Very puffy areolas/nipples post-op (1 month with pictures)

[Timbucktwo]

I got my surgery 4 weeks and 5 days ago for gynecomastia that I've had since puberty and never went away.  I am 26 now.  Post-op I had to wear heavy padding and a compression vest for the first two weeks, lighter padding and compression vest for one more week, and then just a compression vest for about 10 hours a day (or at night when I slept) for one more week.  

So when I was first able to finally have my vest and padding off my chest after one week (only to take a shower/wash the vest) the areolas/nipples were completely flat.  It was when I was no longer wearing padding that my areolas starting to get a little bit puffy.  And now that I am no longer wearing a compression vest my areolas are very puffy (photos attached) like they were before surgery, maybe even more.  They also seem a little bit hard if that helps at all?  If I wear the compression garment overnight my nipples seem to be fine for about an hour after taking it off in the morning but then they go right back to being puffy.

I know that one month is not that long at all after surgery but this just has me very worried.  The surgeon told me he did a combination of liposuction/gland removal but I'm starting to doubt that he did the gland removal.  So I guess the question here is, did I get ripped off?  Or do you think my nipples will flatten over time?  
Thank you in advance!

[Cristalis]

Very protruding indeed. Tell us more about your surgery, you had gland  excision right, your doc made a little incision at the bottom of the areola, right? 
If you say your areola/niples were flat after 1 week then i would say your surgeon took out the gland but in the process of healing you developed scar tissue, thats a hard tissue that can feel like glandular tissue and begin to develop after a few weeks after the surgery.

This tissue can go away in time by itself or if persists for a long time after the healing process is over(six month up to a year) then your doc could inject you with some Kenalog injections(anti inflammatory corticosteroid).

More info probably you could get from the docs from this forums.

[Timbucktwo]

Thank you for your reply.  I posted this in the 'ask a doctor' forum originally but have recieved no replies yet. Yes my surgeon said he did gland exision and lipsosuction (mostly liposuction he said). And correct there are two scars each right under the areola, those are healing just fine thankfully! Good to know its probably scar tissue, would you think massaging the area would help? Or is that moreso for lumpy/uneven areas? 

Also like I said if I wear my compression vest overnight (like I did last night) my nipples look just fine in the morning (not as flat as after surgery but still good). But then after about an hour or so they go back to being puffy. Is that a sign that its glandular tissue or could that be normal with scar tissue as well?

[Dr. Elliot Jacobs]

At one month, there is lots of healing ahead of you -- so I would not spend too much time in worrying -- it won't alter the situation but it will provide you with premature grey hair!

The fact that the nipples flatten out is a good sign -- if it were scar tissue producing the problem, it would not change overnight.,  Besides, scar tissue takes weeks and weeks to develop -- it doesn't appear quickly.

It is possible that your surgeon did not do a lot of peripheral skin undermining during the surgery.  This is a key step in treatment of puffy nipples.  Simply doing lipo or a small gland excision under the areola will still not allow the skin to retract and tighten in all directions.  One must undermine the skin as well, otherwise the excess areolar skin will have no place to go and it will remain puffy.

Dr Jacobs

[Cristalis]

Hi Dr Elliot, im hijacking timbucktwo's thread for a bit to ask you what do you mean by peripheral skin undermining. English is not my native language and as much as i read the meaning and definition of undermining i cant understand what you mean. Thanks!

[Dr. Elliot Jacobs]

OK, let me try to explain.

When puffy nipples are present, the areolar skin is stretched like a dome and it extends above the surface of the surrounding chest skin.  It is ALWAYS caused by solid breast tissue just beneath it -- it is never just fat.  Many guys try to "feel" breast tissue -- but breast tissue may be reasonably soft.

Many surgeons think they can simply (and carefully) remove the breast tissue so that the areola will lie flat.  However, that is only part of the answer.  If the skin surrounding the areola is not undermined (ie separated and lifted up) from the underlying tissues, then the stretched out areolar skin will have nowhere to go and it will continue to bunch up and form a puffy nipple.  If the skin is undermined, then it will re-distribute tension surrounding the areola and it will lie flat and flush with the surrounding skin permanently (assuming the correct amount of underlying tissue has been removed).

