Dr. John Yousif  ●  SIÈR Medi-Spa ● 10554 N. Port Washington Road Mequon, WI 53092 ​●                          ​● 262.241.SSPA​

W H E R E   S C I E N C E   M E E T S   S O P H I S T I C A T I O N



Breast Augmentation


​Breast Augmentation: is a cosmetic procedure that enlarges and shapes a woman's breasts through the placement of implants. You may be a candidate for breast augmentation if you want to enlarge naturally small breasts, restore breast volume lost following pregnancy or weight loss, or improve symmetry.Breast Implant Placement
Four different incisions have been described for breast enlargement:

Around the Areola: The incision is made around the lower part of the areola (darker area around the nipple). These scars typically heal very nicely and are difficult to see. However, if the areola is small it may be difficult to perform the procedure through this area.
Base of the Breast (Inframammary) - The incision is made under the breast just above the natural crease and provides technically easier route for implant placement. The scar however, because of its location, has a greater risk of being wider or thicker. In patients who have large breasts to start with, the scar may be well hidden.
Armpit - The incision is made within the armpit (axilla). The scars in this area typically heal well and are hidden and at the end look like fold in the arm pit. Implant placement via the armpit is performed with the help of an endoscopic camera for appropriate placement of the implants.

Belly Button: The incision is made at the upper portion of the belly button and placement of implants is done by feel. The results of this method certainly depend on the experience of the surgeon but this is a blind method and Dr. Yousif does not believe this is a desirable method.  There are several factors to consider when choosing the location of the incision such as the type of implant to be used, degree of enlargement, patient anatomy, and patient and surgeon preference.

Breast Implant Placement: Subglandular - The breast implants are placed directly behind your breast tissue. If there is adequate breast tissue to cover an implant, subglandular placement can be done. However, if there is limited breast tissue, it may be better to hide the implant beneath the muscle layer.  

​Advantages of Subglandular Placement: Probably less pain after surgery.  It may allow for more central placement of the implants, giving more cleavage.  Implant moves less with muscle contraction
When there is some sagging of the of the breast, subglandular placement may help to push the nipple upward slightly.

Disadvantages of Subglandular Placement:  Implants may be more visible and ripples may be more prominent.  Mammograms may be harder to perform because of the proximity of breast tissue to the implant.  Breast hardening (capsule contracture) may be more frequent
Submuscular: The breast implants are placed beneath the chest muscle.  Advantages of Submuscular Placement:.  Implants less visible especially when there is limited breast tissue.  Breast hardening (capsule contracture) may be less frequent.  Mammograms are easier to perform.  Looks natural.  Results remain longer.  

Disadvantages to Submuscular Placement:  More painful after surgery.  There may be movement of implants with muscle contraction.  Not helpful in breasts with slight sagging to lift the nipple.  Anesthesia and Surgery Facility.  Breast augmentation is most comfortably performed under general anesthesia in a surgery center or hospital setting..  Operative time for breast augmentation is 1.5 hours.
Considerations.  When considering Breast Augmentation three key components need to be decided – type of implant: silicone or saline, size of the implant and where the incision will be made for placement.  We at ARSA spend the time it takes to help answer all of those questions so you receive the best possible outcome from your Breast Augmentation Surgery.

Breast Reduction

Breast Reduction: is a procedure designed to relieve the discomforts caused by large, heavy breasts including:  Understand clearly that although your figure will be significantly improved, your reconstructed breast will not look or feel exactly the same as the natural breast that was removed.  Your oncologist has advised you that reconstruction is appropriate for you with regard to your stage of cancer or treatment.  You feel that you are able to handle the period of emotional adjustment that may accompany breast reconstruction. Just as it takes time to get used to the loss of a breast, it may take some time before you begin to view the reconstructed breast as your own.  You have no additional health concerns that may make the procedure more complicated, such as obesity or heart disease.

​Breast Reduction is a procedure designed to relieve the discomforts caused by large, heavy breasts including:​  Back, neck, and shoulder pain.  Shoulder discomfort and indentations from bra straps.  Skin irritation beneath the breasts.  Enlarged areola (dark area around the nipple).  Restricted physical activity.  In severe cases it can even affect nerves that go to the arms.  Excess breast tissue, skin, and fat are removed to make the breasts smaller and to improve the associated conditions that are associated with large breasts.

Surgical OptionsSeveral operations have been described for breast reduction over the years. Operations can be classified in several ways. Some are defined by the external scars that are left in the breast while others may be classified by various technical parts of the operation such as the way the blood supply is left or returned to the nipple.
Incision classifications.

