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Dr. Linder's Blog


Monthly Archives: February 2014

Beverly Hills Severe Breast Asymmetry – Congenital

This patient presents with severe congenital breast asymmetry.  Preoperative photograph shows right breast is a 36DD, left breast 36C.  Patient desired implants for reconstruction purposes as well as a breast reduction lift on the right.  She is one-week postop.  Notice the symmetry of the nipple areolar complex.  There is some upper pole fullness to the right breast which should come down over the next 5 to 6 weeks.  Severe breast asymmetry such as the following is most easily correctable with high profile saline implants in which 250 cc placed on the right and a 420 on the left.  The right formal mastopexy using the inferior pedicle Wise-pattern technique was necessary in order to bring the nipple up to the even position.  Notice the inframammary folds are now even as well.  The patient will have sutures removed in 10 days and will continue with dry dressing changes twice a day for the next 10 days.

Severe congenital breast asymmetry comes in many forms.  This is an excellent example of a left tubular breast with a right severe grade 3 ptotic hypertrophic breast requiring different size volume implants with a full breast lift on the right.

Saddlebag Liposculpture Beverly Hills

The case example below shows an excellent example of a patient who is in excellent shape; however, has localized fat deposits in the saddlebag distribution of the lateral thighs.  She is 23 years of age, works out regularly, has an excellent diet; however, has lipodystrophy adiposity of the saddlebags and will do great with a straight liposculpture using micro liposculpture with a 2.3 mm cannula, 1 atmosphere of vacuum suction pressure, using the tumescent liposuction technique.


The patient is now four weeks postoperative.  Notice the smoothing out of the lateral thighs, left greater than right.  There is significant reduction in the saddlebag and the lipodystrophy; expect to have either further reduction over the next six to eight weeks.  Liposuction of these areas in thin women should be done very carefully, only in the localized deep fat deposit areas, not close to the subdermis.  It is important to have at least six to eight weeks of postoperative compressive garments such as girdles that were worn by this patient.  Liposculpturing requires skill and should be performed by Board Certified Plastic Surgeons only.  Sculpting these areas in thin women requires finesse and care to prevent contour deformities and irregularities.


Brighton Surgical Center is the center that we use for plastic and reconstructive surgical procedures.  This center has both Medicare certification as well as JCOH, which is the Joint Commission of Accreditation of Hospitals.  Brighton Surgical Center completed both Medicare certification and recertification in 2013 and has recently become a JCOH-approved hospital facility.  These are the two most stringent and higher certifications of accreditation for ambulatory facilities and hospitals within the State of California.  The process of JCOH ensures all patients the highest safety, highest quality of care, treatment and services.  Certification was completed on January 3, 2014 with the Joint Commission for Brighton Surgical Center as an Ambulatory Healthcare Accreditation Facility.  This required inspection as well as observation of surgery and gastrointestinal procedures.

We always desire to have the highest accreditation for the safety of our patients at Brighton Surgical Center where our surgeries are performed under IV sedation and general anesthesia.


The patient below shows an amazing preoperative evaluation showing three dramatic problems.  The first is significant breast asymmetry.  Notice the right breast is significantly larger and wider than the left.  This is associated with, 1) A congenital thoracic chest wall asymmetry.  2) Severe pectus excavatum centrally with a depression deformity of the inner breast.  This is more notable on her lateral and oblique views.  Notice the right lateral oblique view, showing a caving in of the central chest area.  3) There is pectus carinatum of the superior chest wall, right greater than left with association of bowing out and anterior projection of the chest wall, right greater than the left.  In order to reconstruct her breast, different size and shape implants will be used.

On the right breast we will perform a high profile 320 cc saline implant placed in the dual plane technique and the left a moderate plus saline, 450 cc, filled to approximately 480 cc, in order to regain both symmetry and lateral fullness on the left to recreate evenness with the right and to maintain AP projection in a similar fashion.  Her postoperative photos will be shown on an upcoming blog.

Post Anesthesia Complications / Status Post Cosmetic Surgery

Beverly Hills Plastic Surgeon Dr. Linder

Dr. Linder has been filming today for Entertainment Tonight on February 3, 2014. The topic of discussion is Post Anesthesia Hallucinations and Psychosis. In general, after speaking to our Board Certified Anesthesiologist regarding the topic of Post Anesthesia Psychosis, this is not something that we believe truly exists. We should differentiate emergence delirium versus ICU psychosis. Emergence delirium may occur as seen in pediatrics when a child awakes with agitation.

In our practice we do see younger patients who have post anesthetics under general and may have emergence delirium due to Post traumatic Stress Disorder as well. These patients can be treated quickly verbally as well as protection of them from harming themselves and using small doses of Versed or short-acting Benzodiazepine, a valium-like drug. The situation will normally resolve in just a few minutes and the patient may re-emerge after being given the valium or Versed without agitation. ICU psychosis is multi-factorial and may be associated with disorientation associated with environment of pain, lights on for 24 hours, activity such as vital signs that are taken and the patient becomes completely disoriented and progresses to a state of psychosis. This can also be treated with medications and will resolve. The anesthetic ketamine is a dissociative anesthetic which can be associated with a psychotic event. We do not use this in our practice. It is notable that patients having surgery over 4-1/2 hours under general anesthesia do increase the risk of anesthetic-related complications. The most common anesthetic-related complications include cardiac, respiratory and neurological. Our patients are monitored both pre- and postoperatively and intraoperatively with the anesthesiologist. Preoperative evaluations must include full history, physical, and psychological evaluations prior to undergoing any surgical procedure, including plastic surgery.