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Dr. Linder's Blog


Monthly Archives: August 2009


Patients are seen who have nipple hypertrophy and will do well with reduction in the size of the nipple to make it more symmetric with the areolar complex.  These patients often are from Asian, Korean or Chinese descent.  Often, the nipple will be excoriated with the skin.  They can develop dermatitis due to rubbing and will do well with functional reduction in size.  Dr. Linder’s perform technique includes the superior pedicle and excision of the inferior portion or lower portion of the nipple and the nipple is then brought down and sutured down and the sides are then trimmed.  This makes for a significantly smaller nipple, both along the AP projection as well as the width.  Nipple reduction surgery patients are very satisfied both for cosmetic as well as the functional reasons, with reduction in pain, irritation and the dermatitis which occurs due to the raw surface of the tip of the nipple region.

The nipple specimen is always sent to pathology to make sure that there is no evidence of cancer or Paget’s disease.


Patients present to us weekly for plastic surgery of the body.  Dr. Linder specializes in plastic surgery of the body, including breast implants, breast lifts, breast reductions, breast revisions, tummy tucks, paniculectomies and total body lipo-contouring. 

Plastic surgery of the body requires skill and experience.  Experience comes from years of practice, as well as from training and qualified programs leading up to Board Certification in Plastic Surgery.  It is essential that patients find doctors who are Board Certified Plastic Surgeons when considering body sculpting procedures, especially breast augmentations, breast lifts, breast revisions and breast reduction surgeries.  There is no substitute.  Also, find a doctor who specializes in the procedure that you want.  In other words, if you’re considering breast augmentation, find a surgeon who does breast implants every week.  Make sure you look at hundreds, if not over a thousand photographs of the doctors’ before and after pictures.  If they don’t have photographs, be very suspicious.  Also, make sure that their center is certified and the anesthesiologist is Board Certified with the American Board of Anesthesia.


15577Presently, there are many forms of liposuction now available, including tumescent technique, super wet technique, dry technique, power-assisted liposuction, ultrasonic liposuction, and smart liposuction.  I believe the safest approach is tumescent technique liposuction.  I believe that this should be the standard of care because it is safe and predictable when performed by Board Certified Plastic Surgeons under general anesthesia with a Board Certified Anesthesiologist.  Removal of fat can safely be performed using small cannulas such as 3 mm triple lumen Mercedes cannulas with blunt tips to one atmosphere of vacuum suction pressure.  The amount of fat to be removed can easily be taken from the deeper fat tissue areas of localized fat areas along the iliac crest rolls, lower abdomen, hips, inner and outer thighs, as well as the lateral breast.  These are safe zones and usually do well.

Tumescent liposuction requires installation of fluid into the area to be sculpted.  Three components of fluid are 1) lactated ringer or sodium chloride wetting solution; 2) epinephrine to reduce bleeding causing vasoconstriction of blood vessels; and 3) an anesthetic such as local 1% Lidocaine, which will allow for numbing up to 24 hours.

Post liposuction, we always use compressive garments.  For the abdomen, we use abdominal binders.  For the thighs, we use girdles, which will allow for compression for 6 to 8 weeks and allow for a smoother postoperative contour with reduction of swelling and edema.

Tumescent liposuction performed by Board Certified Plastic Surgeons in an accredited ambulatory center under general anesthesia on patients who are good candidates with good skin tone in the specific designated areas will achieve an exceptional result.


To be a specialist in breast revision surgery, the doctor first of all needs to be Board Certified with the American Board of Plastic Surgery.  That means:
1. Needs to be a Diplomate of the American Board of Plastic Surgery, having trained as a plastic and reconstructive surgeon; passed written and oral exams to be a Diplomate of the American Board of Plastic Surgery.
2. The plastic surgeon should specialize in breast augmentation breast revision surgery and perform these operations every week.  The majority of that doctor’s practice should be specifically categorized in reconstruction and breast revision surgery of augmentations.
3. The doctor should have a Board Certified Anesthesiologist.
4. Should have a certified surgery center, inclusive of Medicare and/or State Licensed.
5. Should have hundreds of pictures of before/after breast revisions should be available for the patient’s review, including all the different deformities that can occur, such as bottoming out, capsular contracture, malposition, ruptured implants, etc.  Patients should see before/after examples of each of these categories specifically focused on her specific abnormality or pathology.
6. Patient and doctor should have realistic expectations as to what is possible and what is not possible.  Please realize that once tissue has been manipulated multiple times, it may be impossible to create an absolute normal appearance to the breasts, and that the doctor can only do the best with what tissue remains.  For example, if the patient has had multiple breast lifts, the areolar may not be able to be cut around again because the blood supply problems could lead to devascularization of the nipple and death of the nipple areolar complex.  Therefore, make sure that you and your doctor have realistic expectations as to final results.


The patient below presents status post delivery and breastfeeding for six months. The patient presents with severe Baker IV capsular contracture on the left with a Baker III on the right. The red 2 x 3 cm area above the 12 o’clock position of the left nipple is associated with severe tissue damage atrophy and irritation which if left untreated with a decompression open capsulotomy, would certainly lead to full thickness skin loss with extrusion and exposure of the left implant.

The patient presents with severe pain. There is no evidence of lymphadenopathy, cellulitis or mastitis to the breast; however, the encapsulation is so severe circumferentially around the implant on the left side that it is leading to the edge folding outward, causing severe constant irritation of the subdermis which will lead to full thickness tissue loss and exposure.

The next photograph shows decompression six weeks postoperative with relaxing open capsulotomies and anterior capsulectomy. The implants have been replaced with 500 to 550 cc high profile saline implants. She now presents with soft breasts bilaterally, no further incidents or evidence of irritation to this area with no visible distortion. Decompression is extremely important as soon as the patient starts to develop skin irritation and dermal atrophic changes, as seen on her preoperative photo, to prevent an inevitable exposure of the implant which may lead to an infection and/or loss of the implant.



Beverly Hills Breast Augmentation


A patient presented recently with severe tubular breast deformity on the right, grade 2 ptosis on the left and asymmetric breasts.  She desired implants, however, was too young at the time to undergo a breast lift and declined to have any scarring.  The breasts were corrected by placing implants of slightly fills, 330 filled to 400 on the right, 330 filled to 380 on the larger left side in the dual plane.  A breast lift was not required, as the pocket was made very conservative laterally beyond the lateral border of the areola.  The implants were placed in a very tight and conservative manner which allowed for beautiful cleavage as well as allowing for a nice lift on the left breast, as can be seen on the before/after photograph.

This is an excellent example of how in certain cases an internal breast lift can occur if the pocket is not made too large and symmetry can be obtained by over-filling one implant slightly more than the other.  The tubular breast can be released by radial striation of the bottom of the breast, as seen on the right side.  The lifting is beautiful bilaterally and once again, the only scars are under nipple (periareolar approach).