Two Stage Procedure for Surgery Requiring Skin Excision

[citydweller]

I've seen online that some plastic surgeons (e.g., <a class="underlinelink" href="https://www.gynecomastia.org/doctors/migueldelgado/profile"><a class="underlinelink" href="https://www.gynecomastia.org/doctors/migueldelgado/profile">Dr. Delgado[/url][/url]), offer two-stage procedures. As I understand it, the purpose of this approach is to allow for some skin excision while avoiding the scar along the inframammary fold. From what I've read, in the first stage, the surgeon removes the gland and performs liposuction. The chest is then allowed to heal for a few months.  During that time, some skin contraction may occur, and the blood supply to the nipple that is damaged during the stage one procedure is restored.  In the second stage, the surgeon performs a donut lift or other kind of skin excision around the areola.
I met with a plastic surgeon in New York, where I live, who does not frequently perform gynecomastia surgeries, and he suggested this approach.  A surgeon I met here who does perform these surgeries frequently, however, rejected it, saying that it typically leads to large, flattened, saucer-shaped areolas or too much lax skin.  
Have surgeon had success with this approach?

[Dr. Elliot Jacobs]

Basically, it all depends on how much excess skin you have.  Postive factors are youth and never having been obese -- the skin is then more elastic and can self tighten.

My mantra is to try to get the very best result (a trim, contoured masculine chest) with the most minimal of scars.  To that extent, I prefer aggressive surgery on the first go around.  Oftentimes, both the patient and the surgeon are surprised (even shocked) at how much the skin will self tighten.  I will often caution that the amount of self-tightening cannot be guaranteed after surgery and would offer a second, smaller, skin tightening procedure after six months -- but most often, the skin tightens sufficiently so that the second procedure is only rarely requested.

Just food for thought.

Dr Jacobs

[Dr. Schuster]

It all depends on the size of your breast, position of the nipple and looseness of the skin. Most patient I see prefer to have only one operation. If you are a candidate for a periareolar skin reduction it can be done at the first operation. I think that there is a limit to how much skin be removed with a periareolar reduction without producing distortion or flattening of the nipple areola complex. I think that if your skin is not going to cooperate with shrinking it can create other unwanted problems by letting it shrinking only partially thus creating some folds and irregularities that can sometimes be difficult to smooth out. The nipple graft operation leaves you with a tight smooth chest with the trade off being a longer scar along the IMF. The scar can heal very well though if done properly.

[Litlriki]

Like Dr. Jacobs, I tend to be as aggressive as possible with the first procedure and if I'm concerned that the skin won't tighten adequately, I do a few things to try and encourage as much tightening as possible.  I do a very aggressive liposuction procedure and I remove the gland through a peri-areolar incision like I do normally, but I'm a bit more aggressive with a 3 mm (pretty small!) liposuction cannula and I use it in the superficial tissue all the way up to the collarbone to try and get as much lift from above the nipple.  After I've completed the procedure, I dress the patient with a sheet of sticky-backed foam, which splints the skin and keeps the nipple in good position during the first post-operative week. Often, these patients need no further revision. If the patient requires a smaller areola, and I anticipate that skin removal may be necessary later, I will delay this and use that secondary procedure to correct the other soft tissues as needed.  This works will if the tissue and skin excess is circumferential, but if it's in the horizontal plane, the infra-mammary incision with a small inferior pedicle flap (or a free nipple graft, if the anatomy doesn't allow for the flap) should be considered as the primary procedure, since the flap option is gone once the conventional approach to removal is done--the nipple flap won't work. Photos would be helpful.