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Dr. Linder's Blog


Monthly Archives: July 2012

Dual Plane Technique Silicone Gel Augmentation

In the majority of all breast augmentation surgeries we perform weekly in our Beverly Hills ambulatory facility, breast implants, either silicone or saline, are placed using the dual plane technique (two-thirds subpectoral and the lateral third subglandular).  The anatomy of the lateral pectoralis major muscle extending from the head of the humerus down to the ribcage can be found in an oblique manner canting superolaterally.  As a result, when the implants are placed subpectoral or submuscular, actually the medial two-thirds of the implant are under the muscle with the outer third subglandular without muscle coverage.

The patient presents with bilateral breast dysphoria, involutional upper pole atrophy and loss of upper pole fullness.  She desired to be a nice C-size breast with a natural shape.  Style 20, 320 cc smooth silicone gel implants, Allergan Natrelle cohesive gel implants were placed using the dual plane technique with a very small incision made through the periareolar approach.  Notice her postoperative results at six weeks show excellent cleavage with symmetric inframammary folds and well-healed scarring around the nipple areolar complex.  The upper pole of the breast shows a natural slope without undue rounding.  Even though style 20 high profile gel implants were used, by using the dual plane technique, two-thirds under and one-third over laterally, we were able to achieve a nice upper natural slope with good fullness, especially with an underwire brassiere.  The dual plane technique is considered by myself as the gold standard of the standard of choice when performing breast augmentation surgery.  It allows for excellent coverage of the implants, reduces visibility and rippling of the implant, as well as allows enhanced detection of malignancy, calcifications or breast cancers by mammography with radiology when patients will require screening and diagnostic mammograms in the future.

Tummy Tuck Recovery

Dr. Linder performs tummy tucks every week in his ambulatory surgery center in Beverly Hills.  Tummy tuck surgery should be performed only by Board Certified Plastic and Reconstructive Surgeons.  These surgeons have the experience, training and judgment to perform an abdominoplasty correctly, as well as to understand the risks and complications and how to correct these should they arise.  Our training in general surgery followed by plastic and reconstructive surgery allows us to understand the anatomy of the abdominal wall perfectly.  In a conventional abdominoplasty, a suprapubic C-section-like incision is extended bilaterally to the hips and tissue is then dissected all the way up to the ribcage, called the subcostal margin.  The midline of the rectus sheath is plicated with O-Ethibond Figure-of-Eight sutures in an interrupted fashion in order to bring the muscles back to the midline after childbirth.

Postoperatively, our patients remain with Jackson-Pratt drains for seven days in order to remove serous fluid and small amounts of blood underneath the flap which will also allow for adherence of the flap back down to the muscle and rectus sheath.  Our patients are maintained on oral antibiotics for seven days postoperative until the JP drains are removed.  Abdominal binders are extremely important in that they allow for compression for six weeks which will reduce the swelling and edema in the abdominal flaps.  For pain medication, our patients are either placed on Vicodin, Tylenol #3 or Norco.  We do not require pain pumps and have never used a pain pump in thousands of body sculpting surgeries.  I find it is unnecessary.

Patients are seen postoperative day one.  The dressings are completely changed and the abdominal binder is refit.  The drainage tubes are left in for the next seven days and the patients are instructed to use ice compression on the abdominal wall.  The positioning at home should be semi-Fowler with the back and knees elevated to reduce tension along the lower abdominal flap.

Our sutures are removed usually on Day 14 to 21 from around the umbilicus as well as the lower abdominal flap.  Once all sutures are removed, patients are started on silicone gel spray referred to as Kelo-cote or Bio-Corneum.  This is used twice a day for the next three months and should greatly reduce scarring.  Patients can normally resume activities at six weeks and final results of the abdominoplasty may not be evident until six to 12 months.

