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Dr. Linder's Blog


Monthly Archives: August 2008

Combination Body Sculpting – Beverly Hills Plastic Surgery

Beverly Hills Plastic Surgeon Today’s Blog deals with combination Procedures of Body Work, including breast implants, breast lifts, tummy tucks and total body lipo sculpting.

In general, several factors are important when determining which combination of procedures can be performed and the health condition of the patient must be taken into consideration.

First, if a patient has any significant health problems, including high blood pressure, diabetes or other systemic illnesses, combination procedures can certainly be more dangerous and probably shouldn’t be performed.

Risks for Patients with High Blood Pressure

Patients who have high blood pressure, for example, probably should not have breast augmentation and tummy tucks at the same time, in that if they do have bleeding postoperatively, it could occur from both the subpectoral area as well as the abdominal wall, which could lead to serious blood loss and possible blood transfusions. In my practice, I prefer not to perform multiple procedures where there’s an increased significant risk of bleeding such as tummy tucks and breast augmentation if a patient has high blood pressure control issues.

Risks for Patients with Diabetes

Number two is diabetes. Patients who are diabetic may have serious problems with wound healing and may end up with skin loss or avascular necrosis. These patients should be careful with huge abdominoplasties and breast lifts performed at the same time due to skin slough, tension problems and oxygenation. Bariatric surgical patients may be anemic and may have serious nutritional abnormalities due to their malabsorption from their diet and from status post gastric surgery. They should probably have staged operations as well. Estimated blood loss is very important when considering combination procedures.

Also important is duration of the operation time under general anesthesia. In general, we prefer not to go over five hours when performing surgery because after five hours, it has been shown to increase risks of complications, including deep venous thrombosis, pulmonary embolism and possibly an increased risk for myocardial infarction, heart attacks and/or strokes.

Benefits of Combination Body Sculpting Procedures

Combination procedures are performed on many of our Beverly Hills patients. The greatest advantage of this is for patients who are limited on time in terms of healing, who are healthy and don’t have any medical conditions and are cleared by their internist or our internist can do successfully breast augmentation, breast lifts and tummy tucks as well as liposculpting of the body as long as it is under five hours without any problems.

Certainly, the blood count (hematocrit) needs to be at a normal level as well. All the labs must be evaluated closely, including coagulation and hematocrit prior to surgeries of combination procedures.

When women have had bariatric surgery or gastric bypass surgery, such as women who have had morbid obesity, they do very well with multiple surgeries where there is skin removed from their breasts and abdominal areas. Again, we want to be very careful to check their hematocrit, their coagulation panel, their chemistries, and make sure their electrolytes are within normal limits and then proceed cautiously.

Results of Explantation of Breast Implants in Hollywood

Patients who undergo explantation of their breast implants without reimplantation of their implants can have serious consequences of skin laxity and may have a very horrid appearance to their breasts. Some, however, may do quite well, those who have not had enormous implants placed.

Removal and reimplantation of Breast Implants before and after

Removal and reimplantation of Breast Implants before and after

Interestingly, in this weeks issue, August 14, 2008, of the National Enquirer, there is a photograph of Victoria Beckam, showing her before and after having her implants removed. It is difficult to determine what her breast appearance is at this time because she is covered up. In any case, if you do remove a very large breast implant, placed above the muscle, there is a significant chance that you will have tremendous skin laxity and the breasts will sag horribly.

This can lead to the need for a breast lift. However, a breast lift can be difficult and/or dangerous if the skin thickness is quite thin and the tissue is minimal, which could lead to poor blood supply to the nipple and cause even further skin problems or even death of the nipple.

Only a Board Certified Plastic Surgeon who specializes in breast implant revision should be performing these operations on patients who desire explantation of their implants. This will greatly reduce complications.

Silicone v. Saline, Hollywood Finest

Placement of silicone breast implants has great advantages and disadvantages versus saline breast implants. Let us go through the most important ones.

silicone breast implants

silicone breast implants

The Advantages of Silicone Breast Implants are:

1. Silicone implants are very useful in patients who have minimal amounts of breast tissue. As stated before, women who are very, very thin and have an ectomorphic build, will do very well with silicone implants because it will certainly reduce the visualization of the bag on the side. Saline implants have a higher rate of rippling, especially along the side of the breast where there is no muscle coverage and therefore these patients do well with silicone implants.

2. Silicone feels way softer than saline. It feels more like a natural breast. The cohesive Mentor and Allergan silicone implants are very, very soft and the breasts will feel much more natural with these placed in the subpectoral position.

The Greatest Disadvantage of Silicone are:

1. They are a more high maintenance product, which will require MRI’s to be performed at least every three years. The FDA requires MRI’s because mammograms and ultrasounds are not always sensitive in determining rupture or a shell defect of the silicone implant. MRI’s are very sensitive in determining whether the implant is broken or not.

