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Dr. Linder's Blog


Monthly Archives: June 2012

Plastic Surgery Center, Ambulatory Facility Qualifications

Recently, all ambulatory Medicare licensed surgery centers were recertified in the United States.  This was a Federal Government Medicare requirement.  The recertification process allowed us to importantly review all the reasons why having Medicare licensure is so important.  The certification of Medicare in an ambulatory facility allows a similar standing to those hospitals that are federally certified throughout the United States and the standards must be upheld in a similar fashion.  Recertification was multi-modality.  Investigative team reviewed all the physicians, surgeons, anesthesiologists, registered nurses, and certified scrub techs for credentials and made sure all certifications were updated and were up to present status.  Peer reviews were evaluated for all MDs and similar fields of surgery or anesthesia.

Chart examinations were performed in order to evaluate the specific details of charting both by the surgeon, anesthesiologist as well as by the circulating nurse and recovery room nurse.  Mediations are reviewed, including crash carts, postoperative recovery as well as documents for all narcotics.  Specific minutes as well as quality insurance was also reviewed in order to make sure that all standards are upheld with Medicare.  We are pleased that Brighton Surgery Center is a Medicare certified facility and that it allows the safest environment for a patient to undergo plastic and reconstructive surgery under general anesthesia.  In our surgery center we only allow Board Certified Anesthesiologists to perform anesthesia either intravenous sedation or general anesthesia.

The specific anesthesiologist that I have worked with for over 12 years, I have performed well over 8,000 general anesthetics without a single complication.  Experienced judgment will allow for safe surgery and maintaining Medicare status will allow patient the comfort in knowing that the surgery center is of the highest certification and standards in the United States.  Recently, I received a testimonial with a patient specific to the anesthesiologist and nursing staff.  I provide this for your perusal.


Besides, the two wonderful women you have in your mainoffice; Adrina and Nelli and of course you’re the best plastic surgeon in the WORLD and has always been such a blessing to me and made me feel like family. You have always done all these things and more that I have written below about these three people. So, thank you.

I wanted you to know what a great team you have in Sheila, Nurse Vicki and Dr. Hoffman. Anytime you enter a surgical center, there’s always some anxiety and you’re very nervous, however this team makes you feel like you’re right at home and that they care about the patient!

No matter the procedure you’re having, from the time you walk in with Sheila, to Nurse Vicki and then Dr. Hoffman you forget all about the surgery and before you know it, the procedure is all over. This team I must say, is first class, they really care about the patients and always ensure you’re ok with a smile. (Read More)



Some patients present with significant involutional upper pole atrophy, even slight bottoming out versus grade 1 to 2 ptosis. These can sometimes be correctable without the use of a mastopexy or an inframammary tightening procedure if the pocket dissection is perfectly made. In the example below, the left breast showed significant increased skin laxity over the right side. I did not guarantee the patient that her breasts could be lifted without a mastopexy; however, I did instruct her that I would make as precise a pocket as possible, specifically not opening the lateral pocket beyond the lateral areolar border and not dissecting below the inframammary fold, which may allow some tightening of the external skin and overlying breast tissue.

Breast Lift


Notice, her postoperative six-week results show nice tightening of bilateral breast with the nipple slightly higher on the left than It’s preoperative position. Precision pocket dissection requires excellent visualization. I go through the periareolar approach because it is easy to dissect the parasternal attachments of the pectoralis major muscle and release it precisely. Also, it is easy to not open too much tissue along the lateral breast pocket, staying media to the pectoralis minor and serratus anterior muscle and thereby not allowing for lateral displacement and inadequate cleavage. This is an excellent example of a breast lifting procedure with only an augmentation mammoplasty without a mastopexy. These results are not always obtainable and not always predictable. In any case, should the patient form skin laxity over time due to the weight of the implant, then a breast lift would certainly be warranted. At this time we were able to augment her, tighten up the skin externally without the use of any further scarring that would be required for a breast lift.


Below you will see four examples of different color aspirate, all from Dr. Linder’s liposuction patients.  Tumescent liposuction technique is the gold standard with the American Board of Plastic Surgery.  The three components of the infiltration include Lidocaine, epinephrine and sodium chloride or lactated Ringer’s solution.  It is the epinephrine that causes constriction, reducing bruising, bleeding and blood loss.  The specimen with the darker red cobblestone appears to have more bleeding and blood mixed in.  This is a patient that may have taken an aspirin or an Advil inadvertently or a patient that may simply have a slight coagulopathy.  The yellow and more purified fat, as you can see in the opposite spectrum, is pure lipo aspirate with less than 1% blood loss.  This is the most pure form of tumescent lipo technique in which 99% of the aspirate is pure adipose tissue and lipocytes with less than 1% fat.  As more red cobblestoning occurs, it becomes more obvious that the EBL (estimated blood loss) is increased and patients usually present with more bruising concurrently.

