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Dr. Linder's Blog


Monthly Archives: February 2012

Becker Breast Implant Removal

The patient presented with 36-year-old implants, had no idea as to the specifics or the details of the implant, whether they were silicone or saline.  She was told that they were both.  Well, in that case, it is consistent with double lumen Becker implants, which are no longer used.

In the operating room it was found that the patient had ruptured external saline from the Becker implant with intact silicone inner lining that had not extruded, but was very, very soft.  Notice the two photographs showing that fluid has leaked out completely from the outer saline lumen and that the inner gel is still intact.  Becker double lumen implants were used in the 1970s and 80s, they are no longer considered standard of care.  We take out implants from women worldwide who have had implants in for over three decades, including ruptured PIP implants, Becker implants and Dow Corning gels, as well as the new saline, Allergan and Mentor silicone gel implants.  In any case, any time a patient suspects a rupture, they should see a Board Certified Plastic Surgeon, specializing in breast revision surgery.

Cosmetic Surgery Day

Tomorrow, Friday, February 24 is Cosmetic Surgery Day!

Endomorphic Build with Breast Asymmetry

The below patient presents with severe breast endomorphic build, notice the thick chest wall muscle as well as the pectus excavatum with the slight asymmetry and droop after massive weight loss.  The patient presents to the operating room where we reconstructed her with 450 cc style 45 extra high profile silicone gel implants in the dual plane technique through a periareolar approach.  In order to obtain the results I received, the patient required meticulous dissection of the subpectoral muscle with parasternal muscle attachment release and decreased inframammary fold release on the left and the right.  This actually helped to elevate the left nipple areolar complex without doing a mastopexy.  Notice the inframammary folds appear to be quite even and the upper pole fullness is also symmetric.  Also, the loss of upper pole fullness on the right superolateral breast with a concavity of appearance has been nicely filled with a narrow style 45 Allergen silicone gel implant.  Patients who present with massive weight loss may still have endomorphic build with thick chest muscle.  It is extraordinarily important to use a high profile implant when reconstructing these patients not only to regain symmetry to the midline as seen, but also to regain upper pole fullness.

PIP French Ruptured Implant Surgery

On 2/15/2012, Dr. Linder performed a removal of ruptured left saline implant with a bilateral open periprosthetic capsulectomy. The patient had her surgery performed 15 years ago, but had no idea as to the type of implant that was placed in her body.

In the operating room it was found that the patient had a ruptured PIP implant. The ruptured PIP implant was actually a saline ruptured implant. Of interest, these were prefilled implants placed two decades ago that are no longer FDA approved in the United States. These implants had a history of mold contamination from the prefilled saline solution that was placed in Paris, France. These implants are rarely seen in the United States. This is a very interesting case, as the implant was a 365 cc textured PIP implant for which there was no valvular leak because there was no valve. It was simply most consistent a crack within the textured coating of the implant causing the complete deflation of this bag.

Preoperative photographs show the left implant ruptured compared to the intact right breast. Intraoperative photos show the implant removed. Notice the textured coating and the large patch in the posterior surface which is consistent with the PIP French implants. The patient was reconstructed using Natrelle high profile saline implants and scar tissue contracture release was performed. These are interesting cases and we see the PIP implants from France which are no longer legal or FDA approved in the United States.

Total Male Makeover


The patient to the left presents with massive weight loss, weighing over 340 pounds, having had a laparoscopic banding procedure (gastric bypass surgery), lost over 140 pounds, now weighs 200 pounds even. He has massive amounts of skin from the chest area extending to the lateral breast and extending down to the pannus. He will undergo a partial subcutaneous mastectomy with tumescent lipectomy, lipo-sculpting of the lateral chest area as well as a full panniculectomy or large abdominoplasty with umbilical hernia repair with our general surgeon as well as lipo-sculpting of the hip region.

The second photograph shows the patient undergoing a partial mastectomy. Tissue is being removed in the retroareolar plane, extending to the fascia over the pectoralis major muscle. Once this tissue is removed, complete lipo-sculpting of the rest of the chest from the infraclavicular, parasternal, inframammary into the lateral anterior axillary line was performed. Subsequently, at this time a mastopexy or lift will not be performed. We will determine how much skin tightening occurs and then on a separate stage several months from now a breast lift may be required in order to tighten up representative skin. Looking at the pannus, there is a massive overhang. He does have an umbilical hernia on examination and the general surgeon will be repairing this. In the operating room he was found to have rectus diastasis. The muscles were plicated. The hernia was repaired.

The postoperative photo here on the operating table shows the chest is softened immensely. There is great smoothing out of the chest wall as well as reduction of the lipodystrophy of the lateral breast chest area. Notice the incision is hip-to-hip and there are three drainage tubes in. The abdominal wall is now flat. The patient has done extraordinarily well.

The photograph shows the actual 25 pounds of tissue that was removed from the abdominal wall as well as the liposuctioned fat from the lateral chest and hips.

Patients present after massive weight loss laparoscopic banding procedures for tummy tucks, paniculectomies and gynecomastic surgeries or possible breast lifts. This is an excellent example.

Testimonial of Patient for Breast Enhancement

Dr Linder,

~Perfect~  “Having all the required or desirable qualities or characteristics to be as good as it is possible to be! flawless.”

They say “Nothing is Perfect” but I have to disagree.  My breast augmentation from start to finish was nothing less than Perfect!

From the very 1st conversation with your office, I knew I was in the best of care.  Adrianna and Nelly are amazing.  There was not a question, email or call that they did not respond and answer immediately and with the utmost knowledge, and professionalism nor a detail left unanswered….from every procedure to instructions and what would happen pre, during and aftercare.

