Question about loose skin (pics included)

[thetinwoodsman]

Was just wondering, based off my pics, if I will have a lot of loose skin to deal with when I go through with my surgery.  I am planning on getting it done in the next month or two.  In these pics I am around 265 lbs.  I have been heavy my entire life, especially in high school, but I started lifting weights and gained a lot of muscle mass around 2003, but maintained a weight of around 300 lbs.  The beginning of this year I started trying to cut bodyfat and went from 315 lbs to 265 lbs today.  I am 26 years old, BTW.  I have seen tremendous results everywhere, but my chest actually looks worse now because there is less fat everywhere but my chest.  I am positive this is gyno and based off pics I've looked at of other cases it's a pretty severe case.

I did a consultation with a local doctor and he said there was a chance of loose skin but didn't act too concerned.  He has some before/after photos on his website but I know he doesn't specialize in gyno specifically.  Would love to have some opinions of doctors on this site.  I know ideally I could stand to lose 30-40 more lbs (which I will) but this gyno is absolutely killing my self esteem and I can't wear anything but black shirts.  After my weight loss I actually look great in shirts except my gyno kills my shape.  Sorry for the rant, here are the pics.  My left side seems to have the bigger gland tissue than my right, BTW.

http://img269.imageshack.us/img269/1999/17536578.jpg

Thanks in advance for your feedback!

[Dr. Elliot Jacobs]

One of the problems facing overweight men is that their gyne is an embarrassment and can make them reluctant to go to a gym as part of a weight loss program.  Part of this is physical -- and part is psychological (ie problems with body image).

Weight loss prior to surgery is the ideal way to go.  You might be able to help yourself by wearing a compression garment to provide some shape while you are in process of exercising.

On the other hand, sometimes surgery at your present weight can provide a physical as well as emotional boost to you -- which can then spur further weight loss after surgery.  There is truly no right answer for you.

One way or another, whether you have surgery now or after weight loss, your skin's elasticity has been irreparably damaged by being overweight.  And whether you do surgery now or after weight loss, there will probably be some residual skin laxity.

The good news for you, and this is based only on the photos you have provided and no other medical information, it appears that you are muscular and that your gyne (in proportion to the rest of your body) is relatively small.  In cases I have done similar to you, the skin has tightened -- to some extent.  The result was a flatter and more contoured chest (you should also have some lipo on the side of the chest as well) but with a retained fold under the chest.

If you are left with residual lax skin, the only way to tighten it would be some variation of a skin tightening procedure -- which will leave much more extensive scars on your chest.

So it boils down to surgery with minimal scars and a less than perfect result (albeit considerably improved) versus a tight, contoured chest with lots of scars.  Most of my patients prefer and accept the former.

One other consideration to spur your weight loss: once your chest is flat and contoured, the size of your abdomen may become more apparent.  And the abdomen can only be improved with diet and exercise -- there are no short cuts.

Good luck!

Dr Jacobs

[DrBermant]

Was just wondering, based off my pics, if I will have a lot of loose skin to deal with when I go through with my surgery.  I am planning on getting it done in the next month or two.  In these pics I am around 265 lbs.  I have been heavy my entire life, especially in high school, but I started lifting weights and gained a lot of muscle mass around 2003, but maintained a weight of around 300 lbs.  The beginning of this year I started trying to cut bodyfat and went from 315 lbs to 265 lbs today.  I am 26 years old, BTW.  I have seen tremendous results everywhere, but my chest actually looks worse now because there is less fat everywhere but my chest.  I am positive this is gyno and based off pics I've looked at of other cases it's a pretty severe case.

I did a consultation with a local doctor and he said there was a chance of loose skin but didn't act too concerned.  He has some before/after photos on his website but I know he doesn't specialize in gyno specifically.  Would love to have some opinions of doctors on this site.  I know ideally I could stand to lose 30-40 more lbs (which I will) but this gyno is absolutely killing my self esteem and I can't wear anything but black shirts.  After my weight loss I actually look great in shirts except my gyno kills my shape.  Sorry for the rant, here are the pics.  My left side seems to have the bigger gland tissue than my right, BTW.

http://img269.imageshack.us/img269/1999/17536578.jpg

Thanks in advance for your feedback!