The tumescent technique is the gold standard with the American Board of Plastic Surgery because of up to five liters of lipo aspirate can be removed at one setting under general anesthesia safely, as long as the epinephrine affects reduce the EBL blood loss and amount of blood within the aspirate.

Fat Liposuction Color Chart

300th Blog Post

We’re  excited to have posted our 300th blog!
It is always my intention to provide quality education issues on plastic surgery topics on body sculpting procedures including breast implant surgery, breast revision, breast reduction , tummy tucks and total body Liposculpture ! In the future we will continue to provide new topics including newest innovations !
Thx for following !
Thank You,
Dr. Stuart A. Linder

Bottoming Out Repair Inferior Capsulorrhaphy

The patient presents with severe bottoming out of the right breast, requiring reconstructive surgery, including a superior right open capsulectomy, reshaping and opening up the upper pole of her implant pocket, as well as performing an internal inframammary capsulorrhaphy suturing the release capsule approximately 1.25 inches up.  Subsequently, the inframammary skin was then removed, performing an inframammary tightening procedure.  Her preoperative photos show not only disproportionately too large implants for her, but improper positioning of the implant causing raising of the nipple and bottoming out of the implant down approximately 1.25 inches below the left side.

The patient underwent open capsulotomy, removal and replacement with high profile saline implants, inframammary inferior internal capsulorrhaphy and inframammary skin tightening.  Her three-month postoperative photos show good inframammary fold symmetry with the right nipple areolar complex lowered and slightly more symmetric than preoperative.  Patient feels the implants are more appropriate to her shape and the inframammary fold has tightened nicely.

Bottoming out is a severe complication and can be very difficult to repair, especially with thin capsules.  Luckily, this patient has thicker capsule that could be released from the pectoralis major and superior rectus abdominis muscle attachments and acting as a sling to allow the implant to be elevated to regain symmetry.

Lateral Displaced Implants and Poor Cleavage

The case example shows a patient with inadequate cleavage due to lateral displaced implants.  This patient presents with severe problems.  No 1 is pectus carinatum.  In the operating room it is found that she has lateral displaced implants with the chest wall obliquely slanted downward and off to the side.  She also had implants pockets that were too large and the implants were low profile, causing a droopiness to the breast with poor upper pole fullness and inadequate cleavage.

The patient’s postoperative photo shows on Postop Day 1, the implants were replaced with style 20 silicone gel implants through the periareolar approach and open medial capsulectomy aggressively was performed.  The muscle however was left intact to the parasternal ridge in order to avoid visible rippling of the bag.  The high profile implants, as you can see, have given more upper pole fullness and the cleavage is enhanced.  There has been no lateral capsulorraphy performed.  She will now be placed in an extra small Dr. Linder Bra for the next six weeks which will allow compression to the midline and stabilization of the implant within the pocket.

Patients who present with inadequate cleavage can be brought to the midline in certain circumstances without capsulorrhaphies when a significant increase in volume of the implant size can be performed and the medial capsule can be successfully released with postoperative compression.

The Natural Breast Look

Breast Augmentation

The patient presents with hypoplastic breasts with minimal breast and ectomorphic build.  She has minimal amounts of breast tissue, but there is some thick muscle underneath this tissue.  She will undergo the natural breast augmentation using high profile smooth saline implants in the dual plane technique through the periareolar approach.  She underwent this procedure approximately three months ago.  Her preoperative photographs show her hypoplastic breasts.  A 350 cc high profile saline was filled to 380 cc bilaterally.  Her three-month postoperative photo is indicated, showing good symmetry, good cleavage, nipple areolar complex even, the upper pole appears to have softened quite a bit and she has a very natural appearance to her breasts.  High profile saline implants can be used to develop a natural appearance, especially with women are ectomorphic; however, have thickened muscles of the pectoralis sternal head which will still allow a smooth effacement of the upper pole of the breast and have a natural appearance and fullness that the patients desire.

Double Bubble Breast Deformity, Severe Status Post Pregnancy

The patient presents status post augmentation mammoplasty procedure by a different surgeon.  She now presents with, having breastfed after pregnancy, severe right breast Baker IV capsular contracture, double-bubble breast deformity and severe grade 3 breast skin laxity requiring right open periprosthetic capsulectomy, formal mastopexy bilateral.

The patient’s implants were placed only three years ago and they are intact high profile Mentor saline which will be maintained.  She will undergo open capsulectomy of the right breast in order to circumferentially release the scar tissue and drop the implant inferiorly to a normal position.  She will then undergo a complete breast lift in order to remove the massive amount of loose skin from both breasts, also to reduce the size of the nipple areolar complex.

It is not unusual to develop a severe deformity, including double-bubble breast deformities with Baker IV capsular contractures in women who have breastfed after pregnancy.