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Dr. Linder's Blog

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Monthly Archives: September 2014

BREAST AUGMENTATION, SEVERE BREAST ASYMMETRY

SILICONE GEL MODERATE PLUS RECONSTRUCTION

 

The patient preoperatively, as you can see, has significant asymmetry. The right breast is wider and slightly larger than the left breast which is narrower by approximately 1.5 cm. She also has a pectus carinatum of the upper sternal area. She is an excellent candidate for style 15 Allergan silicone gel implants in the dual plane, two-thirds under the muscle, one-third over. A 371 cc style 15 implant was placed on the right with a 397 on the left. Her symmetry is quite good. Cleavage is excellent. Upper pole fullness is reasonable and the inframammary folds are at precise levels.

This is an excellent example of use of moderate plus, style 15 Natrelle Allergan implants using silicone gel to reconstruct a patient with severe asymmetry and pectus carinatum.

DOUBLE BUBBLE DEFORMITY, SEVERE BREAST DEFORMITY

This is an excellent case example of a patient with severe encapsulated superior retropositioned implants with a double-bubble deformity with an overhanging of the nipple areolar complex.  She desired reconstruction; however, declined any significant scarring, including inverted  T. I decided upon a bilateral periareolar lift with complete release of the parasternal muscle attachments and an inferior displacement of the implants through a total open capsulectomy.  Her postoperative results of three weeks show excellent healing and bilateral repositioning of the nipple. She continues to wear an upper pole compression band. Sutures have been removed at three weeks and she will continue with the Dr. Linda Bra for six week. Notice the reshaping of the breast without a lift of an inverted T, but simple due to the superior periareolar lift and repositioning of the implant to its proper position, the nipples now show some white underneath the areolar which indicates good placement of the nipple areolar complex.

Patients with severe double-bubble breast deformity  can have periareolar lifts without  inframammary scars if they  are the  correct candidate as in this case example, severe double-bubble breast deformity with superior retroposition of the nipple with a periareolar lift.

REVISION LIPOSUCTION (LIPOSUCTIONING TUMESCENT TECHNIQUE)

Revision liposuction has become a very significant part of my practice. Patients come in from throughout the country and in fact, throughout the world, who desire to have revision liposuction in order to improve a previous result.

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There are two problems that I see uniformly. One is inadequate liposuctioning in specific designated localized fat deposit areas or over-liposuctioning in areas where suctioning is performed too close to the subdermis leading to indentations and contour deformities of the skin. The first problem of inadequate liposuction is very common, especially with surgeons who are inexperienced or do not have judgment with liposuction. Only Board Certified Plastic and Reconstructive Surgeons should be performing liposuctioning at any time. The skill of the abdominal wall, the thighs or the lateral breasts requires years of experience and training in both general surgery as well as plastic and reconstructive surgery. Liposuctioning the localized deep fat deposit areas will allow for smoothing and reduced risk of contour deformity.

There are two fat deposit areas, 1) the superficial fat, referred to as Camper’s fascia; and 2) the deep fat, referred to as Scarpa’s fascia. Only Scarpa’s fascia should be suctioned and only deep portions of the Camper’s fascia should be suctioned in order to prevent skin irregularities and contour deformities.

Patients who present with under-suctioning in areas such as the hips, abdomen, periumbilical, lower and lateral thighs are usually unhappy that they don’t see a significant change in the appearance of their bodies that they were hoping for. When I perform liposuctioning, in our Beverly Hills Surgery Center, of the abdominal area I am very careful to remove fat in the hip and flank areas in order to smooth out the contour of the midriff area. When there is a significant amount of fat in the iliac crest roll or the hip regions, this can be taken care of by and what I refer to as the Linder Bi-Directional Liposuction Technique, removing fat both in a vertical and oblique fashion along the iliac crest roll or hips. This completely changes the boxy appearance into a smoother contour and reduces fat above the jean line. Women who wear low-cut jeans enjoy this result because it reduces that hip bulge above the jeans. Liposuctioning of the lower abdominal and periumbilical area depends upon the amount of skin laxity. If it is not significant and there is good skin tone, then suctioning should be significant and somewhat aggressive in order to smooth this area out. Using an abdominal binder for six weeks will help to allow for skin tightening as well.

Liposuctioning of the thighs requires a significant amount of skill, especially the medial thighs which can end up with loose skin as well as contour deformities greater than the lateral. The reason is the medial fat of the medial thighs is more of a looser fat, a softer fat. The thigh fat along the lateral thigh is a denser, compact fat which usually can be suctioned with less contour problems. Suctioning should only be performed in the deep fat deposit areas in the both the medial and lateral thighs. With revision liposuction there is often a significant amount of scarring internally and this can make it more difficult to smooth out certain areas, as well as more difficult to maintain your plane of direction.

Secondly, over-liposuctioning. Patients who present who have had over-suctioning performed by other surgeons are more difficult to fix in that these areas may require fat grafting or simply feathering of these areas to smooth out the fatty deposits that were left behind in specific areas. It can be very dangerous to perform secondary liposuction on an area where the tissue is less than 1 cm thick in that you can end up with inadequate blood supply and subdermal vascular necrosis which can lead to death of the skin. Therefore, when considering secondary liposuction of areas that are over-suctioned, an experienced Board Certified Plastic Surgeon is a must in order to prevent a catastrophe.

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This will go on drlinder.com article entitled “Liposuction Revision for Inadequate Liposuction versus Over-Suctioning.”

Ruptured Silicone Implant

This is a case example of a patient who presents with a ruptured silicone implant who had a breast augmentation only four years ago. She presents with severe Baker IV capsular contracture with a very hardened right breast with severe scar tissue hardening. Interestingly, she denies any incidents of trauma to her breast whatsoever nor heavy workout or exertion. In the operating room, immediately upon opening the incision and entering into the breast pocket through the capsule, loose silicone was identifiable. The posterior portion of the implant was largely torn with loose silicone throughout the pocket.

Patients who undergo silicone implants should simply have MRIs every three years. Often asymptomatic, patients may still have a tear within the shell of the implant that is not obviously identifiable clinically. This patient did have severe scar tissue with a Baker IV capsule which indicated that there may have been some trauma that she however was unaware of, which could have been associated with the posterior rupture of the silicone gel implant. MRIs are very sensitive for ruptured silicone gel implants and should be performed at least every three years per guidelines of the FDA.

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