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Monthly Archives: March 2011

Creating a Slight Breast Enhancement

NOTICABLE BEAUTY

Conservative patients do present to me for breast augmentation.  They are most concerned about maintaining a natural appearance with a subtle change in breast size in order to simply fill out their bra; however, not become disproportionately large.  For this subset of patients, I have found using small style 15 moderate plus Allergen silicone gel implants, using the dual plane technique through a periareolar approach, to be very useful.  Patients who are ectomorphic with minimal amounts of breast tissue and have thin pectoralis major muscles and ask for a very, very natural augmentation result would do well with these moderate plus silicone gel implants.  In general, patients often will only go up one cup size from a full “A” to a full “B” and these patients do well with the mid range moderate plus gel implants placed underneath the pectoralis major muscle.  Tight compressive Dr. Linder Bras in extra small are worn for four weeks with an upper pole compression band in order to reduce upper pole fullness, soften the muscle and lower the implant to a natural position.  The settling process takes approximately four to six weeks. 

Patients from Asia and Korea often ask for this subtle increase in breast size and have been extraordinarily happy with the style 15 gel implants.  Sizes on these patients can range from 158 cc to 213 cc.  The base diameter of a 176 cc moderate plus style 15 is only 10.3 cm, while the projection is 3.4 cm.  This leads to an extraordinarily natural result that this set of patients is quite happy with.

Natural Breast Augmentation Surgery

BEVERLY HILLS, CA – In order for our patients to obtain the most natural appearance on their augmentation mammoplasty procedure and still obtain upper pole fullness, in general, I like to place high profile saline, moderate plus profile saline or silicone gel implants under the subpectoral dual plane technique.  Placing implants with medical two-third muscle coverage allows a softening and an effacement of the upper pole of the implant.

15980Even the style 45 extra high profile implants in my patients who have implants placed under the muscle have shown a natural appearance to the upper pole without an unnatural shape or rounding along the upper pole of the breast.  Secondly, upper pole compression bands are used in all my primary augmentation mammoplasty procedures in order to allow for inferior displacement of the implants as well as softening of the upper pole of the pectoralis major muscle, the sternal head of, and to reduce unnatural appearance.  The upper pole compression bands can be worn for up to four to six weeks, depending upon the thickness of the muscle.  Patients with tubular breast deformity normally wear the bands for a longer period of time.

15976Expertise, experience and judgment of the Board Certified Plastic Surgeon is critical in allowing for a natural appearance to a breast augmentation patient.  In my practice, once again, placing the implants under the muscle using the dual plane technique as well as using upper pole compression bands as well as soft athletic brassieres or the Dr. Linder Bra, will allow for inferior descent and a natural positioning of the implants and softening of the upper pole muscle.

Congenital Breast Asymmetry

Patient presents to our office with severe congenital breast asymmetry.  The general pattern is usually associated with one breast being significantly smaller, often with a tubular shape, poorly ill-defined fold and herniation of breast tissue into the nipple areolar complex.  The opposite breast is usually larger and has a significant degree of laxity or sagginess.  The example below shows significant grade 3 ptosis on the right with the larger breast and significantly tubular breast on the left with no skin laxity.  This is a very standard case of congenital breast asymmetry that we enjoy reconstructing. 

Reconstructing these require experience in judgment and many years of training.  Only Board Certified Plastic and Reconstructive Surgeons should be performing these operations.  This specific patient underwent a right breast reduction with bilateral augmentation mammoplasty of different size implants in order to regain symmetry.  The tradeoff for the reduction of course is scarring, as noticeable on the right breast.  This is a full anchor scar or Wise-pattern technique, which was required.  Note, the postoperative symmetry is even, the folds are even and the nipple areolar complexes are symmetric as well.  This allows the patient to now feel comfortable both in and out of clothing, to wear appropriate bikinis and bras with symmetry and increase her confidence greatly.

