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Dr. Linder's Blog


Monthly Archives: November 2009


In my practice, approximately 98% of my patients are female. Having performed thousands upon thousands of body sculpting procedures, I have been able to decipher my own cognitive perception of female beauty. Their form can be composed of standard proportions of the three body areas. In general, I look at each woman’s body from the shoulders to the inframammary fold or zone one. The secondary zone is from the inframammary fold and subcostal region to the inguinal region just above the groin area. The third zone is the lower third composing the lower extremities or thighs. In my practice, my number one desire is to create proportionality. When placing implants, it is vital to understand the female anatomical landmarks and measurements, including the height of the nipple areolar complex to the inframammary fold, the diameter of the inframammary fold, the thickness of the female pectoralis major muscle and comparison with the amount of glandular and fatty breast tissue superficial to the muscle.

Understanding the female’s chest wall anatomy and the proportionality, including shoulders to inframammary fold, intrasternal distances and intra nipple areolar complex distances, allows me to best fit each specific breast implant and type of implant, saline vs. silicone, to each specific woman’s body, according to desires and proportionality. The midriff area or zone two with female plastic surgery is important in that a specific curvature from the flank or the subcostal margin to the iliac crest or anterior superior iliac spine have a concave shape, allowing for reduction of a boxy or square appearance. This can be performed using bi-directional tumescent liposuction as well as the muffin top procedure for removing fat continuing in the lower belt region along the periumbilical area.

Finally, the lower third in which there is a disproportion of fat in the female form with the anteromedial and posterolateral saddlebags, can be nicely sculpted to reduce the gynoid appearance that can be seen or the pear appearance that women attempt to get rid of. Bi-directional, double layer, tumescent liposculpturing of the lateral saddlebags will help to smooth out the lateral thigh as well as reduction of the anteromedial thigh fat pad help to reduce the touching of the inner thighs, narrowing the lower third to make it proportionate with the upper and mid third of the female form. Watching and having performed thousands and thousands of body sculpting procedures, including breast enhancements, breast lifts, breast reductions, total body liposculptures, paniculectomies and full abdominoplasties on women every week, has allowed me to understand the female form at its greatest and create the most beautiful proportionality for women worldwide.


In my practice, I believe that all breast masses have to be considered very seriously, especially breast masses that are enlarging over a short period of time.  As a case example, recently we saw a patient who had an unremarkable ultrasound showing no evidence of malignancy, no microcalcifications and no indication per radiology for any type of diagnostic testing of the mass itself. 



The patient was to undergo a removal and replacement of implants that were over a decade old, but she had a mass that was approximately 3×5 cm and it was well loculated in the right upper breast.  Even though the ultrasound was normal or negative, did not show any evidence of malignancy, I believed that this should be biopsied intraoperatively with removal and replacement of the implants.  In the operating room, bilateral removal and replacement of implants, open capsulectomy and excisional biopsy of the right breast mass was performed.  The mass was hard, somewhat calcified and very thick.  It was sent to our excellent pathologist at the UCLA Medical Center for diagnostic purposes.  The diagnosis came back ductal carcinoma, which was invasive.  Thank God we took the initiative to do a biopsy at this time even in the face of a false negative report on her ultrasound where she was asked to repeat the ultrasound in six months to one year.  Who knows what the state of this patient would be in six months to one year.  There is a chance that she may not be alive in six months to one year. 

As a result, I believe in my practice all tumors, especially tumors or breast lesions that are enlarging rapidly over a short period of time, should be considered seriously biopsied either with fine needle aspiration, TruKor, or excisional biopsy.



Recently, the U.S. Preventive Services Task Force has changed the screening mammography for women in the United States to 50 years of age.  I believe this is a very controversial subject and topic and there are pros and cons certainly on both sides of the issue.  However, as a Board Certified Plastic and Reconstructive Surgeon,  a Diplomate of the American Board of Plastic Surgery, a Fellow of the American College of Surgeons and as a specialist in breast surgery, including breast augmentation, breast revision, breast lifts and breast reduction surgery, I strongly oppose this new change for several reasons. 

