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Dr. Linder's Blog


Monthly Archives: November 2011

Performing Tumescent Technique Liposuction



The above patient is a young 22-year-old female presenting with gynoid appearance, significant iliac crest roll hip fat as well as anteromedial, posterolateral and infragluteal fold fat.  The patient is an excellent candidate for tumescent liposuction using micro liposuction techniques with infiltration of tumescent fluid.  The patient underwent the procedure and this is her 8-week postoperative visit.  Notice the smoothing out nicely of the iliac crest rolls and the lower anteromedial thighs.  Notice also softening of the lateral thigh saddle bag areas with great reduction in size of the diameter of the thigh itself.  She has a more smooth even appearance of her upper, middle and lower third of her body.

Performing tumescent technique liposuction with Lidocaine, epinephrine and sodium chloride for wetting solution and small 2 and 3 mm cannulas in the bi-directional fashion of the iliac crest roll hip area as well as suctioning the deep localized fat of the inner and outer thigh and infragluteal banana roll area can lead to a very nice natural result with a tapering affect of the lower third to be evened out with the upper and midriff area.  This is a classic example of severe gynoid appearance, correctable by micro liposculpture tumescent technique.

Breast Augmentation to Correct Deformity



The below case is a patient who is 20 years old, presenting with severe tubular breast deformity on the left with severe breast asymmetry and right breast ptosis.  To reconstruct this young lady’s breasts in order to create a normal appearance, requires both different volume implants as well as a formal mastopexy on the right as well as release of the tubular breast deformity on the left.  This patient underwent augmentation mammoplasty procedure with 160 cc high profile saline implant placement on the right and 280 cc high profile saline implant placed on the left.  An inframammary release of the pectoralis major fascia was performed on the left in order to reduce the tubular breast appearance.  She also underwent formal mastopexy using the inferior pedicle Wise-pattern technique on the right to recreate a symmetric nipple areolar position and reduce the grade 3 ptosis.

The patient is now at three weeks postop, sutures have been removed today, the nipple areolar complex positions are even and the size is quite good.  The inframammary folds are even and the swelling is reduced greatly.

Only Board Certified Plastic and Reconstructive Surgeons should be performing these very difficult operations of tubular breast deformity with conical shaped breasts as well as breast asymmetry and ptosis.

Dow Corning Ruptured Gel Implant



The above patient presents with silicone gel implants placed 34 years ago.  These are ruptured silicone gel implants that had been placed over one-third of a century ago.  The patient left the implants in and has now noticed increasing pain.  An MRI shows intra and extracapsular ruptured silicone implant and implant material.  She has undergone open periprosthetic capsulectomy, removal of calcified granulomas, silicone calcifications, ruptured silicone gel implant material and subsequently reconstruction with new high profile style 20 Allergan silicone gel implants.  Notice the calcification and hardness of this tissue.  Over years the silicone will calcify with the collagen and create a thickened, hard scar ball, almost the consistency of chalk.  The patient has also developed calcified granulomas with small circumscribed areas of silicone which have become loculated in the tissue.

Notice the hardness of the breasts preoperatively, associated with this thickened calcified scar ball.  The implant shell has pretty much deteriorated as can be seen on this photograph of the ruptured loose gel material being pulled out of the breast.

Patients who have Dow Corning implants should have them removed as soon as possible.  The tendency for them to rupture within originally 10 years was very high and it is unlikely that any of these implants are intact in any women throughout the world.


Beverly Hills

Patients present to us in greater numbers for consultation, for breast augmentation, breast revision, breast lift, breast reduction, tummy tuck and lipocontouring.  With respect to your breast augmentation or breast revision consultation, it is important that the patient first of all seek a Board Certified Plastic and Reconstructive Surgeon, a Diplomate of the American Board of Plastic Surgery, whenever considering breast surgery.  There are no substitutes for a Board Certified Plastic and Reconstructive Surgeon for any form of breast cosmetic or reconstructive surgery.  Furthermore, a specialist who operates on the breast ever week may be obtained in order to aid you towards your reconstructive or primary augmentation needs. 

 During consultation, it is important that the patient fully evaluated by a Board Certified Plastic Surgeon and not a consultant.  It is vital that the patient be comfortable with the doctor as well as with the doctor’s ability to take care of her plastic surgical needs and if a complication should arise the doctor should be able to correct problem.  As a result, your plastic surgeon should have tending privileges at a well respected hospital within five miles of his or surgery center.  During your consultation, bring a note pad and questions already set to ask the doctor so that you will not forget them during the consultation.  At the beginning of the consultation the doctor should get a quick medical history which should include age, number of pregnancies, family history of breast cancer, smoking history, past medical history, allergy to medication history as well as past surgery or medical conditions.  Preoperative mammogram should be evaluated if necessary.  After this, the doctor should ask subjective questions to the patient as to what her goals are in terms of size, shape, volume, etc.  A formal evaluation will now be performed in the examination room, evaluating the patient’s breasts, inframammary fold distances, as well as discrepancy of the chest wall, including abnormalities and deformities, including pectus excavatum, carinatum or other sternal deformities.  Asymmetries should be noted and marked as well.  Thickness of the muscle, amount of body fat versus glandular tissue will be identified. 

