Underam excision?

[balambala]

Why don't more surgeons opt for an underam excision over a areola-border cut? Is it because underam excisions are good only for minor cases?

Has anyone hear about the underam excision, and whether it is effective?

[Dr. Elliot Jacobs]

I always use an under arm incision (a tiny nick in the skin about 3mm long) as my initial incision.  Utilizing my own custom designed cannulas (which are sharp and capable of removing gland tissue), I am frequently able to remove all the excess tissue (fat and gland) through this incision alone.

However, there are times that I encounter extremely dense gland tissue -- so hard and firm that even my instrument cannot penetrate it.  It is impossible to predict by physical exam prior to surgery if this will be the case.  When this situation is encountered, though, I will then make a peri-areolar incision to complete the removal of excess gland by means of a scalpel. 

My theory is that if I can achieve a good result with only an armpit incision, that is great.  But I do not compromise the result by sticking only with that incision -- if the peri-areolar incision is necessary (the decision being made during surgery), I do not hesitate to use it.

I virtually never make an incision completely around the areola to reduce the circumference -- the scars are always terrible.  Rather, in the vast majority of cases, the areola will shrink just as the chest skin shrinks once the underlying excess tissue is removed.  (Think of a blown-up balloon with a circle drawn on it --when you release some of the air in the balloon and it shrinks, the circle will decrease in diameter just as well).

Many surgeons use a reverse technique -- making the peri-areolar incision first.  They remove excess gland in this way and then use the same incision to perform lipo for the periphery of the chest.  This is also quite an acceptable way to go.

My advice is to discuss this with your surgeon and seek his professional opinion.

Elliot Jacobs, MD, FACS

[DrBermant]

Why don't more surgeons opt for an underam excision over a areola-border cut? Is it because underam excisions are good only for minor cases?

Has anyone hear about the underam excision, and whether it is effective?

Under Arm Incisions Require Sculpture from a remote location and depending on either liposuction or long fine cutting tools.  Some doctors may try the remote location first and then add additional scars by the areola.  I prefer to limit the scars on the surface and internally.
 
Liposuction Is Great for Sculpting Fat

Various types of ultrasonic and power assisted liposuction (UAL and PAL) have been around for quite sime time.  Each surgeon uses the tools and techniques he / she prefers.

There are studies claiming that ultrasonic liposuction does not break down gland cells, these were done to justify the safety in female liposuction breast reduction surgery.  Ultrasonic energy cannot be both ways, good for gland breakdown and safe not harming gland unless there is a difference between male and female breast gland tissue which has not been proven to my knowledge.

Tumescent liposuction is a form of anesthesia where fluid is placed in the tissues to be sculpted.  You can see very graphic pictures of the tumecent technique here.

Liposuction such as ultrasonic, VASER, power assisted, and sharp cutting cannula preferentially remove fat over gland.  Gland tends to exist under the nipple areola region.  When fingers of fat extend between fingers of gland, breast reduction can come from removing the fat and leaving gland behind.  On animation such as flexing the pectoral muscles or putting the arms over head, gland does not compress or move like fat.

When gynecomastia is from fat, liposuction works very well for contouring the chest.  I have seen many patients from other doctors who tried to use liposuction alone techniques that left gland behind that the patients just did not like for Revision Gynecomastia Chest Sculpture.

Here is an example of Revision Surgery after Liposuction alone.   

Here is another revision after liposuction alone.

The problem is picking the right method for what actually is that patient's problem.  That is why I prefer my Dynamic Technique that permits what I find during surgery to guide my sculpture.  The incision at the edge of the areola  opens up my entire spectrum of artist's pallet of tools for my sculpture.  A remote incision robs me of many options and just does not looks as nice.

I have also seen patients with channel problems between remote access sites and the areola / nipple.  Scars, adhesions, and depressions can look terrible.  Check out the lateral (side views) and posterior oblique (side from the back views with and without muscle flexion here to see what I mean.

Ultrasonic liposuction uses energy to help emulsify fat.  Power assisted liposuction uses mechanical vibrating devices to rapidly move the cannula back and forth.  Both PAL and Ultrasonic methods have been around for several years.  Many do not prefer what they do to the tissue.  Others like what they offer.  Both still preferentially remove fat over gland.  Both make the work of the surgeon easier.  Some feel ultrasonic liposuction can cause more swelling, bruising, and the increase the need for drains.

For a liposuction cannula to remove gland, it can also remove connective tissue and other structures which can lead to more bruising and scars.  I have seen so many patients who were unhappy from doctors that used "special cannula to remove gland," that I just prefer to go directly to the problem itself.  Primary surgery is usually better than needing a revision.  All male breasts have gland.  With access to the gland directly, I can peel it off the areola muscle, minimize bruising and bleeding with direct control of the tiny blood vessels, and then reconstruct the contour.

For me however, they also both remove the feel of the tissue sculpture.  I like the much better control I get with my cannula selection and personally I do not like either ultrasonic nor power assisted techniques.  None of the cases on my website used either PAL, Ultrasonic, nor sharp cutting cannula techniques. 

As any artist, I take my cannula selection very seriously and have evolved what permits me to achieve my results.  I have considered and evaluated many, many technologies.  The many different types of cannula I use have their own advantages and qualities.  I pick a subset of these cannula that varies for the many different types of gynecomastia male chest sculpture that I see.

Gland removal by any technique can still leave a depression when  a major part of the problem is from gland.  For gland removal, I prefer the greater precision of removal under direct visualization and feel.  This also give me access to many more elements for my artistic palette of my Dynamic Technique to sculpt the remaining tissues.

This approach permits me to maximize the removal of the firm gland and sculpt the remaining fat.  How tissues move is important.  The human body is beautiful in animation.  That is why I show pictures of the chest with arms up, down, and with muscles tight / relaxed in addition to the results from multiple views.  Such analysis of the results as well as how tissues evolve, the possible need for drains, comfort level after surgery, are important factors in picking your doctor.  It is like an artist selecting a paint brush.  The results are what matters, not with what tool they sculpt.

Hope this helps,

Michael Bermant, MD
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