touch-up surgery. Patient had a persistent fluid cavity after the mini-abdominoplasty despite multiple aspirations. To improve the slight (2 tablespoon sized) but troubling contour irregularity excision was performed via the original incision 10 months after initial procedure. She used this surgery session to do upper and lower eyelid surgery to give a more rested look. Facial photographs were kept off the internet as she wished.
After Weight Loss
Patient weighed over 230 lb. for years and had no pregnancies. With Weight Watchers and exercise she lost about 130 lb. over 3 years. Now 138 lb. at age 46 5’ 8 ½ “ she felt her “skin was too big”. She wanted to be less saggy and improve her self esteem. Her breasts had shrunk from 44DDD to current 36 D. She wanted breast improvement without implants.
First Surgery: Abdominoplasty extended circumferentially removing 1107 grams (2.3 lb.)
Second Surgery 2 weeks later: Breast lift short scar technique (“vertical” style i.e. excessive skin from side of breast used to give better projection and more conical shape yet scar only around areolar and down, no scar side to side under breast) Small amount of breast tissue removed, more from the left, to improve symmetry. R 14.2 gm. removed, L 85.2 gm. removed. No implants were used.
Third Surgery 3 weeks later: Inner thigh lift with R 36 grams, L 42 gm. skin removed
Minor “touch up” surgery in office treatment room 4 months after breast surgery removed residual wrinkles under both breasts. After pictures taken 1 year 3.5 months after first surgery.
39 year old lady overweight since 4th grade lost from 255 lb. -> 170 including 35 lb. over this year before surgery by diet and exercise. Patient has had two full term pregnancies each by C-section and is an Insulin dependent diabetic. Patient 5′ 1″ started surgery at 170 lb. and ultimately achieved her goal of 115 pounds.
First surgery: abdominoplasty/belt lipectomy Specimen weighed 8 3/4 lb. after picture (side view) 4 yrs. 6 months after surgery
Second surgery: Brachioplasty (arm lift) Specimen weighed a total of 11 oz. An infection delayed healing of R arm wound. after picture 4 yrs. 6.5 months after surgery
Third surgery: Lateral chest reduction Specimen weight 620 gm. total after pictures 4 years 3 months after surgery
Fourth surgery: Outer thigh reduction Specimen weight 1 1/2 lb. (739 gm.) after pictures 2 years after surgery
Fifth surgery: Inner thigh lift, liposuction entire abdomen and lateral chest after pictures 12 months after surgery
Sixth surgery: Liposuction upper arms, monsplasty, touch-up abdominoplasty after further weight reduction Specimen sizes R arm 400 cc, l arm 525 cc, mons 73.8 gm., abdominoplasty 51 gm. after pictures 8 months after surgery
Seventh surgery: Breast lift, touch up arm-lift (brachioplasty) (central/inferior pedicle) after pictures 5 months after surgery
After pictures patient weighed ~140 pounds and went on to get down to 115 lb.
Otoplasty and Ear Lobe Reduction
42 yr. old male was always concerned about prominent ears and considered surgery for a couple of years. He didn’t like his large, drooping earlobes. Exam revealed prominent ears due to wide conchal cartilages and reduced folding of the scaphal cartilages. The earlobes were large.
At surgery chonchal cartilage was reduced (the “shell” cartilage). The naturally occurring fold was created in the scapha cartilage. The auricular muscle was reattached and skin was reduced behind the ear. In addition the earlobe was reduced both height and width.
“After” photos were taken 2 years and 2 months after the procedure. He still had palpable but not visible scar behind the left earlobe. It felt as if there was a pencil behind his L ear only during hot weather. This sensation seemed to be easing with time.