How to choose a gynecomastia surgeon
Well, obviously you want to find a surgeon who is very experienced in gynecomastia surgery. That should obvious on the surgeon’s website. Both in their description in their approach to and philosophy about the treatment of gynecomastia and from the before and after photos displayed on the website. You also want to find a surgeon who is truly passionate about treating gynecomastia. If you needed a heart valve replacement, you wouldn’t seek out a surgeon who did one or two heart valve surgeries a month, and certainly not a year. You would want to find a surgeon who does heart valve surgery week in, week out every month of every year. Likewise with gynecomastia surgery. It’s not a life threatening problem, but it is a very significant aesthetic issue and you want to entrust your care with someone who is proficient in all surgical techniques. Gynecomastia treatment is one of the most fulfilling and important parts of my practice. It creates a positive change in patient’s lives. Both in their outward social lives and in their inward intimate lives. Also, gynecomastia surgery is the one surgery that I do for adolescent patients. Young boys with breast development can be treated harshly and cruelly in the locker room and elsewhere. It makes such a huge impact in the life of that child, and a family as a whole, to have it corrected.
Placement of surgical incisions in gynecomastia surgery
Most patients with mixed gynecomastia can be treated through surgical incisions that result in scars that are either barely perceptible or, ideally, invisible. One excellent location for gynecomastia incisions is the inferior boarder of the areola. The color difference between areolar skin and the surrounding chest skin nicely conceals the healed incision. I place a small incision less, than a centimeter in length, at about the 4 o’clock and 8 o’clock position of the areola. Another excellent location of a surgical incision and invisible surgical scar is the hair bearing skin at the inferior portion of the underarm area. The liposuction instruments can be introduced through all three of these incision sites and the arthroscopy shaver is generally introduced through the underarm incision area. Patients with hairy chests can be treated through additional incisions that are usually invisible. But, patients with little to no chest hair should always be treated through these limited incision sites: the boarder of the areola and the underarm area. Look at lots of before and after pictures when you see a surgeon and you will get a clear idea of what that surgeon considers to be acceptable scars. Surgeons who are experienced with and proficient with gynecomastia surgery always place the incisions so that the resulting surgical scars are difficult to see.
What is the best form of gynecomastia surgery?
Well, most adult male patients with gynecomastia have, what we refer to as, mixed gynecomastia. This means a combination of excess fatty tissue peripherally around the breast and centrally behind the areola, a fibrous mass of firm breast tissue. In the vast majority of patients, mixed gynecomastia is treated with a combination of liposuction and then excision of the fibrous mass of breast tissue following liposuction. In my practice, I used power-assisted liposuction using both flared and non-flared cannulas for initial fat reduction. The excision of the fibrous mass of tissue behind the areola can be accomplished two ways. One is by a direct excision through an incision of the inferior boarder of the areola. The second means, which I have transitioned to in my practice, is the use of an arthroscopy shaver to remove breast tissue without an incision at the areolar boarder. However the surgery is accomplished, I strongly feel that gynecomastia should focus on two primary concepts. First, is limiting the surgical incisions and the resulting surgical scars that are used to perform the procedure. The second is respecting the fact that skin laxity can limit the amount of breast tissue and fatty tissue that can be removed in a single surgery. No one with gynecomastia wants to trade the appearance of having excess breast tissue for the appearance of having ugly surgical scars, or for the appearance of having saggy skin that looks like surgery gone wrong. Either way, you still won’t want to take your shirt off at the pool. Make sure that surgeon you select can discuss both of these details with you: 1) the surgical scars and what they will look like 2) the issue of skin excess and whether or not that means the gynecomastia can be removed in a single procedure or whether it should be removed in staged procedures scheduled several months apart.
Can unfavorable results from gynecomastia surgery be corrected?
The good news is that most problems can be at least improved, if not completely corrected. But you need to do your homework and make sure that you see a surgeon that is experienced with the treatment of gynecomastia in general, and specifically, very experienced in the treatment of post-surgical problems following gynecomastia surgery. The problems that patients may have following gynecomastia surgery include: unfavorable scaring, generalized contour abnormalities in the prepectoral area and localized contour abnormalities in the areolar area. The approach that is used depends on each patient’s individual problems. Scar revision is relatively straight forward in many cases but is really only half the battle. The other half of the battle is the intensive and long-term treatment of scars while they are maturing and healing. In my practice we use topical silicone gel agents, topical adhesive silicone patches, a vascular laser to treat the inflammatory phase of wound healing and in some cases, if necessary, steroid injection of scars that demonstrate early thickening or widening. Contour abnormalities in the general prepectoral area are usually the result of over resection of fat by liposuction or under resection of fat by liposuction. Areas that have been over resected can be treated by fat grafting. Areas that have been under resected are treated by additional liposuction. The contour abnormalities in the localized areolar area are generally related to under removal or over removal of the fibrous breast tissue immediately behind the areola. Under removal, is of course, treated by additional removal of fibrous breast tissue. While, over removal is treated by fat grafting – most commonly in the form of solid dermal fat grafts that can fill the space and restore a normal contour in the sub-areolar area. The most important thing to do is to find a surgeon who can show you lots of before and after photographs. You also want a surgeon who not only has a surgical plan for your treatment, but also a comprehensive post-surgical plan for your care in the months and years following your treatment. You also need to find a surgeon who is very upfront with you about the fact that more than one surgery may be required to produce the correction that you’re looking for. The surgeon should also provide you a cost preoperatively for each potential stage, per treatment.