Liposuction of the Saddlebag-Thigh Area

SADDLEBAG DEFORMITIES

As seen recently on national television, Dr. Linder performed a saddlebag operation in order to remove those pesky resistant lateral thigh saddlebags.  Some patients, as seen below, have excessive amounts of fat in the lateral thigh area which cannot be reduced through diet or exercise if it is in fact genetic-induced fat that accumulates in the localized fat deposit areas along the lateral saddlebags.  This patient in particular had a significant amount of fat also around the anteromedial and the iliac crest roll or hip region.

LiposuctionFor national television, she underwent tumescent liposuction, removing fat in two planes, both superficial and deep in a criss-cross manner and the suctioning was aggressively performed with a 3 mm cannula superficial and a 4 mm cannula deep, which allowed the fat to be removed in a smooth contour fashion.  Her after results show significant reduction in the thickness of her leg which has now proportioned her upper middle and lower third of her body.

Suspension Technique for Panniculectomy in a Morbidly Obese Patient

Written by: Stuart A. Linder, M.D., G.M. Buncke, M.D., Timothy Cooper, M.D., J.A. Mele, M.D., G. M. Kind, M.D., H. J. Buncke, M.D. 

 

ABSTRACT

A simplified technique for removal of a large pannus is described. The case presented involves a 63-year old morbidly obese man (more than 500 pounds) with multiple medical problems. Complications encountered when operating on the morbidly obese because of the sheer size of the patient and the body part to be operated on are briefly discussed.

Two operating tables were necessary to accommodate the patient’s large bulk. Preparation of the skin as well as the operative procedure were greatly facilitated by using a hydraulic lift to elevate the pannus. No injuries were sustained by the surgeons of the operating room staff. Total operative time was 2.5 hours, and there were no intraoperative or postoperative complications. This technique may be used to perform other procedures in the morbidly obese that require elevation of a body part.

INTRODUCTION

Contemporary Surgery Magazine Cover

A 63-year old morbidly obese male (estimated weight: 515 pounds) was admitted for surgical correction of an enormous pannus. Indications for panniculectomy included mechanical compression of the lower extremity lower venous system, lower abdominal hygiene, and decreased mobility. The patient initially was admitted to the cardiology service with multiple medical problems associated with his morbid obesity including congestive heart failure, artial fibrillation, and marked chronic venous stasis of the lower extremities. On examination, the abdominal pannus and lower legs appeared markedly lymphadematous.

Preoperative medical workup included pulmonary function tests, echocardiogram, and upper and lower gastrointestinal endoscopy for investigation of microcytic anemia. With aggressive preoperative diuresis, a weight loss of 45 pounds was achieved.

OPERATIVE PROCEDURE

Figure 1: Preoperative view prior to panniculectomy

Intraoperative monitoring was performed using an arterial line and a Swan-Ganz catheter. Two operating tables were necessary to accommodate the patient’s bulk (Figure 1). Preparation of the skin and the operative procedure were greatly facilitated by using a hydraulic lift to elevate the pannus. With assistance from the biomedical engineering department, two intramedullary rods (1/4-inch stainless steel) were bent into lifting hooks. The “Ruger hoist” included an extension book with variable standing positions (450, 750, and 1000 pounds) determined by its length (Figure 2). In order to gain maximum extension of the boom for positioning at the side of the surgical table, a total weight of 450 pounds could be elevated safely. The hooks were connected by rope to a gamble that was mounted on the hydraulic lift. (Figure 3)

The total operative time was 2.5 hours, and there were no intraoperative complications. Equally important, no injuries occurred to either the operating room staff or the surgeons in association with the physical difficulty of maneuvering a morbidly obese patient intraoperatively. The entire operative specimen weighed 100 pounds. The estimated blood loss was approximately 450cc. The patient received one unit of packed red blood cells and two liters of crystalloid intraoperatively. No further transfusions were required.

