Full Story from the beginning.....Real Time with Pics

[gynecomastian]

So here is my story, I thought that it would be a good idea to share it from the beginning in real time.  The purpose is two-fold, first, hopefully some will relate to it, second, to get feedback and answer any questions.  I will try to keep it brief but give enough detail.

Background:
I am 27 years old, 5'10", 175lbs.  See attached pics, worth 1000 words. Gynecomastia with fat and good amount of gland.

Finding out:
I have had gynecomastia since I can remember and have always been embarrassed.  Luckily I was good at sports throughout high school and that helped a lot with friends, girls, etc.  Nevertheless, I have always been self conscious and will not take off my shirt unless I have to.  I do not let it stand in my way as far as going to the pool or beach but I am always aware and it always bothers me.  Throughout my life, honestly doctors never said anything about it, and I guess I was too embarrassed to bring it up.  Until 1 year ago when I got a physical and a doctor finally brought it up and referred me to an endocrinologist.  This is the first time I had ever heard the term Gynecomastia.

What is going on:
I went to the endocrinologist and was tested for a pituitary tumor, kleinsfelter syndrome, and a couple other genetic defects.  I found out that I am infertile (azoospermia) but all other tests came back negative.  I have elevated levels of FSH, LH, and testosterone. I decided to quit testing because we got to a point where if the tests came back positive or negative it would not change any action plan of mine and no one was worried about my general health.

Surgery?:
Now that I knew my big nipples had a term I immediately went to the internet to do some research.  I found this website and have been visiting every now and then.  I started to look at stories on the discussion board and notice a large amount of members getting the surgery and being very happy about it.  I decided about 6 months ago that I would get the surgery but wanted to wait until after the summer so that I could recover in the winter.  I have the financial capability and so I decided to start a plan to get where I wanted to.  The first thing on my list is to lose extra fat and get in shape for the surgery.

Where I am at today:
Today I am training for a marathon on October 18th 2009.  The idea is to motivate myself to lose weight and get in shape.  I ran a half-marathon in May and thought that running a full marathon would get me into the shape I want to get in while losing extra fat for the surgery.  I am also currently evaluating surgeons.  I believe that I have narrowed it down to Dr. Bermant and Dr. Jacobs.  It seems that they have the most experience and I have not heard any bad stories from their patients.

What is the plan:
Train until October 18th.  Schedule consultations with both Dr. Jacobs and Dr. Bermant.  Decide on surgeon and pick a date.

Question for anyone reading this:
1. Is there a reason to choose either Jacobs or Bermant, am I missing someone else I should consider?
2. Do you have a similar story?
3. Do you think surgery can be successful for me, given my pics?

[mizuno]

You can't go wrong with either of them when I eventually do my surgery that's who I will go with.
My personal preference is Dr. Bermant because he goes in and removes the gland via excision under
the aerola 100 % of the time where Dr. Jacobs uses a special cannula and only if their is left over gland
will he go in via excision.

Just my 2 cents.

[gynecomastian]

Thank you very much for the response.  That is great input.

Does anyone else have undiagnosed hormonal imbalances?
Is anyone else at the same "stage" that I am, i.e. getting in shape and evaluating surgery?

I have been thinking a lot about the surgery and I think that I have two main concerns.
1. Sedation, I have never been sedated and I get a little nervous about the process, anyone else?
2. Looking worse than before the surgery, namely sagging skin.  I do not have much fat but feel like there is a large amount of gland and it worries me that my aerola will be large after or that I will have extra skin.

Any thoughts?

[gynecomastian]

I just thought that I would update this thread.  I have continued to train for my marathon and have been getting in good shape.  I will probably post pics soon.  The biggest news is that I have set my consultations with both Dr. Bermant and Dr. Jacobs for October.  I have booked them for the same weekend, will go see both and through that evaluation will immediately choose one to have surgery with and book it right away.  It is the weekend before my marathon, so best case scenario is that I will be in shape for the consultation, choose a doctor, then run my marathon the next weekend, and get surgery the following weekend.  What questions would you ask the doctor at the consultation?

[GoldenGate]

I think you are right on track here.
Your concerns about the areola becoming enlarged seems valid to me.

