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Dr. Linder's Blog


Category: Breast Reconstruction

Severe Bottoming Out Repaired by Internal Capsulorraphy of the Inframammary Fold

severe bottomingThe patient presents with severe scar tissue contracture of the entire collapse of the upper pole of her right breast causing lowering of the implant with the implant approximately 1.25 inches lower on the right than the left. Not only are her implants too large for her body, the technical error by a previous surgeon caused inferior displacement of the implant due to inadequate release of the superior pectoralis major muscle. The pressure has caused constant inferior creep of the implant down over the last three years. The photograph with markings in place show that the 397 low profile style 15 gels will be replaced with 350 cc high profile saline implants narrower and smaller. The superior upper portion capsulectomy was performed rendering complete muscle release up to the clavicle was maintained in the right breast. At this time you can see the photograph showing the muscle attached down to the intercostal space causing complete collapse of the upper pole.

The next photograph shows lifting of the capsule along the inframammary fold which is then released from the inframammary fold of approximately 2.2 cm or one inch.

The next photograph shows the capsule is now being sutured up using strong sutures in order to recreate a sling-like effect bringing the implant up and reducing the bottoming out. The next photograph shows the entire capsule has been completely sutured upward and reattached using a capsulorraphy. Finally, the wound has been closed with large sutures reapproximating the edges and postoperatively she now has a double fixation of the inframammary fold with not only capsulorraphy sling, but also with the skin excision tightening the skin as well as repositioning the nipple areolar complex into its symmetric position to the left side.






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 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


This patient presents from Missouri, having had three operations for her breast enhancement. She has consistently had problems, including right breast double-bubble breast deformity with superior retropositioning of the implant and skin laxity of the lower pole. Also, there is severe bottoming out of the left breast where the implant is placed too low. She underwent a vertical mastopexy; however, the skin inframammary fold was never addressed and the skin laxity remains. She now presents for her first surgery with us in order to have this reconstructed.

In her preoperative photograph, it is evident that the upper pole of the right breast is quite full. There is also skin laxity on the right nipple and is significantly lower than the left side. On the left breast the implant is positioned quite low and there is increased skin laxity along the inframammary fold. The operation included both scar tissue removed, an open capsulectomy of the right breast, as well as an inferior open capsulotomy, releasing the implant bringing it down, as well as repositioning of the nipple areolar complex by doing a complete lift, that is, a formal mastopexy using the inverted-T or the Wise-pattern technique.

breast deformity


Specimen of the capsule removed is shown. The formal mastopexy was performed on the right and on the left a vertical T mastopexy with the specimens now showing skin removed (specimen #2) with 6 cm of skin removed from the inframammary fold reducing her bottoming out from 13 cm down to 7 cm. The implants were also replaced to regain symmetry with slightly different implants. High profile saline implants, 320 cc filled to 330 cc on the right, and 350 cc filled to 380 cc on the left, allowed volume symmetry.


Her postoperative Day 1 photographs are shown. With the bra open, note the upper pole fullness is even. The nipple positions are also the same level and that there is no longer bottoming out of the left breast. With the Linder Bra in place notice the cleavage is enhanced, there is great upper pole fullness with symmetry and the breasts are even. This is the case of a very difficult breast reconstruction where the patient actually presented with two problems, a double-bubble deformity (implant too high) and bottoming out (implant too low). By performing the correct surgery, i.e., a formal mastopexy rather than a vertical lift, it was quite easy to regain symmetry, narrow the breast with high profile saline implants and have upper pole fullness with symmetry as well.



A young lady presented with severe tubular breast deformity with grade 2 ptosis of the left breast and severe breast asymmetry. The patient declined to have any scarring with breast lifts performed. In any case, the patient underwent augmentation mammoplasty with saline high profile smooth implants, 330 cc filled to 400 on the right, 330 cc filled to 380 cc on the left using the dual plane technique, periareolar approach and radial striation of the lower pole of the right breast. Her “before and after” photographs are shown for reference.


Interestingly, the left breast pocket was made very conservative, especially lateral to the areolar border, which allowed the implant to sufficiently tighten up the left breast skin without the necessity of a breast lift. Her cleavage is actually quite good as well. The most important part of this operation was releasing the right breast lower pole inferiorly in order to reduce the tubular shape of the breast (this can be seen nicely on the oblique view), also limiting the pocket dissection on the side of the breast and using high profile saline implants in the dual plane technique, two-thirds under, one-third over. This is an interesting case. Once again, the successful surgery on a patient presenting with tubular breast deformity, sagginess or grade 2 ptosis of the left breast and asymmetry without the use of breast lift scarring.

NY Times Article “After Mastectomies”

Nytimes article "After Mastectomies"A few days ago on January 29, 2017, New York Times posted an article by Roni Caryn Rabin titled After Mastectomies, an Unexpected Blow: Numb New Breasts. The article presents a few patients’ stories about having mastectomies and the subsequent loss of sensations in their breasts. As the article states, “While doctors agree on the need for a mastectomy procedure that spares nerves, they note that the goal of the surgery is to make sure the cancer is gone.”

