post-op questions

[kjd]

Hi,


I'm 36, 6'1'', 215 lbs and had gyno surgery on Nov. 3rd (before and after pictures attached). I had extremely puffy nipples pre-surgery. My surgeon performed lipo (SAFELipo technique) and avulsion (which he described as sucking breast tissue through the lipo cannula provided it is very small amounts). The surgical plan was lipo first and then avulsion or excision (if necessary). I got the sense from my surgeon that he doesn't like to perform excision unless he thinks it's absolutely necessary at the time of surgery given the additional incisions and risks related to the nipple with excision. But I assumed it would be necessary in my case given that I had extremely puffy nipples and given the information I read on this website. I was initially disappointed when I discovered the surgeon had not performed excision. The surgeon said my case turned out to be mostly fatty tissue, although he did remove some breast tissue via avulsion. Anyway, I have two questions for the experts -- the first related to performing lipo alone to correct puffy nipples and the second related to post-op compression:


1. The consensus by surgeons on this website seems to be that in most cases a combination of lipo and excision is necessary to correct puffy nipples. But are there exceptions to this rule? Are there cases where lipo alone can correct puffy nipples? While I was initially dissapointed when I discovered that my surgeon had not performed excision, I was actually generally pleased when i saw the early results. While my nipples still have a little bit of puffyness, there has been a huge improvement -- and it's still early in the recovery process (the after pictures are only 5 days post-op). Even if the early results are the final results, I think I would be happy with them. So I guess I'm just curious if surgeons on this website have had puffy nipple cases where lipo alone has yielded good results? Wouldn’t also mind knowing if you think my early results look good?


2. My surgeon has advised me to wear a compression vest with two 12 inch by 7 inch by 1/2 inch foam pads under it 24/7 for 6 weeks. Wondering if it will negatively impact my recovery or final results if I wear the vest without the foam pads for nine hours a day while I'm at work? I'd continue to wear the vest with foam pads when I'm not at work. The foam pads are somewhat bulky and I'd prefer not to wear them while at work? I'll have worn the vest with foam pads 24/7 for 2 weeks before I have to return to work. Do the surgeons on this website see any concerns with wearing the vest without foam pads while I'm at work?


I look forward to your feedback.

[Dr. Elliot Jacobs]

Congrats on your surgery -- hope it heals well.

It has been my experience that pre-op puffy nipples virtually always mandates an open excision and direct removal under vision.  While I do have a number of very sharp instruments in my operating room, they frequently are inadequate to remove the excess tissue in a smooth, uniform manner.

Your initial results seem to indicate some residual puffiness.  Indeed, as the weeks go by and the surrounding swelling diminishes, you may find that the puffiness returns and mimicks your pre-op condition.  Let's hope that this isn't the case with you.

As for the use of foam, it is at the discretion of your surgeon.  I never use foam -- just a snug UnderArmour plus a really tight compression binder.

Dr Jacobs

[kjd]

Hi,

Thank you for your reply. Just have two quick follow up questions:

1. You indicated that my nipples may return to their pre-op puffyness once the surrounting swelling diminishes. Do you think there is a good chance of this happening or is it just a possibility? If there is a good chance, at what point in the recovery process will I know I'm in the clear -- for example, if it doesn't happen by the 6 week mark, is it safe to say that it won't happen at all? I'm about two weeks post-op now (and well I understand it's still quite early in the healing process), if anything, my nipples have gotten flatter. The other thing is that when I press on my nipples there doesn't seem to be any noticeable tissue behind them -- all I seem to feel is breast bone.

2. Given the variety of opinions/practices by surgeons around compression, sounds like I shoud be OK not wearing the foam pads for part of the day, as long as I'm wearing at least the vest. But do you think mixing and matching the level of compression throughout the day could negatively impact my results?

[Dr. Schuster]

In most cases there is a glandular component which cannot be removed without actual excision. WHether or not this is done through a peri-areolar incision or a lateral incision it doesn't change the fact that it needs to be done. Leaving residual glandular tissue in someone who already has puffy nipples means that it is unlikely that the puffy nipples will not be improved. 

