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Dr. Linder's Blog

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Monthly Archives: March 2010

Breast Revision, Bottoming Out Beverly Hills

Bottoming out can be a significant problem with breast augmentation surgery.  In fact, implants placed in a perfect subpectoral or dual plane pocket over time can bottom out.  This can occur when patients either have increased skin Breast Revision Photoslaxity to their breasts, weight fluctuation and change or have poor inframammary fold support with underwire bras during the day and athletic sports bras during the evening.  Over time, heavier implants can certainly cause the skin to sag and increased laxity can certainly occur.  The below example shows a patient who over time, after two years postoperative, developed significant bottoming out of her right implant.
 The upper pole of the pocket became completely scarred in and developed scar contracture.  The implant was inferiorly displaced and the patient had bottoming out.  In order to correct this specific result, skin laxity was addressed along the inframammary fold.  1) removing skin along the inframammary fold and an inframammary breast lift procedure; 2) superior open capsulotomy and capsulectomy releasing scar tissue along the upper pole of the breast pocket; and 3) replacing of the moderate profile saline with high profile saline implants has greatly reduced the bottoming out of her right inframammary fold.  Please see her postoperative view showing enhanced cleavage, nipple position shows more symmetry and at five weeks postoperative, the inframammary fold appears to be significantly improved.  This is an example of bottoming out with correction by inframammary fold skin elevation by skin tightening, open capsulotomy and high profile implant exchange.

Mommy Makeover Beverly Hills

Mommy Makeover Preop Photos This patient is an excellent candidate for combined augmentation mammoplasty procedure, abdominoplasty, as well as tumescent lipo-sculpting of hips and inner and outer thighs.  The patient has had a cesarian section and has had delivery of three children.  On breast exam, she has involutional upper pole atrophy, loss of complete fullness of her upper breast fullness.  She is a good candidate for silicone gel augmentation mammoplasty procedure using high profile 325 cc implants.  She also has laxity of the lower abdominal skin which will require a further abdominoplasty as well as to tighten up the periumbilical area and the hypogastrium.  She has saddlebags in anteromedial thigh areas which can be sculpted nicely with tumescent liposuction technique. 

Mommy Makeover Postop PhotosThe patient is now six weeks postsurgical, status post silicone gel augmentation mammoplasty procedure with high profile gel 325 cc Natrelle implants placed to the dual plane with a small incision underneath the nipple.  She also has a full abdominoplasty, and plication of the midline rectus sheath.  The rectus muscles have been plicated into the midline.  She also has undergone a core sculpting of the inner and outer thighs.  Please note her pre- and postoperative photos.  The patient is six weeks postsurgical and is doing extraordinarily well.  This is an excellent example of our usual and customary Mommy Makeover procedure combining breast enhancement, full abdominoplasty and sculpting of the inner and outer thigh areas.

Immediate Postoperative Breast Augmentation

In the thousands of breast augmentations and breast revisions, breast reductions and breast lifts that Dr. Linder has performed, he continues to address the compression and immediate postsurgical garment or dressings in a similar fashion.  We do not use a surgical brassiere or any form of brassiere immediately after surgery in the operating room.  Rather, we use a Bias compression wrap, 6 to 8 inches, wrapping the breasts after placing 4×4 gauze, Steri-strips, Xeroform and Reston foam along the lateral breast if tumescent liposuctioning is performed.

Post Surgical Compression GarmentThis Bias compression wrap has been very useful to allow for the accommodating immediate acute swelling which will occur without constriction of the neck area or the chest region.  It also allows for compression and may be useful for reducing some small microcapillary bleeding.  In any case, we use the Bias wrap on all of Dr. Linder’s immediate postsurgical patients whether they are augmentations, breast revisions, breast lifts or breast reductions.  Please see the following picture.

 

Post Surgical CareSteri-strips are used on breast incisions unless the patient has a preexisting history of tape allergies at which time Xeroform (yellow impregnated gauze) will be used (see Photo #2), which can then be placed on the incision sites which is not adherent to the skin and does not cause blistering. Immediately, on postop day #1, the dressings are removed and patients are placed in athletic bras or surgical brassieres and all dressings and 4x4s are replaced as well.

International Patients Beverly Hills

INTERNATIONAL PATIENTS -BEVERLY HILLS

The patient below presented from England for augmentation mammoplasty procedure using silicone gel implants.  This patient is an elegant lady who desired moderate plus silicone gel implants through the periareolar approach in order to have some upper pole fullness and some narrowing along the lateral breast.  Please see her “after” photographs with the moderate plus silicone gel implants, postoperative four weeks.  She is now on her way back to London and had a wonderful result.  Also enclosed is her testimonial regarding her experience with her breast augmentation procedure. 