​​Inverted "T"​: This can also be called the anchor shaped incisions. These are the current standard incisions for breast reduction in the United States. They involve incisions that go around the nipple areolar complex(colored area) continuing vertically down the breast, and then horizontally along the crease underneath the breast. The excess breast tissue and skin is removed, the nipple is repositioned, and the breast is lifted and shaped.

Vertical Incision:​ In some classes the reduction can be done without the horizontal component beneath the breast. This is called a vertical reduction mammaplasty. This operation is most popular in Europe and South America. It does limit the scars but is typically only applicable to smaller and medium breast reductions.
Apron Technique (elimination of the vertical portion): The Apron technique was actually published in the late 1980's by Dr Yousif, It was a variation of another technique previously described which eliminates the vertical portion of the anchor incisions. In Dr. Yousif's variation the breast must be low or "ptotic" to make it suitable for this operation. This technique is well suited for very large breast or very low breasts.

Blood Supply Classification: In the early days of breast reduction surgery, one major way of reducing the breast was to take the nipple areolar complex completely off the breast, reduce the breast size and place the nipple back on a s a skin graft. This is called nipple amputation. This operation is done very infrequently now and in most instances the nipple can be left on the breast and never leaves the body. In any surgery to the breast the blood supply to the nipple areolar complex must be maintained or regained. Currently, this is done by retaining a connection of the nipple to the body where the blood vessels are located. If this does not happen, the nipple will not survive. The connection of the nipple to the body is called the pedicle. The connection or the pedicle can be located beneath the nipple and this is called an inferior pedicle. The connection can be upward from the nipple and this is called a superior pedicle. These the most frequent but there is also an central pedicle and lateral pedicles.  The pedicle is only important to the patient on a technical sense to maintain the connection and therefore the blood supply and nerve sensation to the nipple.

Breast Reconstruction


Surgical Options:
 There are many options available today in breast reconstruction. A woman’s anatomy, the surgeon’s recommendations and your desired results will together determine which method is best for you.

Skin Expansion with a Breast Implant:​ This is a very common method of reconstructing a breast. Following mastectomy, a balloon-type device (tissue expander) is inserted beneath the skin and chest wall muscle. Once the incision has adequately healed, over several weeks, the expander is gradually filled with a salt-water solution in the physician’s office, allowing the overlying skin to stretch. After the skin has stretched sufficiently, the expander is left in place several more weeks to allow the skin to over-stretch and provide a more natural contour for the final implant. Once this process is complete, a surgery to replace the tissue expander for a more permanent implant takes place. The nipple and skin surrounding it, called the areola, are reconstructed in a later procedure – once the breast has settled. A few weeks following the nipple reconstruction, pigmentation is added to the nipple and areola in a short office procedure. In limited cases, when a sufficient amount of skin is available, an implant may be placed without the preliminary skin expansion step.

Flap Reconstruction: Although flap reconstruction is more involved at the initial procedure than reconstruction with an implant, many women still prefer it because it may allow the breast to be rebuilt with natural tissue. Also, unlike the tissue expander method, the breast mound is completed at the initial operation without the need for expansion over an extended time period. In one method, the breast is reconstructed using a tissue flap – consisting of a portion of skin, fat and muscle –that is taken from the back or more commonly from the abdomen. The flap, still attached to its original blood supply, is tunneled beneath the skin to the front of the chest wall. The transported tissue may be full enough to create a new breast mound itself.  With an alternative flap technique, tissue that is removed from the abdomen, is surgically transplanted to the chest by reconnecting the flap’s blood vessels to vessels in the chest region. Although technically more complicated, this microsurgical reconstruction may provide a more natural and less traumatic reconstruction in many women. This is the approach that Dr. Yousif prefers when performing the TRAM flap.  Although recovery from flap reconstruction may take longer than with implant reconstruction at the initial procedure, it does not require a secondary procedure for placing a permanent implant, nor does it require the weekly office visits needed for tissue expansion. Abdomen may appear trimmer after tissue is taken from the area and used to rebuild the breast.  

Follow-up Procedures: Once the breast mound is restored in the initial procedure, one or more follow-up procedures will be performed to replace a tissue expander with a permanent implant, improve on the shape of the TRAM flap reconstruction or to reconstruct the nipple and areola. An additional operation to lift or reduce the opposite breast to match the appearance of the reconstructed breast may also be recommended.​

Anesthesia and Surgery Facility: General anesthesia in all circumstances. For the TRAM flap technique, the inpatient hospital stay ranges from 4-7 days. For the tissue expander technique, the inpatient hospital stay ranges from 1-3 days. Operative time is variable, depending upon the technique and whether reconstruction is performed at the same time as the mastectomy. The number of hours will be determined for each patient by the physician.

