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Category: Plastic Surgery

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.

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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.

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.

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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.

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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
  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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TOTAL MOMMY MAKEOVER UNDER 35

Patients present to my office weekly requiring total mommy makeovers at a much earlier age. This is associated with pregnancy and history of breastfeeding. The case below is a patient who is only 25 years old, who presents with bilateral breast dysphoria, involutional upper pole atrophy, and loss of upper fullness of her breast. She is an excellent candidate for augmentation mammoplasty procedure using a high profile saline implant under the muscle in the dual plane technique in order to obtain upper pole fullness. Her lower abdominal area shows skin laxity with some lipodystrophy at the muffin-top regions.

The patient underwent bilateral augmentation using high profile saline 425 cc Natrelle Allergan implants through the periareolar approach, dual plane and a full abdominoplasty through a tightening of the rectus sheath and liposuctioning of the hips. The frontal view shows slight asymmetry with the right breast slightly smaller than the left and 10 cc more volume was added. It also shows rectus diastasis in the lower abdominal area with the muscles pulled out and a pouching of the lower abdominal region. The side view shows the skin laxity of the abdomen and nicely shows complete flattening of the upper pole of her breast. Her postoperative oblique view shows excellent upper pole fullness with tapering of the implant along the lateral inframammary fold. Her oblique view of the tummy tuck shows nice softening of the hips, well-healed scars around the lower abdominal area and the umbilicus and makes tightening of the rectus sheath in the midline.

Patients under 35, including this 25-year-old, do well with high profile saline implants to enhance the upper pole loss of fullness due to involutional atrophy associated with breastfeeding at a young age and full tummy tucks are excellent procedures for patients who no longer desire to have children in the future.

MOMMY MAKEOVER

WHAT TO DO WHEN YOUR BREAST LOOK DIFFERENT

Breast asymmetry can be associated with normally congenital, developmental or even traumatic or associated with breast cancer which may require breast reconstructive surgery causing breast asymmetry. Breast asymmetry is associated with one breast looking larger or smaller than the other. It can also be associated with one breast being saggier or having more ptosis than the other side. Correcting breast asymmetry can be very difficult, if not impossible. The correction of breast asymmetry may require creative thought, which may include different surgical procedures on one or both breasts in order to create similarities.

Technique #1: Using implants of different sizes to create symmetric breasts. This is most often associated with breast when the nipple areolar complex is above the fold and there is no degree of sagginess (ptosis).

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Technique #2: Performing a breast reduction on a larger breast and simply a breast lift on the contralateral breast if both show sagginess, but one breast is significantly larger than the other.

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Technique #3: Placing an implant on one breast and/or an implant and a lift on the other breast if the contralateral breast has a degree of sagginess or ptosis.

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Technique #4: A breast reduction or lift on one breast alone to even it out with the left breast if the left breast shows no degree of sagginess and similar sizes in volumes can be created with a lift and implant on contralateral side.

Technique #5: A culmination of these multople procedures including breast lifts on both sides with different size implants if there is asymmetry of volume and/or both breasts show a significant degree of sagginess with a nipple areolar complex which may be below the inframammary fold grade III ptoris.

BODY SCULPTING TOTAL BODY MAKEOVER

These examples show patients who have had significant fluctuation in their weight associated with pregnancy, breastfeeding and massive weight loss. As a result, they have undergone augmentation with breast lifts or augmentation with tummy tucks and breast lifts. These patients are excellent examples how patients can regain their life and self-image by having tightening procedures of both the breast and abdominal areas to pre-pregnancy status. Patients often present after breastfeeding with significant fluctuation of skin laxity of the breast causing involutional upper pole loss of fullness and atrophy as well as severe skin laxity where the nipple may be greater than 3 cm below the fold, referred to as grade 3 ptosis. These patients will require a combination of implants (saline or silicone) placed under the muscle and a formal mastopexy concurrently with the complete scar of a Wise-pattern. The first example shows a patient who has undergone an augmentation mammoplasty procedure as well as a formal breast lift, a full abdominoplasty and sculpting of the muffin top hip areas.

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The next patient shows specifically loss of upper pole fullness without skin laxity and abdominal wall laxity with rectus diastasis. Excellent candidate for straight saline augmentation in the dual plane technique and a full abdominoplasty with plication of midline rectus sheath. Both of these are excellent examples of when patients are placed under general anesthesia with a Board Certified Anesthesiologist and full medical clearance can undergo successfully, in an ambulatory facility, full body contouring and mommy makeover procedures without incident.

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WHAT’S IN A NAME?

