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Dr. Linder's Blog


Monthly Archives: November 2008

Surgical Approaches to Elective Breast Augmentation

There are many ways of skinning a cat and there are many ways of performing a breast augmentation. Some ways are simple, standard, predictable and safe. Other ways are more unpredictable and difficult to get perfect symmetry and may lead to increased risk of both immediate operative and postoperative complications. We enjoy doing the periareolar approach, incisions made underneath the areola, from approximately the 5 o’clock position to the 7 o’clock position. It is usually about a 2.5 to 3.5 cm incision along the boundary border of the areola. Usually these scars heal very well, they camouflage well and have a low incidents of keloiding or hypertrophic scarring. By placing the implants through the periareolar approach, it is easy to go subpectoral (behind the muscle) using the dual plane technique and to place the implants accurately, releasing the pectoralis major muscle along the parasternal and along the inframammary fold, accurately and precisely. This allows for more accurate cleavage and inframammary fold symmetry.

Other approaches have been performed throughout the years, including the inframammary incision. This is a standard approach, which is safe. However, working uphill from the inframammary fold superiorly, in my thoughts and opinions, is more difficult than the periareolar in order to centralize the implants directly in the middle of the breast. In other words, working along the middle of the breast, centralizing the implant, is easier than working uphill through the inframammary approach. The tubular breast approach, placing the implant through the umbilicus, in my theory is difficult, unpredictable and probably has higher rate of complications. Placing an implant through the belly button all the way up underneath the muscle accurately, seems difficult, if not impossible, at least in my mind. If the surgeon is going to do hundreds, if not thousands of implants annually, we need to reduce our rate of recurrence of scar tissue, of asymmetry, and of malposition of implants. The tubular breast in my thoughts is not the way to go.

The transaxillary approach has been used for many, many decades and can have favorable results in the right experienced surgeon’s hands. I, however, believe there are a significant number of double-bubble deformities, especially with patients with ptotic breasts, that is sagginess to the breasts, where the implants end up too high (superiorly retropositioned) and the skin over-drapes the implants. This I see on my breast revision patients throughout the United States who present for repair all the time. Therefore, in my opinion, the periareolar approach is the safest, most predictable approach in performing elective augmentation mammoplasty procedures, either with silicone or saline implants.

XM Radio Channel 24, The Pink Channel with Dr. Linder

Dr. Linder Hosting Issues on Plastic Surgery on XM Radio

As of November 10th, Dr. Linder will be hosting issues on plastic surgery weekly on XM Channel 24.

The Pink Channel is sponsored by the City of Hope Los Angeles for Breast Cancer Reconstruction.  Other hosts have included Olivia Newton John, Pink and other celebrities.

Issues that Dr. Linder will be discussing are varied and will include how to do your plastic surgery homework, anesthesia with plastic surgery, working up patients who are undergoing elective cosmetic procedures, breast asymmetry, deformities, total body liposuction versus tummy tuck, the media and plastic surgery, breast lifts and scarring, implant revision – what to do next, five steps to assure a safe liposuction, the truth about scarring and plastic surgery, the Beverly Hills Shape, the truth about plastic surgery (Dr. Linder’s book), five plastic surgical procedures to avoid, five things that can go wrong with plastic surgery, and awful celebrity plastic surgery.

We will be doing 60-second bits on multiple other issues as well on plastic surgery in order to increase public awareness on safety with cosmetic as well as reconstruction of the female body.

Dr. Linder is excited to be working with XM Premier Radio on educating women throughout the country on plastic surgery issues.

Breast Revision in Hollywood – Double-Bubble Breast Deformity and Ruptured Implants

Double-Bubble Breast Deformity and Ruptured Implants

We see patients with double-bubble deformities associated with poorly positioned implants. In my Beverly Hills practice, I very much enjoy fixing and repairing breasts that present with a double-bubble deformity. This means simply that the breast implant is too high and the skin over-drapes it. The nipple is often low on the breast and along the lower pole and the implant is superiorly retropositioned. This normally is associated with poorly placed implants directly from the original surgery either transumbilical or transaxillary. If the parasternal and inframammary portions of the pectorals major muscle are not adequately released, the implant will never fall to a normal position and the implant will be raised superiorly, as if being pinched up with a catcher’s net.

The double-bubble deformity is correctable by several staged operations. The first component of the surgery includes releasing the scar tissue as an open capsulotomy with inferiorly or lowering the implant and the pocket.

The second component may require a breast lift, usually a formal mastopexy where skin is removed around the nipple vertically along the inframammary fold. This will tighten the skin envelope after the implant is now correctly positioned inferiorly. Ruptured implants occur all the time. In general, implants are not lifetime devices. In fact, they can rupture at any time after implantation. Breast implants when ruptured should be removed as soon as possible in order to prevent further collapse of scar tissue around the bags which could cause more difficulty in creating a normal appearance.

Silicone implant ruptures are usually only detectable with MRIs, as they remain silent even with mammograms which are often not sensitive to rupture.

In my practice, patients are asked to have an MRI performed every two to three years after implantation of silicone implants under the muscle.

Patients who have ruptured implants often present to us from throughout the Western hemisphere.

Sometime they no longer have surgeons who have taken care of them in the past because the patients have moved, the surgeon may have passed away or the patient no longer feels comfortable with that specific physician.

As a result, Dr. Linder very much enjoys repairing implants with double-bubble deformities and/or explantation and reimplantation with capsulectomies and/or capsulotomies after ruptured or deflated saline or silicone implants.

Capsular Contracture – Breast Revision in Hollywood

Patients present with capsular contracture all the time in our practice. These patients are seen from throughout the United States and all over the world. Capsular contracture can be defined as scar tissue. Scar tissue can be thick and painful and when surrounding the breast implant can lead to a deformed appearance to the breast. Scar tissue or capsular contracture, can occur within four weeks after an implantation. It is certainly reduced by placing implants behind the muscle subpectorally. In my practice, I almost always place implants behind the muscle in order to allow for decreased visualization and palpability of the implant edge. The muscle acts also to functionally lubricate the implant and allow the implant to move around in the pocket due to the motion in the muscle and will reduce scar tissue capsular contracture.

Four classes of capsular contracture occur and they are graded as Baker classification.

Baker I capsular contracture reveals no hardening whatsoever. There is no evidence of scar tissue. The breast implant is soft and there is no visible distortion or pain on palpation.

Baker II classification can be associated with palpable contracture.

Baker III is palpable and visible distortion of the pocket with the implant with possible malpositioning.

Baker IV is palpable, visible, hard and painful breast that is often cold in nature with complete disfigurement and pain. Patients with Baker IV capsular contracture usually find their way into the operating room for capsulectomy and capsulotomy surgery.

Treatment of severe Baker IV capsular contracture requires removing scar tissue as well as releasing the scar tissue circumferentially around the pocket.

Experienced Board Certified Plastic Surgeons are the only doctors who should be performing these surgeries. They have the experience and judgment to understand how much tissue to remove, as well as where to release the scar tissue.

Recurrence of capsular contracture is usually anywhere between five and 8 percent with saline implants for after repair of the capsulation.