Regarding Surgery

[bluemrgreen]

Hey Docs even though Im pretty sure it takes longer for you guys and more work, is a Free Nipple Graft easier to do than a smaller procedure? For example is  it easier to avoid crater deformity and so forth?

[Litlriki]

The indications for a free nipple graft are rare--I have had one patient in 20+ years for whom that was appropriate due to the size of resection required (he's on my website, treated after prostate cancer treatment with massive breast hypertrophy).  It would certainly not be beneficial for the majority of cases.  Post some photos if that would be useful in addressing your question, but I think it's not likely that you'd require that approach.

Rick Silverman

[DrPensler]

Free nipple grafts are used in massive breast reduction cases in females. Free nipple grafts are not simple procedures and are typically done because the nipple would not survive as a pedicled flap.I have never done a free nipple graft in a case of gynecomastia.

[Dr. Elliot Jacobs]

Interesting question.

In my practice, I have a significant number of patients who have very very large, pendulous breasts -- with lots of extra tissue, lax skin and very wide, low-lying nipples.  These are not my average cases, in which minimal scar surgery can be performed and the skin will tighten spontaneously.

Rather, these cases actually require removal of the tissue, removal of extra skin and placement of the nipples at a higher and more acceptable level. The nipple diameter can be made smaller in the process.  Over the years, I have tried a number of different techniques to achieve the best results for these patients, which I consider to be a taut, sculpted chest with nipples located at an appropriate position.

Some techniques leave the nipple attached on a pedicle (think of this as a peninsula of tissue containing blood vessels).  The extra skin is then removed and the skin sutured tight.  The nipple is then moved under the skin and sutured into a higher position.  The advantage here is that the blood supply to the nipple is more assured (but not guaranteed) and that the nipple should have reasonable sensation.

The problem that I have found with this technique is that the mere thickness of the pedicle, which is needed to carry the blood supply, will take away from the thin-skinned, contoured chest contour that is desired.

I therefore differ with Dr. Silverman in that I do a fair number of mastectomies with nipple grafts (we call them free nipple grafts because at one time during surgery, the nipple is literally taken off the body and then replaced at a better position).  Obviously this is only done when the nipple has to be raised a fair distance.  When there is need to raise a nipple just 1-2 cms, then I employ other techniques.

The downside of free nipple grafts is that occasionally there can be partial loss of pigmentation (although it usually returns over time) and an anticipated permanent decrease in nipple sensation.  All of this is spelled out prior to surgery.  Most guys do not care too much about nipple sensation -- but some do.  If they do emphasize nipple sensations, then other techniques (such as the pedicle described above) are discussed, including their pros and cons.

In essence, when confronted with very large and pendulous breasts, there will most assuredly be larger, permanent scars and other concessions that the patient will have to accept.  There is no perfect way to improve these patients with a minimal scar technique -- there have to be compromises somewhere.  I often tell my patients that it will be a trade-off of scars for a better shape.

Dr Jacobs

[bluemrgreen]

Thank You

[Litlriki]

One thing that you'll find on this forum is that because we deal with a lot of gynecomastia patients, we have tried a number of techniques to get the best results.  As I mentioned, I have used amputation and free nipple graft in one patient who had massive enlargement, and he is pictured on my website.  He developed hypertrophic scars, which are slowly resolving, but he is otherwise quite happy with the result. 

In the cases which are still quite large but not as large or saggy, I have gone with two different options, one using a small pedicle like what Dr. Jacobs described, and unfortunately, I don't have any of those pictured on my website.  I need to post some, and I have very nice results with this approach.  There is a scar in the infra-mammary fold and a peri-areolar scar around the nipple.  As Dr. Jacobs pointed out, the pedicle can create a problem if it's too big, and in one of my cases, I did some liposuction on one side to improve the appearance, but generally, I haven't had to do that.  This is the approach I use most of the time in massive weight loss patients, since the problem is often skin laxity more than breast tissue.  My pedicle is about 1 cm thick, so it's pretty thin, and as mentioned, it can be suctioned later to provide better contour if needed.

The other approach I've been using with "Type 3" gynecomastia is very aggressive liposuction and excision, followed by "splinting" of the skin with sticky-backed foam (Reston Foam) for a week post-op.  I also need to post some of these photos.  It's really remarkable what happens in many of these patients, and I haven't had to excise skin in most of these patients secondarily, though I tell them that it's quite possible that some skin excision a year after the initial procedure might be required.  I have done this in quite a few patients, who would have traditionally required a procedure with much more scarring, and the results have been very good. That's actually the approach that I'd consider for you based on the photos you posted.

I'd be happy to e-mail photos, and I guess I can post some of these cases on this site if I can remember where they go...

RS