To Dr. Linder and all your amazing Staff:

“Since the first time I called your office, I felt completely at peace and totally comfortable.  Adriana was the first person I spoke with.  She is so patient and caring.  She made me feel that there was no wrong question and she took the time to speak with me.  She’s so wonderful.  Then I spoke with Dr. Linder.  I had two previous breast surgeries from my home town of British Columbia, Canada, each one worse than the previous.  I had had a virtual consultation with Dr. Linder.  He right away knew what needed to be done to fix all the scar tissue and mess from the previous surgeries.  I knew that I had to come out to Beverly Hills to have it done right.  My confidence in Dr. Linder was 110%.  He is amazing.  When we spoke on the phone, he was so kind and totally focused on making my surgery a success.  The day before surgery, I came to his office to meet him in person.  He is such an amazing man.  So caring, so patient, he answered any questions and concerns that I had.  He took the time with me to ensure I was totally at ease and at peace with respect to the surgery to come. 
 

On the morning of surgery, I met Beverly and the rest of his staff.  Beverly is such a caring person, just like a mom.  I couldn’t have had a better nurse.  The day after surgery, came in to see Dr. Linder, bandages were removed and I was crying.  Dr. Linder far exceeded my expectations.  I am 110% satisfied.  He’s not only an amazing man, but he is an amazing surgeon.  He instantly changed my life.  He gave me “perfect breasts.”  It was worth the flight over from Vancouver, British Columbia, Canada.

Thank you for all you have done to make me feel beautiful again!  Dr. Linder takes the impossible and makes it possible.  I truly thank you so much for fixing my breasts.  They are beautiful.”
All the best,
Laura P.
British Columbia Vancouver, Canada

Each week blogs will be posted on issues relating to safety and interesting topics in plastic and reconstructive surgery of the face and body. 

Both surgeons have authorized their own books on plastic surgery to educate patients when undergoing cosmetic surgery of the face and body.

Bizymoms.com is a very large and fast-growing website that is dedicated to mothers of the United States.  This site has served moms for over 12 years with over 25,000 articles, over 1,000 experts and 200,000 pages of website information.  Dr. Linder’s article specifically details information on breast augmentation with silicone versus saline implants, risks and complications and how to find a qualified plastic surgeon when considering plastic surgery of the breasts.

Breast reduction surgery when performed correctly will lead to an excellent result.  It will reduce the size of the weight, reduce functional problems, including back pain, neck strain, grooving around the shoulder blades, etc.  The tradeoff for a breast reduction is scarring.  Scarring can be unpredictable, although there are techniques that may help to improve the final result.  Techniques are as follows:

1. Make sure you go to a Board Certified Plastic and Reconstructive Surgeon, a Diplomate of the American Board of Plastic Surgery who is trained and qualified to do breast reduction surgery.

2. Closure of the incision should be performed subcuticular whenever possible in order to reduce external scarring.  In other words, stitches should be placed underneath the skin as much as possible to reduce stitch marks.

3. The correct approach.  A predictable and safe approach to large breast reductions, at least according to Dr. Linder, is using the Wise-pattern or anchor scar technique where an incision is made around the areolar vertically along the midline of the breast and along the inframammary fold.  This allows for correction along the vertical plane as well as along the inframammary fold and the horizontal plane and reducing tissue from both planes which will then allow for a round, nice shape to the breast.

4. Medicare State Licensed Ambulatory Center and a Board Certified Anesthesiologist for the safety of the patient.  This is a must in that a Board Certified Anesthesiologist will be able to take care of the patient’s airway and correct any problems in the operating room that may occur.  There is no substitute for a Board Certified Anesthesiologist.

5. Postoperative care for the suture lines should include scar treatment which Dr. Linder uses Kelo-Cote silicone gel spray in order to reduce scarring for a three-month period, twice a day, once all sutures are removed.

November, 2009

COMBINATION PLASTIC SURGICAL PROCEDURES

INDICATIONS

Patients present to us for body sculpting procedures every week.  Some patients are excellent candidates for combination surgical procedures, including breast surgery as well as abdominoplasty and/or liposuction as well as lipo contouring of the thighs.  Initially, we must make sure the patient is in good health, that there are no significant systemic diseases, including high blood pressure, diabetes, asthma or anemia.  The patient having multiple procedures over the age of 40 should be cleared with a history and physical from a general internist, as well as receive a 12-lead EKG and a full set of labs.  Labs should include coagulation panel in order to check for clotting, a CBC which will include white count and hematocrit as well as a beta HCG may be performed in order to check for pregnancy and an HIV test.  If the patient is medically stable and healthy, she may undergo combination procedures.   

