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Dr. Linder's Blog


Monthly Archives: October 2010

Bottoming Out and Downsizing of the Breast

Many women present to me who have had breast implant surgery several years ago throughout the United States.  As many women age, they desire to downsize their breast implants in order to reduce the heaviness of their breasts as well as at times with bottoming out that may incur, they also desire to tighten up the inframammary fold at the same time.  The below example is an example of a patient who presented from out-of-state with enormously disproportionate breasts.  She is only 26 years of age; however, even at her age she believes the implants a way too large for her body.  She desired to have those removed and replaced with smaller silicone gel implants and an internal capsulorraphy and inframammary tightening procedure was performed to recentralize the nipple areolar complex to the middle of her breasts.  The preoperative photos show disproportionately large breast implants which the patient felt were too large for her body and also causing back pain.  The implants were so large that they were leading to bottoming out as well as where there was inferior displacement of the implants with the nipple now migrating superiorly towards the top of her breast mound. 

The patient underwent, through inframammary incision only, open capsulotomy, removal and replacement with smaller silicone gel implant by 225 cc reduction in size of implants, and subsequently an inframammary tightening procedure through the inframammary mastopexy well hidden along the inframammary fold.  The patient has done well and this is her three-month postoperative photos.  This is an example of bottoming out that can be corrected by an inframammary skin lift with a small internal capsulorraphy along the inframammary fold and a downsizing with significantly smaller implants.

bottoming out  Down sizing

Tubular Breast Deformity Beverly Hills

Patients who present with tubular breast deformity are often very unhappy, not with just the size of their breasts, but actually with the shape.  The components of a tubular breast deformity include No.1, a poorly defined inframammary fold.  In other words, there is no fold along the bottom of the breast or it is not defined well.  No. 2, is a flattening or blunting of the lower pole of the breast in which there is no round shape to the lower breast causing a conical or tubular shape, almost a triangular shape, on an oblique or side view.  Finally, there is also a pseudo-herniation of breast tissue into the nipple areolar complex.  This means that the glandular thick or fatty tissue actually pushes the nipple areolar complex out performing a protrusion that does not look pleasing to the patients. 

It is highly recommended that these patients undergo augmentation mammoplasty procedure either through saline or silicone implants under the muscle with the dual plane technique if it’s a minimal tubular breast.  If it’s an endomorphic thick barrel chest, then we often place the implants above the muscle or subglandular or retromammary plane.  We also release along the inframammary fold in a radial striated fashion in order to round out the lower pole of the breast.  We see patients with tubular breast deformity each and every week, if not several a week, who are really distraught and frustrated with not only the size of the breast, again with a conical tubular shape of the breast, which can be corrected.  Now postsurgically, it is very important that patients maintain a sports bra, athletic bra for approximately six weeks.  They can be fitted into the new Dr. Linder Bra which allows for support, but will not allow the inframammary fold to end up too high.  We also have an upper pole compression band that pushes down on the implants and the muscle and it relaxes the implant and displaces it inferiorly so that 1) it allows rounding out of the lower portion of the breast pocket; and 2) it does not allow the implants to settle into a too superior position.  In other words, the implants don’t end up too high.  So, it is apparent that tubular breast deformities are significant in the population and at least two to three percent of my patients for breast augmentation will present with this.  We can correct this in a useful manner that is predictable as long as the implants are placed correctly, the fold is released, there is release along the lower pole of the breast fascia and a band is used for a significant period of time in order to maintain the lowering of the position of the implants.

Plastic Surgeon Qualifications


ASPSIt is vital that patients do as much due diligence on finding their plastic surgeon as possible.  When considering body sculpting procedures, it is vital that patients find a physician who is Board Certified with the American Board of Plastic Surgery.  This doctor should be a Diplomate of the American Board of Plastic Surgery and may also be a member of the American Society of Plastic and Reconstructive Surgeons, as well as a Fellow of the American College of Surgeons.  There is a circle logo that can be designated on the doctor’s card.  This will also be identifiable by the Diploma by the American Society of Plastic and Reconstructive Surgeons as well as on the Worldwide Journal of Plastic and Reconstructive Surgery, also referred to as the “White Journal.”  Look for that logo of the American Society of Plastic Surgeons when considering body sculpting procedures