As a board-certified plastic surgeon, I believe it is important to share these types of articles so patients can be better informed as they look toward breast reconstructive options.

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


Plastic Surgery Is A Choice After Breast Cancer

Going through breast cancer and losing a portion or all of your breasts can be traumatic. A decision to undergo plastic surgery can be hard not only physically but also emotionally. As a board-certified plastic and reconstructive surgeon, I am thankful for my training, so I can help women who have battled breast cancer regain their self-esteem.

Education is very important during this journey. The better informed a woman is, the more comfortable and confident she will be with her decision. Most of my patients who are in this situation need time to process the information before making a decision. During my consultation and examination, I take time with my patients to help guide them through the available options and discuss the risks and benefits.

For more information on the actual approach for breast reconstruction, please visit breast revision after breast cancer and reconstruction. See also the video below of Dr. Linder explaining his pre-op marking for a breast reconstruction cancer revision surgery.

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



Breast Revision Status Post Previous Fat Grafting And Fat Necrosis Of Bilateral Breast

Pre Op Photo

Pre Op Photo

This is the case study of a patient that presents two years post-autologous fat grafting from a different surgeon.  Instead of undergoing augmentation mammoplasty using saline or silicone implants, a different doctor decided to do fat grafting of her breasts.  Over the last two years she has developed very large cystic fat masses in both breasts, smaller on the right and up to 3 x 6 cm on the left.  The patient underwent a mammogram and ultrasound showing enlarging fat cystic masses, especially in the left breast.  Five extend from the medial aspect of the breast to the lateral, to the superior 12 o’clock position and to the 3 o’clock position.  They are palpable with the largest one almost the size of a golf ball along the lateral left breast.

The patient underwent surgical reconstruction and surgical excisional biopsies of these multiple masses as well as reconstruction using silicone gel implants in order to regain symmetry and correct the deformity of the left breast after removal of these large cystic masses.

In the operating room the patient was placed under general anesthesia.  The right breast was first operated upon.  A 450 cc SRF silicone gel implant

was placed through the periareolar and subpectoral dual plane techniques.  The left breast was then incised under the left areola at which time cystic masses were removed along the left medial two large masses and upon identifying fat necrotic liquified tissue was identified.  (See photograph to the right)  After removing the cystic capsule, the area was coagulated with electrocautery.  All cystic masses were then opened along the superior 12 o’clock position, 3 o’clock and then the largest along the left lateral breast.  All of them had liquified fat within them, yellow and thick viscous fat in liquified form and the capsules were all exenterated, removed and then bovied.  A 385 cc SRF gel was placed on the left to regain symmetry and the patient will be maintained on oral antibiotics for 14 days.  A Dr. Linder Bra and upper pole compression band with sutures to remain in place for 14 to 17 days.

This is an interesting case study, showing that fat grafting does not always work to the breast.  Not only is there the possibility for misdiagnosis of tumors, but the fat may not survive, leaving the patient with enlarging cystic fat tumors or fat masses which should be surgically removed.

Six Weeks Post Op

Six Weeks Post Op

The photo to the left shows the patient after six weeks post op, and she is very please with her breast revision.

Schedule your consultation with Dr. Linder to learn more about breast revision surgery. Call our office at (310) 275-4513 in Beverly Hills or fill out our online contact form today.


There are many reasons why women decide to undergo secondary breast elective breast revision or reoperation. These include capsular contracture, improper initial placement of the implant, rupture of the implant (silicone or saline), bottoming out of the implant, or double bubble deformity implant placed in a pocket superiorly retropositioned with overlap of skin or simply a decision to make a change in the size or volume of the implant.

Capsular contracture, according to the study by Inamed/McGhan Corporation has a 7-year percentage of 16% in women who have undergone elective augmentation mammoplasty (breast implant surgery). Capsular contracture is associated with scar tissue formation around the implant which leads to tightening and hardening with visible distortion and ensuing painful deformity. This can be repaired by either an open capsulectomy with removal of the scar issue directly or a capsulotomy where the scar tissue is released. Capsulotomies are preferred in women with minimal breast tissue in order to reduce the visibility of the implant edge.

Improper placement of the implant by a previous surgery may lead to a myriad of deformities or problems. This may include implants placed too high. This can be seen with transaxillary breast augmentation procedures where the muscle is not adequately released and the implants are superiorly retropositioned.


Revision or reconstruction / reoperation will include releasing the lower pole or the inferior portion of the breast pocket to allow the implant to the positioned in the normal anatomical position. Bottoming out may gravitational dissent of the tissue skin and the implant. Fixing this can be difficult and may require either repairing the capsule internally, sometimes difficult if not impossible to do, versus a breast lift which will remove redundant skin from the lower pole of the breast and reposition the nipple superiorly.