I have to admit I was quite nervous but you answered every one of my 1000 questions and listened to exactly what I wanted…..and I was quite specific in what I did and didn’t want.

My results were not only Spot On but better than I ever could have imagined…Yes, Perfect!

Beyond compare, excellent, impeccable, skilled and superb are a few more words I will use to describe my experience and my results.

Thank you, Adriana, Nelly, Nurse Beverly, Dr Hoffman and of course you, Dr Linder.

Thank you with all my heart.



Patients present to us weekly with needs, including breast augmentation and breast lifts. At times they need combination procedures and at times we will only perform one or the other and stage the second surgery. When a patient arrives in consultation, it is absolutely vital that the Board Certified Plastic Surgeon clinically judge, measure the inframammary folds and determine the position of the nipple areolar complex and its relationship to the fold to determine what type of breast lift, if any, is required as well as what type of implant if augmentation will be performed either concurrently or at a separate stage.


Peri-Areolar Lift

Indications for combination breast lifts and augmentation include patients who have grade 3 ptosis where the nipple is well below the inframammary fold, often 3 cm or greater and they have loss of breast volume referred to often as involutional upper pole atrophy or bilateral breast hypoplasia. These patients do well with combination augmentation mammoplasty either with silicone or saline implants, depending upon thickness of tissue and desires of the patient, placed in the dual plane technique as well as a breast lift which usually is an inferior pedicle Wise-pattern formal mastopexy referred to as the anchor scar. Once it has been determined that a patient requires a combination augmentation mammoplasty and mastopexy, we will determine the amount of breast tissue available. If the tissue is minimal and the patient has very little volume, then I usually will perform the combination implants subpectorally or in the dual plane combined with a formal mastopexy or a vertical lift, depending upon degree of sagginess or laxity of the skin, as well as the degree of position of the nipple areolar complex to the fold. Patients who present with a larger amount of breast tissue, a C or D, also will undergo formal mastopexy first, and if then desire to go larger can be staged and have an implant placed several months later once the healing from the lift has taken place. We prefer to wait at least three to four months postoperatively before placing the implants subpectorally.

The risks of combination breast augmentation with breast lifting are controversial. In general, doctors who are experienced, have excellent judgment and are Board Certified with the American Board of Plastic Surgery who specialize in breast augmentation, breast lift, breast revision surgery are able to capably successfully combine augmentation implants behind the muscle and not jeopardize the nipple areolar complex blood supply by removing skin. In general, skin dissection and undermining around the nipple areolar complex must be conservative only when performing a combination augmentation and a breast lift procedure. We perform lifts with implants concurrently on patients all the time and have been successful uniformly.

In general, patients who have had implants placed in the past who have very thinned out tissue may be at higher risk for skin death, necrosis or avascular necrosis of the nipple areolar complex when performing augmentation with a formal mastopexy via secondary surgery. The reason is the blood supply may already be somewhat jeopardized from the original surgery and performing implants and a lift with a very thinned out blood supply may certainly increase risk of death to the nipple areolar complex or skin loss. Therefore, once again only the most experienced Board Certified Plastic Surgeon should be doing secondary revisions with removal, replacement, and capsulotomies with concurrent formal mastopexies.

Before and after photo of a breast augmentation and lift

The risks of breast lift augmentations combine also will include, as usual, significant scarring, which can include keloid, hypertrophic scarring, hypo or hyperpigmentation and widespread scarring. Avascular necrosis of the nipple areolar complex can certainly occur. Hemorrhage or hematomas can occur with the subpectoral or removal and replacement and once again any time the implant is exposed to the outside world, infection is certainly a possibility including staphylococcus aureus, streptococcus, Pseudomonas, E. coli, and other forms of gram positive and gram negative infections.

Acute Versus Chronic Rupture

Patients present to my office weekly with acute and chronic ruptures. Often, the patients do not know when the implant ruptured; however, I am able to determine somewhat of a timeline by performing what I call a CSI Beverly Hills. As to when the implants may have ruptured can be determined in the operating room. The clearer the fluid usually indicates a more acute or early on ruptured. As the implants lays in the pocket for a longer period of time, over several months, the fluid then becomes yellow straw color with increased protein and fibrin. However, long-term chronic rupture can lead to a darker, almost urine color yellow. This can be associated with a rupture well over six months to a year.

We recommend our patients, as soon as we have identified a ruptured implant clinically or by diagnostic testing with silicone implants with an MRI, have the implants removed and replaced and the scar tissue released as soon as possible to reduce the risk of increased encapsulation and complete collapse of the pocket. The examples below show you a rupture of over six months with a deep yellow fluid collection in the implant versus an acute rupture with a fluid leak through the valve and the clear fluid indicates that it is probably within the last couple of weeks.

Double Bubble Deformity

The patient below presents with severe double-bubble deformity.  The implant is superiorly retropositioned with severe malposition.  She also has enlargement of the right areola.  There is severe scar tissue with a Baker IV capsular contracture.  The patient will undergo bilateral open periprosthetic capsulectomy, release of the infraclavicular capsule and release of the parasternal attachments of the pectoralis major muscle.  The most significant deformity of the breast bilaterally is the inadequate release of the pectoralis major muscle along the parasternal ridge as well as along the lateral inframammary fold creating what I refer to as a “catcher’s mitt” phenomenon and leading to superior elevation of the implant in an unnatural appearance.

The patient is now postoperative day 1 after circumferential open capsulotomy, complete open capsulectomy, complete resection of the medial attachments of the pectoralis major muscle and reconstruction with a style 45, 500 cc Natrelle gel implant.  The patient now has perfect symmetry, elevation has been corrected, the inframammary folds are even and a right areolar reduction has been performed to recreate a symmetric size to the nipple areolar complex.