Hi,


I'm 36, 6'1'', 215 lbs and had gyno surgery on Nov. 3rd (before and after pictures attached). I had extremely puffy nipples pre-surgery. My surgeon performed lipo (SAFELipo technique) and avulsion (which he described as sucking breast tissue through the lipo cannula provided it is very small amounts). The surgical plan was lipo first and then avulsion or excision (if necessary). I got the sense from my surgeon that he doesn't like to perform excision unless he thinks it's absolutely necessary at the time of surgery given the additional incisions and risks related to the nipple with excision. But I assumed it would be necessary in my case given that I had extremely puffy nipples and given the information I read on this website. I was initially disappointed when I discovered the surgeon had not performed excision. The surgeon said my case turned out to be mostly fatty tissue, although he did remove some breast tissue via avulsion. Anyway, I have two questions for the experts -- the first related to performing lipo alone to correct puffy nipples and the second related to post-op compression:


1. The consensus by surgeons on this website seems to be that in most cases a combination of lipo and excision is necessary to correct puffy nipples. But are there exceptions to this rule? Are there cases where lipo alone can correct puffy nipples? While I was initially dissapointed when I discovered that my surgeon had not performed excision, I was actually generally pleased when i saw the early results. While my nipples still have a little bit of puffyness, there has been a huge improvement -- and it's still early in the recovery process (the after pictures are only 5 days post-op). Even if the early results are the final results, I think I would be happy with them. So I guess I'm just curious if surgeons on this website have had puffy nipple cases where lipo alone has yielded good results? Wouldn’t also mind knowing if you think my early results look good?


2. My surgeon has advised me to wear a compression vest with two 12 inch by 7 inch by 1/2 inch foam pads under it 24/7 for 6 weeks. Wondering if it will negatively impact my recovery or final results if I wear the vest without the foam pads for nine hours a day while I'm at work? I'd continue to wear the vest with foam pads when I'm not at work. The foam pads are somewhat bulky and I'd prefer not to wear them while at work? I'll have worn the vest with foam pads 24/7 for 2 weeks before I have to return to work. Do the surgeons on this website see any concerns with wearing the vest without foam pads while I'm at work?


I look forward to your feedback.

[kjd]

Hi,


Turns out Dr. Jacobs was right. After the swelling went down, the puffy nipples returned. While they seem less puffy than pre-op, they are still puffy and I think the chest contour looks worse than pre-op (see attached pictures taken about 6 months after surgery).


Very frustrated with the outcome. The surgeon was suppose to do excision too, if necessary, but he didn't think it. According to the surgery report, he suctioned 280 cc from each side and "There was a very small amount of breast tissue under the areola, which was avulsed using a Kocher through the our inferolateral incision".


A few questions for the doctors:


1. Is this fixable? If so, do you think excision only will do the trick or will I need a combination of excision and lipo? Or was too much fat removed in the first place? Will revision surgery be complex?


2. When I slouch my shoulders, my nipples fold (see attached picture). My nipples do not fold with normal posture or when I raise my arms above my head. What do you think is the cause of the nipple folding and can this be fixed?


3. Should I trust the same surgeon to do a revision? He clearly missed the mark in the first surgery. I think he may prefer to do this surgery in stages -- lipo first, let the patient heal up, and then excision if there's still puffyness -- even though we discussed doing both the first time if necessary.   

[Dr. Elliot Jacobs]

All is not lost.  Fortunately, you do not have a crater deformity.  You do have residual tissue under the areolas which would (at least in my hands) require a peri-areolar excision which would allow for precise removal of only the excess tissues.  

The nipple folding may be due to inadequate release of the surrounding tissues so that adequate re-distribution of the skin may not have occurred.  This, too, is amenable to secondary surgery.

In general, I do not adhere to the "staged"approach to gyne surgery.  IMHO, this all could have been done in one stage.

Also, bear in mind that any secondary surgery is more difficult and less predictable due to the inherent scarring (under the skin) which is the inevitable result from any surgery.  Thus, a revision operation might be longer and more difficult than your primary surgery.  Be prepared for that.

