Ultrasonic Lipo

[roflbbq]

Hello,

Here's my case: http://www.gynecomastia.org/smf/index.php?topic=21688.0

I had my first consultation today. The doctor said I wouldn't need any incision to remove breast tissue and that he'd just be performing lipo on my chest. He prefers ultrasonic procedures. The doctor is credible/board certified, but I forgot to ask him for extra before/after pictures at his office. There was only one on his website.

I thought that puffy nipples were always an indication that you needed glandular tissue pulled out (i.e. not just lipo). Was I incorrect? Based on the pictures in my original thread, would you agree with his methods?

Thanks.

[Dr. Elliot Jacobs]

Ultrasonic lipo can remove fat -- not gland.  If you have gland (and most men do), then your operation will be incomplete and I believe you will not be happy.

Suggest you obtain another opinion from a different surgeon -- and make sure you see more than one example of before and after photos of his gyne work.  A surgeon should not be fixed on just using one technique when approaching an operation -- he should be flexible and experienced enough to use any available method or combination of methods to achieve the best result possible -- during the initial operation.

Dr Jacobs

[DrBermant]

Hello,

Here's my case: http://www.gynecomastia.org/smf/index.php?topic=21688.0

I had my first consultation today. The doctor said I wouldn't need any incision to remove breast tissue and that he'd just be performing lipo on my chest. He prefers ultrasonic procedures. The doctor is credible/board certified, but I forgot to ask him for extra before/after pictures at his office. There was only one on his website.

I thought that puffy nipples were always an indication that you needed glandular tissue pulled out (i.e. not just lipo). Was I incorrect? Based on the pictures in my original thread, would you agree with his methods?

Thanks.

Doctors should be able to show what their techniques offer. Having many examples on a website helps patients better understand that sculptor's skills and limitations of techniques. In evaluating any particular technique, it is a question of what the final results looks like and the path needed to get there. Swelling, bruising, comfort after surgery, also can be important factors in choice of surgical technique. Results should look good while living life, not just in a still photograph.  Seeing how tissues move is also critical in evaluating how good a result is.

I have posted how to pick a gynecomastia surgeon here:

http://www.gynecomastia.org/smf/index.php?topic=16474.0

Liposuction Is Great for Sculpting Fat

Various types of ultrasonic and power assisted liposuction (UAL and PAL) have been around for quite some time.  Each surgeon uses the tools and techniques he / she prefers.

There are studies claiming that ultrasonic liposuction does not break down gland cells, these were done to justify the safety in female liposuction breast reduction surgery.  Ultrasonic energy cannot be both ways, good for gland breakdown and safe not harming gland unless there is a difference between male and female breast gland tissue which has not been proven to my knowledge. 

Liposuction such as ultrasonic, VASER, Laser, power assisted, and sharp cutting cannula preferentially remove fat over gland.  Gland tends to exist under the nipple areola region.  When fingers of fat extend between fingers of gland, breast reduction can come from removing the fat and leaving gland behind.  On animation such as flexing the pectoral muscles or putting the arms over head, gland does not compress or move like fat.

When gynecomastia is from fat, liposuction works very well for contouring the chest.  I have seen many patients from other doctors who tried to use liposuction alone techniques that left gland behind that the patients just did not like for Revision Gynecomastia Chest Sculpture.

Here is an example of Revision Surgery after Liposuction alone.   Here is another revision after liposuction alone.

The problem is picking the right method for what actually is that patient's problem.  That is why I prefer my Dynamic Technique that permits what I find during surgery to guide my sculpture.  The incision at the edge of the areola  opens up my entire spectrum of artist's pallet of tools for my sculpture.  A remote incision robs me of many options and just does not looks as nice.

I have also seen patients with channel problems between remote access sites and the areola / nipple.  Scars, adhesions, and depressions can look terrible.  Check out the lateral (side views) and posterior oblique (side from the back views with and without muscle flexion here to see what I mean.

Ultrasonic liposuction uses energy to help emulsify fat.  Power assisted liposuction uses mechanical vibrating devices to rapidly move the cannula back and forth.  Both PAL and Ultrasonic methods have been around for several years.  Many do not prefer what they do to the tissue.  Others like what they offer.  Both still preferentially remove fat over gland.  Both make the work of the surgeon easier.  Some feel ultrasonic liposuction can cause more swelling, bruising, and the increase the need for drains.

