Skin adhesions and Craters

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Dr Bermant,

On your website, while mentioning gynecomastia surgeries gone bad by other doctors, you have talked extensively about skin adhesions.

Could you please elaborate more on these skin "adhesions"? I mean to ask if its an actual bonding between the skin and an underlying tissue  which is not supposed to be there, or is it just a term to describe the mere visual illusion of the skin looking pulled in because of lack of supporting tissue underneath to push it out.

I hope I was clear enough, and didnt sound too confusing. I tried my best

[DrBermant]

Dr Bermant,

On your website, while mentioning gynecomastia surgeries gone bad by other doctors, you have talked extensively about skin adhesions.

Could you please elaborate more on these skin "adhesions"? I mean to ask if its an actual bonding between the skin and an underlying tissue  which is not supposed to be there, or is it just a term to describe the mere visual illusion of the skin looking pulled in because of lack of supporting tissue underneath to push it out.

I hope I was clear enough, and didnt sound too confusing. I tried my best

Skin Adhesion or sticking to the deeper tissues is a deformity that looks worse on animation. You can see what I mean with the movies on this complication by another doctor's Gynecomastia Surgery Bad Scar Adhesion. As the muscle flexes or arms lifted overhead, skin sticks to deeper tissues. The cause of this deformity is usually scar, but also can be gland as seen in this Male Inverted Nipple from Gland Attaching skin to deeper tissues. Watch how the gland can tether the skin and invert the nipple in gynecomastia alone before any surgical scars. So adhesion is just as the word is defined, an abnormal union of tissues.

Check out the Anatomy of Gynecomastia and The Male Chest and you will see skin, gland, fat, fascia, and muscle. The fat is encased in a network of suspensory tissues and connects the skin to the deeper fascia. This network of fat and fibers is the body's lubrication layer, permitting skin to move in relationship to the deeper structures.  Some parts of our body are naturally designed to have some adherence, such as fingers. This permits us to pick up objects without the skin sliding around.

When all fat is removed or the tissues between are scarred, the skin is stuck to the deeper structures and does not move well. In the inverted nipple example, there is no fat lubrication layer. The gland attaches the skin to the deeper fascia.

A Crater Deformity Complication from Bad Gynecomastia Surgery is a contour problem of adhesion. On a still picture, the contour can be even. But on animation, the adhesion creates the deformity. Some craters also involve such a defect, that the problem can be seen even without animation. So much contouring tissue has been removed under the supporting skin that the cavity deformity exists even at rest.

That is why years ago I started documenting my patients' deformity and results of surgical sculpture with my Standard Pictures for Gynecomastia. The views of pectoral muscles flexing / relaxed, and arms overhead tend to show issues like adhesion and craters. I then developed my Standard Video of the Male Chest which even better demonstrates such issues.

How tissues move on animation is something most doctors do not show with limited views after surgery. Some doctors seem to pick only a few views to demonstrate the before and after surgery contour issues.  This really becomes suspicious when the choice of views shown varies from patient to patient. I have seen patients in my office who bring pictures of themselves that other doctors had used to sell their "expertise." The choice of photos did indeed hide the deformity the patients were complaining about.

My goal many years ago was to evolve my surgical sculpture to look good in real life, playing basketball, soccer, swimming, and what ever activity the human body enjoys. I wanted to sculpt in a way patients could forget about the problem and deformity.  Looking good is not just an exercise in a sales pitch with a still picture or limited views hiding the quality of the result or residual deformity.

Hope this helps,

Michael Bermant, MD
Learn More About Revision Gynecomastia and Chest Surgery

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Thank you for your highly revelatory replies, Dr Jacobs and Dr Bermant. Both of you are most certainly an invaluable asset not only to this site, but also to gynecomastia patients all over the world.

I also had a slightly general question about liposuction. If too much fat is removed via liposuction, cant the patient's body just grow it back over time, especially for people who have a tendency to gain weight?

Is a patient suffering from excessive liposuction and expecting his body to regrow fat, any different from a person who has been skinny all his life but then gained fat by eating excessive calories?

[DrBermant]

I also had a slightly general question about liposuction. If too much fat is removed via liposuction, cant the patient's body just grow it back over time, especially for people who have a tendency to gain weight?

Is a patient suffering from excessive liposuction and expecting his body to regrow fat, any different from a person who has been skinny all his life but then gained fat by eating excessive calories?

