Doctors - help please

[Monkeymonk2011]

Hello there,

Seeking any advice please to help settle my mind. Have undergone liposculpture surgery on my chest approximately 7 months ago, and have never been 100% with my results. Ultimately my main issue is still having puffy nipples. Visited the doctor after 6 months for my follow up and expressed exactly how they still are worrying me and are very prominent, however much to my disappointment the conversation ended with no further work to be done this was put very strongly that he would not do any further work, with the reasons being risk of severe scarring around the nipple, possible indented nipples and the end result looking 'not right' - I was told that i could be so unhappy they might have to insert body fat from other areas and put it back into this area. The decision was for a second opinion to be made after my distress - this was just as unsuccessful being told pretty much exactly the same information. I mentioned about gland removal, and how I'd very much be willing to undergo this procedure to create a 'normal' chest for myself. But similarly to the first doctor, the risk of scars, sagging skin of the nipple that will flop and not retract - I was willing for any of these risks (silly as it sounds) but I'm desperate to live normally now and not be conscious of of my nipples, finally after the conversation a 3rd opinion has been made this was difficult to achieve and was reluctant to be made initially. My vital question is will i receive the same information, is it true any removal of whats behind the nipple will create nasty effects? I believe its the miracle cure, but have been told differently. I pray the 3rd doctor will be my dream come true, but hesitant as i don't see him going against the word of the first 2 and taking up such cosmetic work as part of revision surgery. Is it true what other doctors have said, should i settle for a life with puffy nipples? Please please any information will be highly appreciated.

[Dr. Elliot Jacobs]

Tough problem -- but why not wait until after the 3rd opinion? -- you may be surprised.

Recommend you not speak, at least initially, about the two prior opinions.  That way you can get an impartial opinion from the 3rd doc.

Please bear one thing in mind - revision gyne surgery is demanding and technically difficult.  Many surgeons who do not do this surgery very often will take the "safe" route by recommending no surgery.  Would recommend you consult a gyne specialist surgeon for your third opinion.

Best of luck.

Dr Jacobs

[DrBermant]

Hello there,

Seeking any advice please to help settle my mind. Have undergone liposculpture surgery on my chest approximately 13 months ago, and have never been 100% with my results. Ultimately my main issue is still having puffy nipples. Visited the doctor after 6 months for my follow up and expressed exactly how they still are worrying me and are very prominent, however much to my disappointment the conversation ended with no further work to be done this was put very strongly that he would not do any further work, with the reasons being risk of severe scarring around the nipple, possible indented nipples and the end result looking 'not right' - I was told that i could be so unhappy they might have to insert body fat from other areas and put it back into this area. The decision was for a second opinion to be made after my distress - this was just as unsuccessful being told pretty much exactely the same information. I mentioned about gland removal, and how i'd very much be willing to undergo this procedure to create a 'normal' chest for myself. But similarly to the first doctor, the risk of scars, sagging skin of the nipple that will flop and not retract - I was willing for any of these risks (silly as it sounds) but im desperate to live normally now and not be conscious of of my nipples, finally after the conversation a 3rd opinion has been made this was difficult to achieve and was reluctant to be made initially. My vital question is will i receieve the same information, is it true any removal of whats behind the nipple will create nasty effects? I believe its the miracle cure, but have been told differentely. I pray the 3rd doctor will be my dream come true, but hesistant as i dont see him going against the word of the first 2 and taking up such cosmetic work as part of revision surgery. Is it true what other doctors have said, should i settle for a life with puffy nipples? Please please any information will be highly appreciated.

I see many patients with residual Puffy Nipple Deformity Complication after surgery done by other surgeons, I coined the name and wrote a web page condensing my findings to help teach about this problem and some of the causes I have seen. Check this thread in this forum to see an introduction and resources to see how I manage such deformities:

https://www.gynecomastia.org/smf/index.php?topic=22009.msg148398;topicseen#msg148398

Options for treatment actually depend on the specific problem. Fixing this problem is quite demanding, especially if you are trying to make it look good during motion, flexing, and living life. The solution should be dynamic. A doctor's skills in managing this problem should be investigated looking for before and after pictures and videos to see beyond the talk, just what this doctor's artistic skills look like.