The questions that I would have would revolve around scarring and what your expectations should be regarding that issue.
From the scars that will be visibly left on the skin, to how the different surgery methods will impact the tissue and healing below the skin.  Post the pics when you can and good luck with the training!  Marathons are TOUGH!!!!

[Dr. Elliot Jacobs]

From your photos and information, you would appear to be young and healthy (ie marathoner) and have good skin tone and elasticity.  Any gyne surgery to reduce excess tissues would be accompanied by spontaneous tightening of the skin -- you would not be left with lax skin!  Also, your areolar diameter will spontaneously shrink as the skin tightens.  And finally, if an areolar incision is required, then the resultant scar would also shrink in size spontaneously.  Best analogy:  imagine a blown up baloon with a circle drawn on it.  Now release some air -- what happens to the circle?  It shrinks.  Same thing happens to the areola!

As for your apprehension about sedation anesthesia, I will explain in greater detail when I see you. It is pleasant and absolutely safe -- and you will have no awareness or pain during surgery -- and you will awaken immediately after surgery with no nausea, grogginess, hangover or sore throat.

See you soon!

Dr Jacobs

[KWS86]

Brother, I'm pretty much in the exact same shoes as you. I just posted this thread:

http://www.gynecomastia.org/smf/index.php?topic=19063.msg131324#new

I just thought I had big nipples... boy has my life changed. I'm meeting with a PS in October and I'm going to see a GP on Wednesday. I plan on doing things pretty much exactly like you. Time to start jogging.

Keep me posted.

[DrBermant]

So here is my story, I thought that it would be a good idea to share it from the beginning in real time.  The purpose is two-fold, first, hopefully some will relate to it, second, to get feedback and answer any questions.  I will try to keep it brief but give enough detail.

Background:
I am 27 years old, 5'10", 175lbs.  See attached pics, worth 1000 words. Gynecomastia with fat and good amount of gland.

Finding out:
I have had gynecomastia since I can remember and have always been embarrassed.  Luckily I was good at sports throughout high school and that helped a lot with friends, girls, etc.  Nevertheless, I have always been self conscious and will not take off my shirt unless I have to.  I do not let it stand in my way as far as going to the pool or beach but I am always aware and it always bothers me.  Throughout my life, honestly doctors never said anything about it, and I guess I was too embarrassed to bring it up.  Until 1 year ago when I got a physical and a doctor finally brought it up and referred me to an endocrinologist.  This is the first time I had ever heard the term Gynecomastia.

What is going on:
I went to the endocrinologist and was tested for a pituitary tumor, kleinsfelter syndrome, and a couple other genetic defects.  I found out that I am infertile (azoospermia) but all other tests came back negative.  I have elevated levels of FSH, LH, and testosterone. I decided to quit testing because we got to a point where if the tests came back positive or negative it would not change any action plan of mine and no one was worried about my general health.

If there is an underlying hormone imbalance causing continued gland growth, finding out what problem is first and stabilizing it can be a monster advantage.  Gynecomastia surgery does not stop breast growth. Here is one of the many examples I have seen of Gland Regrowth After Gynecomastia Surgery on someone who had not had an adequate endocrine work up before his other doctor's misadventure.  That is a lot of gland I removed from someone who had another doctor operate without such a careful understanding of the issues involved. That is not the only example of regrowth I have seen.

That may not be an issue if the problem is stable, but unbalanced hormones usually have a reason and the effect on the body often involves much more than just the breast.  It is very rare for regrowth to occur for my patients.  The reasons for that are probably a combination of my Red Flag System, patient education, not rushing every patient that comes in the door to the operating room, and targeting gland first.  Less gland means less target tissue for recurrence.  Although shreds of gland, fibrous tissue, and fat remain behind with any surgical technique that can differentiate into new gland under stimulation.

Surgery?:
Now that I knew my big nipples had a term I immediately went to the internet to do some research.  I found this website and have been visiting every now and then.  I started to look at stories on the discussion board and notice a large amount of members getting the surgery and being very happy about it.  I decided about 6 months ago that I would get the surgery but wanted to wait until after the summer so that I could recover in the winter.  I have the financial capability and so I decided to start a plan to get where I wanted to.  The first thing on my list is to lose extra fat and get in shape for the surgery.

