Crater deformity advice - post fat transfer failure

[isambard]

Hello doctors,
I had gynecomastia surgery 6 years ago with full gland removal and liposuction. After surgery I noticed considerable crater deformity on both my nipples and the area around my left nipple was also generally flatter than the rest of the area around it. Obviously the surgeon over liposuctioned the area.  I approached her for revision of this area, she offered to do a fat transfer to both nipples, (liposuctioning fat from my belly and injecting it under my nipples.) This revision surgery was carried out 2 years ago but I felt not nearly enough fat was injected in the area and consequently within a few days following the procedure the nipples began to deflate again. A full return to the flattened/depressed appearance resumed after a month following the revision surgery.
Attempts to contact the surgeon for further discussion have failed. I now want to attempt to correct this once and for all and would be very keen to have some suggestions. I am considering synthetic filler injections or even implants?? I have heard of fat grafting but am worried this would just be another failed and expensive attempt at moving fat around. I am based in the UK. any insight is much appreciated. Please see pics for reference. 
Many thanks

[Dr. Elliot Jacobs]

You are the poster boy for what I have stated many times over:  if possible, the best treatment for post-op crater deformities is a fat flap operation.  Fat grafting for this problem is fraught with uncertainty -- and often multiple procedures are needed to achieve a modicum of success.

Dr Jacobs

[isambard]

Dr Jacobs, 
Why would you not recommend fillers or implants to fill in the crater? Seems more reliable than fat grafting or fat flaps which, by your own admission, is fraught with uncertainty?
I am based in the UK but could consider travel to NYC for fat flap treatment with you if you are confident some long lasting results can be made. Would be interested in more information on this procedure, costs, and seeing photo examples of this sort of work (can't find any on your website). 
Thank you.

[Dr. Elliot Jacobs]

First, I DID NOT say that fat flaps were fraught with uncertainty -- fat grafting is uncertain.  Fat flaps are an excellent and reliable way to reconstruct a crater deformity PROVIDED that there is sufficient surrounding tissue to borrow from.  From the photos you showed, you would probably be a good candidate for such a fat flap procedure.

Skin fillers could be used for craters but it would be a very expensive and temporary fix, since most fillers last, at most, a year or two, and then would have to be repeated.  Bear in mind, even a small crater volume is multiple cc's of volume.  That is why most docs try to use fat, which (in most patients) is fairly plentiful.

As for photos of reconstruction on my website, please see:  https://ww w.gynecomastianewyork.com/ba-reconstruction-revision-of-crater-deformities.asp    Each patient was reconstructed with fat flaps.

It is difficult to photograph and document craters -- it requires lots of photos to illustrate the depth of a crater by creating shadows.  And then, post-operatively, one must take the same photos in the same orientation to illustrate the improvement.  Not an easy task.

Dr Jacobs

[Litlriki]

Fat grafting can be effective for your situation, but it does appear that you'd likely also have adequate tissue to do some small fat flaps to correct the contour, and as pointed out, grafting is less certain in terms of outcome and can require more revisions.  That can happen with a fat flap too, but not as likely. 

[DrPensler]

There are several issues with your case. This is a common issue with a surgeon who is inexperienced with gynecomastia in my experience. Specifically there is a a too limited excision of tissue over a large area  combined with an over resection of tissue directly under the areola. I call it a doughnut deformity for obvious reasons. The correction requires removal of excess tissue in the areas with residual tissue combined with addition of tissue into the over resected areas. Fat grafting into a scarred bed just does not work well. This is something I can state with a large degree of certainty. Secondary reconstruction are difficult but I would tell you  tertiary reconstruction after failed secondary surgery are an  order of magnitude more  difficult. Typically in tertiary reconstructions optimal results just are not possible something to consider.

[isambard]

Dr. Pensler,

So you're saying there's not hope? Should I consider implants? 

