Gynecomastia & Brachioplasty

[LagoonTrifecta]

Evening docs.  This is addressed to any and all who would be willing to answer it. 

Is it possible to perform brachioplasty (ie: armlift) at the same time as the gynecomastia surgery?  I ask because I've lost considerable weight a few years back and keeping at a stable weight since would like to remedy some of the excess skin issues.  The arm skin isn't very bad; it's mainly stretch marks and just a few centimeters of loose skin, enough to cause unsightly issues when it's stretched or the muscle is contracted. 

Thanks.  Looking forward to hearing some doctor's opinions.

[Dr. Elliot Jacobs]

You are probably a MWL (massive weight loss) patient and what you are asking for is typical of those patients who have lost significant amounts of weight.

Yes, in selected patients, simultaneous brachioplasty and gynecomastia reconstruction can be performed.  Every patients loses weight differently and the patterns of skin laxity and droop also vary considerably.  Thus, an individual consultation is absolutely essential to determine your eligibility for such a combined procedure.

One thing you must know -- there will scars in trade-off for a better and tighter shape.

Suggest your research surgeons in your local area who are expert at reconstruction of MWL patients.

Dr Jacobs

[LagoonTrifecta]

It's true; I lost the weight when I was 17 and have lived with the results since.  I had a tummy-tuck done back in 08, and was told that the gynecomastia caused from excess skin was completely unable to remedied.  Since researching in the last year the gynecomastia surgery I've begun to look at my body with a critical eye.  

I'm 22, and currently unemployed, unfortunately.  Going to college.  So it's going to be a long, expensive road.  Thankfully I have a very supportive family otherwise I would be completely lost.  As it is, things are rough going, and day by day.  For reference, I am going to include a picture with this post, to show what I'm talking about, and maybe give a clearer indication of what I mean.
(Have to remove the space between http and the //)

http: //imageshack.us/photo/my-images/27/img20110705211731.jpg/

Right arm at rest.  As I said, there is just a bit of excess skin there.  

http: //imageshack.us/photo/my-images/215/img20110705211821.jpg/

Right arm flexed.  Gives a better indication of the loose skin.  It's a small flap near the armpit.  (The picture was hard to take, flexing, using my phone and trying not to move too much.  Hence the blur.)  

I understand that an in person consultation would be the best option.  Sadly, given my circumstances, I cannot travel three to four hundred miles (or more!) to speak with each surgeon in turn.  

Is this something that would be a good idea to get done with the gynecomastia surgery?  Or should I wait?  It seems fairly minimal to me, but I'm very ignorant of the amount of work it takes to preform these surgeries.  

Again thank you doctors.  
And thank you Dr.Jacobs, for the very prompt, and helpful reply.  

[Dr. Elliot Jacobs]

There seems to be just a minimal amount of excess skin near the armpit -- this is certainly remediable by surgery.

Why don't you provide us with a series of chest photos (taken by someone else) and perhaps we can comment on that.

Dr Jacobs

[LagoonTrifecta]

Thanks for the prompt reply Dr. Jacobs. 

Unfortunately, as I'm hugely embarrassed about taking my shirt off, photos coming from someone other than myself aren't an option right now.  However; I think I got some decent pictures. 

Front: img7.imageshack.us/i/img20110411220347.jpg/

Profile: img843.imageshack.us/i/img20110411220358.jpg/

A few things:

Monstrous lovehandles, definitely getting liposuction on these.

There is a bit of an.. udder effect going on when I lean down.  My stomach is fine, but directly above it, directly below the breast area, a roll of fat and skin forms, disappearing when I stand up straight.  Judging from the pictures here, is this excess skin/tissue as well, or fat under the tissue problem? 

What sort of scars are to be expected from a surgery like this?   I understand that they are a trade-off; after all I have one directly below my stomach.  I have seen pictures, however, of a man getting a mastectomy and he has a scar tracing from one arm-pit to the other.  Is that what I should be expecting? 

I spoke with another surgeon on these boards during a phone consultation.  After he saw similar pictures of me, he assured me that the "regular operation" would be fine.  How often do gynecomastia surgeons such as yourself and the others on this board preform this sort of surgery?  I understand that it is different from the gynecomastia removal surgery. 

[Dr. Elliot Jacobs]

Your photos show moderately large gynecomastia with an extension of fat around the sides of the chest.  What cannot be determined, except through an actual physical exam, is the elasticity of your skin.  But all skin retains some amount of elasticity -- even skin which had been stretched out by being previously overweight.