Uplifting Without a Lift

Certain patient who present with pseudoptosis (situations where this excessive skin, however, the nipple areolar complex is above the inframammary fold) or grade 1 or 2 ptosis with however small breasts and increased skin laxity, these patients may have a substantial breast lift with the high profile implant such as a style 20 or 45 placed without performing the mastopexy.  The example below shows a patient with grade 2 ptosis, nipple areolar complex between 1 and 2 cm below the inframammary fold.  She underwent a style 20 silicone gel implant placed through the dual plane technique and has a nice lifting with the implant.  The specific positioning of the implant must be perfect with care to avoid over-resection and release of the lateral pectoralis major muscle as well as preventing lateral dissection beyond the lateral areolar border, approximately on the right breast, the 9 o’clock position.  Repositioned of the implant precisely with a perfect parasternal attachment release will allow for increased lifting of the nipple areolar complex as can be seen in the postoperative photo.  Style 20 and 45 gel implants are excellent for lifting breasts significantly without the use of a formal vertical or periareolar mastopexy.


Dr. Linder has now trademarked, patent-pending to the ultimate sports bra.  Sexy Shape Wear’s new Linder Sport Bra is the ultimate bra for vigorous workouts, including ultimate fitness models, muscle and fitness trainers as well as marathon runners worldwide.  It presents with Underwire Free Support (UFS) with a special internal banding that helps support the breasts, at the same time, allowing for complete compression and comfort.  It also has the no-slip ribbing which allows perfect support on the back during vigorous workouts and training.  Its bi-directional stretch both vertically and transversely allows for complete comfort during running long distance marathons.  Finally, it presents with the most beautiful colors, including pink, black and white of any bra in the world.  Dr. Linder is excited to have the Linder Sport Bra coming soon.  It may be ordered online at http://www.linderbra.com/ .


Total Mommy Makeover Status Post Massive Weight Loss

The patient below is status post massive weight loss, over 140 pounds, was actually featured on the Dr. Oz Show with Dr. Linder after Dr. Linder’s total transformation of the patient’s breasts and abdomen. The patient had severe grade 3 ptosis, skin laxity and a massive abdominal pannus after losing 140 pounds. She, however, was left with a massive amount of loose skin from the breasts as well as the abdominal area. She has undergone a formal mastopexy using the inferior pedicle Wise-pattern technique (a massive breast lift) and a panniculectomy, removing the pannus. She also had liposuctioning of the iliac crest rolls or the muffin-top. She is two years postop now and presents with a postoperative photo. Notice that she has excellent fullness and scarring is quite reasonable. Her pannus is gone and she no longer has those rolls of skin and fat along the lower beltline. She is content with the results, even two years later, with the use of underwire brassieres, sports bras and a Dr. Linder Bra at night. She now still has good breast fullness without skin recurrent laxity.

The total mommy makeovers can be performed on women who have had massive weight loss either due to gastric bypass surgery or simply due to diet and exercise. Regardless, removing skin from the breasts and stomach with patients who have a significant amount of breast tissue can end up with nice volume breasts without the use of an implant and paniculectomies can be formed allowing for a night tightening effect concurrently.



The two videos below indicate how ruptured saline implants are removed.  In my practice, I prefer to use the incision sites that were previously made.  If they are my patients specifically, the periareolar incision sites will be reused.  If they were done through an inframammary approach, the inframammary incision is used.  The incision is opened with a 15-blade.  Dissection is carried down to the capsule at which time the implants are removed.  Note, the degree of deflation depends upon the amount of time that has elapsed since the original rupture.  Slow leak ruptures may lead to diffusion of fluid out of the valve at a slower rate versus a complete fracture of the shell of the implant that may lead to a complete ruptured within a very short period of time.  Once the implant has completely leaked out of the normal saline solution, the fluid that surrounds the implant will start to appear yellow which is consistent with a protein fibrin that may be found in the fluid itself.  This is often associated with a chronic rupture.

The videos will show specific implants that have been ruptured and that have been placed over 10 years ago.  Notice the saline solution is clear, which indicates that these are acute ruptures and most likely occurred within the last four to six weeks.  Once the implants are removed, scar tissue is often released and an open capsulotomy is performed.  Once the capsulotomy is performed and the capsulectomy and scar tissue removed as necessary, the implant can then be replaced with a silicone or saline prosthesis.

Ruptured saline implants can be determined clinically by simply examining the chest noting the significant asymmetry.  Diagnostic tests are not indicated.  The patients usually postoperatively from the saline breast revision surgery have minimal pain.  They are continued on oral antibiotics for seven days.