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Dr. Linder's Blog


Monthly Archives: November 2013

Happy Thanksgiving 2013


To All:

This Holiday Season take time for reflection and gratitude for our health, our joys, our lives journeys and for all the fulfilling promises that await us.

We wish you and your family a Happy Thanksgiving!




Patients present for capsular contracture, severe, every week in my Beverly Hills and Las Vegas practice.  What exactly is the capsule that forms around an implant?  Any time a prosthetic device is placed in the body, i.e., hydraulic shunts into the brain, heart valves, aortic valves, mitral valves, prosthetic hips or any other form of internal foreign material, the body creates a capsule within one month.  The composition of a capsule includes collagen, blood vessels, and fibroblast.  Scar tissue formation around internal appliances and implantable devices is common and usual.  A capsule will form a internal protective cover on any foreign object, including a splinter in the finger.  When a capsule becomes thickened due to increase in collagen or myofibroblastic contraction, hardening can occur, leading to capsular contracture of the breast.  Baker I classification is soft, Baker II is palpable, Baker III is palpable and hard, Baker IV is palpable, hard and distortion and coldness to the breast occurs.

The photograph shows portions of capsule removed during a recent capsulectomy.  Notice the thickness of the capsule.  The capsule can vary in color, from yellow to whitish, pure white.  This is associated with silicone calcifications.  It can also be associated with protein within the capsule and can be an important indicator of an acute versus chronic rupture of the silicone implant.  Capsules can present with hardening and calcifications and plaque formation called silicone granulomata which may be associated with a ruptured silicone implant after a long period of time.  Capsule tissue should always be sent to Pathology for diagnostic purposes in order to determine malignancy.  Malignancy can occur within a capsule.  Patients especially with seromas within the breast or chronic seromas should be tested, the fluid, for lymphoblastic cancer.  It is important to realize that capsules are normal.  They do form and will form in any antigen, including a breast implant.  What becomes pathological is when it becomes thick, hard and contracts which may again lead to severe disfigurement and pain.


Patients present for lipo contouring of the body throughout the week in our Beverly Hills practice.  These patients have concerns specifically to the inner thighs or the medial thighs where there is chafing and touching of the thighs associated with lipodystrophy or increased fatty distribution.

This is an extraordinarily difficult area for women to remove through diet and exercise because the fat is quite resistant.  This fat should be differentiated from the fat of the lateral thigh which is more of a compact dense fat.  The medial thigh fat is more of a softer spongy fat and is more difficult to remove through lipo contouring and requires extreme skill and meticulous sculpting in the localized deep fat deposit areas without suctioning too close to the subdermis.  Aggressive sculpting along the subdermis can lead to severe contour deformities and weightiness which women are very displeased with.  Lipo contouring should be performed with small cannulas for the medial thigh.  We use 2.6 mm cannulas in order to reduce the weighty appearance that can occur in especially thin women.  Larger women with increased thickness of fat can undergo more aggressive medial thigh sculpting with 3 mm cannulas and then started with 2.4 or 2.6 cannulas.  This area should also undergo significant postoperative compressive garments.  We consider six weeks the minimum using girdles and Reston foam over the first several days postoperative to reduce the fluid weightiness that can occur and allow for even distribution of edema.  Normally, when our patients undergo sculpting of the thighs, we prefer three areas, always through the iliac crest roll, hip or muffin-tops combined with the lateral saddlebags and finally the medial thighs can be sculpted at the similar time.  The inner medial knees can also be sculpted when there are significant localized fat deposits of the area.  In order to reduce the disproportion of the gynoid appearance to the lower third of the body, medial and lateral thigh and hip suction should be combined concurrently.


The video shows an interesting case with the patient presenting with burning in her right breast.  Her implants are approximately 14 years old.  They were experimental style 45 smooth 400 cc Allergan gel implants.  The patient presents to the office with increasing pain with a sloshy feeling in her right breast.  An MRI would have been useful; however, it was obvious on clinical examination that there was complete rupture of the implant and you can feel softening of the right lower pole of the breast with complete collapse of the upper pole.  Intraoperatively, notice on the video that the implant is completely dissolved of the shell of the anterior surface and that by pulling the implant out there is a yellowish tint to the silicone associated with increased chronic protein which creates a darker yellowish appearance to the implant.

Ruptured silicone implant surgery should only be performed by Board Certified Plastic and Reconstructive Surgeons with experience of the chest anatomy to maintain good vascular blood supply and reconstruct the breast in a standard that is consistent with the American Board of Plastic and Reconstructive Surgery.

Gynecomastia Beverly Hills

We see patients weekly here in our Beverly Hills office presenting with gynecomastic symptoms, including feminizing breast problems, including increased retroareolar breast tissue, gynecomastic tissue, lipodystrophy and adiposity of the entire chest wall.  These men present with similar problems.  They are frustrated that they are unable to wear T-shirts without having prominent nipple areolar complex protrusion through the shirt.  They are very frustrated with also being unable to take off their shirts at the pool setting due to the increased breast tissue found.  Weight loss may be helpful, but in general is not able to completely resolve the problem of severe gynecomastia with gynecomastic feminized tissue production.  There is an increased predominance of gynecomastic tissue in patients who have taken several medications and steroids as well as marijuana use.  Our typical patients as seen in photo gynecomastic 170A frontal view, present with protrusion of the nipple areolar complex as well as increased fatty tissue extending from the anterior axillary line along the midline and down to the inframammary fold.  These patients do well with a combination of liposuctioning using tumescent technique as well as direct partial subcutaneous lumpectomy of tissue in the retroareolar region.  Notice on side view, Photo 190, that the patient actually has a conical pendulous appearance to the breast with protrusion of the nipple areolar complex due to herniation of the gynecomastic tissue causing an outpouching of the nipple.  This is very distressing to men especially wearing tighter T-shirts in that it appears that they have “breasts or male breasts.”

The after-photo from both of these patients presents at eight weeks.  The only incision made was through the periareolar from the 3 o’clock to 9 o’clock position at which the patient has had tumescent lipectomy of the entire chest wall with a small cannula, 2.5 mm, and then a partial subcutaneous mastectomy of retroareolar breast tissue with care not to form a depressive deformity under the nipple areolar complex by over-excision of the tissue.  It is important that the gynecomastic tissue is sent to pathology for diagnostic purpose to rule out any form of premalignancy or malignancy.

Gynecomastia presentation has increased significantly over the last decade.  These patients are extraordinarily happy with the results of removal of this breast tissue through a periareolar excision and are well accepting of that scar.