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Dr. Linder's Blog

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Monthly Archives: November 2012

BREAST AUGMENTATION AND ASYMMETRIC NIPPLE REDUCTION

The above patient presents with significant nipple hypertrophy, left breast greater than right as well as hypoplastic breasts. She is a good candidate for augmentation mammoplasty procedure using high profile smooth round saline implants in the dual plane technique through a periareolar approach and a left nipple reduction reducing the left nipple through a superior pedicle flap. The inferior portion of the nipple was resected straight down to the base. The nipple was then inferiorly repositioned, sutured and the medial and lateral positions of the nipple were then resected and sutured down. Her results now show a five-week postoperative with excellent symmetry to the nipple areolar complexes with still some scarring healing around the periareolar incisions with good symmetry to the upper poles, cleavage and the inframammary folds are even. Nipple reductions should be done carefully through a pedicle base. I prefer the superior pedicle in order to allow viability of the blood supply through the nipple and allow for reduction in size and shape.

Reconstructive Breast Surgery Testimonial

Here is a fabulous patient testimonial that I received this week and I thought I would share as we approach this “Thanksgiving Holiday” weekend.  I am so thankful when a patient takes the time and express their experience with me.

 

Dr. Stuart Linder:

Dr. Stuart Linder is more than a talented surgeon. He is an artist. I was born with a birth deformity called: Severe Pectus Excavatum, and after careful research, it was clear that Dr. Linder is known as THE breast surgeon, specializing in reconstruction and fixing bad surgeries. His reputation is well-deserved. During my consultation, he detailed every aspect of my surgery, and patiently answered all of my questions, easing my concerns. My concerns arose from the fact that I have had two prior surgeries, both of which failed to aesthetically fix my deformity and did not give me the pretty shape or size I’ve always wanted. My indented chest gap, caused by my condition and my severe asymmetry were real concerns, and I also wanted to have bigger breasts.

I thought that I never would have breasts like the ones Dr. Linder gave me. I thought with my condition that I would always have to settle for what I had and hide behind padded bras for the rest of my life. I am forever grateful to Dr. Linder.

My surgery was quite involved, with different sized implants, closing my Severe Pectus Excavatum, and a double capsulotomy to make room for larger breasts. Dr. Linder even brought to my attention that one area of my scar needed revision, because it was wide. He fixed that too, by removing the scar tissue that had formed a wide keloid. I now have perfect, beautiful breasts, with just a tiny line where the incisions were made. I healed beautifully without pain.

For any women reading this and considering breast surgery, I would advise you not to let any doctor operate on you other than Dr. Stuart Linder. With all of my reconstructive needs, you would never know that I did not just have an ordinary breast augmentation. He truly is a brilliant breast surgeon. Thank you Dr. Linder!

V.H.
Los Angeles

Massive Abdominal Pannus

MASSIVE ABDOMINAL PANNUS  WITH VENTRAL EPIGASTRIC AND UMBILICAL HERNIA REPAIR

The patient is a 45-year-old African-American female presenting from out of state with significant abdominal wall protrusion.  On examination, it was very evident that she had a significant hernia, both in the upper epigastric area as well as the umbilicus.  As a result, the patient was scheduled for abdominal CT scan and referred to our general surgeon for consultation for concurrent repair of abdominal hernia repairs with mesh wrap reconstruction and a panniculectomy.  The patient underwent the surgery recently with the abdominal wall reconstructed, requiring mesh graft.  A mesh graft is important and was placed in order to reduce recurrence of this very large rectus diastasis and significant epigastric hernia.  Hernias that are large, especially with abdominal wall diastasis that is severe, usually require reconstruction using a prosthetic mesh graft.  A Board Certified General Surgeon is a must when considering abdominal wall reconstruction concurrently with cosmetic or plastic surgery of an abdominal pannus removal.

The hernia is shown which is quite large from the abdominal wall.  Preperitoneal fat has been exenterated and the hernia fascial defects have been dissected out.  The general surgeon then reconstructs the abdominal wall and the massive abdominal pannus skin is then removed.  These surgeries most likely should be performed in a hospital setting in order to allow for intravenous fluid hydration pain management postoperatively.  Whenever considering large abdominal protruding abdomens, it is extremely important to preoperatively obtain diagnostic CT scans in order to determine the integrity of the abdominal wall for fascial defect hernias.