2. The second disadvantage of silicone is there is a higher rate of capsular contracture and calcification.

3. Obviously, there can be migration of silicone material to the lymph nodes, the axillary lymph nodes or any lymphatic organ within the body.

4. It is difficult to determine rupture of these implants and a rupture can go unknown or silent for many, many years if the patient does not undergo MRI’s.

The Advantages of Saline Breast Implants are:

1. They are easy and simple to use. You can titrate the volume more easily, especially with congenital breast asymmetry patients.

2. If it ruptures, it is obvious clinically to determine because the implant and breast become flattened.

3. The silicone cannot spread or metastasize to any part of the body because there is no silicone, it is simply salt water.

4. They are less expensive and this can be important for patients who have a financial restriction on cost.

The Biggest Disadvantages of Saline are:

They ripple and are visible. You can see the bags along the sides of the chest on many patients because the subpectoral coverage does not cover the lateral third of the bag on the outside.

They feel more like a water balloon. They are obviously less soft than the silicone counterparts because they’re filled with water and therefore in thin women they look more unnatural and will not feel like a natural breast.

Placement of Breast Implants the Beverly Hills Style

Today’s blog has to do with the placement of breast implants, whether saline or silicone. In general, breast implants should usually be placed subpectoral (behind the muscle) whenever possible because:

  1. it reduces encapsulation and scar tissue
  2. reduces visibility and palpability of the bag
  3. it just looks more natural in appearance

There are cases of placing an implant above the muscle. Sometimes if a patient has very thick tissue and has an endomorphic or a barrel chest (this can be seen in a lot of Eskimo or Latin American patients with very thick chest walls), they may do better with the breast implants above the muscle so that the fullness of the bag can be more appreciated and it won’t be as flat or blunted.

However, with the majority of our patients, we like to go subpectoral (behind the muscle).

Subpectoral Placement of Breast Implants

Now what does subpectoral really mean? Patients ask me every single day, “How much of the breast implant is covered by muscle?” Specifically, we use the dual plane technique, meaning that anywhere between one-half and three-quarters of the implant from the middle of the chest towards lateral is covered by the muscle. The lateral third of the bag is usually only covered by breast tissue. So the dual plane technique or submuscular really means about three-quarters of the bag at most is covered by the pectoralis major muscle.

There really is no such thing as total muscle coverage unless the serratus anterior muscle on the side of the chest is pulled up laterally. This really is not performed in elective cosmetic breast augmentation surgery. The serratus muscle should be spared for women who require breast reconstruction for cancer reconstructive surgical purposes.

Therefore, when a patient says, “How much of the breast implant is really being covered by muscle,” in the dual plane technique at most two-thirds or three-quarters is the correct answer.

The most natural looking breast in the world has implants placed in the dual plane with some muscle coverage. This reduces the fullness in the upper pole and allows for a more natural shape. This is especially important in patients who are found in the Entertainment Industry, including Playboy, Penthouse, Hustler and all the other magazines where women make a living off the appearance of their breasts.

The round ball look really isn’t in at this time in 2008 and thankfully, I don’t get too many requests for the round ball stage look with implants above the muscle.

Hollywood Celebrity Breast Augmentation

As a Beverly Hills plastic surgeon, I operate on patients of all walks of life. Patients, however, who are in the public’s eye aka Hollywood celebrities, actresses and models, make a living off of their appearance and therefore their breast augmentation surgery must be done perfectly and the judgment of the size of breast implants must be correct.

When patients, especially actresses who are on sitcoms or ongoing television shows consider breast augmentation surgery, it is very important not to go to too large an implant.

We never want to typecast these patients and make them look disproportionately too large, which could actually cause the patients to lose roles and millions of dollars in revenue. Therefore, actresses should be very careful about considering implants that are disproportionately large for their bodies.

Determining Breast Implant Size

The size of the breast implant will be determined by looking at many issues on each female’s body. Remember, all women’s bodies are different. We look at the inframammary fold diameters, we look at the amount of breast tissue and thickness of the pectoralis muscle and we look at the sternal cleavage as well. Breast Implants should be placed behind the muscle whenever possible and silicone breast implants are preferred if the patient is very thin and has minimal amounts of breast tissue such as with Paris Hilton, Nicole Richie or a swimsuit model who is very thin such as in Victoria Secret’s where they would see rippling along the side of the breast.

This is referred to as an ectomorphic build where there is minimal breast issue and this would cause severe rippling and visibility which looks very obvious either naked or in a bikini, especially when leaning forward.

High profile cohesive Mentor gel implants are excellent for very thin Hollywood entertaining actresses / models in order to reduce visibility, palpability and they appear to have a more natural appearance as well.