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Dr. Linder's Blog


Monthly Archives: May 2013

Patient Reviews for Plastic Surgery

Patient reviews are becoming a very important part of the decision process for plastic surgery. Online reviews from former patients are allowing others the opportunity to see how there experience was.
There are numerous review websites allowing patients to review doctors. As patients, how do they know the reviews are actually from real patients? As doctors, how do we know the reviews posted about us are from our patients?

Medrounds is one more source that is available by partnering with Credential Protection to post only Verified Doctor ReviewsTM.

Angelina Jolie Underwent Double Mastectomy

Actress Angelina Jolie announced in a New York Times op-ed article on Tuesday that she underwent a preventive double mastectomy after learning that she carries a mutation of theBRCA1 gene, which sharply increases her risk of developing breast cancer and ovarian cancer.

On Tuesday May 14th this past week, I was humbled  to contribute my thoughts and opionions on four local news outlets regarding Angelina Jolie’s preventive double mastectomy. I’m proud of the courage it took to bring awareness worldwide.

Dr. Stuart Linder talks to KFWB News 980 about Angelina Jolie MastectomyOriginal Broadcast: May 14, 2013

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Regarding Angelina Jolie Mastectomy Dr. Linder talks to KNX 1070Original Broadcast: May 14, 2013

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Today is an unusual day in that we will be performing three out of four surgeries on men.  They will undergo gynecomastic surgery.  Two patients have significant gynecomastia with significant amounts of glandular thickened breast tissue in the retroareolar area and one of the males will also have lipo sculpting of the abdomen, hips and flanks.  The second male has gynecomastia only in one breast which is very atypical; has unilateral left breast enlargement with enlargement if the nipple areolar complex due to the gynecomastic tissue in his left chest.  The third patient is undergoing excisional biopsy of a large tumor growing out of the left deltoid shoulder area.  This male has had increasing growth over the last six months of a 6 x 6 cm tumor that will be removed from the deltoid region.  It is unusual to have three men in one day, as the majority of patients who present for plastic surgery of the body are women.

The No Lift Breast Reposition


The patient presents with bilateral laterally displaced implants with a deflating left saline implant.  The patient desires to have high profile fuller implants that are narrower and also to bring the nipples lower due to severe bottoming out, right side greater than the left.  She is a perfect candidate for removal and replacement of high profile saline implants of 550 Mentor salines placed, removal of her previous 325 and 335 Mentor low profile implants and replaced with 500 to 550 cc high profile saline, open capsulotomies medially, superior open capsulectomy and inferior periareolar lift inversed, allowing the repositioning of the nipple areolar complex inferiorly with raising the upper pole to greater fullness and less lateral fullness.  Notice her before photographs show a deflating left saline implant, the nipple areolar complexes are laterally displaced, the right nipple areolar complex is superior and is bottoming out significantly.  That is the distance from the bottom of areola fold is significantly longer than the left side.

The postoperative photos are three weeks.  Sutures have not been removed.  The patient has high profile saline Mentor implants, 500 filled to 550.  The cleavage is exceptionally good.  The upper pole fullness is exactly what she desired.  There is left lateral fullness.  The patient actually looks thinner in her bra even though her volume has gone up significantly due to the change in profile of the bag.  Notice also the nipples are evened out and the right inferior areola has lowered and is more centralized significantly without any form of capsulorraphy or internal scar tissue tightening.  This is an excellent example in which very specific open capsulotomies with implant replacement with larger high profile saline implants and repositioning of the areola inferiorly by simply inversed periareolar lift can allow for a more centralized beautiful breast without scars throughout the breast or without the need for capsulorrhaphies internally.

Pseudoptosis Reconstruction

This patient presents with pseudoptosis with involutional upper pole atrophy, loss of fullness of her breast and increased skin laxity.  This patient is an excellent candidate for augmentation mammoplasty procedure using the dual plane technique through a periareolar approach without a formal lift.  She does not desire to have scars throughout her breasts for a breast lift and understands that high profile saline implants will give her some fullness and projection and still some natural upper pole sloping without the scars that would be necessary with a full breast lift.  Although we cannot get the nipple areolar complex completely centralized using a high profile saline implant, it does give some increased upper pole fullness with still nice natural sloping.  Her before photograph shows skin laxity with the nipple just above the inframammary fold, left side a little better than the right.

Recommendation is augmentation mammoplasty procedure using high profile saline implants, dual plane technique in order to create excellent result from a pseudoptotic patient.


