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Dr. Linder's Blog


Monthly Archives: August 2010

Breast Asymmetry and Tubular Breast Deformity


Breast Asymmetry and Tubluar Deformity Before and After Photos

The above 19-year-old female presents with severe breast deformity with a combination of both tubular breast deformity and severe breast asymmetry.  This is an excellent case example of how tubular breast and asymmetry can be reconstructed safely with a single stage operation.  The above patient has a 34A breast on the left and 34AA breast on the right with grade 2 ptosis and severe constricted tubular breast deformity of the right.  The three obvious components include pseudo-herniation of breast tissue into the nipple areolar complex, poorly defined inframammary fold and complete flattening along the lower pole of her breast.  She is now two months post-surgical having undergone augmentation mammoplasty procedure with a 310 cc saline implant placed on the right and a 290 cc saline implant placed on the left.  She also has had retroareolar breast tissue removed from the right inferior nipple areolar complex to smooth out and flattened the protruded shape of her right nipple areolar complex.  At eight weeks, frontal view shows excellent symmetry, great cleavage, reasonable positioning of the right nipple areolar complex in comparison with the left side, smoothing and flattening of the right periareolar incision and a nice rounding shape along the right inframammary fold.  She is extremely happy with the results which will continue to settle over the next three to four months.  She is now wearing underwire bras and supportive athletic bras at night during sleep. 

Again, this is an excellent reconstructive example of combined breast asymmetry and tubular breast deformity, which can be easily and safely reconstructed under one surgical procedure.


The following are the most important steps in finding a qualified physician when considering plastic surgery of the body. 

1. Diplomate of the American Board of Plastic Surgery.  There are no substitutes!  The doctor must be Board Certified with the American Board of Plastic Surgery.  He or she may also be a member of the American Society of Plastic Surgeons and a fellow of the American College of Surgeons.  Board Certified Plastic Surgeons have the years of experience, judgment and qualifications to perform cosmetic surgery of the body in a safe and proper manner.

2. Specialization.  The plastic surgeon that you desire should specialize in the procedure that you desire to have.  If the patient desires breast augmentation, the doctor should perform augmentation mammoplasties (both saline and silicone) every week in his or her practice.  If the doctor does not specialize in the procedure that you want, run.

3. Photographs.  It is very important that the patient see before and after photographs of the procedure that he or she desires to undergo.  These must be photographs of before and after results taken by the surgeon who will be performing the surgery.  Make sure that the photos are authentic.  There should also be hundreds, if not thousands, of before and after photos of the procedure that you desire, as well as specialty photos of variations of procedures.  For example, on drlinder.com, we have well over 2000 sets of photographs on body sculpting procedures with well over 1000 sets of breast augmentation before and after photos.  Specialty photos can include congenital deformities including tubular breasts, breast asymmetry, and breast aplasia. Hundreds of these photographs are available for our patients to review so that it may instill confidence in their upcoming surgical procedure. 

4. Ambulatory Center and Anesthesiologist.  Make sure your center is certified appropriately and that the anesthesia is performed by a Diplomate of the American Board of Anesthesia. 

Following the above rules will greatly aid the patient in enhancing his or her chances of having a successful outcome with realistic expectations.

Breast Implants, Above Vs. Below The Muscle

breast implant placementSaline and silicone implants can be placed either subpectoral, dual plane technique or subglandular (above the muscle).  The plane of dissection normally depends upon each individual woman’s chest wall anatomy.  For the majority of women, we do prefer to place the implants in the dual plane technique, two-thirds under and one-third over laterally.  The reason for two-thirds is the lateral third of the pectoralis muscle is the oblique orientation and there is no true muscle cover on the lateral portion of the breast.  We do not use the serratus anterior muscle in cosmetic surgery normally in order to place the implant in the complete submuscular pocket.  Therefore, the majority of my patients undergo dual plane technique which is considered “under the muscle.”  Women who are thin (ectomorphic) and minimal body tissue should have submuscular cover to reduce visibility and palpability of the implant edge.  Indications for subglandular or above the muscle are women who have very thick chest walls, endomorphic appearance, barrel chest deformity, and women who have very thick amounts of breast tissue and/or muscle.  If you put the implants submuscular in these women, they have a very flattened appearance to the implants and they are often very unhappy with the final appearance.  They lack the fullness of the upper pole of the breast and often will want revision surgery.  After having placed thousands and thousands of implants, I have been able to obviously determine which patients do well with implants above the muscle.  Those are often thick chested women who do possess upper pole fullness and therefore an implant should be placed above the muscle in order to prevent effacement of the upper pectoralis major on the upper pole of the breast implant.  When implants are placed above the muscle on revision often I will maintain the same pocket in dissection.  Sometimes the capsule can be used in order to create more coverage and sometimes the neo plane can be developed by elevating a small portion of the medial muscle lifting it and suturing it to the lower capsule; however, this not always possible.

In summary, implant position placement submuscular versus subglandular depends upon each individual woman’s anatomy, amount of breast tissue and also preference of the final appearance of the breast.  In general, in thinner women, a more natural appearance is accomplished by placing the implant using the dual plane technique or submuscular.