The example here shows a breast augmentation with a mini abdominoplasty and lipo contouring of the hips.  Surgery time is approximately two hours performed under general anesthesia with a Board Certified Anesthesiologist.  The patient is now two months postoperative.  The implants have settled nicely and the contour of her lower abdomen is excellent. 

Other factors important when considering combination procedures include length of time in surgery (in general, Dr. Linder performs surgery in less than five hours) and the amount of anticipated blood loss.  Patients who are healthy certainly can undergo combination surgical procedures with safe, predictable and excellent results.

TOTAL BODY MAKEOVER AFTER GASTRIC BYPASS SURGERY
BEVERLY HILLS

One of the most exciting challenges of plastic surgery for Dr. Linder is reconstructing the entire mid torso, breasts and abdominal area after patients have had massive weight loss.  The above patient flew in from Idaho, having had a gastric sleeve surgical procedure over one year ago performed.  She at the time weighed approximately 300 pounds, has lost over 180 pounds and is now 120 pounds with massive amounts of skin on the breasts and abdominal area.  She was an excellent candidate for a combination of formal mastopexy using the inferior pedicle Wise-pattern technique and abdominoplasty or panniculectomy.  She also had lipo contouring of her thighs.  The photographs show the patient now at three weeks postoperative.  Her before pictures show the nipple areolar complex with grade III ptosis way below the inframammary fold, but notice that she has a tremendous amount of tissue.  Although there is a lot of skin, she has good volume and therefore an implant was not placed.  Rather, a formal inferior pedicle Wise-pattern technique breast lift was performed using the so-call “anchor scar.”  The abdominoplasty was performed with an extensive tummy tuck, dissecting all the way up to the ribcage, removing all the extra skin both above and below the umbilicus.  Three-week postoperative results are shown and sutures have now been removed. 

The challenge of post-bariatric surgery patients for breast reconstruction and paniculectomies is quite amazing and the results are often quite spectacular.

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1. Pseudoherniation of breast tissue into the nipple areolar complex.
2. Poorly defined inframammary fold.
3. Flattening of the lower pole of the breast which leads to a conical tubular shape.

In order to create a normal shape and rounder shape breast, Dr. Linder performs tubular breast reconstruction using high profile saline and/or silicone gel implants using the dual plane technique, two-thirds over, one-third over, releasing the inframammary fold, lowering it to 5.0 cm, as well as radial striation of the lower pole of the breast in order to stretch out the lower pole of the breast.

Postoperative management is extremely important, which will include supportive athletic bras without underwire for four to six weeks, as well as an upper pole compression band which will relax the upper pole of the breast, softening it and bringing the implant down the nipples up.  Please look at the example of a before/after tubular breast deformity in which a 250 cc high profile saline implant was placed through the periareolar approach using the dual plane technique.  The patient is now approximately six weeks postoperative.

The above patient presents with laterally displaced implants placed through the transaxillary approach where the parasternal muscle attachments under the pectoralis were never released, causing her to have laterally displaced implants; cleavage greater than 10 cm.  She was very distraught and unhappy with the appearance of her breasts and was quite disfigured as seen in Preoperative Photo #1.

Patient was taken to the operating room and the implants were exchanged with high profile cohesive 475 cc silicone gel implants and the parasternal muscles were released appropriately and the capsule was released towards the midline and silicone gel cohesive Allergan implants were placed to reduce visibility and palpability of the implants due to thin tissue coverage along the medial breast.  As you can see on Photo #2, postoperatively she has a greatly enhanced cleavage.  She will remain in a tight supportive brassiere for the next six weeks in order to help mold the breasts internally.  Sutures have been removed and the patient is free to use Kelo-cote on the scarring.

It can be associated with the use of steroids, marijuana and other medications.

Gynecomastic surgery can be performed in several variances.  The mild forms of gynecomastia may only require tumescent liposuction technique, liposuctioning the chest area.

In moderate cases, which we normally see, Dr. Linder performs both a periareolar incision with a retro-periareolar excision of a wafer of glandular tissue removed from behind the nipple areolar complex as well as liposuctioning of the chest area from the anterior axillary line along the lateral pectoralis major muscles from the infraclavicular and along the sternal region.

This combination of liposuction and direct excision of partial subcutaneous mastectomy have led to excellent results for gynecomastic surgery.

Very severe forms of gynecomastia with severe skin laxity may require a form of mastopexy which actually requires scars as similarly seen on women that have breast lift procedures.  (Please see the above example of gynecomastic surgery where tissue has been removed from behind the nipple areolar complex both through direct excision as well as liposuctioning of the chest.)