Where I am at today:
Today I am training for a marathon on October 18th 2009.  The idea is to motivate myself to lose weight and get in shape.  I ran a half-marathon in May and thought that running a full marathon would get me into the shape I want to get in while losing extra fat for the surgery.  I am also currently evaluating surgeons.  I believe that I have narrowed it down to Dr. Bermant and Dr. Jacobs.  It seems that they have the most experience and I have not heard any bad stories from their patients.

What is the plan:
Train until October 18th.  Schedule consultations with both Dr. Jacobs and Dr. Bermant.  Decide on surgeon and pick a date.

Question for anyone reading this:
1. Is there a reason to choose either Jacobs or Bermant, am I missing someone else I should consider?

Weight loss to what someone is comfortable before surgery is normally better than gambling on where the weight will come from after surgery. The exception in my practice is for athletes with very low body fat. For my marathon runners, competition bodybuilders, and others needing extremes with body fat, I prefer working on their off season fat.  When they go too low, local resources for rebuilding the chest are much less.  Too little fat and I can no longer target the gland first with nothing left to fill the gland defect.

2. Do you have a similar story?
3. Do you think surgery can be successful for me, given my pics?

You can find a collection of patient experiences with gynecomastia surgery here. Follow the arrows at the bottom of the page to see more.

The best way to determine if any one individual will have successful surgery is after a careful exploration of a patient's medical history, details of the problem, and an examination of the problem as you have planned. Please bring a copy of your endocrinologist's work up to date to your consultation with us.

I have been thinking a lot about the surgery and I think that I have two main concerns.
1. Sedation, I have never been sedated and I get a little nervous about the process, anyone else?
2. Looking worse than before the surgery, namely sagging skin.  I do not have much fat but feel like there is a large amount of gland and it worries me that my aerola will be large after or that I will have extra skin.

Any thoughts?

Here is something I posted a quite some time ago here:

Large areola can be from tissue stretched from breast and fat.  Deflate the envelope like letting air out of a balloon, and the diameter of the areola can decrease.

Check out the many before after pictures of this Areola / Nipple Gallery here, here, and here.  These results are typical for my sculpture of my patients.
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How well the skin, areola and nipple shrink with surgery can vary as I demonstrate in the two balloon examples on that link.  How much skin retracts and the timing depends on

• how much it had been stretched
• how long was it streched
• how much elasticity remains in the skin
• how much was removed during surgery

Notice on one of the balloon examples the circle diameter does indeed get smaller. On the other one, it does not.  Skin that has not been stretched out with weight loss, loss of muscle mass, or otherwise has lost its elasticity has an amazing contracting ability as you can see on the nipple areola gallery links posted above.


Plastic Surgery Anesthesia has evolved over the years.

I prefer local anesthesia alone for long nipple reduction gynecomastia. For almost all other gynecomastia surgery, local anesthesia with sedation provides a safer much more comfortable method.  When 2 stages are needed, as with this problem of enlarged nipples of gland and nipple tissue, I perform the first stage with local sedation, and the second with local alone.  For my upper body lift surgery, when I have to operate all around the chest - front / back, I need Light General Anesthesia.  This is still my Tumescent Technique, but adds the safety of airway protection while the patient is in the prone position.

I perform many revision gynecomastia surgery on patients first done elsewhere.  Many have told me how unpleasant their first doctor's experiences were under local anesthesia alone or General Anesthesia for liposuction and gynecomastia surgery.

You can find an extensive individual patients' experience with comfort and my Tumescent Technique Anesthesia for gynecomastia here.

If you prefer direct links to each of those discussions:

anesthesia and comfort in gynecomastia patient from California

anesthesia and comfort after revision gynecomastia surgery in patient from Hong Kong China

comfort and anesthesia in physician's son with gynecomastia

comfort and anesthesia in gynecomastia patient from Florida

comfort and anesthesia in gynecomastia patient from Illinois

comfort and anesthesia with gynecomastia patient from Texas

comfort after gynecomastia surgery with patient from Colorado

comparing comfort and anesthesia of my revision surgery with prior gynecomastia surgery in Florida

comfort and anesthesia in patient 4 hours from Richmond with gynecomastia

parent of teenage gynecomastia patient commenting about comfort after surgery

comfort after gynecomastia revision surgery on patient from the United Kingdom

comparing comfort of my revision surgery to prior gynecomastia surgery done in New York

Hope this helps,

Michael Bermant, MD
Learn More About Gynecomastia and Male Breast Reduction

[gynecomastian]

Thank you for your responses.