Congratulations on the weight loss! 50 pounds is quite an achievement.

The problem is that Male Fat Pattern extends around the chest, under the arms, and around the back.  Plastic Surgery is not a good tool for a global fat problem. The biggest change I have noticed over the years, is that patients who lose weight tell me that they feel so much better about themselves. It often changes the front to a degree, but the sides and back can see a major benefit from getting the excess total body fat under control.

I advise my patients to get to a weight / body fat percentage they are comfortable with before considering surgery.  A BMI Calculator does not differentiate between fat, muscle, and bone.  Body Fat Calculators can help with the fat percentage and are better at helping understand the fat component.

For those with too much body fat, Weight Loss Before Gynecomastia Surgery can help with the fat, but not the gland.  However, you cannot pick where your fat comes from.

Plastic Surgery is not a good jump start tool for weight loss.  I have seen disasters from patients from other doctors with deformities from significant weight loss after their surgery.  Men tend to put fat on first in the belly and chest bands.  We tend to take of those areas last.  Early surgery and depending on weight loss to predictably change the body is a nasty gamble.  No Surgery Body Shaping Garments are a better temporizing choice. Check out this post for more details about the value of this compression garment:

http://www.gynecomastia.org/smf/index.php?topic=18591

As a surgical sculptor, I view weight loss as a coarse tool and my plastic surgery as a refinement tool.  I prefer to use the coarse tool first, and then my sculpture for refinement.

Gynecomastia patients may need stabilization of their problem before considering surgery.  They may need to lose weight first.  Weight loss patients may have more to loose before they are done. Surgery too soon with further weight loss can result in more loose skin. Being patient helps.

The male chest can be distorted by both Gynecomastia Male Breast Enlargement. Drooping or Ptosis is a frequent problem after massive weight loss or deflation of massive muscles. Such skin may have very little elasticity and tends not to shrink well after surgical reduction. 

Options for this problem are a compromise:

• Live with the excessive weight: Bad for your health.
• Male Mastopexy Chest Lift: Skin reduction scars are a compromise, but can be quite reasonable as demonstrated on the many examples I have posted.
• Low Male Nipples Areola: Reduction without lift can still leave the loose skin and low areola.  Check out this drawing to see how weird low nipples look on the male chest.
• Body Shaping Garments - contouring without surgery.

Limited pictures does not really tell the story about how much is the loose skin a factor. That is why I evolved my Standard Pictures to Show Male Chest Drooping after weight loss which can help others better understand if the loose skin component is a factor.  The bending over views tend to show how much of a contribution the loose tissues make.

Surgery to deal with both the residual contours of gynecomastia and loose hanging tissues can be combined. Excess Skin of the Male Chest is a compromise. To remove the excess, you need an access point where the skin is removed.  I prefer short scar techniques as much as possible.  Male Mastopexy Chest Lift for Drooping Chest or Ptosis can consist of many different Surgical Options for Excess Skin of the Male Chest.

I prefer to individualize each surgical sculpture based on the problem to be treated.  The best surgery minimizes scars.  This is not just the incisions, but the entire sculpted surface.  The chest should also look good in motion, not just a few pictures at selected angles. Sometimes leaving loose skin is a good compromise.  At other times the scars from a skin reduction are a much better choice.  The actual choice for skin reduction incision is quite different for men than women.  A scar beyond the areola is not well hidden on a contoured male chest unless it is hidden in the natural crease of the pectoral muscle as in this Skin Reduction Chest Lift.  Some patients have skin quality good enough for my Short Scar Internal Male Chest Lift Surgery. This internal lift is done through a small 2 to 3cm incision, lifts the drooping tissues, but leaves the loose skin as a compromise.

Here are several examples of patients with various degrees of loose skin after weight loss and compromises performed.

Short Scar Internal Chest Lift After Weight Loss

Short Scar Male Chest Lift

Male Breast Lift (Internal)

Short Scar Male Chest Lift

Skin Reduction Male Chest Lift

Hope this helps,

Michael Bermant, MD
Learn More About Gynecomastia of Male Chest Ptosis - Sagging and Male Mastopexy Chest Lift Sculpture

[thetinwoodsman]

Thanks for the feedback gentlemen.  I had an idea that my stomach would be more pronounced if my chest was flatter, but it's a sacrifice I am definitely willing to make, plus I don't have much of a beer gut and I will flatten it over time. 

