Looking for professional opinion

[daniellee]

Hello All,
As the title suggests, I'm looking for a professional opinion specifically regarding my case of Gynecomastia - and whether or not I have received adequate feedback and operation/procedure proposal.

[Background]
I understand that it's important to understand the background of my case in order to properly provide advice around this, so below I have detailed some of the key underlying factors of my Gynecomastia.
Pubertal Gynecomastia - Growing up in my early teens I had a fair bit of baby fat still, I was often bothered by the appearance of my chest however was too young to really care/do anything about it - let alone know that I may have had a condition.
Once I hit highschool (14-17 yrs old) my spirits were high since I started working out and began to see changes in my figure (Even though the puffy nipples remained) it was nothing that I could not deal with.
Anabolic Abuse - Once I had reached 18 years old, I was beginning to realize that the puffy nipples were not subsiding.
Being surrounded alot of people who were slightly older than I was - all of whom were heavily abusing anabolic steroids without any visible side-effects, led me to believe that if I was to use performance enhancing substances that it may fix my "puffy nipple" problem.
It did...for a while, I was taking a cocktail of substances throughout a 3 year period and I cannot regret this more.
From basic Testosterone to Trembolone to Deca Durabolin..
Eventually it all went south and I noticed that my nipples where getting EVEN WORSE.
Which has led me here, I have not used anything since 2011/12 - my hormones are in-balance yet I'm left with the fruits of my mistakes.

[Initial Consultation]
After finally coming to grips with the fact that I am going to require surgery in order to truly rid me of this problem, I did my research on who may be the best surgeon to help me achieve my goal.
However, being in Australia, I am heavily disadvantaged due to the lack of Gynecomastia specialists.
The main reason for this post is the fact that I have some questions that I want to get feedback on from other professionals in the industry in order to gauge my preferred Surgeon.
[Questions]

• Upon meeting with my preferred surgeon (Highly qualified), he stated that the procedure would be straight forward and drew out where he would remove the glandular tissue from (Around the areola) - I told him that I was concerned that the glandular tissue had developed much further than the surrounding of my areola, and it seemed like he had not seen that before.
• I was also concerned (kind of related to the above) that the surgeon did not bring up the question of an Ultrasound in order to determine and plan the best excision of glandular tissue, maybe he just wants to wait to see if for himself?
• If the glandular tissue HAS developed in higher places such as : (Upper chest, Upper armpit) Is he going to be able to cut this out when the excision is all the way down in the areola?
• The most concerning thing that the surgeon said when detailing the procedure, was the fact that he mentioned something about cutting a ligament on the bottom of my chest to prevent skin folding, As far as I know - males do not have a (Coopers Ligament) so I'm not sure what exactly he is talking about... whatever it is, it sounds like a dangerous thing, as it could only promote further loose/lax sagging and potentially eve lower aerola positioning.... Do any of the surgeons reading this ever use this practice? IE : Cutting some form of flap/ligament inside/under chest line?

I've attached some image/links in order to show you my current build/condition. (Nipples are alot more puffier when not stimulated/cold)

Front View

Side View

Glandular Tissue Guesstimate

[George Pope, M.D.]

It's hard to assess the degree of gynecomastia that you have with these photos.  In the first 2 your are pulling your shoulders way back. This is probably in an attempt to minimize the gynecomastia appearance - perhaps a habit.  But if you DO have glandular tissue, it is probably not a lot.  
I am not sure what the surgeon is referring to when describing cutting a ligament.  There's nothing like that in the male chest.  And in most cases the breast tissue is easily accessible through the nipple areola incision.  Accessory breast tissue in the armpit of a male is very rare - when found in females, an incision in the armpit or axilla is usually required for excision.
Dr. Pope, MD

[Dr. Elliot Jacobs]

You have very mild gynecomastia.  Suggest you consult with a gyne expert in your area if at all possible.  There is no need for an ultrasound -- the extent of the tissue will be determined once the surgeon has begun the operation.  And the talk about cutting Cooper's ligaments makes no sense whatsoever.

May I suggest consulting Dr Guy Watts at drguywatts@gmail.com.  I trained him in gynecomastia surgery in New York and he is now in Australia.

Good luck!

Dr Jacobs

[DrPensler]

You have mild gynecomastia.It would help to re do the side photos with the shoulders in normal position as opposed to a 45 degree view with the shoulders back.

[daniellee]

Hello everyone for your valuable feedback, I have a few updates so I will provide the information and requested images below in hopes of receiving additional helpful opinions.
[Update on Procedure (Proposed)] Coopers Ligament
Okay, so I had a chance to meet with my potential surgeon today, with the hopes of understanding what he meant regarding the "Coopers Ligament/Skin Flap"
I'd just like to say that I have yet to doubt my surgeon, I just want to make sure everything sounds rite.
When asking my surgeon about what he meant when he said cutting the "skin flap" underneath my chest/breast - He went into greater detail revealing the true name of that area:

Inframammary fold/crease - This is what he proposed to cut in order to give any excess skin more room to span out (To prevent skin folding/loose skin)
My whole reason for being concerned about this (even before I knew he was talking about the IMF) was that I am still young, and even though I may have mild gyno, surely cutting the IMF would result in a allover "lower" hanging chest line (something I do not want).
I asked the surgeon if he can NOT touch the IMF because I plan to get back into training weight lifting once I recover from my operation.
He had a think about it - and then agreed that he thinks my skin should tighten again so there would be no need to touch the IMF unless I was unhappy with the results.

