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Dr. Linder's Blog


Monthly Archives: July 2013

IMDb.com An Online Entertainment Site

It was brought to my attention the other day that I was included in IBDb.com website.  Internet Movie Database (IMDb) is a online database of information related to television programs, films, actors, production crew personnel and fictional characters featured in the entertainment media. It is one of the more popular online entertainment media sites and I was excited to be listed for the various shows that I have been asked to participate in over the years.



Techniques Of Choice For Breast Reduction


There are multiple procedures that can be performed through the years, which will reduce the breasts. Dr. Linder favors the inferior pedicle technique (Wise-Pattern). This technique has allowed us to preform enormous reductions without loss of the nipple areolar complex and maintain excellent blood supply to the nipple areola. This is my favorite approach and I use this every week. The operative goals on a breast reduction are always to reduce tissue, reduce the functional pain and weight of the breast upon the back and to aesthetically lift the breast without devascularization of the nipple areolar complex. Inferior pedicle Wise-pattern technique is Dr. Linder’s favorite choice. The scar is an anchor scar, the incision around the nipple, down the middle of the breast and along the inframammary fold. Sometimes a bi-pedicle will be maintained, allowing the superior portion of the pedicle to maintain blood supply to the tissue or the fascia overlying the upper chest wall and this may increase blood supply, especially with long flaps. Importantly, patients should realize that the blood supply is the most key issue when performing a breast reduction and the plastic surgeon needs to be Board Certified in order to have the judgment experience to perform this operation safely and make sure the flaps are not too thin or that the pedicle is not less than in our hand 8 cm wide, which could lead to blood supply problems and necrosis or death of skin or the nipple areolar complex.


Other techniques that have been used through the years include the Benelli or periareolar mastopexy, also referred to as the round block technique. Dr. Linder does not like this technique. He believes that scarring is often poor with stretching around the areolar complex and that there is a better result when the scar is brought down vertically at least through a vertical mastopexy. Distributing tension around the areolar only is often associated with poor scarring. The periareolar mastopexy which is basically useless in this operation in that it does not reduce the breast enough and the scarring is often poor.


The next technique is the vertical scar breast reduction with or without undermining. Beautiful results have been found with this. Dr. Lassus and Dr. Lejour are world renown for this technique. Vertical reduction mammoplasty is more useful for smaller breast reductions, at least in Dr. Linder’s opinion, in not always able to remove the inframammary fold skin on the long reductions which can lead to elongated shaped breasts. In my opinion, the shape of the breast should never be sacrificed for scarring. In other words, an inframammary scar if necessary will greatly improve the rounding shape of the breast.


Other techniques include the central mound technique, the L-short scar mammoplasty and the breast amputation with free nipple areolar complex grafting. This is done for enormous breast reductions where thousands of grams of tissue are removed per breast or the pedicle length is extraordinarily long. It has been stated that free nipple breast reduction is ideal for patients who have enormous breasts or gigantomastia where more than 1000 grams of tissue will be removed per breast and free nipple grafts can then be placed, realizing that there will be complete loss of sensitivity as well as obviously no lactation whatsoever.


It is absolutely vital that all pathological specimens must be sent to the Department of Pathology to determine any cancer or premalignancy within breast tissue specimen. We personally use UCLA Medical Center or Cedars Sinai Medical Center if surgeries are performed there. Path reports are very important and copies should be maintained by the patient as well for their future, including future mammograms.


In our practice all patients undergo mammography if they are going to undergo a breast reduction surgery if they have not had one already. It is vital to have a mammogram and/or an ultrasound so that a map preoperatively will be determined of the breast and this can be reviewed by the radiologist in the future if something new should occur postoperatively, realizing that with the reduction surgery, flaps of issue are going to be rotated, which could lead to difficulty in determining a calcification versus a premalignancy in the future.

High Profile Saline Breast Implants

High profile saline implants are one of the most used implants in my practice.  The advantages of the high profile saline implants include increased fullness projection with decreased diameter.  This implant allows women to look fuller without looking matronly and heavy.  Patients do extraordinarily well with high profile saline implants overfilled because of reduced visible rippling, which can be seen in low profile saline and silicone gel implants.  The patient to the left shows high profile saline implants placed in the dual plane technique using the submuscular approach through a periareolar incision.  This patient is approximately five weeks postsurgical, shows excellent placement of her implants with symmetry of the inframammary fold, sternal region and nipple position.  High profile saline implants are very useful for women who desire increased fullness without a wider diameter implant which can look quite matronly.

Breast Capsules

post-operative breast capsules

Breast Capsules

One of the most common reasons that patients present for secondary surgery after breast implants is capsular contracture. Capsular contracture is associated with a hardening around the implant, saline or silicone that can be painful. The classifications include Baker I, soft supple breast; Baker II, palpable; Baker III, palpable and visible capsule; and Baker IV, palpable, visible, hard, distorted and painful. Patients who present with severe encapsulation have often thick capsules that are formed around the implants. The etiology of capsular contracture is not completely understood or ascertained at this time. It may be associated with a possible micro infection or staphylococcus aureus or epidermis. In any case, the capsule that forms around an implant is normal. All prosthetic devices in the body will have a capsule form around it over four to six weeks. The components of the capsule include: collagen, myofibroblast and blood vessels. The white shear appearance of the capsule as seen in the photograph is associated with a collagen formation. Capsules normally appear shiny and white in appearance; however, they can become thick, hard and darker in appearance, especially with calcifications of granulomas associated with silicone rupture. This is a photograph of capsule removed from the patient recently. She had a severe Baker IV capsular with painful breasts, hardening and distortion. The capsule is quite thick. It interdigitates with the undersurface of the pectoralis major muscle in this case. A small portion of the capsule taken usually cannot be completely removed without taking a small portion of breast tissue. This is why with recurrent capsular contractures and capsulectomies we have to be careful not to over-exenterate too much scar tissue.

Capsular contracture and ruptured implants are the two most common causes for patients presenting to my Beverly Hills practice for breast revision surgery.

Severe Baker IV Capsular Contracture with Severe Double-Bubble Breast Deformity

The patient below is a 28-year-old African-American female presenting with severe Baker IV capsular contracture, implant malposition, scar tissue, hardening with grade 3 ptosis.  Patient is an excellent candidate for total breast reconstruction which would include bilateral open periprosthetic capsulectomy, circumferential open capsulotomy, removal and replacement with style 68 high profile Natrelle 200 cc saline implants through a periareolar approach, removal of her larger 480 cc low profile silicone gel implants and a formal mastopexy using inferior pedicle Wise-pattern technique.  Her before photographs show severe encapsulation and the medial portions of her breasts show actual deformity of the implant edges.  She will require open periprosthetic capsulectomy, circumferential open capsulotomy, removal of the larger silicone implants, low profile and replacement with small high profile saline implants and a primary formal mastopexy.  Her after photographs show her in the Sexy Shapewear Linder Sport Bra.  Notice the reduction in size of her breasts.  Notice the fullness of the upper pole; however, she now has complete corrected nipple areolar complex position centrally into the breast mound.  She also has a beautiful proportionality from a Double-D preoperatively to a mid to full “C” postoperatively.  She is extraordinarily happy with her results.

The corrections of her breasts included placing the implants subpectorally, reducing the low profile to a high profile smaller implant, over-filling.  Subsequently, the formal mastopexy was absolutely essential in order to remove the redundant skin, especially when reducing the volume size of the breast implant and repositioning of the nipple areolar complex.  This is an open capsulectomy for a severe Baker IV capsule with severe malposition and distortion as well as a mastopexy to reposition the areolas and remove the redundant skin.