Many patients present to Dr. Linder for breast revision surgery.  They have concerns over “feeling something that is just not right” within one or both breasts.  It is important to decipher whether there is a mass, lesion, scar tissue contracture or the implant edge that is leading the patient to this disfigurement and/or palpability of a mass versus the edge of the bag.  With saline implants, scar tissue contracture can lead to enfolding of the bag and with a Baker IV contracture, can lead to pointing and deformity of the implant causing the edge to feel obvious and palpable.  Patients often do not know whether this is the implant edge or a mass.  If there is any question and the surgeon cannot decipher a mass from the edge of an implant, diagnostic radiographic testing should be performed.  With saline implants, mammograms and ultrasounds are sufficient.  With silicone gel implants, an MRI can be used in order to determine whether there is a rupture of the cell of the implant as well as to determine the integrity of the implant itself.  Any suspicious mass within the breast should be diagnosed by mammogram ultrasound and if necessary, tissue biopsy through FNA (fine needle aspiration) or true core biopsy.  Because of the significant rate of breast cancer in women (approximately one out of every eight and a half women may develop breast cancer), all masses in our practice are looked at seriously and diagnosed through proper diagnostic and/or biopsies. 

Scar tissue contracture may certainly lead to distortion of the implant causing palpability of the edge of an implant.  Patients often are not sure what this edge is, whether this is a mass or the bag edge.  With silicone gel implants, it is more difficult to detect the edges of the implant on enfolding and therefore MRIs are very useful.  Most importantly, any time a woman’s breast feels different, we must decipher lesions, palpable masses, pre-malignant tumors versus implant edge versus scar tissue contracture.

Because Dr. Linder performs so many surgeries where scarring is such a significant part of his procedures, including mastopexies, breast lifts, abdominoplasties and breast augmentations, reducing the scarring is absolutely a main necessity.  The best product that we have used, certainly in the last decade, has been Kelo-cote or Bio Corneum.  Kelo-cote is a silicone gel spray which is used twice a day after sutures are removed, usually on day 14 to day 21, for at least three months.  The silicone gel spray greatly reduces the redness as well as hypertrophic keloiding of the scars and has smoothed out scars beautifully over the last two years. 

Look out for the next one and two-minute infomercials from Kelo-cote where Dr. Linder has been used as a scar expert for Advanced Bio Technology.  Because we believe so wholeheartedly in the use of Kelo-cote, giving worldwide testimonial as to the benefits of Kelo-cote, goes without reservation.  We look forward to seeing the Kelo-cote used worldwide and on television sets throughout the country.

Case in point, the above patient is a 47-year-old female from Sweden, who is 18 years status post silicone gel augmentation mammoplasty procedure.  The implants were said to be intact on mammogram; however, the patient feels that there may be loose material as well as sagging and scar tissue formation and desires to have them removed.  In the operating room she was found to have bilateral ruptured silicone gel implants and massive scar tissue calcification. The photos show silicone gel free material being removed from the breasts as well as calcifications and severe encapsulation.

In my practice I recommend patients who have implants of a silicone gel nature should have MRI’s every three years and as well should consider removal and replacement after 10 years, especially if there is an obvious sign of rupture.

An interesting article is written by Mark Mingaman, who is a contributing writer for eHow.com, specifically to breast revision surgery.  This is the second article Dr. Linder has been quoted on for capsular contracture.  Dr. Linder describes that 15 to 20 percent of women who have augmentation will experience capsular contracture.  The significance is associated with the body’s immune system performing a capsule, a protective wall, around the implant. 

With respect to the procedure, capsular contracture can occur as soon as four to six weeks after original surgery.  It simply under capsulectomy is opened with an electrocautery device and a thin amount of the breast tissue will be removed around the capsule in order to reduce hardening and pain, however, to reduce visibility and palpability of the implant.  He also describes postoperative reduction of capsular contracture by the use of massaging, vitamin E and Accolate as well as the use of surgical dressings, and sutures should be removed in one to two weeks postsurgically.

