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Monthly Archives: May 2017

Top Doctor Selected by Castle Connolly

top doctors 2017

Castle Connolly notified me late last week that I had been selected as a “Top Doctor of Beverly Hills” for 2017.

Castle Connolly and America’s Top Doctors’ mission is to help consumers find the best healthcare. They are a highly respected health research firm and have been one of America’s most trusted sources for identifying the best doctors for over 25 years.

Castle Connolly bases its selection on medical education, training, disciplinary histories, peers. A physician-led research team screens all potential candidates. Castle Connolly states that the regional Top Doctors are among the top 10 – 15% within their geographical region.

I am happy and humbled to be selected and included as one of the best in my specialty in the Beverly Hills community.top doctor Beverly Hills

To schedule a consultation with Dr. Linder and to learn more about plastic surgery procedures contact us by calling our Beverly Hills office (310) 275-4513 or by filling out our online contact form.

 

 

 

 

SILICONE VS. SALINE

During consultation, questions often arise as to which implants will be best for the patient, silicone vs. saline. Although both implants are still available, FDA has still restricted the use of silicone gel implants to women who meet specific criteria.

In the United States, both Mentor and Inamed provide FDA approved silicone gel implants for women who meet the specific criteria. This specific inclusion criteria, according to mentor’s adjunct study, is that the patient be female, that the patient be willing to follow the study requirements and that the patient must have at least one or more of the specific indications, including 1) postmastectomy for cancer reconstruction; 2) a severe deformity which can include status post traumatic or a congenital deformity, including pectus carinatum excavatum tubular breast deformity or severe asymmetry such as in Poland syndrome, or finally breast ptosis, meaning sagginess to the breast which requires some form of mastopexy or breast lift. Final criteria can include replacement or revision from either reconstruction from breast or breast augmentation in which silicone gel implants were used previously.

There are exclusion criteria as well, which can be found on the Mentor Preoperative Patient History Record. These include the patient having any history at this time of an abscess or infection anywhere in the body. If the patient is pregnant or nursing, they are excluded from the study. If the patient has any symptoms of diagnoses of lupus or scleroderma, uncontrolled diabetes, tissue that is incapable of handling the silicone gel implant, including radiated tissue or psychological reasons.

If a patient meets any of the criteria as described above and the patient has a desire to either add silicone gel implants and/or continue with them after replacement, then the patient will need to fill out with the plastic surgeon the entire informed consent.

THE RISKS

The informed consent will include specific details which will mark out the risks and complications associated with the surgery. These will include infection, hematoma or collection of blood, serous fluid collection (seroma), capsular contracture with scar tissue formation as well as anesthetic risks. Capsular contracture can occur with either silicone or saline and may require removal of the scar tissue, referred to as a capsulectomy, or release of the scar tissue (capsulotomy) in order to allow more volume space and room for the implant to move.

Silicone implants may deflate, rupture or leak and may require replacement. They may be more difficult to detect because although there is a rupture of the intracapsular shell, it may not be detected for many years. Mammograms and even ultrasound may not detect the rupture and an MRI may be required in order to get a more definitive answer. Extracapsular silicone migration can occur as well as this may lead to free silicone which migrates to the lymph nodes under the armpit or the axillary lymph nodes or into other parts of the body. If an implant is ruptured, it should be removed as soon as possible. Increased scar tissue formation certainly may occur as well as migration of the silicone gel to different parts of the body.

Other complications associated with silicone gel implants, include silicone gel bleed. This is simply the oil of the silicone migrating through small micro pores within the shell, which may bleed through and be trapped within the scar tissue around the implant. This may increase calcifications. Mammography interference and difficulty in detecting calcifications versus cancer may also be associated with silicone gel implants, especially when placed in the retromammary pocket (above the pectoralis major muscle).

In contrast, saline implants may be more user friendly in that 1) we’re able to change the fill volumes of these implants with women who have asymmetric breasts are able to titrate the volumes of the implants to even out the breasts to make them more symmetric. Saline implants also if they shall rupture are an all or none phenomenon and within several weeks it will be quite apparent that the implant is deflated. The fluid from a saline implant when placed preoperatively in a sterile environment will be absorbed or resorbed and should yield no harmful effects to the patient.

Capsular contracture certainly can occur with saline implants, although in my practice I have found it to be less likely than silicone gel, as there is no silicone gel bleed with saline implants.

In the future, silicone gel implants may be available to the general public. At this time, it is still under FDA review and although the advisor panels have approved the silicone gel implants to be reviewed by the FDA, there is no definitive answer at this time. In general, as in any surgery, the use of silicone versus saline implants must be tailored to the needs and specifics of each individual. It is important to choose the specific implant carefully. The patient once again needs to be included within the criteria outlined by Mentor and/or Inamed Corporation in the United States of America.

