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Monthly Archives: October 2011

Combined Muffin Top and Banana Roll Liposculpturing

The patient to the left presents with a gynoid appearance with severe lipodystrophy of the iliac crest rolls.  She has a disproportionate amount of fat on the hip area.  She also has significant banana rolls which extend under the infragluteal fold out to the lateral thigh saddlebags

This patient underwent tumescent liposculpture technique in a bidirectional fashion at the muffin top as seen on the “Dr. Oz Show” with Dr. Linder and Dr. Oz.  She also underwent infragluteal fold liposculpture in order to reduce the fat along the buttock area as with Dr. Linder on the show “The Doctors.” 

Note her after-photo at four weeks.  The iliac crest roll shows a beautiful, natural contour without contour irregularities or deformities and smoothing out of the hips.  She also has a nice cut along the infragluteal fold showing a nice lower buttock division to the upper posterior thigh.  This patient is wearing a compressive garment for four weeks and will continue for another four weeks.  Combined tumescent technique of the infragluteal fold and the iliac crest rolls can allow a patient to have a nice lower third proportionate sculpting procedure when performed under general anesthesia using the tumescent technique.

Abdominoplasties with Concurrent Hernia Repairs

Recently, the patient presented with a very large periumbilical lower abdominal epigastric hernia combined with significant amounts of abdominal skin laxity.  This patient will require both a concurrent epigastric umbilical hernia repair with our general surgeon at the same time as the elective panniculectomy/abdominoplasty.  Patients who present with hernias should be seen by general surgeons as well as, if required, have diagnostic testing, including ultrasound and abdominal CT scans if necessary. 

The patient above underwent a full abdominoplasty with a hernia repair by our general surgeon, repairing both the epigastric hernia, the umbilical hernia and tightening of the rectus sheath at the same time.  Large hernia repairs, especially after gastric bypass surgeries should include the use of a Board Certified General Surgeon, especially with the use of mesh grafting of the abdominal wall.

Micro Liposulpture of Beverly Hills

Patients who present for revision liposculpture may require the use of very small cannulas.  The example below is a patient who underwent four liposuctions in Toronto, Canada as well as in Britain.  Unfortunately, she was left with some contour deformity of the periumbilical abdominal area which will be very difficult to correct without the use of very small 2 mm cannulas.  Very conservative tumescent technique liposculpture is required in order to prevent a distortion of the tissue that is trying to be feathered and sculpted.  Very small amounts of tumescent fluid through a 50 cc syringe can be infiltrated gently into these periumbilical areas on this patient in order to smooth out and lipo-sculpt with a very small 2 mm cannula.  The cannula acts not only to suction out the small amounts of fat in a perpendicular fashion, as well as to break up the scar tissue that can be found from the sub-dermis directly down to the overlying Scarpa’s fascia or even deeper down to the fascia of the rectus abdominus muscle.

This patient had the 2 mm cannula used in order to directly break up through a pre-tunneling technique the scar tissue without the suction on and then 1 atmosphere of vacuum suction was applied to remove a small amount of fat in perpendicular direction and to smooth out and feather out the periumbilical area.  When considering revision liposculpturing, very small cannulas can be used in order to reduce further contour deformities at this time.

Status Post Gastric Bypass Breast Reconstruction Revision

This patient underwent a gastric bypass procedure using the Roux-en-Y Gastroplasty at over a 130-pound weight loss.  She subsequently underwent augmentation mammoplasty procedure and a breast lift formal mastopexy by a different surgeon for severe involutional upper pole atrophy, and severe grade 3 ptosis. 

Her preoperative photos indicate unfortunate complete malposition of the implants.  There is a double-bubble deformity on the left.  The implant is superiorly retropositioned with the skin over-draping the nipple.  She also has an inadequate breast lift on the right from a vertical mastopexy that was performed which was the incorrect operation, thereby creating an inadequate result.  The patient subsequently underwent implant removal and replacement with high profile saline implants with 650 cc.  Open capsulectomies were performed.  The inferior capsules were released on the left.  The implants were dropped down to the correct position and a revision formal mastopexy using the inferior pedicle Wise-pattern technique was accomplished.  Now postoperatively, you can see that the nipple positions are even, the implants are positioned correct, there is no further malposition and she is extraordinarily happy with her results. 

Patients who have gastric bypass surgery through lap bands, Roux-en-Y Gastroplasties, etc., will often require both removal of skin for severe grade 3 ptosis as well as implant placement in order to regain volume.  It is absolutely essential that a Board Certified Plastic Surgeon who specializes in breast reconstruction perform this operation to increase the probability of a successful outcome.