There were no postoperative complications. The patient was extubated with removal of a central line on the second postoperative day. Embolic prophylaxis with subcutaneous heparin was administered for five days until ambulation. Unna boots were placed on the lower extremities every three days to aid in the reduction of edema and as a treatment for chronic venous ulcerations. After one week, the patient was transferred to a skilled nursing facility from which he was discharged on postoperative day 13.

DISCUSSION

The pathophysiology of Panniculus morbidus was described by Petta et all in 19921. A large pannus creates a vicious cycle of lymphatic and venous congestion leading to further ischemia and lymphedema, ultimately resulting in celluitis, abcess formation, and infarction. During surgical dissection it was ecident that this patient has a markedly lymphadematous pannus.

Surgery in the obese patient has been associated with an increased incidence of complications and mortality including deep vein thrombosis, pulmonary embolism, pneumonia, sepsis, and would dehiscence with fat/skin necrosis. Obesity is commonly defined as being more than 20% over the ideal body weight; morbid obesity is defined as being more than twice the ideal body weight. In a review of the literature published in 1985, Hirsch et al2 found a variable, but nonetheless high (20-78%), incidence of complications following surgery in the morbidly obese patient. Abdel-Moneim noted a 2.6% mortality rate from surgery in obese patients.3 According to Foley and Lee,4 the incidence of would infections in morbidly obese patients is as high as 40%, and would dehiscence is ten times more likely to occur in this patient population. Reducing operative time may decrease the incedence of would sepsis, would dehiscence, and hernia formation.

Various techniques have been described to aid in suspension of the pannus. Richard5 described placement of a rigid bar through the pannus to provide suspension and enhance manipulation. Meyerowitz et al6 described the transverse placement of Rush nails for suspension. The skewered Rush nail method has been modified by bending the intramedullary rods into hooks. Sterilized “shark hooks” also could be used easily. Matory (7) et al described a pannus elevation technique using rope suspension with towel clips and Steinmann pins.

The method of suspension used in this case allows complete surgical resection of the pannus without requiring multiple assistants. The hydraulic lift boom was extended to its greatest length to maintain the sterile field. The nurse controlled the manual pump that is used to elevate the pannus on the hoist. Our biomedical engineers recommended using a thicker rod, at least 3/8-inch in diameter, to prevent the bending that was evident with the 1/4 inch rod.

CONCLUSION

The technique describes for panniculectomy will expedite the operation, reduce blood loss, and optimize the volume and venous return. Visualization of the vessels is easier and hemostasis is more readily accomplished with reduced blood loss. Prevention of injury to the operating room staff and surgeons also is an important consideration.

REFERENCES

  1. Petty P, Mandon PN, Black R, et al: Panniculus morbidus. Ann Plast Surg 28:442-454, 1992.
  2. Hirsch J, et al: Health implications of obesity: NIH Consensus Development Conference statement. Ann Intern Med 103:1073, 1985.
  3. Abdel-Moneim RI: The hazards of surgery in the obese. Int Surg 70:101, 1985.
  4. Foley K, Lee R: Surgical complications of obese patients with endometrial carcinoma. Gynecol Oncol 39:171, 1990.
  5. Richard EF: A mechanical aid for abdominal panniculectomy. Br J Plast Surg 18:336, 1965.
  6. Meyerowitz BR, Gruber RP, Laub DR, et al: Massive abdominal panniculectomy. JAMA 225:408, 1973.
  7. Matory WE, O’Sullivan J, Fudem G, Dunn R: Abdominal surgery in patients with severe morbid obesity. Plasty Reconstr Surg 94:976:987, 1994.

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LARGER BREASTS BECOMING MORE COMMON

Over the next 12 months, another 500 or so women from around the world will be sporting larger breasts-breasts that are perfect as far as the human eye can discern.

These women will have one plastic surgeon to thank for their enhanced cleavage, Stuart A. Linder, MD, FACS, who is thought to operate the single highest-volume breast implantation practice in Beverly Hills, California.