Liposuction removes / kills fat cells, and fat removed by liposuction is gone forever. However, remaining fat cells can still lose or put on extra fat.  Liposuction is not an alternative to losing weight. Fat will again go on or come off with the typical Male Body Fat Distribution.  When typical fat remains in the male breast, weight gain can result in a recurrence of gynecomastia.  When all fat is gone, such as in the depression of a Crater Deformity Defect after Bad Gynecomastia Surgery, the deep hole with no fat cells will not put on fat. The surrounding wall of fat can deepen with weight gain.  With weight loss, crater walls can lose fat and thin.  Of course weight loss will not help with an animation defect.  The motion of the stuck adherent tissue still looks bizarre.

Before risking a specific claim for a crater defect revision working like a fat graft, try to find results on animation. Fat grafts tend to partially survive and usually ends up more firm than fat, something like the firmer distorting tissues of the gland of gynecomastia.  I have yet to see the results from any surgeon from a significant crater defect after bad gynecomastia surgery filled in with a fat graft that moved naturally. Yes, it may look good at rest in a few selected still photographs. But life is not a still picture from a certain angle that looks better than other angles. Living means movement and not just hiding the poorer contours and being able to look natural with the chest exposed during sports or other activities.

Hope this helps,

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

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Thank you for your response Dr Bermant.

I do understand that you highly recommend against the fat graft technique, and I am sure you have very valid reasons for that. However, is it please possible for you to show pictures/videos to demonstrate the subpar results that you have quite often mentioned about on this forum?

I know we could probably look them up by ourselves, but as laymen to the medical field, most of us on this forum would have a hard time finding such pictures/video on the net, and even if we did we would have a hard time spotting the deformity since we lack the keen eye of a plastic surgeon.

As an expert of your field, you have better access to such information more than any of us could ever imagine. It would be indeed helpful to all of us if you posted such videos/pics somewhere so that the patient can be adequately forewarned about what he is about to, or could, get into. Such pictures/videos wont be quite different in principle from the crater example deformities you have posted on your website. Just like fat grafts, crater deformity is not what you give, but simply warn against on how it could be a disaster in the hands of a wrong surgeon.

I speak for the majority of us, that such a gesture on your part would be indeed very kind and warmly welcomed by sufferers everywhere.

[DrBermant]

Thank you for your response Dr Bermant.

I do understand that you highly recommend against the fat graft technique, and I am sure you have very valid reasons for that. However, is it please possible for you to show pictures/videos to demonstrate the subpar results that you have quite often mentioned about on this forum?

I know we could probably look them up by ourselves, but as laymen to the medical field, most of us on this forum would have a hard time finding such pictures/video on the net, and even if we did we would have a hard time spotting the deformity since we lack the keen eye of a plastic surgeon.

As an expert of your field, you have better access to such information more than any of us could ever imagine. It would be indeed helpful to all of us if you posted such videos/pics somewhere so that the patient can be adequately forewarned about what he is about to, or could, get into. Such pictures/videos wont be quite different in principle from the crater example deformities you have posted on your website. Just like fat grafts, crater deformity is not what you give, but simply warn against on how it could be a disaster in the hands of a wrong surgeon.

I speak for the majority of us, that such a gesture on your part would be indeed very kind and warmly welcomed by sufferers everywhere.

It is quite difficult taking a patient with a disaster from another doctor and ask them to permit me to document the deformity to show to others why a technique does not work. Not all patients are candidates for revision surgery and such requests can be stressful for both the patient and myself.  Some of the patients coming to me with deformities are kind enough to permit me to show such issues. Perhaps some day I will be able to show such a disaster.  I may already have such a case, but have so many other things to put up on the web of what I do offer, that putting up what I do not offer is just not a high priority for me.

Your request is actually misplaced. The request should be for the doctors claiming the technique works to demonstrate that it works. Such demonstration should include the animation and video which really show the refined aspects of the sculpture. A still picture is just not enough. A firm puffy nipple can look great with a stimulated areola. On motion, the deformity is revealed. Check out this new video I just posted last night:

Revision of after gynecomastia surgery done by another surgeon.

Watch how the deformity moves before and the natural sculpture after. Look at the Before and After Revision Gynecomastia Surgery Pictures and particularly look at the gland left behind by the other doctor. This firm tissue, like a firm fat graft, just does not move well and left a puffy nipple deformity that made the patient unhappy with his other doctor's surgery.

As a courtesy, I have passed on my experience of what I have seen and felt. I have seen several such disasters of fat grafts on the chest by other doctors. If something works, you should be able to demonstrate with actual examples that it works and moves naturally.  I document what I am able to do, why are you accepting the undocumented statements of doctors who claim it works?

Hope this helps,

Michael Bermant, MD
Learn More About Revision Gynecomastia and Chest Surgery