Side Effects | Recovery:  Recovering from breast reconstruction will vary significantly depending upon the method chosen, whether immediate reconstruction is performed, and individual factors.  In general, it may take up to 6 weeks to recover from a combined mastectomy and reconstruction, or from a flap reconstruction alone. If implants are used without flaps and reconstruction is done apart from the mastectomy, your recovery time may be less.

Duration of Results: It is very normal to go through a period of adjustment to your new look. Concerns about the reconstructed breast are likely to pass within a few months as a woman begins to incorporate her reconstructed breast as her own.

Most women who undergo breast reconstruction find that the procedure provides both physical and emotional rewards. For many women, breast reconstruction represents a new beginning, the chance to put breast cancer behind them and get on with their lives.

Gynecomastia Correction 


Gynecomastia Correction: This surgery is performed to reduce enlarged, female-like breasts in men using liposuction and/or cutting out excess glandular tissue.

Mastopexy | Breast Lift 

A breast lift may be performed at any age, although most plastic surgeons recommend waiting until breast development has been completed. Pregnancy and breast-feeding may affect the size and shape of a woman's breasts, so you may wish to postpone surgery until after having children. There are still many women who go through surgery before having children, knowing that they may have pregnancy-related changes later.  You may be a good candidate for breast lift surgery if you have any of the following conditions:
Breast firmness or substance which is "sagging", but a size that is satisfactory to you.  Nipples and areolas moving downward, especially if they are positioned below the crease of the breast.  In some cases, women have breast lift surgery to correct inherited traits or asymmetry (one breast may be well-developed and in the appropriate position while the other is not).

Surgical Options:  There are different techniques available for breast lift surgery. Your anatomy, surgical indications and your desired result will determine the specific method chosen. The most common method of breast lift surgery involves three incisions. One incision is around the areola (the dark part around the nipple). Another runs vertically from the bottom edge of the areola to the crease underneath the breast. The third incision is a horizontal incision beneath the breasts that follows the natural curve of the breast crease. There are other methods that may reduce the amount of incisions, and this is determined at the consultation depending on the surgical indications and the patients desires.

Anchor lift: This lift involves all the above incisions. With this operation Dr. Yousif performs a special internal architectural positioning of the breast tissue to provide superior fullness and aesthetic shape. This procedure is usually done when a patient does not want increased volume but only a lift.

Vertical lift: The vertical lift is a lift does not have the horizontal portion of the scars beneath the breast. It has been called the "Lollipop Lift". Although this can be done without an implant it is most often done along with implant placement. When this is done in combination, Dr Yousif has found that placement of the implant through a trans axillary (arm pit) gives the best results.

Periareolar Lift: This is a lift with only an incision around the nipple areolar complex. The procedure was popular in the 1990's. The reduction of scars is an advantage however this procedure has certain problems. It tends to flatten the breast and the incision around the nipple areolar complex has puckering around it. Although the puckering improves with time the flatness of the breast does not. Dr. Yousif only finds this indicated for small lifts.  Following removal of the excess breast skin and shaping of the remaining breast tissue, the nipple and areola are shifted to a higher position. The areola, which is sometimes overstretched in the sagging breast, may also be reduced in diameter. The nipple is lifted to the appropriate position and the skin is closed around it. The nipples and areolas remain attached to the underlying breast tissue, thus typically allowing for the preservation of sensation and the ability to breast-feed.
If you have decided that your breasts will be enlarged at the same time they are lifted, breast implants will be required (refer to Breast Augmentation in the procedures section).


Recovery:  Within the first week following surgery, you will begin to move about more comfortably as the days go on. You may be able to return back to non-strenuous work within 7-10 days following surgery. The chest wrap is usually removed in the office within a couple of days following surgery. A support bra is then worn for 4-6 weeks. Most stitches dissolve on their own.
After several weeks, any bruising, swelling and normal periodic discomfort will diminish. The support bra, at this point, may also be discontinued. Sensation within the nipple and areola will gradually improve. After about 4 weeks, you may return to most of your normal activities including exercise and lifting.  After a few months, your breasts will start to settle into a more natural shape. Incision lines which initially are pinker, will begin to fade.