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Dr. Linder's Blog


Monthly Archives: September 2012

64th Prime Time Emmy Awards

In this year’s 2012 Emmy Awards, it is obvious that the best dressed had consistencies of extravagant colors, as seen on “E” red carpet.  Sofia Vergara was considered to be the best dressed in her Zuhair Murad gown paired with Neil Lane bling.  Her dress nicely accented her physique, including her natural curve, breast line and hips.  Also, elegantly dressed included Nicole Kidman in her Antonio Barardi gown with jeweled beading.  Honorary mention went to Emily VanCamp, Hayden Panettiere was considered one of the most poorly dressed as was Lena Dunham, as these dresses showed no advantages of curves, but rather block form to the upper and midriff area which uniformly is the least glamorous of all dresses.  Betty Draper’s dress was stunning and black from Zack Posen gown and black nicely accenting her shoulders and curves from her flanks to her hips.

Finally, Ginnifer Goodwin was gowned in orange and yellow embroidered Monique Lhuillier which showed off elegant vintage, 1960 style, with a classic appearance sloping from shoulders to hips.  Most impressive were the amazing colors of the gowns this year.

Plastic Surgical Team Beverly Hills

For any successful surgical outcome, it requires teamwork from several multi-talented physicians, nurses, and techs.  As you would expect, your plastic surgeon must be Board Certified with the American Board of Plastic Surgery and Diplomate of the American Board of Plastic Surgery and should also be members of the American Society of Plastic Surgeons.  The anesthesiologist putting the patient to sleep should equally be Board Certified with the American Board of Anesthesia.  Here, they should be qualified in all forms of IV sedation and general anesthetics, including the use of laryngeal mask airways and endotracheal tube intubations as well as understanding all aspects of critical care medicine.  ACLS is required from both the Anesthesiologist and the Director of Nursing.  The Director of Nursing must be a Registered Nurse in all Medicare licensed ambulatory facilities such as ours at Brighton Surgical Center.  The Director of Nursing should have years of experience in both ICU Hospital as well as ambulatory outpatient surgery facility patient management.  The Recovery Room Nurse must be a Registered Nurse as well in all Medicare State Licensed facilities.  The circulating nurse in the operating room can be an RN or an LVN.  We use RNs.  They should be well-versed at all aspects of circulating, including helping to prepare each patient in the operating room, pulling supplies, filling out all paperwork and accountability for instrument needle sponge counts with the scrub tech as well as performing a timeout at the beginning of the surgery which includes patient’s name, allergies, surgery that will be performed and antibiotics that are given.

Finally, the Certified Scrub Tech should have years of experience in plastic surgical procedure understanding the instrumentations and how to expose tissue during the operation to allow for easier surgical manipulation by the plastic surgeon.  The Certified Scrub Tech is also responsible for the sterility of all instruments and autoclaving of all supplies.  Every aspect of the chain is essential in the loop of creating excellence for our final surgical outcome.

Lifting Without a Lift

Some patients may present with grade 1 or 2 ptosis, which may be lifted internally by maintaining a pocket of perfect dissection.  When pockets are made overly enlarged such as lateral dissection, implants will often go lateral to the side and may have poor cleavage final results as well as increasing skin laxity and sagging.

The example shows a patient who has had significant skin laxity, left greater than the right, by making a very conservative pocket bilaterally, especially on the left and not dissection lateral to the lateral nipple areolar complex.  High profile silicone implants under the muscle are able to lead to a nice tightening of the breast without a breast lift.  On looking a her preop photo, I was not convinced with the patient that I would be able to achieve as much tightening as we did; however, by maintaining a conservative pocket dissection, not opening the lateral breast as seen by the hatch marks, the implant was able to take up nicely the entire space leading to a nice tightening result as well as the left nipple areolar complex was then elevated slightly with greater symmetry to the right than preoperatively.  In other words, specific precision pocket dissection on patients with skin laxity, may help to tighten the breast from the inside out.  The final results are not always guaranteed though.

Breast Revision Surgery Review

Patients who undergo breast revision surgery must realize that by having a secondary, tertiary or having had multiple surgeries in the past, that the original components and anatomy of the breasts have been manipulated and therefore an absolute perfect or normal result may not be possible.  Patients must have realistic expectations.  When revealing a patient’s breasts after they have had a previous surgery, I look at implant position, sternal distance, scarring, positioning of the implant, upper pole fullness, subpectoral versus retromammary placement of the implant and determine what the true possibilities for correction are.  In other words, once a woman’s breasts have been operated on, many variables and factors are permanent and unchangeable.  On review, the examination will allow the Board Certified Breast Revision Specialist to determine what is and what is not correctable, including positioning of the implant, repositioning of the implant, visibility of the bag, palpability of the bag, cleavage, inframammary fold, asymmetries, and malpositions.  No results can be guaranteed from any specific surgery with respect to final scarring, recurrence of bottoming out or recurrence of capsular contracture.  Only Board Certified Plastic and Reconstructive Surgeons should be performing breast revision surgery, as these are very difficult operations.  Ruptured implants may be difficult to fix, especially with extravasation of ruptured silicone from the previous old Dow Corning implants which can lead to extracapsular calcification and migration into the axillary lymph nodes.  Removal of the entire capsule can leave women with no tissue coverage, leading to severe palpability and visibility of the bag.

Patients who have undergone multiple revision surgeries may no longer be candidates for a breast implant, as the tissue becomes thinned out, there may be substantial coverage to prevent visible rippling palpability and this may require explantation with no longer implant placement.  Recurrent long-term effects of breast revision surgery can include skin laxity recurrence, bottoming out, capsular contracture, widespread scarring, keloid hypertrophic scarring, implant malposition, recurrent rupture of silicone or saline implant.  In reviewing patients for revision, it is apparent that scarring and scar tissue contracture may occur over time.  No plastic surgeon can guarantee a final and permanent outcome.

ISAPS 2012

I had the opportunity to attend in Geneva, Switzerland the International Society of Aesthetic Plastic Surgery 21st Congress conference during the first week of September. This Congress is open to all qualified plastic surgeons with an interest in aesthetic surgery.