Standard procedure

[hatemymoobs]

Doctors:
What is your standard procedure- step by step?

I'm wondering for excision and lipo- which should come first in the operating room and why?
 
Thanks!

[Litlriki]

I start with liposuction.  Initially, I inject wetting solution for tumescent anesthesia. I do initial liposuction, which decreases the overall amount of fatty tissue, helping to delineate the glandular tissue. Then I make a small incision along the edge of the areola, and this can be pretty small, depending on the size of the mass I need to remove.  By doing the liposuction first, the mass removed will be smaller, thus allowing for a smaller incision. I then create the small button of tissue which I leave behind under the nipple/areola.  I may thin that out a little later.  Then I dissect out the remaining fibro-fatty mass (the "gland") and remove it.  I do some more contouring liposuction to make sure everything is nice and even. I check to make sure nothing is bleeding, and then I stitch up the wounds.

Different surgeons will approach this differently, and if they do it regularly, the technique that they are comfortable with is right technique for them, providing they get fairly consistent good results.

Rick Silverman

[Dr. Elliot Jacobs]

My procedure is very similar to Dr. Silverman.  Most of my operations are performed in my office ambulatory operating suite.  Anesthesia, for the most part, is "twilight sleep."

I start with local anesthetic injection to numb the breasts.  Then tumescent fluid is injected.  Then, I perform "aggressive" liposuction with a specially designed "aggressive" cannula (which I designed myself) which is capable of removing both fat and breast tissue.  Many times, this "aggressive" lipo is sufficient to remove everything -- and the patient is left simply with a nick in the skin on the side of the chest.

Sometimes, however, there is very dense breast tissue directly beneath the areola.  In these cases, even my instrument may not be successful in removing the breast tissue -- and then, without hesitation, I will make a peri-areolar incision and remove the balance of the tissue that way.  Thus, there is a "decision tree" for every operation.

In essence, I try to do the surgery with the very least amount of scars -- and only add a peri-areolar incision if absolutely needed.

Dr Jacobs

[George Pope, M.D.]

My technique is very similar to Dr. Silverman's.  I use general anesthesia in almost all cases.  Very rarely I will only need to remove glandular tissue without liposuction, and that can be done under local anesthesia.  But I perform most of my cases exactly the way Dr. Silverman has described.

Dr. Pope, MD

[hatemymoobs]

Thank you for your feedback.
I've been to 3 doctors. One of the 3 I won't even consider.
Of the other 2 they both have different approaches.
One goes in through the armpit and I think first does liposuction. Then after getting most of that out uses some kind of scissor like tool cuts out the breast tissue and excises it- through the armpit. When I asked how he can see what needs to be removed, he said it's all done by feel, which kind of made me nervous. Thoughts?

The other doctor I'm considering has the standard textbook procedure. Incision under the nipple, liposuction first, tissue excision second, and close up when done- leaving just a bit of tissue under the nipple so it doesn't adhere to the muscle on the chest.

I really am afraid for the scarring on the nipples, but am also afraid of a doctor going in blindly cutting out tissue.

Does the skin on the aureola typically scar better (thinner) than other parts of the skin on peoples body?

Thanks docs!

[George Pope, M.D.]

One big advantage of the scar at the areolar margin is that there is a color difference between the darker areolar skin and lighter chest wall skin.  That helps to camouflage the scar.  A color transition is great for hiding a scar.

Regarding the two techniques you describe, I can only speak for my experience and the way I do the procedure.  I take out the breast tissue that cannot be suctioned out under direct vision.  There is no way to see that tissue through an axillary (armpit) excision, unless a fiberoptic scope or retractor is used.

[hatemymoobs]

Thanks Dr. Pope.
I think he would have mentioned if he uses a scope when I asked how he sees what he's doing. Instead he just said it's done by feel.... which kind of freaks me out.

The patient coordinator there has been really good about returning my emails quickly. Last week I asked if I could get in touch with any past patients to ask them questions about their experience with their surgery etc... I haven't heard back.

The other doctor, without asking, has given me 2 people to communicate with, who I have heard back from and heard they were very pleased with the results.

How can I know when I've found my surgeon? I feel like I have... but I don't know if I should continue seeing more and more.... 