In essence, a standard approach to your chest should suffice to help you (it should include lipo of the sides of the chest as well).  What cannot be predicted is how much your skin will tighten -- but it will tighten somewhat.  Worst case, most likely, would be a flattened and contoured chest with a residual fold at the bottom of the chest -- quite similar to many men and quite normal in appearance.

As for love handles, those can be suctioned -- either simultaneously or at a different time.

Dr Jacobs

[LagoonTrifecta]

Thank you again, Doctor Jacobs. 

Another question: I've just learned that the exaggerated lovehandles I've gained after the tummy-tuck surgery are commonly called "dog ears".  I've heard of a few methods of removing these; reopening the scar, and removing the excess tissue, to just the simple lioposuction procedure, depending on the degree of the lovehandles. 

Which would you recommend?

[Dr. Elliot Jacobs]

There are no photos provided.  Yes, "dog ears" can occur after tummy tuck if there is continued lax skin which extends beyond the abdomen (ie it begins to circle around towards the back).  But dog ears do not produce love handles -- there is a difference.  There are a number of techniques that can treat dog ears -- but obviously you need to be seen by a surgeon in order to determine what would work best for you. Perhaps consider returning to your original surgeon who performed the tummy tuck and ask him what he would recommend?

In cases of major weight loss, sometimes treatment of the dog ear / lax skin can extend all the way around to the middle of the lower back, thereby becoming what we call a "belt lipectomy."

Dr Jacobs

[LagoonTrifecta]

Ah, sorry, perhaps I should have been more clear.  The photos provided at the beginning of the thread. 

I would return to the previous surgeon, however; he retired shortly after working on me.  So unfortunately, that is not an option. 

For reference:

img7.imageshack.us/i/img20110411220347.jpg/

[Dr. Elliot Jacobs]

Sorry, guy.  From the photo you posted, it appears that you have love handles -- probably from your prior overweight.  If you have dog ears from your prior tummy tuck, they do not show on this photo.

In any event, the love handles could probably be helped with appropriate liposuction surgery.

Dr Jacobs

[LagoonTrifecta]

I have honestly never been more relieved to hear that I have lovehandles.

This means that liposuction will reduce/remove them, and what's left could be taken care of with exercise and without the rather gruesome idea of reopening the tummy-tuck site and removing the skin? 

If so, hallelujah, doc, you just made my day. 

[Litlriki]

I'm just catching up after being away, and I thought I'd second Dr. Jacob's replies regarding your surgery.  I'd start by treating your chest in a conventional way and see how your skin responds.  You might still require further treatment to remove lax skin, but at least looking at nipple position and the location of you skin excess, removal of the gynecomastia should result in a fairly acceptable outcome without the bigger scars of skin resection.  Of course, if you don't get enough skin retraction, you might need to address that, and I'd suggest waiting at least a year to make that decision after the initial treatment.  One technical point, I do liposuction with a small cannula all the way up to the clavicles to try and encourage retraction of the skin on the upper chest, in order to achieve some "lift", and I find this to be especially helpful in heavier patients.  Because the suction that accomplishes this is superficial, the surgeon needs to be careful not to create any furrowing or rippling, but this is avoided by use of the smaller cannulas and even suction. 

Regarding your arms, I wouldn't suggest skin removal there unless it can be done with a scar high in the axilla.  The scar that extends down the arm tends to be unsightly, often remaining ropy and frequently red.  In arms with a  lot of hanging skin, where the benefit is significant, the scar may be worth it, but yours don't look that bad.  I'd be very careful about addressing them, and in fact, some liposuction might be adequate to get skin retraction to improve the appearance.

Good luck,

Rick Silverman

[LagoonTrifecta]

Thank you for the reply, Doctor Silverman! 

I've heard the same thing from three such surgeons, so I'd say that's the way to go!  It's nice to know that another complication isn't involved.  This whole process has been the most harrowing, frustrating thing.  My nerves are as frayed as they've ever been.  I'm hoping that the skin will retract well -- I'm not looking for moviestar chest, just something I am comfortable with.  As long as I don't look like a melting icecream cone any more, then I'd say that's an improvement! 

There are slight stretchmarks beneath each breast however, and that is worrisome.  As well as the extra 'droop' below the pectoral area when I bend over.  I'm worried the skin may be too stretched there, and won't retract well after the surgery, or will require additional work.

Hahaha.. yes.  I think I'd gotten a little worked up when I started looking at my arms.  A case of a critical eye getting a bit too critical.