It is well known at this time that Dr. Frank Ryan, Beverly Hills Plastic Surgeon, passed away from an automobile accident on Pacific Coast Highway, Monday, 4:34 p.m.  It is stated that he had climbed Point Dume with his dog with and subsequently on the drive down, rolled his jeep over a cliff in Malibu.  I knew Frank Ryan personally over the last 13 years of practice, as we both have offices in the same building on Bedford Drive in Beverly Hills.  We have run across each other at meetings, hallways and restaurants, it seems, on a regular basis.  He was a remarkable person.  He was very caring and giving as well as an obvious side to him.  Watching Blake and Alexis, my children, grow over the last 9 years, he always commented on how large and amazingly beautiful they were and how they continue to blossom.  We had the utmost respect for him as a person and the practice that he built.  I remember the times we spoke about our lives, accomplishments and hard work that we both put into our practices every single day to create quality plastic surgery on our patients and to continue to give a good name for our profession. 

Frank Ryan was simply a nice, nice guy.  He never had a bad thing to say about a person.  He was soft-spoken, articulate and just a pleasure to hang out with.   Kristal and I, with our children, Blake and Alexis, had the honor to attend his Candlelight Vigil on the 17th of August in Zuma Beach, Malibu.  It was obvious by the hundreds and hundreds of people that were there, including many of his celebrity clientele, that he was so very, very loved.  I will miss seeing Frank in the elevator, at meetings, plastic surgery conventions and just talking at restaurants about how life is, how things are going, how the kids, how he’s doing and how the Bony Pony Ranch and what charitable events he would be holding in the future.  His death is certainly a humongous loss to all of us in Beverly Hills.  I considered him a great colleague, a wonderful human being and humanitarian. 

May he rest in peace and may he be blessed in heaven.  Your colleague, Stuart.

International Society Aesthetic Plastic Surgery

AUGUST 14 TO 18, 2010

The annual meeting of ISAPS 2010 in San Francisco here at the Moscone Convention Center has been an informative and educational experience.  This has been an exciting meeting with beautiful weather and fine dining.  Topics have included AP issues in plastic surgery as well as multiple sessions.  Session one was specifically regarding Periocular Rejuvenation, describing both cosmetic and reconstructive surgery of the periorbital region.

Session two is specific to Facial Rejuvenation.  Section Three, Rhinoplasty, with Nasal Reconstruction.  Fourth session is corresponding to Aesthetic Breast Surgery which was fascinating; and Session Five was associated with Aesthetic Reconstructive Surgery.  This is an International Society Meeting with doctors from throughout the globe, extending from countries, including Columbia, Switzerland, London, Paris, Australia, Spain and China.  Once again, this is an excellent meeting with both educational and informative objectiveness.  Please see letter from Governor Arnold Schwarzenegger specific to attendees.


Tumescent liposuction technique is considered one of the gold standards of liposuctioning performed by Board Certified Plastic Surgeons in the United States of America as well as throughout the world. 

Before and After - Liposuction 1







Tumescent simply means to place fluid and specific substances or medications within the fatty cells, which will help to hydrate and help to remove the fat in a uniform and consistent pattern.  The technique and tumescent liposuction usually includes using three components:  1) the wetting solution, either lactated ring or normal saline solution.  This solution can be infiltrated with a Kline needle infiltrator hooked up to a pressurized bag which will then allow once again for a uniform removal of fat in the deep fat deposit areas.  The fat should usually be removed from the deeper fat layer, staying away from the subdermic which could increase risk of contour irregularities and deformities of the skin.  The second component is Lidocaine.  One percent Lidocaine, 40 cc, is often placed with the tumescent liter per liter of fluid and this helps to relieve pain up to 24 hours or more.  The third component is epinephrine.  Epinephrine is simply a vasoconstrictive agent which causes blood vessels to constrict thereby reducing bruising and bleeding.  Epinephrine is often used 1 cc per 1:1000 part per 1 liter of normal saline or lactated ringer.

 Before and After - Liposuction 2




We have used the tumescent liposuction technique over the last 13 years without complications.  It is an extraordinarily safe approach.  We do not usually place more than 3.5 to 4 liters at any time of wetting solution in our patients.  Dr. Linder prefers to stage large body sculpting techniques rather than to take the risk of using high amounts of epinephrine, lidocaine or excessive amounts of wetting solution fluids.  We perform our liposuction technique using the tumescent technique under general anesthesia.  By placing the patient under general, they are completely immobilized, intubated on a respirator and the plastic surgeon can do his or her work without consideration of patient movement.  Movement on the abdominal wall can be very severe which could lead to perforation of the abdominal wall with intestinal perforations. 

Before and After - Liposuction 11







Liposuction technique using the tumescent approach is safe and certainly the gold standard in the United States.


Pseudoptosis is basically a form of ptosis or skin laxity of the breast where the nipple areolar complex is above the inframammary fold; however, there is redundant skin.  This is often seen with patients who have been breast feeding or some patients who have been pregnant.  However, they have not had the nipple descend below the inframammary fold.  In fact, pseudoptosis patients are excellent candidates for straight augmentation mammoplasty procedure without breast-lifting.  In other words, they get excellent results with silicone or saline implants placed in the dual plane technique without the necessity of scarring of the vertical or Wise-pattern anchor scars. 

Before and After - Augmentation

 Examples of pseudoptosis will be shown.  Note that there is excess skin, however, the nipple is well below the fold which allows an excellent stretching of the skin of envelope by using saline and/or silicone gel implants under the muscle without the need for skin laxity.