19 year old desiring breast augmentation. She has a difficult presentation, with a tuberous breast deformity as well as very widely spaced nipples: these present special challenges to the surgeon to achieve a nice outcome. Note that with a breast augmentation (alone) the nipple position will not change; the implants need to be positioned directly behind the nipple or it will not have a good result. After trying on our sizers, she decided that her goal was approximately 550 cc. She was augmented with 550 cc smooth round high profile silicone gel implants placed subpectorally (under the muscle) via inframammary incisions. The procedure was performed in-office in our fully accredited (AAAASF) facility under light sedation and local anesthesia. Results shown at 2 months.