Revision Advice?

[kensaimage]

(EDIT--I am moving an old topic to this forum as it does not seem to be getting any responses, and I just found out about the "ask doctor" column. One doctor did respond, but I have an update and need some advice. I will post the original here and the recent update in a new post)

Original Post
I had vaser lipo done last February along with a full abdominoplasty. I'm mostly happy with the results all around, except for the chest area. My nipple region still protrudes slightly. During my last follow up, my doctor said that he doesn't believe the problem is left over tissue, but skin. He says that he believes the skin was like that for so long that it needs time to fully retract. He also said that if in six months time (which will be by the end of this month now)it hasn't shown adequate tightening, there would be a "simple" skin tightening procedure he could perform. He spoke about making a cut around the areola line and pulling it together, or something along those lines.

Well, I'm a bit concerned cuz I'm not sure of whether to trust him on it or now. My right side looks relatively good, and I can press it "inward" with little resistance with my finger. There is some soft tissue underneath, but I can kinda see how it could be skin. In the shower, if I turn my body against the water and it hits that area, the skin presses inwards. And I can sorta "tighten" it with my hands and it looks much better. But when I let go and I have my arms down, it sorta "poofs" outwards. Major concern is that my left side has a really hard lump underneath the nipple that is painful. This lump was not there prior to surgery.

Regardless, I decided about a month ago to go get a second opinion, just to be safe. This new doctor did an exam and feels that there IS too much tissue and wanted to excise the remainder. He thinks that the skin would shrink up well. He also speculates that the hard lump on the left is traumatized tissue from the lipo that should hopefully soften up. He gave me a quote and out I went.

At the end of the month, I go in for a final follow up with my doctor to talk about options. But I'm not sure how to proceed. This doctor did very well on my stomach. I even have regained nearly full sensation under the belly button, something I researched was very rare for that particular procedure. And he seems like he knows what he was doing. He said he didn't believe any remaining tissue was causing my contour problem. And the thing is, both doctors have a good point in a different way. My doctor does insist removing any further tissue would cause a deformity.

So do I do this skin tightening thing and adjust the contour, or do I get more tissue excised and hope the skin simply adjusts around that?

[kensaimage]

Updated Post
So, update. Whereas I don't have the means to upload pics, I still really would like to get multiple opinions here so I can make sense of whats going on. I'll do my best to describe. I understand its difficult to help without a visual, but any input provided regardless is much appreciated.

So yeah, today was my six month follow up. The doctor and me apparently have very different opinions on what is considered "masculine", as my nipples on either side still protrude about a quarter inch on both sides. In my opinion, it goes completely within the contour of the chest. He thinks otherwise. BUT, good news. He set me up with a physical therapy place for my scar tissue lump. I will go twice a week for up to 20 visits. They're gonna do ultrasound and professional massage therapy to destroy the lump. I'm actually really excited for it!

However, that still leaves me with a conundrum. After I realized I couldn't convince him what I considered to be "flat", I finally just said "this is what I want". He sorta gave me a look and asked me to lift my arm up over my head, so I did. When I do this, my chest is COMPLETELY flat. Really flat, actually. Not a trace of gyno. He then began to poke and prod and told me that when I raise my chest, the breast tissue underneath lifts up. I asked him then if he could simply make it look that way when I have my arm down and not have it sorta "slouch outwards" when I do. He told me that I had two options, but both would leave me partially screwed.

Option 1. Excise more glandular tissue. He even finally was clear with me for once and said that it would look like that even with my arm down if he did that. So I said "perfect", thats EXACTLY what I want. "HOWEVER"...he says. If he does this, when I lift my arm up, my nipple will pull inwards, revealing a deformity. He felt strongly enough about it to warn me not to come back afterwards saying its deformed if I chose to go that route. Naturally, I don't want to look deformed...so I asked what else I could do.

Option 2. Some procedure I can't pronounce, lol. Basically, a peri-areolar something. The procedure involves cutting a donut shape around the nipple, removing the excess skin, then stitching it back in all tight. I asked if thats a thing he's had to do before with patients, and he told me thats something woman do to lift there breasts...."AWESOME", I thought to myself in my head. Now I feel extremely embarrassed, and I was already feeling a bit flustered.

The quote I got was not pleasant, either. He considered it my "personal preference" despite me arguing that no man would consider this "masculine" when his nipples protrude further from his body than his upper chest wall. So as far as money saving, I am SCREWED. I don't think I really want him doing anything else chest related anyway, since he apparently has no idea what a male chest looks like. I mean, I wanna like this guy. He did an awesome job on my stomach. But I just can't seem to communicate with him here. I scheduled another second opinion with the same doctor I described in my first post. I told him I may make another appointment if my six month follow up left me with an unsatisfying result, as my current surgeon is a bit infamous for when it comes to answering my questions or addressing my concerns. But I can't help but think he may have a point. With my arm all the way up, its totally flat. Yet it changes so drastically with my arm down. Poking at it in this way, I can totally see how any further tissue removal would result in a "cave in" when my arm is up. But then again, I don't understand. If a guy can be born without gynecomastia, and his chest can look flat no matter where his damn arm is, why can't mine after surgery? I truly believe this doctor is trying to, at least in his mind, do me a favor. But is there no happy medium where my chest can just be flat? Arm up or down?

Thanks for any input. Hoping somebody out there has an experience they can share that may help me. I don't wanna make a mistake and have a deformity, but I still have obvious nipple protrusion with my arms down. What is going on?

[DrPensler]

You need to provide photos. As a general rule I perform excision of glandular tissue in 99% of my patients.

[DrPensler]

As a general rule I perform excision of the glandular component in 99% of patients.The most common cause of revision in patients I see is inadequate resection of glandular tissue.Photos would be helpful.

[kensaimage]

I tried adding some pics, but it keeps telling me the file size is too large, despite it only being one picture

[Litlriki]

As per Dr. Pensler, it's tough to advise without photos.  If tissue was excised in addition to the VASER procedure in the chest, I would recommend waiting up to a year and possibly considering a Kenalog injection, since scar tissue in the subareolar location can cause persistent swelling of the sub-areolr remnant, and Kenalog can help that. 

Regarding the appearance with arms raised versus arms at side--I opt for the appearance with arms down.  You don't walk around with your arms in the air.  It's common to have the areola look a little depressed with arms up after an adequate resection, but this should be pretty subtle and something that you and those close to you and your surgeon might notice...but not something that's obvious without really making a point of looking at it. 

As for cost...I know what I charge for such revisions, and it's an expense that covers my costs, but not more . I clarify that at the time of the initial consultation, so patients know what future expenses might occur.  I do these revisions in my office under local, so the fee is quite modest.

If you're able to post some photos, we might be able to address your concerns specifically.

Rick Silverman