As for returning to your original surgeon, that is your call.  But it might behoove you to solicit another opinion before you return to him to discuss.

Good luck!

Dr Jacobs

[kjd]

Thank you for your reply, Dr. Jacobs. So, if I understand you correctly, additional liposuction is likely not required to fix this -- just excision?
I'm quite hesitant to go back to my original surgeon for a revision, even if it's free. I think the result speaks for itself -- he doesn't have enough experience doing this surgery. Not sure I want to take my chances with him again.
I'm not opposed to travelling to get this fixed by an expert like yourself, provided its not too cost prohibitive. Do you do email consultations for out-of-town patients? I'm in Canada. Please let me know.  

[Dr. Elliot Jacobs]

No, I usually do additional liposuction on revision cases because most of the time, insufficient tissue has been removed. The lipo also helps to re-distribute the skin -- which hopefully should take care of the nipple in-folding. And then I would excise any residual sub-areolar breast tissue.

Yes, I do email consults.  Send me an email with your name and email address and I will send you the appropriate information.

Dr Jacobs

[kjd]

So I had revision surgery (lipo and excision) in October 2016 (about 18 months ago) from a plastic surgeon in Toronto that specializes in gynecomastia surgery. Unfortunately, the results are not what I was hoping for. While I no longer have puffy nipples, I now have creases/folds in my nipples when my arms are by my side at rest and these creases/folds worsen when I hunch my shoulders. In addition, when I flex or raise my arms horizontally or above my head, I have indents in my nipples. After spending plenty of money on two surgeries, I am still not comfortable taking off my shirt in public and am regretting my decision to have surgery in the first place.
Question for the experts on this site: Is my case still fixable? Is there still hope? What technique would you recommend? Do you think some sort of skin excision will be required to fix the creases/folds in my nipple such as a crescent incision above or below the nipple or something more invasive?
I have attached pics. 

[kjd]

A few more pics.

[kjd]

Any thoughts/advice from the doctors?

[Dr. Elliot Jacobs]

You still have obvious craters although your overall shape is much improved from what you started with.  You have now had two operations, both of which leave cumulative scar tissue under the surface.  This makes any subsequent attempt at revision that much more difficult and unpredictable.  That being said, you might still be able to get some improvement.  Suggest you visit an expert in gyne surgery for another opinion.  That's the best advice possible.

Good luck.

Dr Jacobs

[kjd]

Thank you for your reply, Dr. Jacobs. I went back to the plastic surgeon that did the revision to see what could be done, if anything (again, he is located in Toronto and specializes in gynecomastia surgery). We discussed doing scar release, fat flaps and an inferior crescent nipple incision (bottom half of nipple). He said he doesn't normally do incisions like that, but said it could help improve the nipple creases/folds in my case. He did not make any promises though. He said even with scar release and fat flaps, scar tissue often finds a way to reattach. He said it's a 50/50 chance it will work. 
Do the doctors on this board think this is a reasonable treatment plan in my case? I feel like I have one last shot at this, and would appreciate your advice/thoughts to guide me in the right direction.    

[Dr. Elliot Jacobs]

Yes, I think this is a a reasonable approach.  It is also important that the doctor stressed the difficulties and unpredictabilities of revision surgery so that you have realistic expectations about anticipated results.

I would add one other surgical "trick" to consider in order to deal with the lax skin -- and that is to do wide skin undermining to try to deal with creases, etc.  This can allow the skin to re-distribute itself.

Dr Jacobs

[kjd]

Thank you again for your reply. Good to hear you think that is a reasonable approach. Just a few more questions about my case that I have been wondering about:
1. I am generally happy with my chest contour when my arms are by my side at rest, other than the nipple creases/folds. How is it that the creaters aren't noticeable when my arms are by my side at rest, but very noticeable when I flex or raise my arms. Is this the result of too much tissue being taken out during the revision surgery or is this purely due to skin adhesion?
2. Is it possible that the nipple creases/folds could improve without doing the inferior crescent incision or should I definitely get that done along with scar release and fat flaps? Do the experts on here ever use an inferior crescent incision to remove loose skin and improve nipple creases/folds?