Protocol about asking for a revision

[rhyno18]

Quick background.  I had pretty severe gynecomastia most of my adult life.   I had surgery last October with the doctor using excision to remove the tissue.

From the first visit post op through today, it still looks like there is quite a bit of tissue left, nothing close to being flat or contoured.  It almost looks like a uneven bulge sitting under both nipples. My doctor seemed pleased with the result and even though he could literally stick his finger in the skin that was left or jiggle it - he felt that it would improve over time.

It's been 5 months and it still looks the same.  I want to ask him about a revision in our visit next week to see if it's even an option if I'm in the same place in October.  But I almost feel like he's trying to convince me things are fine.

On one hand, the results are MUCH improved.  I feel much more comfortable wearing golf shirts or t-shirts.  But I did pay $5,000 bucks for this and feel like if a revision is something that is available, it should be considered.

Thoughts?

[McGilli]

I agree with you. You paid a lot of money - and it sounds like there is still maybe a little work to be done.

I can't figure out from going through these forums how revision cost works.

I didn't have to pay for a revision. Some others here don't have to pay.

But some people here post and say they had to pay another maybe 2K for a revision from the same surgeon etc.

So I'm just saying I hope he doesn't want to charge you to do a revision....

[rhyno18]

The original cost had 3 items, and $3000 for the PS fee, and $1200 for the outpatient surgical center he used and $400 for the anesthesiologist.

I would think the surgeon would consider any correction or revision as part of the original fee. But I don't know I would be expected to pay all/part of the other costs.

As I consumer I would expect him to absorb the costs to make it right, just like anyone else I would contract for a large job.

But the first part would be getting agreement that my results aren't where we wanted them.

I am also considering a second opinion . I have this nagging feeling my case was a bit more complicated than expected. My procedure went longer than expected and he told my wife the the recovery room there was a lot more tissue than he anticipated.

I already have an odd dent when I raise my arm... Kind of a crater. If I get a revision I want to be crystal clear on what our goal is.

[Dr. Elliot Jacobs]

Revision surgery (and its costs) can be tricky.  There are two people involved in the revision -- the patient and the surgeon.  Assuming there has been an improvement and there are acceptable scars and contours, then the patient may indeed want more done.  The surgeon may disagree and his disagreement has to be respected.  He knows what your original condition was and hopefully removed enough in his opinion to do the job without taking any risks of contour deformities (ie crater), etc.  When you ask a surgeon do operate on you, you are then consenting for him to use his best judgement in performing the surgery.  Some patients are difficult to satisfy because "they know better than the surgeon."  They know that "there is more tissue that can be removed."  But in actuality, removing more tissue may open up a can of worms that cannot be fixed.

On the other hand, some surgeons do indeed leave patients with less than ideal results.  Those surgeons must be honest enough to admit it.  Resolving the patient's complaint and the surgeon's evaluation of results is where the problem lies.

Speaking for myself as a surgeon, I feel I must be honest with all my patients. I do a lot of aggressive work in order to remove as much tissue as possible without creating any contour problems.  The goal is to remove enough tissue so that the patient has a contoured chest -- but not so much that it caves in or is not consistent in the "fat pinch" test from the adjacent areas of the body.  Above all, gynecomastia surgery is an artistic operation -- one must know how much to remove and how much to leave -- it is not simply cutting out the excess tissue.  And that artistry is based, in part, on years of experience.

No one is perfect -- neither the patient nor the surgeon.  On rare occasion, a patient may return to my office and ask for additional work to be done.  If I honestly feel that I can improve it, then I do the revision with no charge for the surgery but with a small charge for the anesthesia and operating room.  However, if I feel that the patient is out of line with his demand (ie he just doesn't understand) or that any further work would likely lead to problems rather than improvement, then I decline to do a revision.  And admittedly, I have had one or two patients over the years who leave my office "pissed" at me because I did not acquiesce to their demand that I do more.  Unfortunately, that does occur.  I live with this, though, because I feel I have been honest with my patient. There is a famous dictum with which I live as a physician: primum, non nocere (First, do no harm).

There are no easy answers as regards handling costs of revision surgery, or indeed whether it should be done at all -- but I hope I have provided some insight into the two sides of the issue. 

When considering gyne surgery, it would be best that the possibility of revision and the attendant costs be discussed with your surgeon prior to any operation.

Dr Jacobs

[rhyno18]

Dr. Jacobs,

Thanks so much for your thoughtful reply.  It gives me a lot to consider going into my follow up visit.

If I would have received nearly that level of explanation, I think it would be easier to accept my results.  I knew that given the large amount of tissue being removed (probably a big b worth), I needed to be realistic with my results.  And at 5'10, 205 lbs, I could stand to lose another 20 lbs or so, so I know some fat is involved.  Plus my gynecomomstia had a bit of an odd shape - rather than pointing straight out, they almost protruded at 45* angles.  You can tell he did a lot of work to bring symmetry back to my chest and centering my nipples.  

In each post op visit there has been almost an insistence that everything looks fantastic.  And while I'll admit, it looks WAY better than before, it doesn't quite seem right.  The large bulges under the 'equator' of each side, the way there is still a lot of mass when I bend over, the pinch test, the crater when a raise my right arm.

If this is as close as we could get with my condition than fine.  But I'd rather him be honest about what we both are observing, than being dismissive.   The bottom line is I can easily live with the results.  They are much better than what I had before.  But until we talk openly about the current condition, I'll feel like the job wasn't completely finished.

[McGilli]

Well, maybe dropping those 20 pounds or more might help you to see if it really is breast tissue left, or if he just left normal fat there to try and keep your body from looking uneven.

Good luck.

And yes thanks Dr Jacobs - that was a great explanation.