Severe Breast Asymmetry Augmentation Correction

The patient (pictured on the left) presents with severe breast asymmetry.  A 21-year-old white female, presenting with hypoplastic left breast, good candidate for augmentation mammoplasty procedure using high profile saline implants.  The patient underwent augmentation mammoplasty procedure using the dual plane technique through the periareolar approach.  She is now eight weeks out of surgery.  On the right breast, a 200 cc high profile saline implant was filled to 240 and on the left a 350 cc filled to 380 cc.

The patient is now shown eight weeks out.  She has excellent symmetry.  There is some redness around the periareolar scar in the Linder Sport Bra.  It is noticeable that she has good symmetry.  There is equal upper pole fulness and the patient is happy with her results.  Breast asymmetry without skin laxity can normally be corrected by different volume saline or silicone implants, although saline implants are slightly easier to use due to the ability to titrate the volumes of the bags.

 

Rupture Rate Analysis Silicone Implants

Three major FDA-approved companies, Allergan, Sientra and Mentor, have now provided us with their three-year rupture rate for both primary augmentation and revision augmentation. Primary augmentation for Mentor, N=551 with 0.5%, revision augmentation, N=146, 7.7% and Sientra breast implant three-year rupture rate, N=1,115 for primary augmentation with 2.5% andN=362 for revision augmentation, 0.0%.

Finally, for Allergan silicone-filled breast implant three-year study, N=455 with 2.7% and for revision augmentation, N=147 rupture rate of 4.0%. It is notable that the highest rate of rupture was found in the Mentor secondary revision augmentation or the breast revision surgical patient. The lowest rate within the kit is by the revision augmentation by Sientra, 0.0%. It is difficult to determine how this could be possible with a 0.0% secondary augmentation when there was a 2.5% rupture rate with a primary augmentation patient after three years with a Sientra implant.

The Allergan implant study shows 4.0% rupture after three years with secondary augmentation or breast revision patients. The lowest rate of primary augmentation rupture was found with the Mentor Corporation, 0.5% versus the 2.5% with Sientra and 2.7% with Allergan. How to interpret this data may be difficult in that comparative analysis may be impossible due to different methodologies for calculating the data.

When to replace your implants

Because there is great confusion as to when to replace saline and silicone implants, especially associated with ruptured implants, I have created a new website referred to as www.rupturedimplant.com.  Please view this specific site for greater details for removal and replacement of ruptured saline, silicone, Dow Corning, Becker implants, double lumen, polyurethane implants and gummy bears.  With respect to saline implants, patients who have a slow leak may have visible rippling from the implant without a complete rupture.  When this becomes obvious and there is asymmetry associated with the leakage and visible rippling, I do recommend the implant be replaced.  If the implants are greater than five years old, I usually recommend replacing those saline implants at the same time under general anesthesia.  For patients who have an obvious complete rupture of the saline implant and the implants are over five years, once again, I recommend bilateral removal and replacement with new saline implants.

For patients who have implants less than five years old, however, there is visible rippling, wrinkling or rupture, I leave it up to the patient as to whether they decide they want to replace the contralateral breast.  Reasons for replacing it may include change in volume to the implant with a different implant size or changing the profile of the bag or changing the implants from saline to silicone gel.

For ruptured silicone implants, I recommend any implant over five years old be replaced and contralateral reconstruction at the same time.  Once again, implants that are less than five years old may be left in the contralateral breast with only reconstruction of the affected side.  Patients who desire volume change or implant profile change should obviously have bilateral removal and replacement of implants.  MRIs should be performed on patients with silicone implants every two to three years in order to determine the integrity of the shell’s bag.  Positive Linguine’s sign is associated with a ruptured implant.  Any implant that is over 10 years old should be replaced.  Women who present with implants over 10 years old; however, do not show ruptured silicone or saline and have significant capsular contracture, I believe should have bilateral removal and replacement of their implants.  Implant wear and tear with the shell over time may lead to a rupture of the bag.

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