Tubular Breast With Augmentation

before and after tubular breast augmentation

I was presented with a female patient who requested breast augmentation surgery along with correcting what she called her “constricted breast.” During her examination, I found that she had a condition called tubular breast deformity. Tuberous breasts or tubular breasts are a result of a congenital abnormality. After listening to her goals, we agreed to her expectation and scheduled her surgery date.
During her surgery, I released and removed the constricted breast tissue. I selected the moderate plus saline implants for its wide base and the least amount of anterior/posterior projection.  I used 360 cc implants and overfilled the left to 410 cc and the right to 400 cc to achieve a nice balance.
The photo on the right is eight months post-surgery, and she is very happy with the shape and fullness of her breasts.

To schedule your consultation with Dr. Linder or learn more about breast augmentation surgery, call our office at 310-275-4513 or fill out our online contact form today.

 

 

 

Breast Revision With Lift

breast revision

Pre-Op & Post-Op 2-Weeks

The patient presented is 28 years old and was looking to revise a previous breast augmentation. During her examination, I could see that her right breast had a downward elevation of the nipple-areola and a lower inframammary fold due to bottoming out. The left breast had scar tissue, also known as capsular contracture, which had formed around the implant. After listening to her expectations and agreeing on her goals to regain her breast appearance, we scheduled a surgery date.

During her surgery, I removed the old implants, repaired the breast pockets, and placed 425 cc saline high profile breast implants. I overfilled the 425 cc to 500 cc in both implants to create fullness and performed a Benelli Lift technique to raise the nipple slightly on the right side.

As you can see by the patient photo to the right, she is now four weeks post-surgery, and she has balanced symmetry and nice volume in both breasts.

after photo breast revision

Post-Op Photo 4-Weeks

To schedule your consultation with Dr. Linder and to learn more about breast revision or breast lift, contact us by calling our Beverly Hills office (310) 275-4513 or by filling out our online contact form.

 

WHAT ARE TUBULAR BREASTS?

Tubular breast deformities are not all that uncommon. By definition, it is associated with herniation of breast tissue into the nipple areolar complex, constriction along the lower pole of the breast causing a poorly defined inframammary fold. Often the nipple areolar complexes are also lowered causing some degree of sagginess or ptosis.

Repair of the tubular breast can be performed by placing saline or silicone breast implants either through the subglandular or under the muscle with a dual plane technique. In the past implants were usually placed above the muscle in the subglandular pocket. However, presently Dr. Linder places the implant most commonly in the dual plane, two-thirds under and one-third over the muscle, depending upon the degree of the tubular breast deformity. If there is a very thick amount of glandular tissue subglandular retromammary placement may be preferable in order to allow some upper pole fullness along the medial sternal area (towards the middle of the chest cleavage area). If, however, the tubular breast is associated with minimal amounts of breast tissue, then Dr. Linder places the implants usually under the muscle medially in order to reduce visibility palpability of the implant edge.

RECONSTRUCTION OF TUBULAR BREASTS

Reconstruction of a tubular breast includes breast augmentation with saline or silicone implants, releasing the inframammary fold, the crease line underneath the breast, to a proper position and scoring of the lower pole of the breast in order to evaginate it outward, allowing it to become more rounded in shape. If there is a significant degree of sagginess, then a breast lift may also be required with a reduction of the size of the areolar.

Postoperatively, a tubular breast should be treated with an upper pole compression band which will allow relaxation of the upper portion of the breast, allow the implant to be inferiorly displaced and allow for the lower pole of the breast to become more rounded and less flattened in shape. The bands can sometimes be worn up to six to eight weeks, depending upon the length and time it takes to lower the implant to regain a normal rounded shape. Tubular breast deformity reconstruction is a challenging operation, but in the hands of a Board Certified Plastic Surgeon, can be a wonderful operation with a very satisfied patient.

Tubular Breast BHTubular2

REVISION LIPOSUCTION

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.

BHLipo1

BHLipo2

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
  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.

BHLipo3

BHLipo4

Breast Augmentation With Benelli Lift

primary augmentation

The female patient presented is 26 years old and was looking to improve her breast appearance by increasing her breast volume and position. However, her thoughts about having a breast lift were concerning because of the potential scarring. During her examination, she showed a mild degree of breast sagging, and based on her expectations, a lift would be needed. After examining and listening to her goals, we agreed to schedule a primary augmentation and lift.

During her surgery, I placed 400 cc saline high profile breast implants. I overfilled the right implant to 440 cc and the left side to 455 cc to create fullness and symmetry. Because the implant alone would not elevate the breast enough and knowing her concern about scarring, I performed an incision type called the Benelli Lift to raise the nipples slightly.

As you can see, the patient is only four weeks post-surgery, but she has nice volume and symmetry, and she has a more youthful appearance.

To schedule your consultation with Dr. Linder and learn more about breast augmentation or breast lift call our office at (310) 275-4513 in Beverly Hills or fill out our online contact form today.

 

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