Lipo first or gland removal ?

[steelhead]

For the two main doctors on this board when doing gynecomastia surgery what do you do first ?

[Dr. Elliot Jacobs]

I perform aggressive lipo first (using cannulas of my own design) -- and sometimes that is all I need.  I am able to remove fat and some gland with this method.  Net result:  one small incision on the side of the chest.

However, sometimes I encounter some really hard, dense gland -- and this is usually directly under the nipple.  Even my instrument cannot remove this.  If it is small, I have some instruments which can this gland from the same small side incision.  If it is large, however, I will then, without hesitation, make a peri-areola incision and remove it that way.

My average is roughly 50% peri-areolar incisions -- probably higher in younger men and lower in older men.

My philosophy is to minimize the incisions as much as possible.  However, I am not reluctant to make a peri-areolar incision -- it heals exquisitely well in most cases.

I am aware that other doctors have other preferred methods -- that's fine.  They ALL WORK!

What counts is the final result -- not the road by which you arrived at the result.

Dr Jacobs

[DrBermant]

For the two main doctors on this board when doing gynecomastia surgery what do you do first ?

My sculpture has evolved over the years. Although a normal male chest will have a tiny amount of gland, it should not show when the areola muscles relax and in motion. A chest should look good beyond just a few still pictures. How it moves when playing sports, exercising, flexing are critical.  It does not take much gland to distort the male chest. Residual gland and scar move like gland and scar, fat moves like fat. 

I prefer my Dynamic Technique where, what I find during surgery helps guide what needs to be done.

When gland is present, and it usually is, I prefer to start with and target the gland first. By concentrating on gland, I target the tissue that compresses the least and reserve the remaining fat as a potential tool for my reconstruction. 

Liposuction is fine for fat.  However, all forms of liposuction

• specially designed sharp cutting cannula
• ultrasonic
• vasor
• power assisted

all preferentially remove fat over gland.  Check out the Normal Anatomy of Gynecomastia.  When fingers of fat are between fingers of gland, liposuction alone tends to suck out the fat condensing  the gland behind making a mess. 

When significant gland is present, I start at the edge of the chest skin areola interface. That is a great place to fool the eye about a scar. Typically for normal gynecomastia, I need only one small incision on each side often about 1.6 cm (a little over 1/2 inch). This is much better than needing 4 incisions.  Direct access to the gland gives me direct access to controlling hemostasis (bleeding). This is a major factor in minimizing Bruising and Swelling with my Gynecomastia Surgery and why I can post such Early Healing After Gynecomastia Surgery Pictures.  Less swelling and bruising often results in greater Comfort After Gynecomastia Surgery.

Liposuction is but one of many tools of my artist's palette for surgical sculpture of the male chest and gynecomastia.

• Excision,
• Liposuction,
• Microliposuction,
• Nipple Sculpture,
• Mastopexy Male Chest Lift,
• Skin Reduction,
• and other techniques.

My Fat Flaps can bring fat into a crater.  A flap is tissue moved with a blood supply.  Adjacent fat transfered with a blood supply tends to survive, much better than a graft.  When carefully done, fat flaps tend to look like normal fat, feel like normal fat, and move like normal fat.  There are limitations to what fat flaps offer since fat still connected to its blood vessels will move only so far.

Try to go through the entire section about male chest sculpture on my site to learn what my techniques of surgery have to offer.

When liposuction is used first, a hole is often dug in the fat making a "flat" contour.  But the firmer gland does not compress like the fat causing distortion. In addition, techniques that target the gland remotely need to come at the gland from the gland edges and often leave a layer of gland under the areola that can look bad when the areola muscle relaxes and on animation.

Here are just a few of the many examples I have seen and treated:

Revision Gynecomastia After Failed Liposuction By Other Surgeon

Revision Puffy Nipple Gynecomastia After Failed Liposuction By Other Surgeon

Revision Gynecomastia After Liposuction and Partial Gland Excision By Other Surgeon.

