Dr. Stuart Linder is a Beverly Hills board certified plastic surgeon, specializing in body sculpting and reconstructive procedures including breast augmentation, reduction, lift, liposuction and tummy tuck » Continue Reading
The patient below presents from the Middle East, unhappy with the appearance of her breast implants placed in Israel. She has cohesive anatomical gummy bear implants that are textured and have rotated. She wants a smoother, softer appearance to her breasts without the hard texturing and appearance that came with this specific implant. The patient had the implants removed and replaced with style 15, 339 cc moderate plus gel implants. She now is two weeks postop. Notice the softening of the upper poles of her breasts. There is more of a natural appearance to the breasts. The superolateral breasts show a more softer appearance as well without the bulging anteriorly. Style 15 gel implants are used on some patients who have enough tissue coverage to reduce visible rippling which may occur due to the underfill of these implants. However, the most natural appearing implants usually are associated with lower profile moderate and moderate plus.
In my practice, I reserve the style 15 gel implants to patients such as this that will give a more natural appearance, especially along the superolateral breast.
Multiple factors are required to achieve a successful outcome in plastic surgery. Not only must the surgeon be Board Certified with the American Board of Plastic Surgery, but the facility should be licensed as ours is with Medicare licensure and the anesthesiologist should be Board Certified with the American Board of Anesthesia. In my practice we only used Certified Diplomates of the American Board of Anesthesia. In other words, Board Certified Anesthesiologists to put our patients to sleep either under IV sedation or general anesthesia. I believe there are no substitutes that Board Certified Anesthesiologists have the experience and judgment to perform anesthesia in a safe and controlled environment. Medicare law requires that a timeout be performed in the operating room. That means before the patient is put to sleep that one of the members of the operating room team will give the patient’s name, specific operation, allergies and antibiotics given. This is referred to as a “timeout.” This is very important to reduce mistakes in the operating room. This is considered standard of care. Interestingly, recently I just operated on a patient who had two surgeries performed on her breasts in a three-month period with a disastrous outcome. What is most interesting about this patient is specifically that she states not to have seen her plastic surgeon either before surgery, in other words, the doctor was not seen and did not mark the patient, he was not found in the operating room nor was he seen in the preop holding postoperative recovery room after she was extubated. She interestingly did not even see the doctor for the next seven days. In other words, the patient never saw the doctor whatsoever from the beginning of surgery to one week after. It is extremely important that your plastic surgeon mark you himself or herself in the preop holding area, that you see the doctor in the operating room as well as in the postop recovery room. It is also vital to see the surgeon the next day in order for him or her to remove the dressings and place you into your surgical garment. This is considered standard of care in the United States and all patients should be treated by at least the standard. The Board Certified Anesthesiologist that we use has performed well over 7,000 surgeries with me and thankfully has an excellent and perfect record. Complications can occur during the anesthesia and as a result, anesthesiologists who are Board Certified have the experience and training to anticipate and treat these problems to prevent life serious and threatening disasters.
The patient presents with a severe deformity after she had breast augmentation performed by a different surgeon twice, as well as a breast lift. At this point the implants have fallen to a significantly low level with severe bottoming out as seen in the preop photo. She also has severe breast asymmetry with the distance from the right nipple areolar complex 9 cm and 12 cm from the left inferior areolar to the inframammary fold. In order to reconstruct this difficulty deformity, the patient will need to have the implants removed and replaced with high profile saline implants as well as secondary formal mastopexy as well as inferior open capsulorraphy to reposition the inferior capsule superiorly. The patient’s postoperative photo shows at six weeks, the nipple areolar complexes are now equal and symmetric, found centrally in the middle of the breast, the scars are healing nicely, the patient has nice upper pole fullness, as she desires the high profile, desiring a slightly rounder shape implants. The tightening of the inferior capsule has brought the implants up nicely, allowing fur superior retropositioning of the implants and complete correction of the severe bottoming out. Bottoming out can occur due to descent of the skin over time. This may occur with larger implants and may also be associated technical error where the inframammary fold is lowered too much aggressively by an inexperienced plastic surgeon. Only Board Certified Plastic Surgeons should be performing this difficult bottoming out procedure.
Patients present to my office in Beverly Hills status post pregnancy, weight loss and status post breastfeeding with massive amounts of skin laxity after significant weight gain and then significant weight loss after pregnancy.
This patient specifically has severe grade 3 ptosis and her nipples are well below the inframammary fold. She has significant amounts of lower abdominal skin laxity with stretch marks extending 3 cm above the belly button. The patient underwent silicone gel augmentation using high profile silicone implants behind the muscle with a complete mastopexy, formal breast lift, removing skin using the anchor pattern or Wise-pattern technique, full abdominoplasty with tightening of the rectus sheath and muscle internally. Her postoperative results are at six weeks and still show some redness of the scars around the nipple areolar complex and vertically; however, the nipple positions are now placed perfectly in the central portion of the breast. She has a natural appearance to her breast with good tightening.
