Adhesion vs crater

[mrichards]

I had surgery in early January of this year with a very experienced and (I think) well regarded gynecomastia surgeon and apparently all went well. Fairly soon afterward I noticed an indentation on my left chest just above and medial to the nipple, only when I flexed. I knew there was (and likely still is) swelling so I wasn’t too concerned. It has persisted and may even be a little worse, so I sent a photo to the surgeon who said that it’s an adhesion. The contour at rest is pretty much normal. The surgeon wasn’t too concerned but recommended massage and offered to check me, but I live half the country away so I can’t do that for awhile. He said it can take up to two years to see if it will go away, and we didn’t really discuss what could be done if it doesn’t resolve.

I’m overall pleased with the result, particularly my comfort in clothes. I’m 45 so I know I don’t heal like I used to and I didn’t expect perfection, but the indentation looks weird when I flex and I’m aftaid I’ll be even more self-conscious with my shirt off than I was before. My question is, will this likely go away? Will massage help? What might need to be done if it doesn’t, and how effective is that treatment?

Thank you.

[Litlriki]

It's still very early in the healing process to say that any type of contour deformity is permanent. You'll see lots of changes in the coming months, and you can manipulate the tissue with massage during that time to break up any adhesions that may form during the healing process. So if you have an area that is tethered or indented slightly, breaking up the tethering connections can improve the appearance.  If this doesn't resolve, then there are minor surgical interventions that can improve it by surgically releasing any adherent spots and possibly injecting fat in the area if needed.  But patience first!  I typically tell my patients that we won't even discuss revisions before 9 months to a year--Not so sure about two years. 

[mrichards]

Dr. Silverman, thank you so much for your reply. That gives me some hope and reassurance.

[Dr. Schuster]

I agree with Dr. Silverman. Too early to know final result. Hang in there.

[DrPensler]

At surgery patients are optimized at rest. It takes a variable amount of time for the soft tissue to resolve. In the early postoperative period I like patients to stay active.Essentially you sound like you are responding as expected.

[mrichards]

Thank you all for the replies. I know that I’ll need to be patient and not worry too much for at least the next 4-6 months (we’re going on a cruise with friends next month which is why I’m focusing on it more than I should), but I’d love a little more advice or reassurance. I can see some gentle indentation on my medial left breast even at rest now. It stands out most with direct overhead light. This area feels a little “hollow” compared to the surrounding tissue. Does this point more toward over-excision of tissue, or could this still be adhesion? It becomes more apparent with raising my arms (the right side looks a bit lumpy with same movement). I can upload some photos if that helps. If it is the result of over-excision, can that also improve with time and massage? And lastly, how often and aggressively should I be massaging? Any advice on technique? Once again, thank you all.

[Dr. Schuster]

Impossible to know for sure about the indnt. It is good that it feels "empty" since this most likely means that the gland was properly removed. If all you feel is the thin skin of the nipple/areola, too much might have been removed. Try not to dwell on it now. I recommend deep tissue type of massage to my patients. I think it helps to break up any thicker scar tissue and prevent adhesions. You should follow our own surgeon's advise though. Hang in there.

[mrichards]

I’m 6 months since surgery now and just wanted to check in. The tethering on my left chest has not changed. It’s only noticeable with movement, particularly flexing. With flexing, the area just in from the nipple caves in, and to a lesser degree, up, and a crease forms just beneath the nipple. I’m pleased with the the results in clothes and when standing still with my shirt off, but I’m pretty self-conscious that it will jump out with any movement.

My main question is, what are the odds that it will resolve without the need for a second procedure? I’ve massaged the area pretty regularly but can’t tell any difference. If there is a chance, how long should I wait, AMD is it likely to gradually improve or suddenly release?

Finally, if another procedure is required (fat flap or graft), would most recommend that I see the original surgeon (he’s a good ways away from where I live) or should I seek a second opinion, probably closer to home?

Thank you.

[Dr. Schuster]

I don't suspect that it will change much after 6 months. One other option would be to see a physical therapist who could perform ultrasound and deep tissue massage. The downside is extra expense for you if it doesn't work (and I think the odds are that it won't). I always recommend returning to your original surgeon unless you have lost confidence or logistics make it impossible. The recommendation for flaps or grafts would be made by the surgeon. Good luck.

[Litlriki]

I agree with Dr. Schuster's response. Photos might be helpful, but I'd still recommend that you initially work with your primary surgeon unless you don't have confidence that he can address it. You should have been told about revisions and any cost associated with that, and at least in our office (and many others), revisions are done in a way to minimize patient expense.  When I do revisions on other surgeons' work, the patient is new to me and is treated as a new patient, including surgical fees. 
Rick Silverman