A question for Dr. Jacobs... when you say that I will have a retained fold under the chest, what exactly do you mean?  Do you have any example pictures showing this?

The doctor I consulted with had 3 levels of surgery he could do; level 1 was just lipo of the chest area, level 2 was lipo combined an incision around the bottom of the areola where they went through and removed the gland tissue, and level 3 was for very severe cases where they did level 2 along with skin tightening that left significant scars right around the base of the pecs.  I am definitely leaning towards level 2.  He told me level 2 would give 100 percent correction as far as the gyno was concerned but with a chance of loose skin, but said that he has never had any issues with bad cases of loose skin.  He recommended twilight anesthesia and not full, and the price was around 3500 after all fees.  Any comments or concerns on this? 

[thetinwoodsman]

Also, another question, I forgot to even ask the doctor about this during consultation, what is the likelyhood that he will use drains post surgery, or does it vary depending on the doctor's personal preference?

[Dr. Elliot Jacobs]

The use of a drain is determined by the surgeon's judgment of the need for them at the time of surgery.  Drains may be thought of a "safety valve" if leakage of fluid or blood is suspected or anticipated post op.  Some surgeons use them routinely; others use them based on what transpires during surgery.  There is no right or wrong as to the use of drains.

The "fold" that I refer to is technically the "infra-mammary fold" -- ie the crease underneath the pec muscle.  In cases of skin laxity, it may be difficult to eradicate the fold and provide a chest which is contoured and as tight as the head of a drum.  But as I previously said, for someone who is or has been overweight, the skin can tighten only so much after surgery.  If you have lipo (with/without excision), your gyne will be smaller and then skin will tighten to some extent.  And the result of this minimal scar surgery may be quite satisfactory to you -- but perhaps not perfect.

Another point:  when faced with cases such as yours where there is a question of residual skin laxity, I usually discuss a possible two-stage approach.  That is, do the major surgery with minimal scars first. The skin will undoubtedly tighten -- to some extent. Then at 6-8 months post op, the patient and surgeon meet again to discuss the results.  If the patient is satisfied, then I am satisfied.  If the patient wants to be tighter, then an additional operation can be done which will deal with a much smaller extent of lax skin (because the skin has had 6 months to tighten).  This would then result in much smaller scars.

By the way, I do not differentiate about my methods when discussing possible surgery with the patient.  During surgery, I do whatever is necessary to get the best result possible, be it lipo alone, excision alone, or most commonly, a combined approach.

Dr Jacobs

[DrBermant]

Also, another question, I forgot to even ask the doctor about this during consultation, what is the likelyhood that he will use drains post surgery, or does it vary depending on the doctor's personal preference?

A good question for your doctor. Drains after surgery help remove fluid from surgical sites and hold tissues together during early healing. They are more uncomfortable than not needing drains, require additional antibiotics, need an additional scar for placement, and can slow the healing process.  It is quite rare for me to use drains for my gynecomastia surgery. I have evolved the techniques for my patients' Comfort After Gynecomastia Surgery that I need drains about once every 1 to 2 years for my male breast reductions.  I still need drains for my Tummy Tuck Abdominoplasty, usually one for each patient, and 4 drains for my Lower Body Lift Surgery.  It is a function of body location, the compression garment is just more effective on the chest with rib support than the softer stomach.  Patients always tell me the relief they have after the drains are gone.

Hope this helps,

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

[Dr. Elliot Jacobs]

Drains should be thought of as a "safety valve" if the surgeon thinks it is necessary.  They will remove any fluid or blood that might collect after surgery.  Usually, a surgeon will decide upon the use of drains during the operation.  Some surgeons use them routinely on every case; others not at all and still others only if they deem it necessary.

Drains are useful but they can be uncomfortable, while they are in and during the moment that they are removed.  They also pose a theoretical risk of introducing infection into the wound area.  Most of the time, when drains are in place, a surgeon will keep the patient on antibiotics.

My preference is to avoid drains whenever possible.  Indeed, I use a drain only once or twice a year on average.

Dr Jacobs