[Ultrasound]
After consulting my surgeon about my concern that I may have developed breast tissue in the higher chest region (I could be mistaking these granular consistencies for my Lymph nodes) - My surgeon replied that even if an ultrasound did reveal small scattered amounts of breast tissue in the higher chest region - It would probably be best to leave them alone and not create further scarring/skin stretch as it would be harder to get to from the areola and would probably do more harm then good.

Below is a few more photos to go along with this information.
I really want to trust my surgeon because he seems like a very genuine guy - I'm just concerned about the fact that he 'did' intend to cut the IMF in order to let the skin span out more - until I asked him specifically not to.
Does anyone think that I am a candidate for IMF excision/tampering (Don't know the correct procedural name) - If I only take out the breast tissue and do not touch the IMF, would muscle growth fill up any excess skin?

Link to new Photos
Photo Album  - 45 Degree/front etc

[daniellee]

Okay, 
So I've heard back from one doctor/surgeon - who insists that IMF incision should only be done in extreme cases of Gynecomastia.
An according to my previous photos uploaded, I only have very mild Gynecomastia. 
I requested to my surgeon that he DOES NOT conduct IMF incision - any only to do Liposuction + Gland excision...
However the fact that he intended to do IMF incision in the first place has me concerned.
Looking at my photos in the last post, does anyone think that I would be an IMF incision candidate?

[daniellee]

So far only Doctor Elliot Jacobs has been able to answer my question realting to the IMF incision when dealing with mild cases of Gynecomastia. 
This whole issue/question has risen from the fact that my initial consulation with a surgeon in Sydney Australia had full plans to create an internal incision in my IMF to "Let the skin spread out more" which to me sounds like a really bad idea for a young person - I fear my surgeon has only dealt with older patients who will no tbe too phased by having their IMF loosened - For me that is the exact opposite of what I was looking for. 
To top it off, I asked the surgeon if he had any concerns about potential breast tissue that may have developed higher up on my chest - He replied by saying even if there was tissue up there it would be better to leave it in order to prevent even more excess skin. 
If I was not weary enough as it is - I forgot to ask the surgeon if he shows the tissue that he extracts to patients for a psychological closure purpose, Not wanting to spend another 300 just to ask that one question, I hoped that one of the staff would know and could tell me or ask the surgeon for me over the phone... The staff acted if I had just asked them some bizarre question and were overall very rude about it - nor did they even know the answer to that question. (Strange when they even go to operations I was told).
Between inconsistencies like this and the attitude of the staff, I'm going for a second opinion.
Can any more surgeons please give me advice on whether or not I am a candidate for IMF incision (my photo's are above).
My biggest fear is that IMF incision will give me an overall saggy looking chest - I'd rather not get IMF incision and just build up muscle and good fats to fill out any excess skin.

[Dr. Elliot Jacobs]

Daniellee

With all due respect to you, there are times when too much information for a lay patient without medical and surgical knowledge as a background is a dangerous thing.  While a well informed patient is terrific, sometimes delving into the intricacies of a proposed operation and trying to tell the surgeon what to do and not to do can actually be harmful in the long run.

For example, the discussion re IMF incision, in which you solicited my opinion.  In your case, an EXTERNAL IMF incision is absolutely not needed.  However, if the surgeon were to release the IMF internally (through a peri-areolar incision) to allow the skin to tighten, that might be helpful.  In fact, I do this many times in order to allow any excess skin to re-distribute.  The technique works very well.

Moral:  speak to your surgeon and attempt to understand what he wants to do.  There is a fine line between inquiring and understanding the surgical plan -- discussing the pros and cons with the surgeon -- and actually telling the surgeon what to do.  Your best job would be to find a surgeon with enough experience in gyne surgery -- and then trust him/her to do the best job for you.

Dr Jacobs

[DrPensler]

I cannot see a reason for an IMF incision.

[daniellee]

@Dr. Elliot
Hello Doctor Elliot, I understand where you are coming from regarding an over-informed patient and that the trust should be with the doctor who is proposing the operation - However, I was not blatantly stepping out saying "Hey I think this guy is wrong", I do believe multiple factors led me to the conclusion that the surgeon who proposed this method was accustomed to working on older gentlemen or males with more severe cases of gynecomastia in which IMF incision (Internal) would be suited.
I've since chosen NOT to use this surgeon as I'm very disapointed in their service.
@DrPensler
Thank you Dr. Pensler, I appreciate your statement - However limited my understanding of cosmetic anatomy may be, there were obvious red flags - even some that I had the decency not to mention. 
I've since found a new surgeon and will be seeing them soon to have an evaluation.

Many thanks to everyone who contributed insight into this.

[daniellee]

I'd just like to say that I've since found another surgeon/professionial in Sydney NSW. 
I am going to go with this surgeon and am going to document the whole process before and after.
One of the key deciders for me was the fact that the surgeon was not put off by my own interest in the medical procedures, specifically the non-sense with cutting open my IMF from the inside (Which would have given me 50 year old pecs). 
Be careful out here guys! Just because a doctors got a good reputation online does not mean they are the best doctor for you ~ 
I'm speaking only about Australia (I don't know enough about the other surgeons so I would not act like I do).

[Dr. Schuster]

Just a couple of things to add to the comments made by the other surgeons.

The ultrasound the doc was speaking about may have been the use of Ultrasonic Assisted Liposuction. I use it routinely and I believe that it help break down a good portion (but not all) of the breast and fatty tissue as well as perhaps causing some slight skin shrinkage. This has help enable me to perform the Lateral Pull Through technique using a single small lateral incision successfully for the majority of my patients over the past ten years.
Also, the "ligaments" the doc was speaking about may have to do with the fibrous attachment of the IMF to the chest. While this is not a true ligament, in certain patients I will detach the IMF to allow it to slid downward just a small amount. I thionk this can help re-distribute the lower breast skin a little.