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Dr. Linder's Blog


Monthly Archives: January 2013

Breast Revision, Bottoming Out and Ruptured Implants

23581The patient  presents with bottoming out of her right breast implant after six years post-surgery with different surgeon, as well as ruptured left saline implant.  The patient below has multiple components to her diagnosis, including a deflated left saline implant, asymmetry to the breast and significant bottoming out of the right breast with the implant inferiorly displaced approximately 2.5 cm or 1 inch.  The patient required bilateral open capsulectomy, removal of ruptured saline implant and replacement with style 68 high profile Natrelle saline implants with different fill volumes and inframammary fold tightening and inferior open capsulorraphy to reposition the capsule and the inferior mammary fold up.  The patient is now six months postoperative, shows excellent symmetry with nipple areolar complex even and volume equal.  The scarring has healed well along the inframammary fold and the fold has held up nicely over six months without recurrent bottoming out.  Patients who undergo breast revision surgeries such as severe bottom out correction and replacement should have surgeries performed only by Board Certified Plastic Surgeons with the American Board of Plastic Surgery.


Patients from all over come to Beverly Hills to have their breast reduction performed with Dr. Linder. The breast reduction procedure involves removing skin, fat and glandular tissue. The normal breast is composed of 50% fat and 50% glandular tissue. When patients have an excessive amount of fat, breast tissue and skin, they may have bilateral breast hypertrophy or if enormous breasts arise, they may be called “gigantomastic breasts.”

Breast reduction procedures are usually performed using the Wise-pattern technique which is an anchor scar where dermoglandular tissue is removed both in the medial and lateral breast and the nipple areolar complex on the inferior pedicle is superiorly retropositioned.

Breast Reduction

Breast Reduction

The scarring is significant and the scar is a Wise-pattern or an anchor scar. With this in Dr. Linder’s hands leads to maintaining good blood supply to the nipple areolar complex to prevent devascularization or problems with loss of death of the nipple.

Often, breast reductions require suction lipectomy of the lateral breast, removing tissue from the axillary tail-of-Spence. When the lateral breast is quite full and this is not suctioned, the women often complain of inability to bring their arms down to the sides of their chest without constant heaviness and fullness to the sides.

Patient symptoms with breast reductions usually include severe back pain, neck strain, grooving from the shoulder blades from the bra straps, and rashes (intertrigo) along the inframammary folds associated with hygienic contact dermatitis or infections.

They do well with the breast tissue removed from the inner breast as well as a drainage tube placed for 24 to 48 hours. Sutures usually remain for up to 21 days. A lot of tension occurs along the incision sites due to bringing these flaps tightly into the midline. The newer technique, the Lejour technique, is a technique where a lollypop scar is made without the inframammary fold scar. Usually, tissue is removed as a central glandular resection without the inframammary fold. We, however, prefer to use the Wise-pattern or the anchor scar.

Mommy Makeover Beverly Hills Style

The patient below presents for Mommy Makeover Procedures.  The patient has multiple complaints of the body, including breast dysphoria and grade 2 ptosis with sagginess of the breast as well as abdominal wall laxity and vertical midline scar status post gastric bypass surgery procedure as well as a significantly large pannus requiring a panniculectomy, liposculpture of the hips, repositioning of the umbilicus and repair of an upper epigastric hernia with a general surgeon.

tummy-tuck-1b1Her front views preoperatively show grade 2 ptosis; however, patient declines a breast lift at this time and therefore conservative high profile saline implants will be placed subpectorally in order to reposition her nipples without performing a skin lift.  She also has a large abdominal pannus of lower abdomen with midline upper epigastric hernia found on abdominal CT scan.  The patient was referred to Dr. Robert Uyeda, our general surgeon, for concurrent reconstruction of abdominal wall with abdominoplasty and augmentation mammoplasty procedure.

The patient’s after photos show a very nice contouring of the lower abdominal area.  The midline vertical scar is now found below the umbilicus and the umbilicus has healed nicely.  The abdominal hernia was repaired with epigastric mesh, Marlex mesh graft reconstruction as well as liposculpturing of the iliac crest rolls and implant placement in the dual plane technique.  The patient is very happy with the results, showing a full C size breast with dual plane saline augmentation mammoplasty procedure using high profile saline implants, full tummy tuck with complete skin removal, tightening of the rectus sheath, hernia repair and sculpting of the iliac crest roll and muffin top procedure.

tummy-tuck-1a1Mommy Makeovers in Beverly Hills are performed in my operating room weekly.  These patients should be preoperatively evaluated by their internists, cleared for surgery for general anesthesia and if hernias are found, abdominal wall reconstruction should be performed concurrently with a general surgeon.

Muffin Top Procedure Revisited

muffinTopDr. Linder performed muffin top procedure for the Dr. Oz Show last year.  This patient is now two months postop with an excellent result and example of the muffin top procedure.  The preoperative photograph shows a very squared appearance to the flank and hip area extending to the lower abdominal pannus.  She declined to have an abdominoplasty at this time and had a straight tumescent liposculpture procedure in a bi-directional fashion of the iliac crest rolls extending to the lower abdominal area.  Her muffin top procedure is shown, giving her a beautiful contouring and concavity of the iliac crest hip region extending to a softening of the flank region and the overhanging drape of the skin has tightened quite nicely without a tightening procedure or skin excision.  A muffin top procedure when performed correctly, using small 2 and 3 mm cannulas, can allow for a nice recontouring and decreased pre-jean roll fat.  The after photo shows a great thinning and narrowing of her mid-torso with the lower abdominal fat debulking and excellent contour.

Umbilicoplasty Surgery

Patients presents for umbilicoplasty reconstruction most often concurrent with full tummy tuck procedures.  The umbilicus is an area that can be a focal point on a woman’s abdomen due to gaining of weight, loss of weight as well as pregnancy.  The umbilicus can change shape, form and also can go from inverted to externally protruded or vice-versa.  During a full abdominoplasty, dissection is carried well up above the umbilicus up to the subxiphoid process.  The umbilicus is maintained at stock to the fascia of the rectus muscle; however, a new hole will be made and the umbilicus will be sutured into its new position.  There are limitations as to how much change can be performed on the umbilicus in order to prevent devascularization.  Skin around the umbilicus can be removed; however, it should be done somewhat conservatively in order to prevent a disproportionately large umbilicus.  Also, the shape of the umbilicus can be changed from round to oval, pear-shaped in either the vertical or in the transverse manner.  Creation of an umbilicus after weight loss or reconstruction can require excision of skin with excision of portions of the umbilicus in order to smooth it out, reduce visible deformities around it.  Examples of an umbilicoplasty are shown below.  Note the skin has lost elasticity in that the umbilicus sometimes can be hidden by the overhang of skin from the upper abdominal area.  Problems with umbilicoplasty surgery can include keloid scarring and hypertrophic scarring which can lead to complete constriction and contraction of the umbilicus which may lead to a hole to close up.  This can be problematic as to infections and malodorous discharge.  As a result, umbilicus reconstruction to maintain the external skin is approximately 1.5 cm vertically by 1.25 cm transversely, according to Dr. Linder.

Umbilicoplasty reconstruction requires significant skill.  Again, there are limitations associated with the final result as you cannot always correct the specific aesthetic appearance of the umbilicus without devascularization.  Only Board Certified Plastic and Reconstructive Surgeons should perform this difficult operation.

Happy New Year!

Happy  New Year from Dr. Linder and staff. Here’s to a Healthy and Beautiful 2013.