Yes, there are many more examples of this technique on my website.  Gland targeted first and almost all removed, the surrounding fat replacing that gland.  I have never seen a crater deformity from my sculpture. 

The technique does not stop in the operating room.  Patient education, after surgery care, Compression Garments, Scar Care are but a few of the attention of detail that permits our patients to have maximum swelling at the time of surgery, quick recovery, and move on with their lives. 

You will not find many of my patients on the forums to answer your questions.  A few post but then disappear putting their gynecomastia behind them.  However, there are many patients who have been willing to share their gynecomastia surgery experiences on many pages of my website and in this forum.  (Start at the first page and then follow the arrows).

But in the end, each surgeon has the methods he / she prefers. It is the result that counts. But that should be a result

• that a patient does not need to keep his arms down or not flex his muscles to hide deformity,
• a result that looks good from many different views and looks good even on animation while living life no longer hiding the chest with clothing,
• and a result that does not typically need so much bruising, swelling, and discomfort to get to the other side.
  

Hope this helps,

Michael Bermant, MD
Learn More About Gynecomastia and Male Breast Surgery

[steelhead]

Thanks doctors !

Dr. Bermant I think your technique sounds like the best approach.

" When gland is present, and it usually is, I prefer to start with and target the gland first. By concentrating on gland, I target the tissue that compresses the least and reserve the remaining fat as a potential tool for my reconstruction. "

" Gland targeted first and almost all removed, the surrounding fat replacing that gland. "

[Dr. Elliot Jacobs]

You are certainly entitled to your own opinion.  However, please keep a few things in mind.  If you read carefully, "dynamic technique" means that decisions are made during surgery which may alter what the surgeon does during the surgery.  In fact, I described the same thing, in that my surgery is dictated by what I find during surgery -- and is altered during surgery as the case may demand.  

Oh, and by the way, fat flaps and other types of flaps are standard techniques and are used routinely by all plastic surgeons every day.

Finally, the cannula which I designed CAN remove breast tissue -- I have many doctors around the country who have bought this cannula, tried it and love it because it brings a whole new dimension to the performance of gyne surgery.  

Like I said previously, what counts is the final result, not the road by which you arrived at it.

Dr Jacobs

[steelhead]

Very well noted Dr. Jacobs.

I did not mean any offense to your technique at all.

[George Pope, M.D.]

I agree whole-heartedly with Dr. Jacobs.  We are all trained in plastic surgery to think on our feet and alter the procedure as indicated based on what we find at the time of surgery.  That is what makes plastic surgery so challenging and so interesting.  Each case can be different.

And I also perform liposuction on the chest before I remove the gland tissue.

Dr. Pope

[Dr. Cruise]

This particular question is akin to the "holy grail" of gynecomastia surgeons. What I particularly like is the exceptionally high level of competence in all the responding plastic surgeons. As you know, gynecomastia is relatively uncommon for most plastic surgeons but is VERY common for those of us who have a passion for it. I agree with all that has been said. The only thing I would humbly add is my opinion about liposuction alone. 5 years ago I did a relatively high percentage of my cases with liposuction alone (somewhere around 50%). I used very aggressive cannula ( I must try Dr. Bermant's). Most of my patients were very happy. You can see where I am going with this. Most is not good enough. I had to take a small percentage back for excision.

My response to this was to be even more aggressive with the liposuction. I tried to stay strictly within the gland but the problem I had was that the fat within the gland and the fat outside the gland are different. The surrounding subQ fat is much more responsive to cannula than the intra capsular fat. This may cause an over resection of fat right at the margins. When this happens the dermis can adhere to the underlying pec major. This can be a big problem.

Currently, I use liposuction to make for a smooth transition along the margins and usually resect the gland. I find it more predictable in my hands to surgically leave exactly the amount of fat/gland behind when I am looking at it than with a cannula.

I don't believe this approach to excision is as germane to the surgeons on this forum but it is for the plastic surgeon who does gynecomastia correction infrequently.

[steelhead]

Thanks Dr. Cruise another interesting perspective.