The patient below presents with a 125-pound weight loss after a laparoscopic banding procedure leaving her with severe asymmetry, grade 3 ptosis (right breast significantly larger than the left with asymmetry), a significant abdominal pannus, skin laxity, rectus diastasis and lipodystrophy of the hips.  The patient is now two months postoperative with 500 cc high profile Natrelle saline implants placed in the dual plane technique, formal mastopexy or Wise-pattern skin excision was performed, creating a tightening procedure of bilateral breast, as well as a full abdominoplasty with plication tightening of the rectus sheath and liposculpturing of the muffin-top area was accomplished.  Preoperative photos show severe asymmetry requiring slightly different volume implant placement (right smaller than left in terms of volume of implant size) and bilateral complete mastopexies reducing the large areola to 4.2 cm.  Notice the right areola preoperatively was approximately 9 cm wide.  She also has skin laxity in the lower abdomen which requires a full abdominoplasty with plication of the midline muscles of the rectus sheath. Her oblique views show excellent contouring with nice fullness to the upper pole of her breast associated with the high profile saline implant.  She has good nipple positioning without skin laxity along the inframammary fold.  The lower abdomen shows nice concavity with tightening of the rectus muscles, excellent definition of the midline and smoothing out of the hip region.  Patients who undergo gastric bypass surgery from Rouen-Y procedures, gastroplasties or laparoscopic banding, once they have lost a significant amount of weight, reaching the baseline, will do well with reconstructive surgery of both the breast and abdominal areas, as this patient is an excellent example.

The Hybrid Plasma Scalpel

I recently had the opportunity twice to use the new Canady Vieira Hybrid Plasma Scalpel.  This is the most advanced electrosurgical energy wave that has been developed for surgery and endoscopy.  It is extremely useful for precision dissection and immediate hemostasis.  The fact that plasma is the most common form of matter in the universe and is considered to be the fourth state of matter, allows flexion of free moving electrically charged particles of electrons and free radicals with the use of this coagulation cutting device.  It is known as a plasma gas which includes helium, xenon, argon, neon, krypton and radon.  The hybrid plasma cautery device integrates high frequency monopolar current with inert plasma gas diverted into a cold plasma beam which allows precision cutting and coagulation concurrently with biological tissues.  I used this device both on a breast reduction procedure as well on a full tummy tuck abdominoplasty.  The scalpel has a fine tip needle-like ending which allows for extremely fine excision and incision of tissue.  The hybrid argon plasma coagulator allows for immediate beam coagulation and reduced blood loss.  The scalpel delivered a precise beam of less than 1 mm diameter and the depth of injury is quite low at only .1 mm.  This device has been used in general surgery for exploratory laparotomies and multiple GI surgical procedures and cardiothoracic surgery for replacement of pacemakers, open heart surgery and vascular bypass; orthopedic surgery for hip replacements and amputations, total knee reconstruction as well as organ transplantation.  For plastic and reconstructive surgery, it has been used for mammoplasty, both breast augmentation and breast reduction, although placing this intrathoracic could be a problem.  It is very useful for mastectomies, abdominoplasties and excision of breast tumors.

Haute MD Network Offers Access to Affluent Audience


I am very excited to have been selected to be a part of the Haute MD Network. Haute MD Network offers concierge access to premiere cosmetic specialists around the country. They are an exclusive, invitation only membership-circle connecting the most trusted and respected doctors and surgeons with the country’s most discerning, affluent audience. I look forward to my relationship with Haute MD and there membership program.


Interestingly, everywhere you look today, society is gauged, measured and delineated according to weight loss, weight management and maintaining a thin, streamline physique.

Patients today are undergoing more body lift surgeries after massive weight loss than ever. According to the American Society of Plastic Surgeons, “ More than 106,000 body contouring procedures were performed in 2004, that is up 77% over the last five years.” In fact, nearly 56,000 procedures were associated with massive weight loss alone have been performed in the last year. There were 43 times more lower body lifts in 2004 versus 200 (ASPS, March 16, 2005).

The need for panniculectomy surgery, as well as other plastic surgical and reconstructive surgeries associated with massive weight loss procedures have exploded, associated with the increased number of bariatric surgery procedures over the last five years. In Fact, the number of tummy tucks (abdominoplasty and panniculectomy) was approximately 16,810 in 1992 up 102,497 in 2004, according to statistics from the American Society of Plastic Surgeons. This shows an increase of 510% over the last 12 years. With the massive weight loss, we as plastic surgeons will continue to see more and more patients requiring panniculectomy-type surgeries to remove the massive hanging pannus (overhanging skin and fat of the abdominal area.)

Panniculectomy should be differentiated from an abdominoplasty. A panniculectomy is usually associated with incisions of the abdominal pannus. This should be compared with reconstructive abdominoplasty with the muscles of the abdominal wall (rectus sheath plicated). Paniculectomies have been shown to be performed with other operations, including gastric bypass surgery (Foley procedure), hysterectomies and herniorrhaphies, if necessary. Patients who require a panniculectomy, excision of the abdominal pannus or apron, easily show functional signs of the massive abdominal excess skin and fat, which can include hygienic rashes along the suprapubic area, which may extend from the inguinal area and the groin creases, up to the hips. The massive amount of weight may also cause functional back pain from the lower and mid-back region, which will be greatly improved by removing this enormous abdominal pannus.