“I’ve specialized my practice in cosmetic breast augmentation procedures,” says Dr. Linder. “I achieve spectacular results uniformly because of my insistence on using a periareolar approach and sub-muscular placement whenever possible.

Dr. Linder, a solo practitioner, prefers implanting through the areolar because it affords safety and a consistent, predictable outcome. “This way, I don’t have implants ending up at different levels as is often the case when surgeons go through the armpit,” he says. “Going through the armpit may make it more difficult to accurately get the folds symmetric. But from the incision through the areola, I can get the folds almost absolutely symmetric. The implants, therefore, are positioned at the same level, and the nipples are up at 5 degrees.

I most often use smooth, round saline implants under the muscle because the shell of the implant doesn’t adhere to the capsule or the tissue and the implant can move more freely in the pocket. Additionally, because I implant through the periareolar approach, one often finds identifying the actual incision site afterwards to be quite difficult.”

SURGERY EVERY MORNING

Approximately 90 percent of Dr. Linder’s cases are breast augmentations, mastopexiesreductions, and do-over’s of other surgeons’ sub-optimally performed breast procedures. The remainder are liposuction and tummy tucks. If a patient requests minimal facial plastic surgery, Dr. Linder will consider it but usually refers to other plastic surgeons. “It was because I concentrated my practice in breast surgery that I was able to quickly develop so large and successful a practice,” explains Dr. Linder, who hung out his shingle in 1997. “My mentor said it would make good business sense, because of my young age, to make breast and body sculpting the focus of my practice.” The advice, says Dr. Linder in retrospect, was some of the best he’d ever received. “I was only about 30 at the time and still in plastic surgery residency,” he continues.

“I was told that since most patients seeking breast augmentations are young themselves, they would feel comfortable with me as their plastic surgeon. But, if I were to attempt a more generalized practice, I would have to appeal to older patients and could expect as many as 80 percent of them to decide to go elsewhere-possibly turned off by my young age. The assumption those older patients would make is that because I’m young I wouldn’t be experienced enough to do the job right.”

Nobody advised him on this, but Dr. Linder decided early in his practice to exhibit flexibility with regards to fees. That, too, it turned out, was a sage move. “I wanted to structure things so that if I’m dealing with a patient who is employed as a secretary, I wouldn’t charge her what a movie star might be expected to pay,” he says. “I believe in being sensitive to a patient’s financial status. Besides, I know I’ll make a lot more in the long run by handling it that way. Specifically, the patient is going to afford her breast augmentation, and therefore, will be so thrilled that she’ll send five or six friends to see me. But, if I charge an unreasonable amount, that woman won’t become a patient. And if she never becomes a patient, I won’t be doing surgery on those five or six friends of hers”.

Dr. Linder reports that he sees roughly 35 new patients per week. To accommodate that many consultations, his office is open Monday through Friday, plus half a day on Saturday. He also performs surgery every morning. Dr. Linder says he believes in maintaining a busy operating schedule, not only to keep his surgical skills in topmost form, but also avoid any delay in giving patients what they want.

ATTRACTING PATIENTS

“Every month I gain 30 or 40 new patient consults from the internet,” he says. Such use of the Internet is the only form of advertising Dr. Linder employs at present. He does not run newspaper ads or television commercials because those forms of paid our reach tend to attract flighty problematic patients. Dr. Linder prefers to rely instead on word of mouth as the principal means of pulling in new patients, just as he has done since the practice debuted. Dr. Linder explains that he chose to set up shop in Beverly Hills because of the exclusive city’s cache with consumers. “Beverly Hills has the image of being the place where the world’s greatest plastic surgeons are found, “he says. “If you were a woman in Idaho who wanted to have the absolute best breast augmentation done, where would be the first place you’d think to start shopping for a plastic surgeon? Right, Beverly Hills, California. For that reason I felt it would be easier to attract patients to my practice by being here. And, I was correct about that. Being here in Beverly Hills really helped me hit the ground running.”

