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Dr. Linder's Blog


Monthly Archives: May 2011

Repair of Double-Bubble Breast Deformity

Recently, I performed another interesting breast revision surgery on a patient from Las Vegas, Nevada.  This patient is a performer in one of the Super Shows in Las Vegas.  She had implants placed twice by previous surgeons.  She developed scar tissue contracture with superior retroposition of the implant.  She had a horrendous double-bubble deformity which I refer to as a “catcher’s mitt” syndrome.  This is simply where the muscles are not detached along the parasternal ribcage and also around the lateral inframammary fold.  In the operating room it was found that the implants could not be lowered without complete release and transection of these muscle attachments through the chest wall.  Once this was appropriately performed, the implants laid perfectly.  She went to a smaller silicone gel implant and the final stage included a formal mastopexy revision and removing skin from around the nipple areolar complex and vertically along the inframammary fold.  She will now be able to perform pain-free.  The implants now lie in the appropriate inferior position and the nipple areolar complex has been recentralized to the middle of her chest wall along the breast mound.

Panniculectomy vs. Abdominoplasty


Many patients are confused as to the terms, Tummy Tuck, Abdominoplasty, and Panniculectomy.  In fact, all three of these are very similar operations.  An Abdominoplasty and a Tummy Tuck are both the same operation in which skin is removed after significant undermining of the abdominal wall and tightening and plication of the rectus sheath muscles with permanent sutures.  A Panniculectomy is an enormous abdominoplasty, often referred to as removal of an abdominal pannus.  This can occur after massive weight loss such as bariatric surgical or gastric bypass patients.  These patients who have lost well over 100 pounds, often have a massive abdominal apron or pannus which requires careful dissection and removal of the pannus.  Usually the abdominal wall is so diastatic and so thin that suturing the wall is not feasible or appropriate.  Paniculectomies are enormous abdominoplasties.  The dissection is usually less aggressive superiorly up to the subcostal margin in order to maintain blood supply of the flap down to the abdominal wall.  The umbilicus is usually spared, but in some circumstances must be removed in the larger paniculectomies.  Paniculectomies are always performed under general anesthesia, two, if not three, Jackson-Pratt drain tubes will be placed in order to drain the fluid that accumulates after the flap dissection, for at least 7 to 10 days postoperative.  In the enormous paniculectomies I do not tighten the muscles internally.  This is instructed to the patients preoperative and that normally the muscle will tear with these sutures, increasing the risk for bleeding and not really greatly affecting the final outcome.  Paniculectomies are a functional surgery.  In fact, patients often have hygienic problems with as dermatitis along the suprapubic region extending along the inguinal creases bilaterally.  They may also have lower back pain significantly due to the massive amount of skin over-draping, which can drape all the way to the suprapubic region. 

Abdominoplasties on the other hand are normally considered a cosmetic or elective procedure in which again simple removal of tissue and skin with tightening of the rectus sheath is performed.  Patients who undergo abdominoplasties normally have had one or more children, large deliveries or have had a mild to moderate amount of weight fluctuation.

Style 45 Natrelle Silicone Implants

The style 45 gel is a great choice for women whom desire increased AP projection, narrowed diameter, and increased upper pole fullness! The  photo to the side is a example  of 600 cc style 45 with perfect proportion for this model. This implant is not for everyone! The final style determination should be made with your breast goals and anatomy in mind !


Sternal chest wall deformity or Pectus Carinatum Deformity is associated with a pigeon chest appearance, associated with deformity and protrusion of both the ribcage and the sternum. This anomaly congenitally is often referred to as a pigeon chest. There is bowing outward externally of the chest wall. It usually occurs as a solitary abnormality that may be associated with other genetic disorders or syndromes. It is contrary to pectus excavatum, which is associated with contour depression deformity of the midline or sternum. The etiology of pectus carinatum is when the sternum does not lie flat and rather it is a congenital deformity in which the costochondral junction and the midline sternum protrude anteriorly.

Peterium Carium Before and After

We operate on patients in our Beverly Hills practice with pectus carinatum, although it does not appear to be as frequent as the pectus excavatum patients that we see. The sternal deformity should always be evaluated for other abnormalities or other syndromes.

What occurs is the sternum protrudes and there is a narrow depression along the sides of the chest which gives a bowed out appearance to the chest wall similar to that of a pigeon chest. Normally, these patients have normal heart and lungs. Patients with pectus carinatum aesthetically can be improved with breast augmentation by placing subpectoral implants in the dual plane technique using high profile saline or silicone gel implants.

It is seen in approximately one in 400 births. People who have pectus carinatum normally have normal development of both the cardiac and pulmonary systems. These patients present with an outward rigidity of the chest wall. They can be associated with asthma as well as pulmonary insufficiency. Some children with the pectus carinatum may also present with scoliosis or lumbar lordosis which is a curvature in the spinal cord and vertebral column. It may also be associated with a mitral valve prolapse. The prognosis is usually excellent for pectus carinatum and surgical treatments can include surgical release of the costochondral junction as well as the sternum with repositioning with wires and/or rods. Some patients will have bracing as a first line treatment which of course is a noninvasive method of correction.

Below you will see examples of pectus carinatum that are somewhat correctable in patients who have significant pigeon chests or pectus carinatum. In order to reduce this effect, the implants can be placed in the subpectoral pocket. Care must be taken to avoid a pneumothorax and therefore a small cuff of muscle is maintained on the parasternal ridge and along the costochondral junction. Our patients are instructed that cleavage postoperatively will be affected by the carinatum and that the implants will be laterally displaced by the chest wall and that to minimize this there should be less dissection lateral to the areola which will allow for enhanced cleavage and a reduction in the visualization of the carinatum. Deformity of pectus carinatum are seen in my practice monthly; however, the severe cases can make it quite difficult to establish any cleavage unless significantly larger implants are used. Conservative size implants usually lead to lateral displacement of the implants over time with lack of cleavage when patients do not wear bras. Wearing the Dr. Linder Bra, extra small size post perioperative period may help to allow for compression of the implants and an enhanced cleavage as well. Pectus carinatum, although not all that common, seen in one in 400 patients, can be correctable by thoracic surgical procedures if severe and if patients present with pulmonary cardio insufficiency.

Peterium Carium Before and After profile right view

Peterium Carium Before and After profile left view

- See more at: http://www.drlinder.com/psarticles-carinatum.htm#sthash.4jZ1YZM4.dpuf

KNIFESTYLES Of The Rich & Famous Star Magazine

Beyonce’s Plastic Surgery

In newsstands this week Star magazine gave me the opportunity to comment regarding Beyonce’s new shape.

I stated “her cleavage has greatly improved, there is upper fullness which is a sign of an implant.”

Take a look at May 16, 2011 edition of the Star magazine for more details.

200th Posting On Breast Surgeon Blog


FireworksWe are excited to have hit the 200 blog mark here on May 2, 2011.  I have found that blogging weekly has allowed patients both educational and learning experience on all aspects of body sculpting procedures.  The main purpose of our blogs is to educate patients on breast augmentation, breast revision, breast reduction, abdominoplasty and lipo sculpting procedures. Our patients who have flown in from 24 countries read our blogs weekly in order to continue to learn new information on cutting edge procedures, upcoming television programs, documentaries and specific body sculpting procedures.  We will continue to dictate blogs on the breast surgeon blog website in order to allow for continued learning, educational as well as entertaining value.

Thank you for your continued support on reading our blogs and your added comments.