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Dr. Linder's Blog


Monthly Archives: July 2009


breast_rev81aRecently, we’ve seen an increased number of breast revision surgical patients here in Beverly Hills.  These patients present with a multitude of problems, including severe encapsulation with Baker IV capsular contractures, double-bubble breast deformities, malpositioning of the implants, ruptured silicone and saline implants with painful breast deformities and a multitude of other problems.  These patients can also have combinations of the above with double-bubble deformities and ruptured silicone implants concurrently or malpositioning of the implants with bottoming out.

breast_rev3In any case, each case is a puzzle and the puzzle needs to be reviewed in order to recreate a normal appearance and shape of the breast.  We prefer to see the patients a minimum of two times preoperatively in order to determine what is necessary to correct the patient’s deformities.

Please refer to www.breastrevisionsurgeon.com and www.lasvegasbreastrevision.com to evaluate the different complications of breast augmentation and how they can be successfully repaired in a safe and predictable manner.


breast_assymetry1In general, we see patients of all ages who are considering breast augmentation, breast reduction and breast reconstructive surgeries.  The age of the patient is very important.  Obviously, up to a certain age, physiological growth continues to occur.  Generally, the age of 18 is usually, in my opinion, considered the cutoff for elective augmentation mammoplasty or breast reduction surgery.  However, there are exceptions to this rule.  The first exception in treating a teenage female who is under the age of 18 would include a severe congenital deformity, including congenital breast asymmetry in which one breast is significantly larger than the other, which can cause physiological, emotional and developmental distress.  As patients arise in their teenage years and in high school, there are emotional as well as physiological reasons to undergo breast reconstructive surgery to regain symmetry prior to the age of 18.  In general, I like to obtain a patient’s pediatrician as well as the parental guidance in order to continue forward with reconstructive surgery to maintain symmetry of these younger patients.

Massive breast hypertrophy, also referred to as gigantomastic breasts, can also occur in teenagers, referred to as juvenile breast hypertrophy or gigantomastia.  These patients may not be able to wait until 18 years of age to undergo reduction mammoplasty to reduce the massive size of their breasts, just due to simply increased pain, neck strain, grooving along the shoulders, physiological and emotional embarrassment.  These patients also may undergo surgery at a younger age if considered clear both mentally and physically, as well as with parental supervision for consenting the patient.

In general, when patients decide on body contouring, including augmentation mammoplasty procedure and liposuctioning and are under the age of 18, we normally have the patients wait until the age of 18 so that the majority of physiological breast growth is completed.



A case was presented to me a couple of days ago as an acute emergency.  Description of the case includes a patient who underwent silicone gel augmentation approximately 20 years ago in the submuscular pocket.  She had dental work approximately three months ago and has had increasing swelling and tenderness to her bilateral breasts.  She was referred by an infectious disease specialist to Dr. Linder for evaluation and reconstruction.  Upon seeing the patient in consultation, it was obvious that she had some form of an infection, though no specific organism had been determined.  The patient showed a three-month history of myalgia, fatigue, intermittent fevers, and swelling (right breast greater than the left).  This occurred three months after dental work and a mandibular abscess debridement with a root canal.  The patient was set up for surgery in the hospital at which time the surgical consent included bilateral exploration of chest, explantation of silicone implant and implant material, open capsulectomy, bilateral cultures and sensitivities (aerobic, anaerobic and fungal nature), irrigation and drain placement bilaterally.  The implants could not be replaced for several months until the patient is completely cleaned and has been cleared by an infectious disease specialist.  

Surgery took place and she did extraordinarily well.  Of interest, the tissue appeared to be quite slimy and grungy which appeared to be possibly a staphylococcus, epidermis or aureus type of infection, though cultures are pending. 

The point of this interesting case is I believe patients who undergo dental work or who have breast implants should undergo prophylactic antibiotics.  The amount of time or duration of the antibiotics is variable and there is no specific standard.  However, I believe 24 hours before and up to 24 hours after would be reasonable in my patient population to have prophylactic and continued oral biotics to prevent staphylococcus infections.

Beverly Hills Breast Revision Cleavage

Patients present to Dr. Linder for both augmentation and breast revision surgery weekly. We enjoy the reconstruction and challenge of repairing breasts that were done elsewhere. Over time, scar tissue can form around breast implants. This can be associated with breast feeding or simply capsular contracture which occurs due to the body’s walling off of the implant. This is a case example of a severe Baker IV capsular contracture with 8 cm sternal cleavage, lateral displacement of the implants with severe pain along the lateral superior portion of her breast. The patient presented with minimal cleavage and wide laterally displaced breasts.

Preoperative photos show areas that the scar tissue will be released under the tissue using the periareolar approach. This patient underwent bilateral open periprosthetic anterior capsulectomies and a medial open capsulotomy releasing the pocket carefully along the underbelly surface of the pectoralis major muscle and then releasing the parasternal attachments of the pectoralis major muscle. The implants were then replaced with larger high profile smooth silicone gel implants of 500 cc Mentor high profile gel style 4000 implants. The patient did extraordinarily well and as you can see her cleavage is now approximately 1.5 fingerbreadths.

The implants now lay at a proper position with the left inframammary fold lowered slightly to even it out with the right side. This is an example of a breast revision for severe scar contracture with lateral displaced implants to improve her cleavage which is apparent in her postoperative photograph.


implantIn Beverly Hills we perform breast augmentations weekly.  Breast augmentations can be performed using silicone as well as saline implants.  Silicone implants are now FDA-approved and there are two FDA-approved companies, Mentor and Allergan Pharmaceuticals.  Both implants are excellent.  Both implants come in moderate, moderate plus and high profile, both in silicone and saline implants.  We prefer the high profile gels whenever possible because of limited diameter and increased AP projection.

Breast augmentation in Beverly Hills should be performed in licensed surgery centers with Board Certified Anesthesiologists and Board Certified Plastic Surgeons only.