Feedback regarding consultation for liposuction (post gynecomastia)

[vhiller]

Dear Doctors,
 
I recently had a consultation with a board certified plastic surgeon in New York City who is the director of plastic surgery at a reputable hospital on the upper east side. I spent an hour with him discussing my situation, undergoing an examination, and his describing what he could to rectify my concerns. He performs about one gynecomastia surgery per month.

I developed moderate gynecomastia during puberty and had it removed when I was 22, which was in 1989. I'm now 43. I've never been completely satisfied with my results. My plastic surgeon (in NJ) removed both glands and accompanying breast tissue however he did not perform liposuction, which resulted in remaining fat deposits and a chest contouring that appeared feminine despite my normal body weight. Twenty years later I am finding that these fat deposits have increased, and that is normal given my age and weight. I continue to be dissatisfied with my chest and never remove my shirt around other people. It's the contouring/shape rather than the size of my chest which is the source of my anxiety and dissatisfaction.

The NYC surgeon asked a series of good questions about my expectations. He said that my NJ surgeon did an excellent job, which I was pleased to hear. He also said that he could not comment on why my NJ surgeon chose not to do liposuction. He (NY surgeon) suggested doing ultrasonic liposuction to correct the excess fat and scar tissue. He explained that he would have to enter from the sides, possibly two points of entry on each side, rather than the nipples since the previous surgeon did such a good job of concealing the incisions but more importantly, because he could feel scar tissue under both nipples and was concerned about the complications that could arise from opening up the existing incisions. I'm not terribly concerned with incision marks after this procedure since I am quite hirsute and therefore my chest hair will most likely cover the external incisions.
 
Logistically speaking, the procedure should take no more than two hours, I would be under a general anesthesia, and that I would wear a compression garment (again, something that I was not required to wear after the gynecomastia excision) for at least thirty days after the procedure. Given my age, physical activity, normal weight and general health, he felt that I would be a good candidate.
 
I walked away from the consultation feeling that this surgeon accurately described my situation, that he heard me, and that he was clear that the liposuction would be purely cosmetic and not medically necessary. His staff was easy to work with and his fee is within the average range for upper east physicians who perform gynecomastia and related surgeries.
 
Given this, here are my questions:
 
1) Looking back to my 1989 surgery, when I was 22, was it normal for a surgeon to not perform liposuction in addition to removing the glands? Should I have worn a compression garment instead of an ace bandage?
 
2) Based on what I've told you about my recent consultation with the NYC plastic surgeon, are there any questions that I should be asking? Do you question the procedure (ultrasonic liposuction) that this physician has recommended?
 
3) I've taken Klonopin (2 mg. per day) for anxiety disorder for the past fifteen years. I raised this with the plastic surgeon and he seemed to think that given my overall health there should be no complications with the anesthesia or surgery. Has this been your experience with your patients.

Thanks in advance for addressing or commenting on any or all of my questions. I will appreciate your response.

[Litlriki]

Thanks for providing a detailed description of your history and your recent consultation.  It sounds like you've gotten accurate information and that you have a good plan.  Conventional liposuction, Ultrasonic assisted liposuction, or the newer laser-assisted modalities are all reasonable options for your situation based on your description.  Revisions or situations where extra skin tightening is desired may be indications for UAL or a laser-assisted procedure, though some of the benefit may be more theoretical than actual. 

Regarding the historical question of no liposuction in 1989, I'm afraid that I would have to defer to one of my more senior colleagues to know what was "standard" at that point.  During my training (1990 to 1992), I didn't see a lot of gynecomastia surgery, and I don't recall that liposuction was a standard tool in the procedure.  Indeed, during my early experience, I used liposuction for many or most of my procedures, but not all of them, and I recall a patient in whom I only used excision, who would have had a much better result with the techniques I use currently.  Within a short time, however, liposuction along with excision were standard in my practice.

As for the Klonopin, I don't think that should be an issue.  Just inform your anesthesia personnel of your medication use, and they should advise you further.

I hope that's helpful.

Good luck,

Rick Silverman