Are puffy nipples considered gynecomastia, and what is the best form of treatment?
The term ‘puffy nipples’ refers to what we call pure glandular gynecomastia. Meaning, there is an excess of breast tissue directly behind the areola without a proliferation of fatty tissue, making the entire chest area look full and feminized. Puffy nipples would probably be better referred to as puffy areolas, because it really is the entire areola that is somewhat conical or convex in shape. It projects outward from the chest and calls attention to itself. Puffy nipples are best treated by surgical incision by scars or incisions placed right at the boarder of the areola. One can make a fairly long curvilinear boarder incision along the bottom of the areola and directly excise the entire mass. Or, one can make limited incisions on either side and use what is called the ‘pull-through’ technique, which is essentially a piecemeal excision of the excess tissue. Treatment of puffy nipples really is a just right surgery. One needs to remove just enough tissue to create a cosmetic improvement and eliminate an appearance of puffy nipples. But, not so much tissue that you leave a concave or conical, or even scared appearance to the areolar surface. I prefer to use a technique that involves small incisions on either side of the areola, through which, a piecemeal excision of the tissue excess is performed. I think this leaves smaller, fainter scars, a more normal appearance and has a much lower likelihood of scar retraction, which can be obvious and disfiguring. Make sure that you see a surgeon who is board-certified and who is experienced in the treatment of puffy nipples and can show you several examples of before and after photos of patients with this problem.
What is the best surgical approach to the treatment of gynecomastia?
Most male patients with gynecomastia surgery have what we refer to as mixed gynecomastia. We say mixed because it involves both excess of fat and excess of breast tissue. The amount of breast tissue excess can be variable, as can, the amount of fatty tissue excess. But because there are two different issues going on, a multimodality treatment is important to affect an aesthetically ideal cosmetic improvement. The three step approach to gynecomastia reduction involves: liposuction, followed by fibrous tissue removal, followed by direct excision of a small amount of fibrous tissue on the backside of the areola. First, liposuction is performed using metal cannulas. Some of which are flared and some of which are not flared. The flared cannulas are used initially with the aspirator, or suction device, turned off. The flared cannulas are very effective at breaking up fatty tissue prior to removal by aspiration or suction. Once the excess fatty tissue is adequately mobilized, a non-flared cannula is put on the electric hand piece that pistons the end of the cannula back and forth a few millimeters to enhance the efficiency of fat removal. Fat is removed using the non-flared cannula and the patient is then evaluated in the upright sitting position under general anesthesia to ensure that the fat removal is smooth and aesthetically ideal. Once fat reduction has been accomplished, the second stage is removal of the fibrous tissue. This is accomplished using an arthroscopy shaver. An arthroscopy shaver is a hollow tube that has a device on the interior that chews up fibrous tissue that cannot be removed using a liposuction cannula. This device is somewhat more aggressive than a liposuction cannula. The shaver is used to remove the firm fibrous breast tissue directly behind the areola. Once this is completed, the patient is again brought into upright sitting position and the reduction effect is assessed to make sure that it is smooth and symmetrical. Lastly, at the end of the procedure, through small incisions made on either side of the areola, a very small amount of breast tissue is removed from the posterior surface of the areola to eliminate that little bit of conical shape, or excess projection of the areola itself. This stepwise excision of breast tissue and excess fatty tissue is the best means to accomplish a smooth and aesthetically ideal gynecomastia reduction.
What is the Ideal Approach to Gynecomastia Surgery?
What is the best approach to gynecomastia surgery? Well the approach that is taken varies with a patients starting point. Some patients need just a small mass of breast tissue removed right behind the areola. More commonly patients have a proliferation of fatty tissue along with the breast tissue and that requires liposuction as well. Regardless of the actual surgery that’s required my focus in treating gynecomastia patients is to, as much as possible, avoid the surgical scars that may leave the surgical patient to be just as self-conscience as they have been about their breast volume.