During my evaluation, I prefer to define just what the original problem was, what degree of stability of the gynecomastia, what was done, and what the patient has learned so far about treatment options. To achieve the results seen on my web pages, I feel the patient education has been a critical component. It becomes easier having a patient with a high degree of basic understanding about such issues before starting the consultation. That is why I have build such an extensive website and resources. That way patients can become familiar with the issues before even starting a consultation.

If you are going into another consultation with a surgeon who you could not find much about how they did their work before setting up the consult, you are again gambling for what you will encounter.

Hope this helps,

Michael Bermant, M.D.
Board Certified
American Board of Plastic Surgery
Member: American Society of Plastic Surgeons and American Society of Aesthetic Plastic Surgeons
Specializing in Gynecomastia and Surgical Sculpture of the Male Chest
(804) 748-7737

[Litlriki]

Drs. Jacobs and Bermant have covered most of the basics.  The question I have after reading your post is whether or not you're getting independent opinions (your 2nd and 3rd opinions) or if these are surgeons in the same practice, who would obviously have the information about your surgery and the opinion of the previous surgeon available to them.  Similarly, are any of the surgeons especially interested in the care of gynecomastia patients. 

Those of us who deal with this problem frequently often provide care for the mild cases--the "puffy nipple syndrome," which really describes the mildest form of gynecomastia, whereas many plastic surgeons only see more significant cases or only see a case or two of gynecomastia a year. Additionally, puffy nipples are often not apparent in a cold examining room, so even the most aggressive surgeon might be hesitant to operate on a normal looking chest, whereas those of us who deal with this all of the time are used to patients with contracted nipples but a clear history of puffiness. 

Finally, what a surgeon considers normal or acceptable will differ based on his or her experience, and gynecomastia is no exception to this observation.  I am often reminded of a paper that came out in our primary journal discussing ultrasonic liposuction alone for treatment of gynecomastia.  The surgeons involved are very good and reputable, and generally, they had good outcomes.  I was struck, however, by the appearance of one of their patients, whose post-operative photos looked like many of my pre-operative patients, since the nipple remained somewhat prominent after the chest was treated with liposuction alone.  If there is a glandular component to the gynecomastia, this is undoubtedly what will result if the glandular component is not resected.  If a patient describes nipple puffiness during my evaluation, I will invariably excise some portion of the sub-areolar tissue in order to avoid this problem.

Good luck.

Rick Silverman

[Monkeymonk2011]

Thank you very much for the responses much appreciated. All opinions were provided in the same practice - I did not state my separate experiences or advice given to either of the surgeons just expressed my concerns and hoped for some improvement.

I have come back today from my 3rd opinion from a surgeon who's opening speech was 'that he was here on behalf of me and not being behalf of my first surgeon or second' -think this was to make me feel rest assured and meaning if he saw a problem the others didn't that he will cure it (i can only assume). He also hadn't looked at my case file just my chest in the flesh and what exactly was bothering me - he only went on to look into it after to see surgeon's comments along with before and after pictures - hoping this was independent although private talk could have taken place. Regardless of that he was very genuine even with the fact that he'd get paid more to do more but he wouldn't want to risk my appearance, this kind of made me smile.

The doctor took a feel of the breast area and felt no gland tissue, he noticed that the right side was slightly larger than the left however stated perfection cannot always be achieved - and perfect symmetry is near impossible to achieve. He stated my results are very good for liposuction but he also would not do any nipple work due to them becoming 'indented afterwards' or looking 'odd' he was very nice about the situation although I was disappointed (naturally) at the news i felt a little reassured with his advice. I went on to ask is there any other options available for me, he said frankly no and any doctor doing any work would be a little silly especially so early into it he said to wait for the development and recovery of the chest fully.

My advice was to basically wait a year and come back to the clinic, where any hard tissue/scar tissue that may have deposited in the nipple may have subsided by that time and, and to talk my with initial surgeon about my chest. he said to carry on massaging the area and its best to wait a whole year. I'm guessing this is what I'll do for now, I'm looking into a compression vest that may hide them being visible from T-shirts - the more i think about it/nipples the more down i get, i am going to try and keep positive for now ps its not easy though!