Abdominoplasties normally differ from a panniculectomy in that not only is skin and fat removed, but application of the midline rectus abdominal wall muscles is normally performed. Patients undergoing abdominoplasty usually do not have the same symptoms and functional problems associated with this massive pannus. Literature describes abdominoplasty and panniculectomy as two different procedures. Once again, the panniculectomy is usually only associated with the direct excision of the skin and fat, while abdominoplasty allows for reconstruction of the abdominal wall. A grading system has been developed, associated with scale of 1 to 5 with the higher grades associated with patients with heavier weight. They have also found the correlation that the higher grades have with more problems postoperatively. The higher the grades may also be associated with increased dehiscence of the wound (opening of the wound) with increased rash along the incision site with infection and breakdown of skin. Similar incisions are performed with abdominoplasty and panniculectomy along the lower pubic area extending to the hips; however, often in a panniculectomy a midline incision will be made below the breast bone, extending all the way to the muscle and up to the belly button n order to maintain good blood supply to the thick flap of tissue in order to maintain blood supply of the lower flap to prevent loss of skin which could occur with inadequate blood supply.

Abdominal paniculectomies should be differentiated from a belt lipectomy. A belt lipectomy usually is associated with direct excision of skin and fat circumferentially around the abdomen as well as the back region above the belt line. This is often performed in patients who have had massive weight loss from gastric bypass or bariatric surgery.

Typically, a dermolipectomy or an abdominal/panniculectomy is removal of loss skin and fat from the lower abdominal area. Tightening of a muscle can often also be performed which would bring the rectus sheath anterior muscle layer to the midline and help tighten up the middle abdominal region. Hernias should be evaluated, especially if it’s palpable on clinical examination and should be worked up with an ultrasound and if necessary a CT scan if it’s large. It should be referred to a general surgeon and may require the use of Marlex mesh graft reconstruction of the abdominal wall. Patients who have undergone gastric bypass surgery, especially with upper midline procedural scars in the past, have shown a significant instance of incisional hernias to the upper midline scar and should be evaluated preoperatively with general surgeon.

Complications associated with either an abdominoplasty or panniculectomy include bleeding such as a hermatoma which may be associated with opening of a vessel which may require returning to the operating room to control the bleeding. Drainage tubes are normally placed for 7 to 10 days until the amount of fluid through the drains is minimal. Infections may be associated with graft placement with concurrent hernia repair as well skin infections which may be associated with cellulitus or erythema. These must be immediately attended to, usually requiring IV antibiotics in a hospital setting.

Severe scarring can certainly occur along the incisions site and the patient must realize that the scars are always a trade off removal of massive amount of tissue and there can never be a guarantee of the final outcome of any scars. The scars can include keloids, hypertrophic scarring, widespread scarring, hyper or hypopigmentation or a variety of the above. Skin breakdown through rare can occur if dissection is to great which causes inadequate blood supply to the flap being pulled down.

Other complications can include fluid collections called seroma in which the fluid is formed within the extra abdominal space that was created. This may require a secondary drain placement once again and antibiotics.

Finally, deep venous thrombosis of the legs, which could lead to pulmonary embolus clots in the lungs, can be deadly and patients should have some mobility immediately after surgery, as well as special pneumatic boots within the operating room during the operation to reduce this incidence.

Revisions of these large paniculectomies are not uncommon, especially when patients desire debulking of the upper abdominal area or the hip regions or flanks. We prefer to wait six months prior liposuction of the upper abdominal or flank areas after abdominoplasty or panniculectomy surgery to reduce the incidents of skin loss or flap death.

Concomitant surgeries are often performed with large paniculectomies for massive weight loss, which may include breast augmentation to regain fullness with or without mastopexies or breast lift to remove the excess skin of the lower breast regions. Brachioplasties (removal of skin from the arm.) and thigh plasties, both medical and lateral, may help to smooth out the thigh area with removal of massive amount of lax skin from the inner and outer thighs. These surgeries are all associated with significant scarring. Once again, the scarring is unpredictable and the patient must understand the trade off of the scars for the removal of this massive amount of skin and fat.

Massive paniculectomies are excellent surgeries for the patients who either had massive weight loss by diet and exercise or by bariatric surgery. Similar to breast reduction, patients have greatly improved quality of life with massive amount of heaviness of skin and fat that often weighs upon their backs through the day is gone and rashes are also no longer present and hygienic infections are reduced greatly. These can include fungal-type infections. Patients normally feel much improved both in and out of clothing after the surgery.