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Monthly Archives: October 2012

48-Year-Old Ruptured Dow Corning Implants

Yesterday, I had the privilege of removing Dow Corning silicone implants that were now 48 years old; in fact, several years older than me.  As expected, this was an extremely time-consuming and difficult surgery, as the silicone implant material had calcified over the last 35 years due to disintegration of the shall of the implant bag.  The calcifications were so hard and the shell was so thick, possibly up to a quarter of an inch thick, that boney rongeurs were required in order to pull out the tissue and capsule.  The electrocautery Bovie and scalpel were unusable on this capsule due to the massive calcifications and hardening.  Exenteration of the capsule took a significant amount of time.  Removal of the patches on the posterior wall was quite tedious as well, in order to prevent a pneumothorax.  The silicone implant material can be seen by the photograph  as liquid silicone gel with minimal evidence of remaining silicone shell.  The size of the implants was absolutely impossible to determine due to the loss of integrity of all shell and demarkation.  This operation required aggressive exenteration of the capsule, thickened, hardened shell, removal of silicone material, irrigation and Bacitracin antibiotics and reconstruction using style 45 silicone Allergan gel implants with a formal mastopexy breast lift in order to retighten the skin.  Her breasts are now soft and supple and hopefully the patient will live another 75 years with excellent results.

Removal Of Polyurethane Implants

Recently, I removed polyurethane implants on a patient that were placed over 20 years ago in Romania.  These implants have been shown to cause sarcoma and cancer in rats.  They are no longer FDA-approved in the United States of America.  Upon removal of the implants, they were found to be textured coated; however, they were saline-filled.  The implants were removed with smooth silicone cohesive gel Allergan style 20 implants placed.  She now has a three-week postoperative photo as can be seen.  Notice the excellent symmetry and the inframammary fold incision is healing well.  Polyurethane implants have been taken off the market in the United States for many years.  They do have breakdown to Toluene Thiamine which has been shown to be linked with cancer in lab animals.  Should you have polyurethane implants you should consider having these removed even if there is a remote but small chance of carcinoma.

Breast Reduction Vs. Breast Lift

Patients often ask us as plastic surgeons upon consultation, “Do we need a breast reduction or should we have a breast lift performed?” This of course is associated with the amount of breast tissue which is both glandular and fatty tissue versus the amount of breast skin and skin laxity that the patient has. An experienced Board Certified Plastic and Reconstructive Surgeon will be able to indicate on clinical examination and by palpation of the patient’s breast, the amount of skin versus the amount of glandular fatty tissue that is creating the breast enlargement or hypertrophy.

On examination, patients may often look much larger than they actually are because the breasts are so loose, the skin is so lax, that they have enormous draping breast. Actually, when the skin is removed and the breast is elevated, the breast volume is really greatly reduced and the size of the breast is truly not as large as the woman thought she was.

For example, many patients come to us who have had massive weight loss and now have very wide inferiorly displaced grade III ptotic breasts that are sagging and they look enormous in pictures, but actually they are very flat, have minimal upper pole fullness. These patients should only undergo a formal mastopexy or breast lift. Tissue should be conserved and minimal or no breast or glandular tissue should be removed, with only a formal breast lift performed in order to maintain as much volume as possible.

BREAST LIFT

On the other hand, some women present with enormous breasts that have an enormous amount of glandular and fatty tissue throughout the breast, especially the lateral aspect extending to the anterior axillary line. These patients should undergo a significant reduction of breast tissue of skin, fatty and glandular tissue in order to reduce the overall size of the breast to reduce the symptoms that the patient has which usually include back pain, neck strain, grooving around the shoulder blades and rashes underneath the breast creases.

BREAST REDUCTION

So, when considering a breast lift versus a breast reduction, it is absolutely essential that the doctor make the correct judgment call and patients who have skin problems perform breast lifts and patients who have massive tissue problems perform reduction mammoplasties in order to reduce the symptoms of the enormous heavy breasts.

ABDOMINOPLASTY

Recently, I posted an article on abdominoplasty and tummy tuck procedure on www.drlinder.com.  Tummy tucks are one of my most common surgical procedures that I perform in my Beverly Hills Surgery Center.  In order to create a beautiful abdomen with patients who have either had significant weight loss, fluctuation of weight or have had multiple pregnancies, it is often standard to not only remove skin and fatty tissue through a long C-section-like scar, but also to perform the tightening effects of the rectus abdominis muscle by plication.  Tightening of the rectus muscle will allow for a firmer abdomen.  Patients who have rectus diastasis may have both above and below the umbilicus and this must be addressed by the surgeon both preoperatively as well as in the operating room.  It is extraordinarily important that only Board Certified Plastic and Reconstructive Surgeons are performing abdominoplasty procedures.  These are complicated operations that require the skill and experience of truly Board Certified Plastic Surgeons.