[Litlriki]

I'm glad to hear that the last consultant spent some time with you, and his recommendation to wait a little longer isn't unreasonable.  I'm guessing that if you have had persistence of your "puffy nipples" since the original surgery, and that hasn't improved by seven months, the problem will remain at a year.  At that point, I'd encourage you to at least have a consultation with a surgeon who specializes in treatment of gynecomastia.  That will either clarify that you need to have tissue removed from under the areola, or it will put your mind at ease that you don't need to have anything more done.  Going back to see the same surgeons will likely leave you as dissatisfied as you are now.

Good luck,

Rick Silverman

[Monkeymonk2011]

Hello again,

I've become a bit of a frequent message sender in the past couple of months, and feel I should really ease off and possibly deal with my issue rather then getting so caught up on it. I thank all the doctors for all the responses for my posts in the past, all have been fully informative, reassuring and can feel the expertise ooze from every response I read.

Not sure if you'll remember the posts as i know you deal with numerous amounts of people, but I've been extremely unhappy about my chest for 7 years (am now 21), finally decided to do something about it and underwent Lipo surgery - A little naive at the time, did not fully research anything just jumped on the opportunity.

During the time explained my main concerns - breast like appearance, and puffy nipples. Nipple work was deterred by doc, and went for a lipo only route. (Wish i thought twice with hindsight as want gland taken out now, but possibly not this is why I'm posting) anyway, 7 months later the breast like appearance has been diminished and looks relatively normal - although sitting down still kind of breast like. However still have puffy nipples, you may recollect I went for a second and third opinion, the risk of removing any gland was explained and all 3 did not want to touch them - so I settled with the information.

Third time around i was told I didn't have breast gland, What i wanted to ask firstly is :

1: What are the methods for finding this out (amount of breast gland)? - my doc took his palm and went on a circular motion on both breasts and came to a conclusion of no gland

2: I expressed i noticed gland - He stated approx 1-2% which is normal and if removed would leave 'craters'

3: Would taking this small amount be possible? Should i understand the side effects and forget any procedure (it would have to be elsewhere now i.e not same practice or with any of the surgeons seen), i mean I'm still really bothered!

Its tough because I'm now thinking I have some mental issues, my mum thinks I have some mania with regard to it - after 3 opinions with relatively the same information should i just settle my mind? Perfection may only be possible in my mind, and my perception of perfection may be distorted.

I still walk with a bad posture, don't want to wear plain shirts due to nipples poking out and the thought off taking any t-shirt off in front of a girl is killing me - I mean is this now a mental problem?

I paid £3000 for 35cc removed from each side (a small amount of fat I believe?) but the price was a little steep, i don't know if doing gland excision would amount to the same price if not more being applied. Mum starting to think I'm mad, making me think I'm also mad. Its tough, real tough i really dont know what to do...

Please at least answer the 3 points above (If necessary I will include pictures to better understand everything) I kind of feel I'm losing the plot with it all... I mean i tried tightening a belt on them for a period of time, pressing them in real real hard with my fingers hoping it would stay like that! Crazy as it sounds, ahh my lordy

[Litlriki]

Posting some photos would be helpful, especially if they capture the image of what you see as problematic. In other words, make sure you're nice and warm and the nipples are as puffy as possible. 

Based on your previous posts and the collective experience of the surgeons on this board in dealing with dissatisfied patients, I'm guessing you're not crazy, and that in fact, you required glandular excision in addition to the liposuction at the time of your original procedure.  It would hardly be surprising that the surgeons who are looking at you now see your current state as so mild that it doesn't warrant further treatment.  But frequently that's the result of the nipples being contracted during your visit, and palpation is not very productive when the condition is mild--it's really something that must be visualized.  Sometimes, however, the ambient temperature in the office prevents the puffiness from being readily apparent, so your surgeon and his colleagues may not be able to see what you see. 

Presuming that you do still have a glandular component, that can be addressed, but you should definitely have it done by someone experienced in caring for this mild form of gynecomastia, otherwise you might end up with "craters" or worse.

Please post some pictures.

Rick Silverman