[Litlriki]

No surgeon can (or should) give you a 100% guarantee of a perfect result, so if you're looking for that surgeon, you won't find him/her--and if you do, you might run the other way anyway.  What you should find is a surgeon with whom you're comfortable asking questions, comfortable with explanations of technique and overall management, and one who provides you with photos of good results and, as you've found with one of the surgeons, satisfied patients who are happy to share their experience with you. 

I know that there are many good surgeons with lousy people skills, and I would guess that such a surgeon should have a great support staff, so that you aren't so aware of the inadequate "bedside manner."  But the accessibility is important, and your level of comfort in dealing with the surgeon and the practice is important.  I think it does sound like you may have found that, and continued searching may just drain your resources, presuming there is a charge for the consultation, and cause you more stress.

Good luck,

Rick Silverman

[hatemymoobs]

Thanks doctor.
I saw the doctor I thought was right for me again today.
I actually only wanted to come in and see additional photos and do a second consult at a later date. I only wanted to stop in at last moments notice because my endocrinologist is across the hall and I had an appointment with him today.

When I went to the surgeons office to see photos, the doctor said he wanted to see me, and he showed me the same photos as before- no more. He asked why I want to see photos and I should concentrate on the procedure, not his photos- since each patient is different.

While I see his point, I also wonder if that is his cop out for not having more photos. Perhaps he's showing me all the photos of this type of surgery. If that's the case he hasn't done near as many as the office manager claims he has done.


He seemed short- and yes Dr. Silverman- he didn't seem to have very good bedside manner so it made me feel uncomfortable. However, like you say many skilled surgeons don't have the best bedside manner. My dad experienced the same thing when consulting with back surgeons for his surgery to his back- horrible bedside manner but highly recommended and sought after surgeon. Makes it difficult for me because I'm emotion driven a lot of the time. I go by what FEELS right.

I have another doctor in mind- I love his artistic approach and the fact that he's an artist in his spare time, but I think I didn't like that he only does about 4-5 gynecomastia surgeries per year.

Doctors- crucial question here- should I be looking for a surgeon who does a certain number or more per year? Is 1-2 per year enough? Or do I need someone who does 30+ per year?

[Dr. Elliot Jacobs]

Doctors- crucial question here- should I be looking for a surgeon who does a certain number or more per year? Is 1-2 per year enough? Or do I need someone who does 30+ per year?

Can't comment on whether the bedside manner is as important as the surgical skills -- that will have to be your own decision.  But definitely, you need/want a surgeon who does more than 1-2 gyne procedures a year.  This is a difficult operation to get right -- as you can see from many posts on this forum from unhappy patients.  Perhaps more than anything else in your decision tree, make sure your surgeon is sufficiently interested and experienced in gyne surgery.

Good luck!

Dr Jacobs

[hatemymoobs]

Dr Jacobs

Thanks Doc!
My endocrinologist has prescribed Testim (testosterone gel) since my levels were very close to the bottom of the scale. I'm not sure if there has been recent growth or if I'm just growing more self conscious and aware of the problem with the gyne... I'm going to try this out, see how it makes me feel and keep my fingers crossed that some of my chest will get smaller from balancing the hormones.

If that doesn't work surgery is in for me. Just will have to find the right one, which is the hardest part for me since I probably can't fly around the country to see experts in that category.  

[DrPensler]

1) I evaluate the patient
2) Based on the individuals anatomy an operative plan is designed to correct what I perceive the problem to be.

[Litlriki]

I agree with Dr. Jacobs that you want someone who does more than 1 - 2 of these a year. 

I'm not sure where you're located, but if you're not happy with the choices you have locally, it's possible to do a "remote consultation" via e-mail and a phone call or two.  I get quite a few requests for this sort of preliminary evaluation, and I have found it to be very productive, both for me and for the patients.  I don't charge for this service, though I know that some surgeons may.  To some degree, you've already gotten many opinions from the surgeons on this forum, but I don't think you've ever posted photos, so we're just providing general information. 

RS

[George Pope, M.D.]

I think 1 to 2 cases per year is pretty low.  Most of us who specialize in gynecomastia surgery do 1 to 2 cases per week, or more.

Dr. Pope, MD