-I

There are several issues with your case. This is a common issue with a surgeon who is inexperienced with gynecomastia in my experience. Specifically there is a a too limited excision of tissue over a large area  combined with an over resection of tissue directly under the areola. I call it a doughnut deformity for obvious reasons. The correction requires removal of excess tissue in the areas with residual tissue combined with addition of tissue into the over resected areas. Fat grafting into a scarred bed just does not work well. This is something I can state with a large degree of certainty. Secondary reconstruction are difficult but I would tell you  tertiary reconstruction after failed secondary surgery are an  order of magnitude more  difficult. Typically in tertiary reconstructions optimal results just are not possible something to consider.

[isambard]

Doctors (Jacobs, Silverman, Pensler)
Thank you for your attention and responses.
I have seen Dr Jacobs' crater revision pictures (using fat flaps). They do appear successful but the size of the depressed area appears to be much smaller than my affected area. Covering just the nipple area. If you see my chest in profile (pictures at top) you can see that a large extent of my chest is depressed and flattened. It would take a lot of fat grafting to get this right.
I've noticed that none of you have advocated for the implant option as a surefire way to resolve the shape and contouring issues. Is that because it is not something done in your clinics or is it not a suitable solution? I would prefer the natural fat flap method but it does seem like there is a level of risk that could just turn out to be a big waste of money. But it sounds like something I should approach your clinics for pricing and consideration. 

Thanks again,
I

[DrPensler]

<a class="underlinelink" href="https://www.gynecomastia.org/doctors/jaypensler/profile">Dr. Pensler[/url],

So you're saying there's not hope? Should I consider implants?

-I

I am saying exactly what I stated nothing more,nothing less.
What I was implying is secondary surgery is difficult and different than primary surgery. Take some time and find a qualified surgeon. As far as implants they are certainly easy to insert,the issue is they are static and firm . Implants also may slightly shift with time resulting in an adverse result. Your issue to rehash is that there is an area of over resection ( requires augmentation) and an area of under resection ( requires removal or transposition of tissue).

There are several issues with your case. This is a common issue with a surgeon who is inexperienced with gynecomastia in my experience. Specifically there is a a too limited excision of tissue over a large area  combined with an over resection of tissue directly under the areola. I call it a doughnut deformity for obvious reasons. The correction requires removal of excess tissue in the areas with residual tissue combined with addition of tissue into the over resected areas. Fat grafting into a scarred bed just does not work well. This is something I can state with a large degree of certainty. Secondary reconstruction are difficult but I would tell you  tertiary reconstruction after failed secondary surgery are an  order of magnitude more  difficult. Typically in tertiary reconstructions optimal results just are not possible something to consider.

[Dr. Elliot Jacobs]

I could not agree more with <a class="underlinelink" href="https://www.gynecomastia.org/doctors/jaypensler/profile">Dr. Pensler[/url].  

You appear to be concerned about craters under the nipples as well as a flatter upper chest.

When I examine patients for revision, most of the time, the over-resection of tissue is limited to the nipple area, where over-zealous removal of tissue can result in a crater deformity.  On other areas of the chest, sometimes there is a bit too much tissue remaining, therefore leaving a "donut" type of deformity.

When considering revision, I will often do secondary liposuction of the surrounding excess remaining tissues and then use fat flaps to fill in the crater.

In your case, you seem very concerned about flatness of the upper part of the chest as well as the craters below the nipples.  I would submit that the upper breast flatness really is normal and is part of a defined chest that your original surgeon provided.  However, it appears that he did take out too much tissue under the areolas.  The additional tissues further up on the chest and towards the armpit may indeed be residual fat that should have been removed as well. Perhaps additional lipo in those areas would help to provide you with a more defined chest and a better contour overall.

Obviously, the above are just thoughts based on just a few photos that you provided.  Your best chance for a better result is by visiting a gyne expert.  But remember, you have now had two operations and have scar tissue from BOTH operations.  Any potential future operation should be undertaken with the goal of improvement, not perfection.

And by the way, implants would not improve the crater deformities at all.

Good luck!

Dr Jacobs