BREAST LIFT, BREAST AUGMENTATION REVISION

The tubular examples show patients who underwent breast augmentation and breast lifting by a different surgeon with unsatisfactory results.  Both of these patients had breast lifts that were performed with inadequate amounts of skin removed as well as with implants placed in the malposition.  As a result, these patients have required total breast reconstruction requiring bilateral open periprosthetic capsulectomy, circumferential open capsulotomy, removal and replacement with larger high profile saline implants and complete revision formal mastopexies using the inferior pedicle Wise-pattern or anchor scar technique.

Note on example 1, the nipple areolas are actually quite stretched out.  She had a Benelli lift, around block technique, which simply caused stretching of the areolas with widespread subtle-like scarring.  She is very dissatisfied that the nipple areolas actually did not elevate whatsoever.  Rather, she ended up with widespread areolas and the nipples still in the low position.  The implant is high on the left with scar tissue contracture and is a flat moderate profile showing a very displeasing result.  Her after photo notably shows high profile 600 cc saline implants over-filled to 650 cc, open capsulotomy lowering the left implant and complete revision of the breast lift showing a nicer pattern to the nipple areolar complex, reducing the tension around the areola, allowing for a more rounded shape and less of a sunray appearance.  The vertical scar has actually healed quite nicely as well.

Example 2 indicates a patient who underwent augmentation mammoplasty procedure twice and a breast lift by a different surgeon with severe encapsulation and right double-bubble breast deformity.  Flattening of bilateral breast was extremely unpleasant to the patient.  She also underwent open capsulectomy, replacement with 700 cc high profile saline implants through the periareolar approach and then open capsulotomies high profile implants were used and then the nipple areolar complexes were reduced with a complete formal mastopexy.  The after photo shows a nice rounding shape to the breast, no longer flattening along the inframammary fold.  The nipple areolar complexes are now in the proper position.  The right one has been lowered and there is no further bottoming out.

Breast augmentation mastopexies require tremendous experience in judgment by Board Certified Plastic Surgeons.  Make sure your doctors are specialists in breast augmentation as well as reconstruction and revision when considering this difficult operation.

Dr Linder,

Thank You!  At 60 yrs with 3 surgeries behind me, I was scared to death to try to fix my problem again. From the first phone call with Nellie, ( I luv you Nellie!) she put me at ease and that gave me hope of walking in another office.  Meeting you, sealed the deal. You were so kind and understanding. Very professional to tell me you would ‘help me’ make the decision regarding size according to my body, skin, previous surgeries, etc..I was very, very afraid until I met you and your staff. You ARE a master at revision surgery!!  My boobs are wonderful, Awesome, in fact!!  The whole procedure was something to learn from. Choose the best and you won’t regret it!  Adrianna, I appreciate you!  All your help and kind hug made me cry! Surgery staff, you’re the best!! I will tell everyone, EVERYONE…if you want the best, see Dr Linder!!!!  Again, thank you soooooo much for my 20yr old looking boobies!!!

A.C

California

LIPOSUCTION REVISION BEVERLY HILLS

Liposculpture requires finesse, experience and judgment.  Removing just the amount of fat is not always as easy as it may seem.  Apparently, some patients do present with over-liposuctioning which can occur from either inadequate judgment or patients, as in this case, having been operated under IV sedation without an anesthesiologist in which she was in severe pain throughout this procedure and therefore movement on the table may have caused the surgeon to have difficulty in determining how much fat to remove.  In this specific case, she had liposuctioning of her inner and outer thighs, infragluteal folds, lateral buttocks and hip area.  Note, there is a significant amount of contour deformity along the lateral thighs with severe contour irregularities, depressions, as well as asymmetries.  In order to fix this specific patient, she underwent general anesthesia, areas were then micro lipo-sculpted with a small 3 mm triple lumen Mercedes cannula to 1 atmosphere of vacuum suction pressure using the tumescent technique.  Fat grafting was not required, as simply smoothing out and feathering technique from both the localized deep fat deposit areas as well as the subdermal region was accomplished, smoothing out the larger contour deformities.  This was performed on the iliac crest rolls, the lateral thigh region as well as the anteromedial thighs.  Notice the hips have nicely been contoured, giving her less of gynoid appearance and more of a narrowing along the belt region. Liposuctioning under IV sedation or local can be extremely difficult, if not dangerous, and that control of the patient and the patient’s airway is at risk.  As a result, our patients for significant liposculpturing are always placed under general anesthesia, tumescent technique liposuction is performed, and very small cannulas are used in order to smooth out the specific areas and try to reduce the contour undulations and irregularities.