The patient’s abdominoplasty shows tightening of the rectus sheath, still healing scars of the umbilicus and the Pfannenstiel incision. The liposuctioning of the iliac crest rolls smooth out the hips nicely. The patient will be maintained on Bio corneum silicone spray twice a day for six months. She has worn an abdominal binder for six weeks and will continue for another four weeks. Her postoperative course if uneventful and she has an excellent result for a mommy makeover, having had an abdominoplasty, liposuction of the hips, breast augmentation and a formal mastopexy using the inferior pedicle Wise-pattern technique.
The example shows a before and after typical result of a bilateral breast augmentation performed on an African-American woman through the periareolar approach. I have never seen on my patients a hypertrophic or keloid scar of the periareolar in an African-American patient, having performed thousands of augmentations on women of color. The close-up of this bilateral periareolar after six weeks once again here shows no evidence of hypertrophic scars, keloids, widespread or hypopigmentation.
I believe it is very safe to perform periareolar approach augmentation mammoplasty procedures on women of color and that I have not seen an increased incidence of poor scarring in these areas. All of my breast augmentation patients will have scar cream of some sort placed after the sutures are removed, which can include Bio corneum with silicone gel spray, vitamin E or Kelo-cote (silicone gel without the sun block).
The key to excellent scar results is associated with surgical technique in many cases and reduction of tension on the incision sites. Periareolar incision approach on all women heal with excellent scars as long as they are multiple layer closure as well as running subcuticular sutures in the skin and possibly Steri-strips or skin adhesive that helps to reapproximate the dermis and epidermal layers.
Dr. Linder’s newest product line of the Ultimate Sports Bra for all women is now available worldwide. Through Sexy ShapeWear™, the LinderSport™ Bra is now available in hot pink with a black piping lining as well as the elegant black with the pink embroidery and finally the new white Linder Sport Bras with a tan embroidery and inner lining. These are the ultimate sports bras of ultimate compression and comfort, bi-directional stretch and Underwire Free Support. The Underwire Free Support helps to hold the breasts up during rigorous activities, including weightlifting, fitness modeling, gym work and marathon running. The Sexy ShapeWear™ commercial will be seen on cable starting the last week in August. Look for it on E!, Bravo, Oxygen and Lifetime. To purchase your LinderSport™ Bra, go to www.linderbra.com and click on Linder Sport. We are excited that Dr. Linder’s newest product line from Sexy ShapeWear™ is now available for women worldwide.
Silicone gel implants can rupture either through a direct tear within the shell of the implant or microscopic leakage can occur over years through the shell itself without an obvious tear or loss of integrity of the shell. The video here shows a patient recently operated on with ruptured silicone implant calcification material surrounding the bag and with calcification within the capsule. On examination of the implant, notice there is a microscopic porous leakage of silicone particulate through the implant shell and that the actual silicone is quite sticky externally and it stretches out as small fibrous silicone and silicone beading. This patient’s implants were placed approximately 12 years ago. The implants have no obvious tear within the shell of the implant, but there is the microscopic silicone leak. By placing the implant directly on a piece of paper and lifting it after 30 seconds, a film of silicone can be identifiable on the paper. This shows that there is microscopic leakage of silicone material through the older silicone shell of the implant. This may not be as prevalent with the newer cohesive gel implants with thicker silicone shells, but over time I believe that most implants will have microscopic porous leakage through the shell and that implants should therefore be replaced either way, whether found to be ruptured on MRI or just due to the microscopic leakage over time. Ten to 15 years postoperatively, the patient should have silicone implants replaced due to this phenomenon.
For the majority of my breast reduction surgeries performed weekly, I perform my reductions using the inferior pedicle Wise-pattern technique. The inferior pedicle technique removes tissue from the inner and outer sides of the breast and above the inferior pedicle superiorly. After removing the medial and lateral dermoglandular wedge, the inferior pedicle is raised superiorly and the nipple areolar complex is maintained on this inferior pedicle which is attached to the chest wall pectoralis fascia. In some cases where the base pedicle is narrow, a bi-pedicle technique can be used where dissection superiorly is not carried down to the fascia. This maintains an excellent blood supply to the inferior pedicle when it thin or narrow, less than 8 mm in base width. We perform breast surgeries in our Medicare licensed ambulatory Beverly Hills Surgery Center weekly. Breast reductions require specialized Board Certified Plastic and Reconstructive Surgeons who have the ability to understand the anatomy of the chest wall, blood supply and nerves. Maintaining the inferior pedicle as thick as possible will increase survivability of the nipple areolar complex.
The picture shows the inferior pedicle where tissue has been removed both along the medial and lateral quadrants and the inferior pedicle above will be superiorly retropositioned and the medial and lateral flaps will be sutured down to the midline of the inframammary fold. Scarring on breast reductions are the number one concern and this can be minimized by meticulous suture technique postoperative silicone gel scar treatment using Bio corneum for up to three to six months and scar revisions as necessary after one year.