Rupturing of the silicone or saline breast implant may occur, requiring certainly reoperation. A ruptured saline implant becomes quite obvious as it will with the all or non phenomenon deflate over a reasonably short period of time and the obvious asymmetry will be present. The deflated implant should be removed as soon as possible to reduce the amount of scar tissue contracture around the implant as it becomes smaller. Ruptured silicone implants may be more difficult to determine, however, MRI studies have made it much more predictable and sensitive to determine a small rupture in the silicone bag. These implants should certainly be replaced if ruptured.


A double bubble deformity simply is usually associated with the implants superiorly positioned under the muscle and the overhang of skin drooping over it. This usually will require a combination of surgical procedures, including an open capsulectomy (removing the scar tissue and dropping the implant to its proper position) and a formal mastopexy. This is a true breast lift where excess skin from the lower pole of the breast must be removed with the nipple positioned higher. In summation, once a woman has had breast implants, it is not unlikely or unusual that sometime in the future she will have to undergo a secondary surgery for one of the above problems that may occur. The repairs again may include removing and replacing the implants with saline and/or silicone, performing a breast lift in order to remove or reduce the excess skin capsulorraphy which may require internally tightening of the capsule, capsulectomies and capsulotomies which simply are removing or releasing scar tissue to allow for a normal shape and reduce pain when there is severe tightening of the breasts.

Breast Reconstruction Status Post


This patient presents with breast implants placed in Costa Rica in which she pusses out and ended up with severe abscesses. Implants were removed in Costa Rica three months later. She is now seen one year later, traveling to Beverly Hills for reconstruction.

Pre Op Photo

Post Op Photo

On a close-up view of the bottom vertical scar of the bilateral breast, right greater than left, you can see the thinness and laxity of the skin which is quite thinned out poor vascularity, continuous. Postoperatively, the patient underwent augmentation mammoplasty procedure using 465 high profile style 68 Natrelle saline implants through a lateral periareolar incision under the nipple. Her postoperative view shows excellent fullness, scar healing nicely under the nipple, shape is excellent and the breasts now remain soft with no evidence of recurrent scar tissue and there is nice shaping of the lower poles of the breast compared to her preoperative photos.

Patients travel internationally to have breast reconstruction here with Dr. Linder in Beverly Hills in order to often repair problems, including infections of previous breast augmentation surgery.


Patients present to my office monthly for breast asymmetry repair. Patients are very unhappy with the appearance of their breasts, especially when one is significantly larger or a different shape and/or size then the other. In fact, breast asymmetry is a very commonly searched term on the internet. In general, breast asymmetry is associated with different size breasts, as well as shapes that may be different, such as tubular breast deformity, as well as sagginess or skin laxity of one or both breasts, which also leads to a symmetric appearance. As a result, the Board Certified Plastic Surgeon needs to appreciate both volume and skin laxity discrepancies on both breasts. Asymmetry in general with most women’s breasts is quite normal. However, when it becomes one-half to greater than one cup size in difference, patients can become very distraught. Younger patients often present for breast asymmetry reconstruction, often presenting with their parents, in order to repair the breasts and make them appear and feel normal. Most of the women do not want to have an exaggerated or enlarged appearance, rather they want to recreate a symmetric, even appearance with possibly a slight increase in volume.

Our first case is a breast asymmetry or the young 18-year-old female presents with severe right breast hypertrophy in which the left breast underdeveloped and the right one became enlarged. A reduction mammoplasty on the right with a small implant lift on the left allowed for good symmetric repair of the upper breast as well as elevating the nipple areolar complexes even bilaterally. She underwent, of course, the anchor scar which is evident. The scar is well worth the tradeoff of her now normal appearance and symmetric, even breasts.


The second example below shows a significant asymmetry in which the left breast shows a tubular-like deformity with pseudo-herniation of the breast tissue into the nipple areolar complex, poorly defined inframammary fold and loss of complete volume. The right breast on the second example shows grade 3 ptosis in which the nipple is well over 3 cm below the fold. As a result, this patient underwent an augmentation mammoplasty procedure bilaterally with invariably different size implants, as well as a mastopexy on the right breast using the inferior pedicle Wise-pattern technique or anchor scar. Her postoperative appearance shows symmetric, even breasts with the nipple also at the same position.


A final example shows significant breast asymmetry of volume only. This patient does not require any form of lift or reduction. Through a periareolar incision and a dual plane technique, high profile saline implants were placed behind the muscle, 520 cc on the right and 420 cc on the left. The 100 cc difference gained us approximately one cup size in volume on the right, evening out her breasts beautifully.


In conclusion, breast asymmetry is an extremely common problem that we see every day as breast specialists. Doctors performing reconstruction for asymmetric breasts should be Diplomates of the American Board of Plastic Surgery. In other words, Board Certified Plastic Surgeons, who have tremendous experience and excellent judgment on how to reconstruct breast deformities in women in general.