DOW CORNING RUPTURED IMPLANTS

We see patients who present with implants from the Dow Corning era.  Those are implants placed well over 20 to 35 years ago.  These implants are obviously no longer allowed on the market.  The company is no longer producing these implants.  The Dow Corning implants were smooth shelled implants that had a Dacron patch on the posterior wall.�
This photo is an example indicates a patient who recently had explantation, open capsulectomy and removal of ruptured silicone implant capsule material silicone granuloma extraction, reconstruction with Allergan cohesive gel style 20 implants.  The patient had the silicone loose implant material completely exuded and removed through her previous inframammary incision.  Subsequently, the pocket was irrigated with antibiotic solution.  Total exenteration using electrocautery was required to remove the thick and hard shell of the calcified silicone material circumferentially in the pocket from the infraclavicular parasternal ridge along the anterior axillary line, along the lateral pectoralis minor muscle to the inframammary fold.  The posterior chest wall capsule shell was also removed.�

Note, the pictures of the implant showing complete loss of integrity, probably well over 15 years ago had been ruptured.  Notice the thick, hard calcified shell of the entire exenterated capsule that has been removed, that this is silicone that has bled into the tissue through the capsule and has now caused calcification, hardening and actually loose calcified silicone material within the pocket.�
All Dow Corning implants should be removed.  The integrity of all these shells probably last less than 10 years.  These should be removed as soon as possible, the pockets should be cleaned and all scar tissue and capsule should be exenterated.  Reconstruction with saline or silicone implants can be performed.

PEAR SHAPE GYNOID APPEARANCE

Patients present weekly to us for liposculpture of the lower third of their bodies associated with gynoid or pear-shaped appearance.  Although their upper and middle third may have a nice trim appearance and be quite sleek in character, the lower third can also be disproportionately large, leading the patient to be greatly distressed.  Women often have muffin-top fat deposits as well as lateral saddle bags which leave them with the appearance of a very large lower third.  Through bi-directional liposculpture of the hip, iliac crest roll as well as liposculpturing of the inner and outer thigh saddle bag area, we can greatly slim out the entire lower third of the body given them a more proportionate symmetry from the lower third to the middle and upper third.  Please see the below example. 

This patient is a 21-year-old female presenting with severe gynoid appearance, a pear-shaped appearance with a significant amount of lipodystrophy adiposity fat in the lateral saddle bag area and extending to the infragluteal fold.  This can be removed both along the inner and outer thigh through tumescent liposculpture technique and the iliac crest roll muffin top can be suctioned out in order to obtain a nice contour.  This is referred to as tumescent liposculpture under general anesthesia.  On this patient 1.25 liters of fat was removed after tumescent fluid was instilled. 

Postop Day One appearance with the patient in the sitting position shows nice smoothing out of the hips and narrowing of the inner and outer thigh, giving her much more proportionality with her upper and mid third.

BREAST CANCER AWARENESS

October 2011

Because my practice is so focused on body sculpting of women, including a high emphasis on breast augmentation, breast revision, breast reduction, breast and breast reconstruction, Breast Cancer Awareness Month is extraordinarily important and close to my heart.  I see patients every day in the operating room where I remove tissue and send to pathology at UCLA Medical Center for diagnosis.  Unfortunately, I do detect breast cancers almost annually on patients who have undergone elective surgical procedures.  In fact, we have detected this year alone two different procedures on a capsulectomy and a breast reduction a ductal carcinoma in situ in a stage 1 breast cancer which has required oncological mastectomy with breast reconstruction in both cases.  It is vital that patients who undergo any form of breast biopsy removal or reduction that the tissue be sent to Board Certified Specialists in Pathology so diagnosis of the tissue can be made, realizing that one out of nine women will develop breast cancer at some point in their lives.  Breast Cancer Awareness Month is important for us all to remember that self-breast examination should be done monthly, that mammographies should be done at the age of 40 or at the age of 35 for women who are undergoing any form of breast implant or breast reconstructive surgery as well as breast reduction and breast lift.  Breast cancer awareness includes preoperative mammograms, ultrasounds, MRIs every two to three years for all patients who have silicone gel implants and screening mammography for all women over the age of 48, remembering that breast mammography will save lives and that all tissue specimens should be sent to Pathology for diagnostic purposes in order to detect early stages of breast cancer which can be life-saving.

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