 

Post Operative Photo “Before I saw Dr. Linder I’d had 2 other consultations in Beverly Hills, and had not felt happy enough to proceed with Breast Augmentation. I even decided not to bother at all. Then I was surfing the net and I came across some pictures of the best before and afters I’d ever came across. The name under the photos was Dr. Linder so I booked a consultation with him
At my consultation I totally relaxed- sometimes you just know you are dealing with the BEST, and I totally felt confident to go ahead with BA. Dr. Linder’s vision and skill were obvious.
The result? Totally natural, and more importantly, extremely beautiful. Being English, I was frightened of that “done” American Look. He’s the best, it’s simple, and so are my beautiful, natural looking breasts.”
London, England

 

  We are always very excited to have our international travelers present for body sculpting procedures.  It is a privilege to be able to work on women throughout the world.

Postoperative Management Of Our Augmented Beverly Hills Patients

Acute v. Delayed

Linder-blogIn the Acute Phase or first six weeks postoperatively, Dr. Linder instructs his patients not to do any heavy lifting over five pounds to prevent bleeding and hematomas, as well as to refrain from aspirin, Advil, Motrin, Excedrin, Ibuprofen or blood thinning products which could cause clotting deficiencies.

Acutely, we also make every attempt necessary to prevent infections by preventing water and sweating to the incision site around the areola.  This can be done by keeping the incisions clean, dry, changing gauze twice a day for 14 days, maintaining Keflex, or oral antibiotics for 7 days postsurgically.  Keflex 500 mg q.i.d. or pan allergic patients Cipro 500 mg p.o. b.i.d. times one week.  Our patients are maintained in athletic sports bras and upper pole compression bands in order to lower the implants to a correct anatomical position which has a more natural appearance.  Our implants are placed in the dual plane at least two-thirds under the muscle and lateral third subglandular and the upper pole band relaxes the upper pole muscle and softens the implant pocket, lowering the implant to a nice position.

Delayed or chronic postoperative care should include, once all sutures are removed and the patient is happy with the position of the implants, supportive brassieres all the time.  At night patients should wear athletic sports bras in order to maintain position and prevent malposition and displacement of the implants during the sleep phase and during the day, underwire supportive bras are useful in maintaining the inframammary fold and preventing bottoming out of the implants. 

These are Dr. Linder’s specific instructions.  Other surgeons may have their own postoperative management and care.  Please refer to your own surgeon for his or her specific instructions.

Compression Garment Mechanisms Beverly Hills

Compression garments are used in a multitude of recovery procedures, status post plastic and reconstructive surgery.  The garments include facial surgery garments, contour garments, as well as postsurgical compression garments which may include surgical brassieres with compression as well as girdles and binders for abdominal contouring as well as thigh liposuction and contouring procedures.  The garments include facial surgery garments, contour garments, as well as postsurgical compression garments which may include surgical brassieres with compression as well as girdles and binders for both abdominal contouring and thigh liposuction and contouring procedures.  The mechanism of the compression garments is to reduce swelling and bruising as well as discomfort to the surgical areas.  Compression bras should be snug and fit, which allows for reduced swelling and also maintains positioning of the implants without malposition, also reducing swelling and edema.  However, there should not be direct midline contact and therefore a 4×4 gauze may be placed as a spacer for these patients. 

The upper pole compression band is another form of a garment that helps to reduce upper pole fullness.  It also allows the implants to be inferiorly displaced, reducing upper pole fullness that is unnatural, and is useful for lowering of the implant immediately postsurgically. 

Mid-Thigh Girdle by Contour

Abdominal binders are used on abdominoplasty and tumescent lipectomy lipo-sculpted patients.  These are worn for at least six weeks, if not longer.  This allows for reduced swelling and edema.  It also helps to reduce pain and discomfort.  When contouring the thighs, girdles are usually worn that can be from the hip area or above the hip area, if the upper abdominal area is suctioned, down to the mid-thigh region or down to the knee, as necessary. 

These compression garments may also be used on mastectomy patients of course, which helps to provide support and maximum compression after recovery.  The material should be soft, often combinations of Spandex as well as cotton.  This will reduce irritation and abrasion.  Normally, the compression garments are worn continuously for a prolonged period of time in order to maintain shape of the implants postoperatively and prevent malposition of the implants.

