Gynecomastia surgery with skin excision

[Ohno23]

(I posted a topic with more pics weeks ago but it seems to be stuck in approval ... hopefully this one works.)

I have gynecomastia and loose skin from losing around 90lbs almost a decade ago (I'm 25 now). I've visited three surgeons for gynecomastia surgery who have all told me I also need some kind of skin removal, but each surgeon had different approaches:

- One wants to do a double incision (long horizontal scars) with free nipple graft.
- One wants to do a double incision using the pedicle technique (nipple stays attached). I would prefer this over FNG if I had to choose.
- One wants to do a donut lift (skin removed around nipple in a donut shape). They also told me my particular case will have a higher chance of needing a revision.

Obviously, I want the least scarring possible. Double incision would give me the worst possible scars, which leans me towards periareolar/donut incision which only scars around the areolar. But if I'm not suited for it, the complications (areolar/scar stretching, remaining loose skin) could end up looking just as bad if not worse. It just seems like double incision techniques are reserved for the worst cases -- is mine really that bad? What do you think?

[Ohno23]

More pics

[Ohno23]

A few more .. I have more than this but I'll stop here unless you think others will be helpful.

[Miguel Delgado MD]

All options are reasonable. However, the best option for you is the minimal incision technique or a 2 stage procedure.  Therefore, in my hands, I would select a fourth option based on your requirements.  I would do a standard gland excision and heating the skin underneath for additional skin contraction and let it heal for 4-6 months.  This may be all that is required. If there is lax skin at this time, then do a peri-areolar skin excision for additional tightening.  I would not do a double incision unless the scar were not a big issue for you or you want a quick solution.  Good luck.

[Ohno23]

Thanks. To be clear, while I prefer minimal scarring, I wouldn't want it at the expense of an obviously worse chest. So my goals are:

1. Flat/tight-ish chest. It doesn't need to be perfect because the skin on the rest of my body isn't either (though it retracted much better than my chest), I just don't want any sag/obvious laxity.
2. Correctly positioned nipples. For my worst side, it seems like it needs to sit at least 3cm higher than where it is now. Is that achievable?
3. 10-20% reduction in areolar size. From what I've read, I basically get this for free after the gland is removed. It comes down to whether or not the surrounding incisions will end up stretching it out.

I guess a lot of this is hard for you to answer from photos alone. It seems like I'm a borderline case and my biggest worry is that if I need skin excision I may regret not just going with the double incision for more guaranteed results. I know that other doctors here like Dr. Jacobs prefer not to use the donut/periareolar incision, so I'd also be interested to hear their thoughts.

[Miguel Delgado MD]

Based on the recent criteria I believe that a free-nipple is best.

[Dr. Elliot Jacobs]

The 900 lb gorilla in the room is your prior overweight condition, which has effectively diminished the ability of your skin to self-tighten.  In addition, one side is decidedly more droopy than the other.  While your goal of minimal scars is admirable and understandable, I believe the best option for a tight, contoured chest would be a double incision with free nipple graft.  Yes, there would be more scars -- initially.  But in time, they will fade substantially.

A double incision will enable the surgeon to make the areolas as small as you desire, place them in a symmetric and appropriate position, and provide taut skin so that your underlying muscle contour will be visible.

The other options, though tempting, cannot provide the above results in one operation -- and perhaps not in more than one operation.

Tough case -- sorry there are no easy answers.

Good luck in your choice.

Dr Jacobs

[Ohno23]

Thank you. With now only 1/5 surgeons in favor of it it's probably safe to write off the donut lift.

I have one last question: Is there a reason why both of you prefer a free-nipple graft over the pedicle method? My understanding is that there's much less risk of complications like nipple loss, pigmentation changes, etc while still allowing for repositioning/resizing, though it may not be able to achieve the flattest possible chest (unsure to what extent).

[Dr. Elliot Jacobs]

Yes, you can use a pedicle method -- but a pedicle has to have sufficient tissue bulk to provide blood supply to the nipple.  The added bulk will be detrimental to a nice, smooth, muscular contour that one can achieve with a double incision operation.  And a pedicle operation will still result in horizontal scars plus scars around the areola -- the same as a double incision.

If it were me, I would opt for the double incision.

Dr Jacobs

[Dr. Schuster]

There are several different procedures for correction of gynecomastia when there is skin excess. The ones you list are certainly the most common. I do not perform the pedicle flap procedure because I think i leaves to much bulk beneath the skin which ultimately leaves too much puffiness. In addition there are some pedicle flap procedures that resul in a vertical scar. I would certainly avoid these. The peri areolar skin reduction is very good for minor amounts of skin removal. I think you have too much skin for tis technique. I would favor the nipple graft technique in your case. It will leave you with the tightest result. The trade off is the horizontal scar along the inframammary crease which generally heals very well. The nipple graft itself usually heals fine.