The undermining process adds more surgical time, some additional bleeding (which has to be controlled), etc and some surgeons may not be willing to do this or may not be trained to do this.  However, IMHO, this is the ONLY way to operate on a puffy nipple and be sure that it will remain flat and flush with the surrounding skin.

I hope this has helped clarify the process.

Dr Jacobs

[Timbucktwo]

Although my surgeon is fantastic -he is board certified and everything- I doubt he took out a lot of peripheral skin as well. I looked at photos of other gynecomastia surgeries he did and none of them had the huge puffy nipple like I did/do. So in short, I'm pretty much stuck with my puffy nipples unless I decide to get another surgery?
Again thank your for your responses Dr. Jacobs, very informative!

[Cristalis]

Thank you Dr Eliot, i now understood perfectly what you meant.

Timbucktwo, is too early to tell your final results and worry about.
Maybe its the cause of the problem Dr Eliot spoke of, maybe its something else. I ask my self if it could be sweling and seroma over there that could be drained? Have your doc seen you lately?

Dr Eliot? Could still be sweling and or seroma present after 5 weeks? If he says that in the first week he had his areola flat and that now when he takes his compression vest off is flat for an hour coukd be some swelling?

[Dr. Elliot Jacobs]

Obviously, I cannot diagnose this particular case.

But in general, any physical changes that come and go over a period of hours can only be fluid, not scar tissue.  Scar tissue is a one way street -- it takes time to develop and once it is there, it is there -- it doesn't come and go.

Dr Jacobs

[Timbucktwo]

Is there any other signs that I could look for that would show it is fluid and/or swelling and not just leftover peripheral/glandular tissue?  I'm supposed to see my surgeon Dec 20th (about 5 weeks) to get the post-op photos done. So I'm sure he figured I would have healed by now.

[Timbucktwo]

It is now 6 months after surgery and I just wanted to update anyone reading this that my areolas are not as puffy as they were in the photos I have attached. They're still not as small/flat as I'd like but I am hoping with more exercise and healthy eating that I can make them look a little better.  If that doesn't help as much as I want it to I guess I will have to find a more suitable surgeon to help out. 
Thank you to everyone that had helped me out on this thread (that's you Dr. Elliot Jacobs)!

[Cristalis]

Hey

Good that they arent that puffy anymore. That cluld indicate it wsscar tissue that resorbed with time. Why havent you posted some pics too so we can see the difference?

Also what your doc said about the puffyness at your follow ups?
In my opinion diet and exercise wont make it better, if its scar tissue your doc should have injected some corticosteroids that could help the resorbtion.

[Timbucktwo]

Yeah sorry I will post the updated photos. Dont get me wrong though they're still pretty puffy, it was not scar tissue it turns put. 

[Cristalis]

If its not scar tissue what caused the puffiness? Gland left behind? What did your doc told you? Im curious! You paid big money to get rid of your condition but you still have it, the doc should have told you what it is and maybe he could do a revision.

 You told us he is board certified so my thoughts are that he should have explained what is going on and to revision to problem. who was your doc? Why everybody is afraid to mention names here??

Do you have hard tissue under your areola? If not maybe the cause of puffiness is exactly what Dr Jacobs talked about, the undermining of the skin.

[Timbucktwo]

The puffiness was exactly what Dr. Jacobs was talking about.  My doctor was Dr. Epstein in Northbrook, MAE Plastic Surgery.  He told me I could get another surgery done to help flatten/shrink my areolas if I wanted to, but I'm not sure I'm going to do that just yet.  Are revisions free of charge or?  I'm not sure how that works.  But I'm sure somewhere under the contract I signed that he made it so it would not be free of charge.
But anyways, here is a link to my before and after photos:
https://www.maeplasticsurgery.com/gallery/gynecomastia/gynecomastia-case-19514/
As you can see they're still a little puffy but the difference is still huge so I am still pretty satisfied with the surgery.  At least I can wear normal shirts now without feeling super embarrassed.