Scar position is extremely important.  Lowering the scar just above the suprapubic hairline will allow women to wear bikinis and lingerie without showing the scar.  This may therefore however require a vertical small scar in the midline from the previous umbilicus hole which will then be revised in three to six months once the tension is reduced using a V-Y plasty.  Liposculpturing of the iliac crest roll hips concurrently is often performed in my patients in order to allow smoothing out and reduction of the muffin top that can occur.

Abdominoplasty procedures when performed correctly lead to excellent results.  Obvious tradeoff is a significantly long scar.  These scars can be treated postoperatively with Kelo-Cote, Bio-Corneum silicone gel spray, silicone gel sheets as well as car revisions and laser therapy.

Breast Cancer Awareness Month

October, 2012

Because a portion of my practice deals specifically with breast augmentation, breast revision and breast reconstruction, the month of October is an extremely important month for us.  Breast cancer is considered the second most common breast cancer found in women after lung cancer.  One out of 8-1/2 women worldwide will develop one form of breast cancer.  Breast cancer is treatable if found early.  A monthly self-examination and annual mammography will greatly help to reduce death from a malignancy.  Detection of early stage breast cancer will greatly increase survivability of the woman.  Most breast cancer tumors are surgically removed.  Women who develop ductal carcinoma in situ or stage 0 have a 100% chance of survivability with treatment.  Those diagnosed with stage 2 have a 98% survivability at five years with surgery.  Women with stage 3, however, fall to 67% and stage 3B, down to 54%.  It is extremely important that women do self-breast examinations and annual mammograms in order to monitor and allow for surveillance of breast tumors.  Signs of breast cancer can include swelling of the breasts, armpits, enlarged lymph nodes or a palpable mass.  A lump can be painless and may have uneven edges.  They may be soft, tender and round.  There may be changes of the skin of the nipple areolar complex.  There can be fluid from the nipple itself.  There can also be changes in the shape and size of the breast.  Early signs of breast cancer do not always present with pain, however, if you do have pain in the breast or nipple area, consult your physician immediately.

Mammograms should be performed annually.  Surviving breast cancer should be the norm.  Reconstruction after the surgical procedure including partial mastectomy, radical mastectomy or modified radical mastectomy with lymphadenectomy or lymph node removal can be performed by a Board Certified Plastic Surgeon specializing in breast reconstruction.  Tissue expander implants or autologous tissue transfer can be performed to recreate a normal shape to your breast and recreate symmetry.

PLASTIC SURGICAL ANESTHESIA

A perfect surgical result requires more than just perfect surgery, it requires a perfect anesthesia experience.  Our anesthesiologist has performed over 7,000 general anesthetic surgeries with me alone.  His experience of over 25 years of anesthesia with a flawless record speaks for itself.  In our Medicare licensed ambulatory surgery center, we require our anesthesiologists to be Board Certified Anesthesiologists and Diplomates of the American Board of Anesthesia.  This allows us the safety net for the possibility of interactions and reactions with any type of medication as well as any other type of life-threatening situation, including cardiac or respiratory that would require the experience of only a Board Certified Anesthesiologist.  CRNAs are useful; however, I do not believe in our surgery center that they are equivalent to the experience of Board Certified Anesthesiologists.

I consider a good anesthesiologist to be somewhat an analogy to an excellent pilot.  The takeoff is associated with putting the patient to sleep during induction.  The maintenance of the patient under general anesthesia is the in-flight period and the landing is associated with the finesse extubation of the patient without increased nausea, vomiting or increased motion upon our wrapping of the patient’s breasts or abdomen after the surgery has been completed.  Experienced Board Certified Anesthesiologists have the training and experience to take care of our patients with any situation that may arise.

Severe Double-Bubble Deformity Status Post Pregnancy

The patient presents with increasing painful breast deformity associated with scar tissue contracture after pregnancy.  The double-bubble deformity is a reasonably common problem that I see throughout the month.  These patients presents with severe encapsulation of the upper fold of the implant causing superior retroposition of the implant and a droopiness of the skin leading to severe deformity.  A double-bubble breast deformity on this patient on the right shows superior retroposition of the implant with inferior displacement of the nipple areolar complex.  Her six-week postop photo shows elevation of the nipple areolar complex to its appropriate position with a formal mastopexy using the inferior pedicle Wise-pattern technique and an open capsulectomy with inferior displacement of the implant, lowering it to appropriate position.  The cleavage is now symmetric and even.  The inframammary folds are even and the upper pole of the breast now shows good symmetry.  This can be a difficult surgery.  Patients need to be in sports bras or soft bras without underwire for at least six weeks in order to allow inferior repositioning of the implants over time.

Double-bubble breast deformities require skill and experience of a Board Certified Plastic Surgeons who specialize in breast revision and reconstruction surgery.  Multiple planes of release and repositioning of implants must be performed correctly in order to preserve nipple areolar complex sensitivity and blood supply as well as to reposition the implant to an appropriate position.

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