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Dr. Linder's Blog

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Monthly Archives: May 2014

TMZ Live, Plastic Surgery Trends

 

I was featured on TMZ Live with Harvey Levin and Charles Latibeaudiere last week (May 23th) talking about the big hand rejuvenation trend happening right now. Engagement photos on social media has sparked this new fad. This is the first time I have been interviewed via Skype, something new.

Breast Reduction Revision

Breast reduction revision is a very tricky operation because blood supply has already been violated once to the nipple areolar complex and therefore the Board Certified Plastic Surgeon must be very diligent and experienced with this technique. It is absolutely vital that the nipple areolar complex maintains its blood supply and that the base pedicle is not dissected. Revision can occur for a symmetric breast as well.

REVISION FOR HEMATOMA

Revision for hematomamay require evacuation of the hematoma with a drain placement. Revision of your skin flap with ischemia and skin loss can be associated with wet-to-dry dressing changes and subsequently debridement of the area and advancement flap closure.

WOUND SEPARATION AND DEHISCENCE

Wound separation and dehiscence may be associated with infection which needs to be treated prior to closure. Seroma formation can occur as well around the pedicle and this should be evacuated to prevent tension or pressure necrosis on the pedicle.

CELLULITIS

Cellulitis as described is usually associated with bacteria either streptococcus or staphylococcus aureus. This needs to be treated aggressively with intravenous antibiotics. Cellulitis will be treated with our patients immediately after surgery, given Keflex 750 mg p.o. b.i.d. and we may use Cipro 750 mg twice a day of they are penicillin allergic. We give all of our patients intravenously Ancef 1 gram unless they have pen allergies. We may then give Cipro or Vancomycin.

NIPPLE AREOLAR ISCHEMIA OR LOSS OF THE NIPPLE

If their blood supply is poor early on, this can often be salvaged by releasing sutures around the areola. The doctor needs to be diligent upon this.

DOG-EARS

Dog ears can occur. If they do, they can be removed over time by surgically excising them in a 4:1 elliptical fashion. Scarring must be determined, hypertrophic versus keloid. Remember, keloids are often worsened with revision excision and therefore it must be determined which one it is. Kenalog injections, steroids, are often used in order to reduce the scarring.

FAT NECROSIS

Fat necrosis needs to be resolved by debridement and cleaning the area with irrigation as necessary.

ASYMMETRY

Asymmetry can be corrected once the breast is completely healed by revising the breast reduction and redoing the scars. Nipple areolar complexes are often asymmetric and these can be redone as well in order to regain symmetry.

DOW CORNING RUPTURED IMPLANTS

 

photo-79 SEVERE DOW CORNING BILATERAL RUPTURED 
SILICONE BAKER IV CAPSULAR CONTRACTURE
SILICONE CALCIFIED GRANULOMAS

The patient presents to the operating room today with bilateral 510 cc Dow Corning Silicone Gel Implants placed approximately 22 years ago.  The implants were completely dissolved with the shell and piecemeal calcifications and silicone calcified granulomas notable throughout the entire breast.  The patient desired to have the implants cleaned out.  All silicone implant, implant material and calcifications and capsules were removed as well as a replacement with high profile saline implants.

Notice on her preoperative photo the right implant is disfigured severely with constriction of the bag showing displacement midline even over the parasternal ridge extending to the left breast.  The patient in the operating room was found to have severe encapsulation, complete ruptured silicone gel implant and implant material.

Notice these photographs of the intraoperative implants as they were taken out and removed, the silicone is now yellow in appearance as it has had increased proteinaceous build up over the last several years.  She also has the textured Dow Corning silicone shell which is scarred and show severe hardening.

There is also a patch that is notable, showing a 510 cc Dow Corning gel implant.  This patient has just undergone her surgical procedure with Dr. Linder and the implants were replaced with 500 cc filled to 570 cc saline.  The implants show excellent symmetry at midline.

There is no longer touching with the implant allowing for some lateral release and normal shape to her breast.Patients with Dow Corning silicone implants should have them removed as soon as possible, as these implants have completely dissolved, ruptured and calcified with both intra- and extracapsular translocation of the silicone material with possible spread to lymph nodes.

 

 

 

 

 

 

 

 

 

 

 

BREAST RECONSTRUCTION STATUS POST MASSIVE WEIGHT LOSS

GASTRIC BYPASS SURGERY

The patient presents with significant weight loss notable 150 pounds after Roux-En-Y gastroplasty.  She now has significant grade 3 ptosis, skin laxity and will undergo augmentation mammoplasty with high profile saline implants and a formal mastopexy using inferior pedicle Wise-pattern technique.  This is extraordinarily complicated surgery associated with her breast showing different diameters as well as skin laxity, left greater than right and the nipple areolar positions are low with a base pedicle distance up to 12 cm.  We must maintain blood supply and her postoperative results show excellent symmetry with superior fullness of the upper pole.

This patient has been instructed now at eight weeks and she will continue with Bio corneum for the scarring as well as an underwire bra during the day and the Dr. Linder bras for sleeping at night.  These were very challenging cases, as the vascularity of the nipple areolar complex can be more tenuous associated with the long pedicles which are associated with severe gastric bypass for patient weight loss and laxity.

AMERICA’S TOP SURGEONS 2014

EXCELLENCE 2014

I was honored to be recognized by the Consumer’s Research Council of America as one of their “America’s Top Surgeons” for 2014. Being chosen for this award is exciting and very special to me. This is the sixth year in a row for me and I appreciate this recognition.

San Francisco Aesthetic Meeting 2014

The last day of the Aesthetic Meeting in San Francisco was April 28, 2014 – hard to believe it’s already been a full week since then. I always enjoy this meeting, and, as I stated a few weeks back, I enjoy receiving the education needed to stay at the top of my craft, improve patient safety, and enhance my practice. As I reflect back, I found the course on “Combined Breast Augmentation and Breast Lift Surgery (Mastopexy)” as well as a course on “Graft Material” for breast reconstruction using products like AlloDerm® and Strattice™ excellent.

I look forward to attending next year’s meeting in Monterey.

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