Device Identification Cards – Beverly Hills Breast Implants

N_logoBoth Allergan Pharmaceuticals (NATRELLE® Collection) and Mentor Pharmaceuticals (Johnson and Johnson) have saline and silicone implants that come with device identification cards within the implants.  There are stickers located in the internal product packaging.  The stickers should be placed on the cards that should then be given to the patients post-surgically.  All patients should maintain these cards that have vital information about their breast augmentation surgery.  The style of the implants will be included as well as the catalogue, lot numbers and serial numbers.  For future reference, when patients undergo a future surgery, the surgeon or different surgeon will have the ability to determine what the patient has in her body which will make this reoperation simpler and more straightforward.  The serial and lot numbers can be identified on the cards as well as the style numbers.  The style numbers will dictate the specific type of implant, saline vs. silicone, as well as high versus moderate profile.  For example, a Mentor reference 350-3380 is a 380 high profile saline implant.  Patients should maintain their cards and the operative surgeon should maintain stickers both in a catalogue and implant prosthetic device folder of all patients undergoing prosthetic devices.  As well, stickers should be placed in the surgeon’s own personal chart as well as the surgical facility chart.  The device information will also be placed in the nursing notes within the surgical facility charting.

Teenage Tranformation Beverly Hills Plastic Surgery

The patient below presented to my office at the age of 18.  She had lost well over half her entire body weight, over 140 pounds.  She was left with massive amounts of hanging skin from her breasts and abdominal area.  She had such a remarkable weight loss that she will be featured on CBS Early Show in New York in the upcoming month of March 2010.  The surgery was filmed as a documentary and below you will see her “before” photos.  She has severe grade 3 ptosis, massive amounts of abdominal wall skin laxity and a massive pannus.  She also has had massive weight loss.  Although she is quite young, only 18 years old, she is an excellent candidate for plastic surgery in reconstruction of her breasts and abdomen.  The perfect surgery for this patient is a formal mastopexy (a breast lift), without implants, and a massive tummy tuck (referred to as a panniculectomy).  The muscles were not plicated as she is only 18 years old and she may have children in the future.

Teenage Tranformation The patient underwent a formal breast lift and abdominoplasty or panniculectomy procedure approximately two months ago.  Her postoperative photos, as you can see, show excellent elevation of the skin.  Her nipple areolar complexes were made smaller to approximately 5 cm (they were 12 cm preoperatively).  She also has an excellent abdominoplasty result showing the entire roll of skin is gone.  This will reduce her weight of tissue causing her back pain.  As well, the rashes and dermatitis are now permanently resolved.  The patient could not be happier.  She and her mother are absolutely delighted with the results.  We are excited to have this patient featured next month on national television.

Breast Revision and Mini Abdominoplasty

COMBINATION PROCEDURE,  BREAST REVISION AND MINI ABDOMINOPLASTY IN BEVERLY HILLS
The patient below presented to Dr. Linder from Beaumont, Texas.  She was unhappy with the hardening and scar tissue as well as the appearance of her breasts.  She had painful breast deformity with significant scar tissue and encapsulation of the pockets.  The nipples were also significantly low on her breasts that she really had somewhat of a double-bubble breast deformity, the left side greater than the right, with some skin over-drape, nipple positioning low and the implants superiorly retropositioned.  On the abdominal area she disliked the lower abdominal poochiness and the adiposity lipodystrophy of the lower abdominal iliac crest rolls.  She also had some indentation from a previous cesarian scar along the lower abdominal wall.  This patient is an excellent candidate and example of a breast revision surgery with bilateral open periprosthetic capsulectomy, removal and replacement with high profile cohesive silicone gel implants and a formal mastopexy, and in this specific case, a vertical mastopexy, repositioning of the nipple areolar complex superiorly with a lollipop-like scar. 

 
Breast Revision and Tummy Tuck pre-op and post-op photos
Pre-Op and Post-Op Photos

The mini-abdominoplasty was perfect in this situation in that she did not have enough skin laxity to perform a full tummy tuck; however, I could bring the skin down, tighten the rectus sheath, plicate the rectus muscle and lipo sculpture the hips to give her a cleaner, smoother appearance and narrow the hips as well.  Notice, in her postoperative photo she has softer breasts, the nipple areolar complex is now central within the breast itself rather than inferiorly positioned as well as the cleavage is enhanced and she has more natural upper pole fullness. 

The abdominal area shows nice contouring of the lower abdominal.  The pooch is pretty much resolved and gone and the hips are much smoother.  The patient is extraordinarily pleased.  In fact, the following testimonial from the patient indicates her thoughts from her surgery.

“I live in Texas and found Dr. Linder on the internet. I called his office and spoke with Adriana the office manager. She was amazing and answered all my questions. I then scheduled a phone consult with Dr. Linder. I immediately felt comfortable and at ease with Dr. Linder and scheduled and appt. to meet with him. Always looking for an excuse to visit California, I flew out to meet with him. Afterwards, I was confident that his expertise and wisdom concerning breast revision surgery would give me great results. I scheduled my surgery and was amazed with the results. I experienced very little pain or discomfort and had excellent care by Dr. Linder post op. I am very pleased, this is my 3rd breast surgery and in the words of my husband, he says my breast look “magnificent”. We are both very happy. Thanks to Dr. Linder and his surgical staff for a wonderful experience.”

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