I have done my best to capture my experiences in consultation below.  Please not that this was MY experience and you may differ.  I strongly suggest visiting more than 1 doctor and making a personal decision.  Your experience may be completely different than mine.

I went to see both Dr. Jacobs and Dr. Bermant this weekend and I would say that they are both terrific surgeons and great at what they do.  I feel that either of them would do a great job.  I will give you a brief overview of what happened at *my* consultation and that way anybody reading this can be familiar with the process.

First I visited Dr. Jacobs.  He is a very charismatic guy.  He was great to be around and at the end I was ready to hop on the operating table and have surgery right then and there.  His consultation was very relaxed.  He did a physical examination to check for gland vs. fat and checked for the amount of muscle that I had.  He went through the entire process, pre-procedure, during the procedure, and after the procedure.  I had asked him about my concerns of cratering, loose skin, and too much gland left over.  He seemed very confident that I should have no problems and that I was in ideal condition to have the operation.  He did bring up concern over the fact that my hormonal problem had not been root caused.  The entire consultation took about 45 minutes and went really well.

A couple of days later I visited Dr. Bermant.  He is a very thorough doctor.  He made sure that I was aware of everything and pretty much “stuck to the book”.  His physical examination was much more involved.  He made measurements, filled out forms, and observed from several different angles.  I asked him about the same concerns of cratering, loose skin, and too much gland left over.  He seemed confident about a good operation but stopped short of any kind of guarantee.  He also brought up concern over the fact my hormonal problem had not been root caused.  The entire consultation took about 1 hour and 15 minutes.

These were the overall feel for both of the doctors and I think that it is probably safe to say that both doctors are very skilled at what they do and that one is no better than the other, but merely they are different.  Some people may find Dr. Jacobs more suited for them and others may choose Dr. Bermant.  Either is a good choice and is an individual decision that must be made.  However there are some fundamental differences I believe and these are what I would like to make my decision based on. 

First, Dr. Jacobs uses a special (sharp) cannula of his own design to first liposuction from incisions in the armpit and with this cannula is able to get gland tissue as well (Dr. Bermant may dispute this).  However, if he needs to, he will not hesitate to make incisions around the areola and excise gland through that method.  He has told me; and I fully expect that he will need to do this to me.  In contrast Dr. Bermant always makes incisions around the areola and excises gland first.  He then uses liposuction to contour the fat underneath.  Dr. Jacobs procedure takes about 90 minutes and Dr. Bermant’s can take anywhere from 2 to 3 hours.

So the question is which Doctor I choose.  I know this is a personal decision, but any thoughts are appreciated.  I am getting one more set of hormonal tests to just double check and once those return, if it is what I expect, then I will arrange the surgery.

Thank you for reading.

[Personal1]

Good luck with everything, I'm sure you'll get great results whether its with Dr. Jacobs or Dr. Bermant

[decimal]

Its been over a month now, so wondering did u get surgery yet?

[gynecomastian]

Thank you for the feedack and thank you Decimal for keeping me honest.  Well I chose to go with Dr. Bermant and my surgery is scheduled for this Saturday!!!!  I am very nervous but very excited at the same time.  Words of encouragement are.....well, encouraged.  I am trying to remember how to upload pics again and once I do I will post some more recent "before" pictures.  I will be sure to post "after" pics as well.  Please let me know if anyone has any questions.  Wish me luck!

[steelhead]

Yeah good luck man and I truly mean it !
Definetly keep us updated as I intend to have this surgery sometime this year and I'm torn between
Dr. Jacobs and Dr. Bermant.
The only problem for me is the smoking 
I need to quit anyways.

[gynecomastian]

So it is the day before surgery and I am in Chester, VA waiting for my pre-op.  Here is a pic that I promised.  Thank you for the reply steelhead and good luck with the smoking; this should be more than enough motivation to quit.

[gynecomastian]

Well, I went in for my pre-op and it went well.  I feel very good about the procedure but mother nature has thrown in a twist with one heck of a snow storm here in Chester.  It never snows in Chester!  Anyway, I am all marked up for the surgery tomorrow and feel fairly relaxed.  Going to try and get some sleep tonight and hopefully things will go well tomorrow.