First of all, breast cancer is one of the most common forms of malignancy found in women in the United States today.  Screening mammographies in general are quite inexpensive, ranging between $80 and $150.  I believe this is a small price to pay to detect early pre-malignant or malignant cancers in younger females in their 30’s and 40’s.  

mammogram example

Mammogram X Ray Example


Personally, I believe that all women at 40 years of age, regardless of family history, should have screening mammographies unequivocally.  Patients who undergo breast surgery, including implants, breast reductions and breast lifts should undergo preoperative diagnostic and screening mammographies at the age of 35.  Multiple studies have shown that mammograms at 40 years of age save lives.  Dr. Vogel has cited several lines of evidence which support the American Cancer Society’s recommendation for screening mammographies for women between the age of 40 and 49, including evidence of early detection of breast cancer and how it does save lives as seen in the Journal of American Medicine in the 1995 issue.  Certainly, increasing screening mammographies to 50 years of age will save billions of dollars a year, but at what price?  Unquestionably, cancers will be undetected in women in their 30’s and 40’s with an increased risk of metastasis and certainly an increased risk of mortality.  In fact, in my practice we have performed breast reconstruction operations for bilateral mastectomy patients in their late 20’s and early 30’s.  If these patients had not had mammographies they would certainly be dead.  Therefore, for the above reasons, I will continue to recommend mammograms for all women at the age of 40, for any woman with a family diathesis of breast cancer at the age of 35 and for all women who undergo any type of breast surgery as well at the age of 35.


Symmastia is a condition in which the skin and tissue of the breast sternal area and the midline is longer attached.  This can occur either due to genetic congenital deformity or technical difficulties or poor postoperative results from plastic surgery.  In the last two weeks, we have repaired two patients with severe symmastia.  One person presented from Puerto Rico with implants actually penetrating beyond the sternum and deviating to the contralateral breast.  In this case example, smaller implants were used by Dr. Linder.  The medial muscle was released and the lateral capsule was opened up.  The inframammary folds were tightened and the nipple areolar complex positions were realigned.  The postoperative results show excellent improvement with a more normal appearance to her chest.

The second example shows the implant was performed twice by different surgeons.  There were two pockets, both subglandular and submuscular which had merged, causing the implants to push towards the midline and beyond.  This was easily repaired by opening up the lateral capsule creating a new single pocket, placing a smaller implant and performing an open lateral capsulotomy.

Pre-op (different surgeon) and Post-op Photos

Pre-op (different surgeon) and Post-op Photos

Symmastia, in my opinion, should never occur from plastic surgery of the breast.  It is in general a technical error by any doctor.  Only Board Certified Plastic and Reconstructive Surgeons should be performing breast augmentation surgeries, especially breast revisions, on difficult problems such as symmastia.


I felt after reading this I would share Laura’s thoughts.

Breast Revision Beverly Hills TestimonialTo Dr. Linder and all your amazing Staff:

“Since the first time I called your office, I felt completely at peace and totally comfortable.  Adriana was the first person I spoke with.  She is so patient and caring.  She made me feel that there was no wrong question and she took the time to speak with me.  She’s so wonderful.  Then I spoke with Dr. Linder.  I had two previous breast surgeries from my home town of British Columbia, Canada, each one worse than the previous.  I had had a virtual consultation with
Dr. Linder.  He right away knew what needed to be done to fix all the scar tissue and mess from the previous surgeries.  I knew that I had to come out to Beverly Hills to have it done right.  My confidence in Dr. Linder was 110%.  He is amazing.  When we spoke on the phone, he was so kind and totally focused on making my surgery a success.  The day before surgery, I came to his office to meet him in person.  He is such an amazing man.  So caring, so patient, he answered any questions and concerns that I had.  He took the time with me to ensure I was totally at ease and at peace with respect to the surgery to come.

On the morning of surgery, I met Beverly and the rest of his staff.  Beverly is such a caring person, just like a mom.  I couldn’t have had a better nurse.  The day after surgery, came in to see Dr. Linder, bandages were removed and I was crying.  Dr. Linder far exceeded my expectations.  I am 110% satisfied.  He’s not only an amazing man, but he is an amazing surgeon.  He instantly changed my life.  He gave me “perfect breasts.”  It was worth the flight over from Vancouver, British Columbia, Canada.

Thank you for all you have done to make me feel beautiful again!  Dr. Linder takes the impossible and makes it possible.  I truly thank you so much for fixing my breasts.  They are beautiful.”
All the best,
Laura P.
British Columbia Vancouver, Canada


Dr. Linder and Dr. Kotler have created a new international website, http://www.american-plasticsurgeons.com/.  This is a concierge website for international travelers worldwide to Beverly Hills for cosmetic surgery.  Dr. Linder operates below the neck on the body and is referred to as “Dr. Body,” and Dr. Kotler operates above the neck and is referred to as “Dr. Face.”  Both surgeons specialize in their specific parts of the anatomy.  Well over 10,000 patients have undergone surgery from the above surgeons with over 60 years of experience in training as well as private practice. 

Each week blogs will be posted on issues relating to safety and interesting topics in plastic and reconstructive surgery of the face and body. 

Both surgeons have authorized their own books on plastic surgery to educate patients when undergoing cosmetic surgery of the face and body.