Some would assert that Dr. Linder – a man of seemingly boundless energy and enthusiasm – hit the ground running the moment he was born in 1965. A native of Los Angeles, Dr. Linder says he settled on a career in plastic surgery by the time he was 13. “I can thank my father for inspiring that choice – he’s one of the great pioneers in the field of anesthesia,” Dr. Linder says. “Occasionally, he’d take me into the operating room to observe surgeries – all kinds of surgeries. But the operations that most fascinated me were the reconstructive surgeries and cosmetic plastic surgeries.”

Once Dr. Linder set his sights on a career in plastic surgery, he never wavered. “I was awed,” he recalls, “by the idea that it was possible to reshape and remodel the human body. I still am. Then, there’s the fact that results are observable almost immediately. I mean, you can do breast or a tummy tuck, and you see the difference in two hours. Take the dressings off the next day and, wow, the effects are awesome.”

Dr. Linder went to college at the University of California, Los Angeles, form which he received an undergraduate degree in bio-chemistry in 1987. Dr. Linder continued on at UCLA through medical school (completed in 1991) and general surgery residency (finished in 1994). For his training and fellowship in plastic surgery, Dr. Linder headed up the coast to San Francisco and St. Francis Memorial Hospital, where he spent the next three years. Immediately afterward, he returned to Los Angeles and set up his Beverly Hills practice.

In 1999, Dr. Linder became a diplomate of the American Board of Plastic Surgery, and a member of the American Society of Plastic and Reconstructive Surgeons, as well as the Los Angeles Society of Plastic Surgeons.

Reducing Rippling of the Breast

REDUCING RIPPLING – MEDIAL VISIBILITY

Patients present to me who either have had multiple breast augmentation or breast revision surgeries and/or ectomorphic with minimal amounts of breast tissue to start.  They may encounter visibility or rippling of the implant along the medial breast edge. This can occur even on a primary augmentation on very thin ectomorphic patients who have minimal amounts of breast tissue or have prominent costochondral junctions.  Methods to reduce visibility around the medial breast can include changing the implant to a rounder style implant.  Style 45 high profile silicone gels, which are the extra high profile rounder implants, greatly reduce the visibility and rippling.  By physics, the rounder the object becomes, the less palpability and/or visibility along the edge of the implant.  As a result, we have had excellent results removing moderate and moderate plus silicone implants and/or textured saline implants and replacing them with style 45 high profile gel implants.  This can be done as well with a cellular dermal matrix graft which may be placed along the medial breast in order to allow for more tissue coverage. 

linder1Please see the example of the style 45 high profile gel implant.  Note that it does have increased AP projection, narrow based and increased upper pole fullness.  This implant may not be for all women.  However, it will help to reduce the visibility and palpability of the implant edge.  We have used this in the last two weeks on four patients from London to the United States (Ohio) for reconstruction purposes and this style 45 implant has shown to reduce the visibility and rippling on each of those patients.  Consider this implant for reducing medial breast cleavage rippling which can be a difficult problem to repair.

Breast Implant Placements

Placement of Breast Implants

Saline or silicone implants may be placed in one or two planes, either the subglandular retromammary or the dual plane technique or subpectoral two-thirds under the muscle, one-third over.  The majority of our patients with primary augmentation we prefer the dual plane technique, placing the implant behind the muscle along the medial two-thirds and behind the glandular tissue on the lateral outer-third.  However, patients who have endomorphic build such as barrel chest deformity or severe pectus excavatum with thick breast tissue may do well with implants placed in the subglandular pocket. 

Advantages of the dual plane technique include decreased visibility and palpability, decreased scar tissue contracture or ease for mammography for the radiologist.  Disadvantages of the subpectoral pocket include more pain, stiffness, and sometimes flexion deformities when the parasternal attachments of the pectoralis major muscle are not released.  Advantages of subglandular include easy placement, less pain postop; however, many disadvantages including increased risk of scar tissue contracture, difficulty reading mammograms, more visibility, palpability of the bag and a less natural appearance.

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