Laser Liposuction ("Smart Liposuction") is just another variation of trying to destroy fat cells while in the body using laser light energy.  There are no reliable studies that it will also destroy gland well.  If it did, it would also destroy connective tissue, fascia, and dermis all closely related to light absorption in the body.  I have seen disasters from patients who had been told that the method would help their gland.  Some had defects I could not help.

For a liposuction cannula to remove gland, it can also remove connective tissue and other structures which can lead to more bruising and scars.  I have seen so many patients who were unhappy from doctors that used "special cannula to remove gland," that I just prefer to go directly to the problem itself.  Primary surgery is usually better than needing a revision.  All male breasts have gland.  With access to the gland directly, I can peel it off the areola muscle, minimize bruising and bleeding with direct control of the tiny blood vessels, and then reconstruct the contour.

For me however, they also both remove the feel of the tissue sculpture.  I like the much better control I get with my cannula selection and personally I do not like either ultrasonic nor power assisted techniques.  None of the cases on my website used either PAL, Ultrasonic, nor sharp cutting cannula techniques. 

As any artist, I take my cannula selection very seriously and have evolved what permits me to achieve my results.  I have considered and evaluated many, many technologies.  The many different types of cannula I use have their own advantages and qualities.  I pick a subset of these cannula that varies for the many different types of gynecomastia male chest sculpture that I see.

Gland removal by any technique can still leave a depression when  a major part of the problem is from gland.  For gland removal, I prefer the greater precision of removal under direct visualization and feel.  This also give me access to many more elements for my artistic palette of my Dynamic Technique to sculpt the remaining tissues.

This approach permits me to maximize the removal of the firm gland and sculpt the remaining fat.  How tissues move is important.  The human body is beautiful in animation.  That is why I show pictures of the chest with arms up, down, and with muscles tight / relaxed in addition to the results from multiple views.  Such analysis of the results as well as how tissues evolve, the possible need for drains, comfort level after surgery, are important factors in picking your doctor.  It is like an artist selecting a paint brush.  The results are what matters, not with what tool they sculpt.

Hope this helps,

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

[roflbbq]

Very helpful responses! I'm definitely going to multiple surgeons before I make the call. I spoke to another one today. He said that in certain cases he did do an excision, but his combination of Laser/Ultrasonic techniques usually emulsified everything he dealt with. He said that excision was something he used to have to do regularly prior to incorporating some new technologies (quoted below) and that he's had to do it less and less over the years. His main focus in the conversation was on skin-tightening and lipo rather than talking about gland excision. What do you think?

Ultrasonic liposuction is helpful for removing the tissue and may avoid skin excision in many patients. It is now considered the treatment of choice for many men with large breasts. The type of surgery recommended depends on the pattern of enlargement. The most common traditional method is to remove the excess tissue through an incision around the nipple. The incision extends out from the nipple at 3 and 9 o'clock. Liposuction is used to improve the contour or remove additional fat. The operation is under a general anesthetic (you are asleep). This is an outpatient procedure and done here in the office.

Dr. Roche uses the Erchonia laser in combination with ultrasonic liposuction. The Erchonia laser speeds up healing and reduces pain and swelling. For more info on the laser click on the following link (erchonia link).

[Dr. Elliot Jacobs]

Yes, there are many high tech treatments which many doctors are pushing.  And, of course, the public really likes high tech anything, especially lasers.  The question is whether the high tech device really adds something to the results.  And don't forget the extremely high cost for these lasers -- which the surgeon has to pay for as well -- all adding to the cost of your surgery.

For your information, ultrasonic lipo has largely been abandoned by most surgeons around the world -- but a few still use it.  And the concern about skin tightening is unnecessary -- you are young and your skin will have enough elasticity to tighten considerably on its own -- you don't need a laser to encourage skin tightening.

And if you have puffy nipples, nothing will replace appropriate direct excision.

Good luck!