1. BRA BULGE

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Bra buldge is that pesky fat pad that can be found just lateral or outside the outer edge of the pectoralis major muscle. When women wear brassieres, it’s not infrequent that this bra fat that pushes out can be irritating, painful, rashes can form and they can develop dermatitis. This bra bulge can also be unsightly, especially in clothing where this lateral breast region is exposed. On national television Dr. Linder performed a bra bulge procedure, removing this fat using a small triple lumen Mercedes tip cannula to sculp the lateral fat pad resolving the bra bulge. The results can be quite traumatic. This can be performed under either local IV sedation or general anesthesia, depending upon the amount of adiposity. Patients with increased skin laxity at this region may require a skin excision at the same as tumescent liposuction of this bra bulge fat pad. Compressive garments for at least six weeks should be used postoperatively. Sutures remain in for approximately 14 days.

2. MUFFIN TOP

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The Muffin Top specifically is associated with the adiposity or lipodystrophy fat pads within the iliac crest roll or hip region and the lower flanks. It can also extend to the lower abdominal or periumbilical region. Dr. Linder performed a muffin top procedure on national television recently. The patient was brought to the operating room, administered general anesthesia, although IV sedation may be used on smaller localized muffin top regions of the hips. The fat is directly lipo sculptured with tumescent technique using a bi-directional technique. Both superficial and deep fat is removed with as 4 mm and a 3 mm triple lumen Mercedes blunt tip cannula. Subsequently, fat is removed directly perpendicular to the pelvic bone in order to smooth out and contour the medial hip region. The results can be absolutely fantastic. Six weeks of compression garments are placed. Patients who have significant fatty tissue around the lower abdomen can be sculpted at the same time leading to a completely sculpted muffin top region.

3. MUFFIN BOTTOM

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The Muffin Bottom consists of sculpting three different regions at one time, the infragluteal fold, the medial posterior thigh and the lateral posterior saddlebag region. The muffin bottom can be sculpted using the tumescent technique under either IV sedation or general anesthesia. This was sculpted for a national television program recently and the results are dramatic. Care must be taken to avoid over-sculpting the infragluteal fold to prevent increased skin laxity or contour deformity.

4. SADDLEBAG PROCEDURE

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Saddlebags are that localized fat deposits in the outer thigh region which cannot be removed through diet and exercise. These are resistant genetic fat pads which can only be removed through direct surgical liposculpture. Dr. Linder performs a double layer criss-cross technique using a deep 4 mm cannula and a superficial 3 mm cannula to remove the fat in the lateral thigh region in a criss-cross perpendicular manner. Meticulous and precise sculpting of the lateral thigh as well as removing some of the anteromedial inner thigh and iliac crest roll or hip thigh fat can completely contour the thigh, removing the saddlebags and proportionating the lower third of the body with the midriff and upper portions of a woman’s anatomy. This was performed recently on national television with the following pre- and postoperative results. Liposuctioning of different areas of the body follow similar patterns with respect to technique. I use tumescent fluid in all these regions in order to

  • 1) contour the fat, hydrating the fat cells, reducing the contour deformity and skin irregularity;
  • 2) reduce bruising and bleeding by using the epinephrine to vasoconstrict the blood vessels;
  • 3) to use Lidocaine in order to reduce pain by allowing for numbness.

HOW TO PAY FOR A BREAST AUGMENTATION

Patients come every day to see Dr. Linder for breast augmentation surgery. As the years go by, an increased number of patients will present with needs for financing. As a result, we now work strongly with three excellent financing companies.

  • Care Credit
  • Med Choice Financial
  • Capital One Healthcare Finance

Patients may also use merchant accounts, including Visa, Mastercard and American Express. If, however, they decide to finance, we work closely with all three of these carriers.

They offer easy payments for cosmetic enhancement and procedure fees can range from $1,000 to $25,000 upon request and approval. Care Credit is a leader in patient financing and has a payment plan for everybody. Patients can pay over time with no interest or low interest payment plans that fit their lifestyles and budgets. Patients can apply online and can be approved prior to arriving at Dr. Linder’s office during consultation.

Med Choice Financial also makes it easy to apply and an answer can be received within just a few minutes. They will allow the patient to use the card for their entire family. They offer no payments, deferred interest plans and low minimum monthly payments. An online application is being updated and their phone number is 1-800-358-8980.

Finally, Capital One Healthcare Finance offers great rates, as low as 1.99% APR for 18 months interest free. They do not have hidden charges or fees and there is no prepayment penalty.

We have worked with these programs for over 10 years and they all have been found to be strong lenders for patients’ financing needs for body sculpting procedures with Dr. Linder.

When considering breast augmentation, saline or silicone or breast revision surgery, all three of these financing companies are very, very useful and with approval on credit, will finance patients for plastic surgical procedures and body sculpting with Dr. Linder. For more information feel free to contact Dr. Linder.

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