To become a Board Certified Plastic Surgeon requires many years of experience and many years of training.  There are no substitutes and there are no quick weekend courses.  The physician first must graduate from an accredited medical school in the United States of America, then proceed to a residency and surgical training a minimum of three years.  These residencies often include general surgery training from three to seven years.  Subsequently, fellowships in plastic and reconstructive surgery, either two or three years, can be obtained.  Once those fellowships are finished, the surgeon will then sit for Board Certification.  First, written boards, which the exam must be passed and finally oral board certification in which the surgeon will meet with several examiners to determine that they are qualified to perform the many scopes of plastic and reconstructive surgery.  These scopes include hand surgery, facial reconstruction, cranial reconstruction, cosmetic surgery, body reconstruction, micro vascular surgery and hand surgery.  Board Certified Plastic and Reconstructive Surgeons are qualified, experienced and have the judgment to understand problems that may arise from surgical procedures, as well as the blood supply and the anatomy that is vital in performing surgeries safely and reducing risk to the patients.

Star Magazine October 25 Issue

Dr. Linder is proud to be the Beverly Hills consultant for Star magazine.


Recovery After Bra Bulge Lipectomy

The bra bulge lipectomy procedure is an excellent procedure.  It is relatively non-invasive.  On smaller patients it can be performed under IV sedation and even possibly local anesthesia when it is a small localized bra bulge.  With moderate to severe bra bulge, this may require IV sedation, even general anesthesia, especially if skin resection is required as well.  In the majority of cases; however, tumescent lipectomy in a bi-directional manner can be performed, removing the fat

Patients often ask how long is the recovery period for this procedure.  It is relatively short.  In fact, patients have gone back to work on postoperative day number one.  In general, tumescent fluid is infiltrated into the lateral pectoralis major area and the bra bulge tissue is then suctioned out with a 3 mm triple lumen Mercedes cannula with a small stab incision made along the lateral pectoralis major border, interior to the anterior axillary fold.  Patients are given six weeks of compression garment with a chest wrap.  The suture is removed on postop day seven.  The patient can shower seven days later and is maintained on antibiotics for one week.  Normally, only Tylenol is required for pain management.  However, if a significant large bra bulge is removed, then Vicodin ES may be given.  In general, again, patients can get back to work in 24 to 48 hours.  There is minimal discomfort and this procedure leads to predictable excellent reduction of that uncomfortable lateral fat pad and the embarrassing fat that is seen along the lateral breast region.

Bra Bulge Lipectomy Technique

Liposuction of the bra bulge

This is a special procedure that Dr. Linder performs in which he performs bi-directional lipectomy or liposuction of the bra bulge.  This is fat that extends along the lateral pectoralis major muscle, wrapping around it.  This fat can be very significant and can cause discomfort, pain and difficulty for women bring their arms down to their sides.  It also can be a cosmetic frustration in which wearing brassieres can be difficult or bikinis in which the thick amount of bra fat causes embarrassment to patients.  Using a bi-directional liposuction with a small incision made in the anterior axillary line just lateral to the pectoralis major border, using tumescent technique liposuction, this fat can be removed with as triple lumen Mercedes cannula and sculpted. 

Six weeks of compression will allow for nice skin tightening on the majority of patients.  The patients should be examined preoperatively with the arms up, to the side and straight down, in order to determine the amount of skin laxity.  The bra bulge lipectomy procedure is useful for women who have significant amounts of lateral breast hypertrophy and bra bulge fat. 

 Please see the below example of the before/after patient who underwent the braw bulge lipectomy procedure.


before photo after photo

Profiles of Breast Implants

Profiles of Implants

Today, implants can be placed either moderate, moderate plus or high profile.  There are also anatomical shaped implants.  In my practice, we prefer high profile as well as moderate plus profile.  The profile of the implant is associated with the diameter of the bag.  The wider the implant, the more of a moderate profile the implant would be, such as the McGhan Allergan Style 68 Moderate Profile.  A mid range implant is a little bit narrower diameter with a little bit more AP projection as a moderate plus saline or silicone implant.  High profile implants have the roundest highest AP projection and the least diameter or based diameter.  Many of the women who desire a natural appearance do well with the moderate plus silicone and saline implant placed under the muscle or the dual plane technique.  High profile implants are very useful for women who are very narrow to begin with and would like more AP projection.  My least favorite implant is the moderate profile which is also referred to as Style 68 low profile implant because it leaves a woman looking very wide and reduced AP projection and more matronly in appearance.

High Profile Implants

Moderate Plus Implants

Moderate Implants