Bottoming out occurs when the implant gravitationally descends, lowering in the pocket and the nipple elevates within the pocket. The nipple may actually end up on top of the breast which leads to a severe deformity referred to as “bottoming out.” This can occur due to the pocket technically being made too low and the inframammary fold ending up low on the chest well or due to with time patients not wearing supportive brassieres, including underwire bras during the day and sports bras at night or sleep bras which will help to maintain position. If you think about it, it is difficult for the inframammary fold to maintain a large, large implant and over time without support of the fold, the fold may lower and fall. Ways to impair it include internal capsulorrhaphies (tightening the capsule into itself), autologous dermal matrix, including AlloDerm and allographs, which can be quite expensive, as well as neo-pocket formation and autologous dermograph placement or a simple inframammary tightening procedure with an inframammary lift, removing the skin around the inframammary fold, which may elevate the fold and then tighten the lower breast, and recentralize the nipple areolar complex into the middle. (Please see the following example of a severe bottoming out.)

Bottoming out surgery can be very difficult to repair and therefore, it is most important during original surgery that the implants be placed through an approach which is simple, such as the periareolar approach, where the inframammary fold can be lowered absolutely as accurate as possible and not too much.

The below patient presents with severe Baker IV capsular contracture with malpositioning of implants, done through the transaxillary approach.  Her preoperative view shows complete distortion with superior retropositioning of the implant with hardening and a grotesque appearance to her breast.  The patient works in the entertainment industry and this is obviously distressful for her in that her breasts do not appear normal in way fashion. 

In order to correct this problem, an open capsulectomy was performed bilaterally.  A new implant was replaced and lowered with an open inferior capsulotomy, anterior capsulectomy and a formal mastopexy using the inferior pedicle Wise-pattern technique was performed in an anchor-like fashion in order to remove the redundant skin.  Notice, her postoperative view with a normal appearance to bilateral breast, good symmetry, nipple areolar complex symmetry is excellent, and she now has a normal appearance to her breast. 

Double bubble breast deformities require skill, experience and judgment, which can be found with Board Certified Plastic Surgeons.

Dr. Linder has had the opportunity to attend the 2010 Aesthetic Society Meeting for the American Society of Aesthetic Plastic Surgeons.  Interesting course topics included Breast Revision Surgery, Surgery using Acellular Dermal Matrix or ADM as well as Neo Pocket Formation for Severe Breast Deformities, including Symmastia and Malposition of Implants.

Interesting courses also included Safer Sedation and Analgesia for Office Based Surgery, Optimizing Outcomes in Breast Augmentation as well as Revision of Breast Augmentation Mastopexy and Augmentation Mastopexy.

Dr. Linder also had the opportunity with his family to tour the White House, Capitol Hill as well as many of the fascinating monuments throughout the Washington, D.C. area.  This was an excellent informative, educational and entertaining meeting.

breastimplantlasvegas.com

Breastimplantlasvegas.com will be launched in the very near future.  This site has been developed in order to educate patients with breast augmentation surgery in general.  We go through all the specifics and facts of breast augmentation surgery, including the history of breast augmentation, the chemical composition of silicone itself, the postoperative care and management of breast augmented patients, identification cards from your breast implant surgery, as well as postoperative recovery time.

With respect to saline implants, great detail is given as to the surgical technique and candidates for saline versus silicone gel implants.  With silicone implants themselves, the 7-year complication rate for primary versus secondary augmentation patients is given, courtesy of Natrelle Collections.  Placement of implants as well as implant shapes, including high profile moderate plus and moderate profile implants, are described in detail, including examples of before and after photographs.  Breast deformities are also described, including breast asymmetry, tubular breast deformity, pectus carinatum and pectus excavatum.  Photograph examples are also given. 

Finally, breast implant revision, which is a large component of Dr. Linder’s practice, is described with respect to breast asymmetry, capsular contracture, ruptured implants, double-bubble breast deformity, cleavage, both primary as well as revision, implant malposition, severe bottoming out, volume revisions, anatomically shaped implants, symmastia, implant explantation and scarring on the breast mound itself.  You may also refer to breastrevisionsurgeon.com and lasvegasbreastrevision.com  for more details on breast revision surgery.

Again, the main purpose of this site is to become an encyclopedia of wealth of information to educate women throughout the world, as well as Beverly Hills and Las Vegas, Nevada on breast augmentation and breast revision surgery itself.  I hope you find this very useful.