Next, the patient should look at many before and after pictures with the plastic surgeon showing what she likes and what she does not like.  The implants can then be looked at, silicone versus saline, looking at the profiles of low moderate, moderate plus, high profiles or extra high profile gels versus the saline high profile Allergan implants.  Pros and cons of each type of implant should be discussed and at this time a size determinant of the implant and silicone versus saline should be made.  Finally, risks and complications should be discussed, including, infection, scar tissue and rupture and deflation of implants.  The need for MRIs should also be discussed every two to three years with silicone implants. 

Any further questions from the patient can now be given and then the patients will be sat down with a consultant for scheduling and price issues.  It is vital that the patient ask questions regarding the surgery center and its certification as well as the anesthesiologist being Board Certified.  During our consultations we have streamlined them to allow patients to go through this process in approximately 30 to 45 minutes.

Cedars-Sinai Department of Surgery


This weekend, November 4-6, I attended the Cedars-Sinai Medical Center Plastic Surgery weekend of conferences.  Topics of this year’s conference included Dental Plasty Techniques, Selection of Options in Breast Enhancement and Revision Surgery, Fat Grafting Technique, including Facial, Breasts and Body Contouring, Primary and Secondary Rhinoplasty Surgery, including Functional Nasal Disorders.  The oculoplastic cosmetic surgery and reconstruction of the eyelids with blepharoplasty by Guy Massry, Steven Fagien and Robert A. Goldberg were exceptional.  The discussion on facial rejuvenation, including Restylane, Juvéderm, Dysport Botox by Dr. Eaves from the University of North Carolina was also well done.

Concomitant Augmentation Mammoplasty Plus Mastopexy

Patients often present with loss of upper fullness of their breasts, referred to as involutional upper pole atrophy as well as severe skin laxity or referred to as grade 3 ptosis.  These patients do well with implants placed as well as a mastopexy or skin removal and raising of the nipple areolar complex at the same time.  Some doctors will stage these operations, placing the implant and then performing a lift several months later.  However, that has a pitfall requiring two surgeries, is more expensive and requires two general anesthetics.  The majority of the patients that I see in consultation, I have found it completely safe to do a combined augmentation mammoplasty procedure with a silicone or saline implant placed behind the muscle with a breast lift, either a vertical or a complete inferior pedicle Wise-pattern anchor scar technique lift performed concomitantly. 

 The example here shows a patient with complete loss of upper pole fullness, severe ptosis, grade 3, the nipple is well greater than 3 cm below the fold and an implant has been placed under the muscle with a formal lift, removing skin both vertically and along the inframammary fold.  Her postoperative photographs show a nice elevation of the nipple areolar complex. 

This is a four-week photo.  Notice there is still some pink around the areolas and the vertical scars.  This, however, will soften with time.  The position of the areolas shows nice lifting and the nipples are at a direct straight out position.  It is safe to perform both implants and lifts at the same time as long as you find a qualified Board Certified Plastic and Reconstructive Surgeon who specializes in augmentation mammoplasty and mastopexy, understanding the anatomy and blood supply to the nipple to prevent any type of avascular episodes.

Plastic Surgery on Entertainment Tonight

On November 1, 2011 I was on Entertainment Tonight to discuss a patient regarding Tummy Tuck Revision. I always appreciate the opportunity to consult for ET CBS television.

I will expand on this patient and procedure in an upcoming blog.

High Profile Implants, Reshaping the Breasts

The  patient to the left is an excellent example of a patient who has involutional upper pole atrophy, loss of upper pole fullness of her breasts, slight droop of the nipple areolar complex with grade 1 ptosis.  This patient is an excellent candidate for high profile saline implants in order to regain upper pole fullness and elevate the nipple slightly without a formal mastopexy.  Please realize that this is a three-week postoperative photo and there is still significant upper pole fullness and swelling that will resolve over time.  In any case, this patient underwent 400 cc high profile, style 68, Natrelle saline implants filled to 440 cc bilaterally through the periareolar approach with the implants in the dual plane, two-thirds under the muscle and one-third over.  Her two-week postop results show a nice narrowing of the breasts with excellent cleavage pattern.  There is a nice upper parasternal ridge with perfect cleavage.  This is an excellent example of reshaping the conical tubular-like saggy grade 1 ptotic breast for a more full narrowed breast with tapered appearance and increased upper pole fullness.