Dr Jacobs

[DrBermant]

Very helpful responses! I'm definitely going to multiple surgeons before I make the call. I spoke to another one today. He said that in certain cases he did do an excision, but his combination of Laser/Ultrasonic techniques usually emulsified everything he dealt with. He said that excision was something he used to have to do regularly prior to incorporating some new technologies (quoted below) and that he's had to do it less and less over the years. His main focus in the conversation was on skin-tightening and lipo rather than talking about gland excision. What do you think?

Ultrasonic liposuction is helpful for removing the tissue and may avoid skin excision in many patients. It is now considered the treatment of choice for many men with large breasts. The type of surgery recommended depends on the pattern of enlargement. The most common traditional method is to remove the excess tissue through an incision around the nipple. The incision extends out from the nipple at 3 and 9 o'clock. Liposuction is used to improve the contour or remove additional fat. The operation is under a general anesthetic (you are asleep). This is an outpatient procedure and done here in the office.

Dr. Roche uses the Erchonia laser in combination with ultrasonic liposuction. The Erchonia laser speeds up healing and reduces pain and swelling. For more info on the laser click on the following link (erchonia link).

Sorry, you have not done a good job for your homework at all. I have posted here on how to pick a gynecomastia surgeon:

http://www.gynecomastia.org/smf/index.php?topic=16474.0

Did you check what, (if any) Board Certification the doctor has?

Did you check what training (if any) the doctor had?

Is the doctor trained as a Plastic Surgeon or is he / she just a self declared Plastic Surgeon or yet even worse a Facial Plastic Surgeon? (I have yet to understand how a "Facial Plastic Surgeon" can have credentials to operate on a gynecomastia male breast reduction.)

Do they belong to the American Society of Plastic Surgeons?

Do they have malpractice cases or disciplinary actions against them?

Do they have proof of what they say with photographs or movies?

In my opinion, only 4 examples of 2 views of each patient with mediocre results is hardly proof that a technique is successful. If a particular doctor's results are what you like, then that becomes a potential option.

I personally have never used a 180 degree incision unless I am revising another surgeon's scars. My incisions at the edge of the areola measure from 0.6cm to about 1.8 cm (0.2 to 0.7 inch) for a typical case of gynecomastia. This is much smaller than the incisions many doctors need for their ultrasonic surgery and the scars hide much better at the edge of the areola than at the lower chest or armpit regions. Don't forget that views of how the chest looks like with arms overhead can be important to anyone playing sports. Going around hiding scars by keeping arms against the side is just ridiculous.

I have yet to see an ultrasonic technique have as little Bruising and Swelling After Gynecomastia Surgery or Comfort After Gynecomastia Surgeryas what my patients typically achieve. Actually, I have operated on many patients who did have prior ultrasonic liposuction done elsewhere. They all complained that their prior surgery hurt much more and they were much more bruised. If someone claims something like that, they should be able to back it up with documentation such as pictures or numbers.

No that is hardly the "state of the art" unless there is real proof out there that it works that I have yet to see.

Hope this helps,

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

[roflbbq]

Thanks for the responses. My homework on the Doctor did reveal he was reputable/board certified before I met with him. It was his claim that he could emulsify gland tissue that got me wondering. I appreciate the sanity check. Will be visiting more surgeons soon. Thanks again!

[DrBermant]

Thanks for the responses. My homework on the Doctor did reveal he was reputable/board certified before I met with him. It was his claim that he could emulsify gland tissue that got me wondering. I appreciate the sanity check. Will be visiting more surgeons soon. Thanks again!

Here is where you can check if a doctor is really board certified and just what they are certified in:

https://www.abms.org/WC/NameAndLocationSearch.aspx

You will need to log in at no charge to look up this information.

Hope this helps,

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

[George Pope, M.D.]

I agree with Dr. Jacobs, in that ultrasonic liposuction has pretty much fallen out of favor.  Keep in mind, and I know this sounds cynical, that a surgeon who has purchased one of these machines wants to get his/her money out of it.

At any rate, from the mid-'90's until around 2005, I performed ultrasonic lipo on many gynecomastia patients.  I always had to open them to excise breast tissue directly.  I never saw the ultrasonic energy completely emulsify the true breast tissue.

Good luck in your search for a plastic surgeon.  You really need to get several opinions.

Dr. Pope, MD