Has anyone had revision surgery/procedures they're happy with?

[gggg]

Has anyone? From what I understand there are two types of procedures available for revision surgery if there's some form of crater deformity following a previous gynecomastia surgery (fat grafts and fat flaps). Both are fat transfers to improve proportionality by filling the voids under the areolas and surrounding areas. Fat grafts are fat injections, where the fat is injected out of separate areas of the body and injected into the breast regions, while fat flaps take adjacent fat around the breasts and move them around slightly to retain the fat with its attached blood supply (there is no attached blood supply for fat grafts). While fat grafts are obviously less invasive and costly (it's not surgery like fat flaps), Dr. Bermant has argued on these forums that because fat grafts are transferred without a blood supply, much of the transferred fat cells tend to die and become firm. Dr. Bermant also seems to suggest that after repeated fat grafts the appearance of the crater deformity would likely improve if someone is standing still, but upon animation or movement the results of fat grafts are far from ideal (or at least less ideal than the results of a carefully operated fat flap surgery, which he argues produces more natural looking results in animation/movement). Dr. Bermant argues the reason for the greater fat flap results is that fat flaps tend to look, feel and move like normal fat, which is not usually the case for fat grafts. That said there are limitations to who can be a candidate for fat flaps/what fat flaps can acheive (too much scar tissue, too little normal surrounding tissue/fat around the breasts, fat connected to blood vessels will only move so far, etc).

I was just wondering if anyone would be willing to share their stories with any type of revision surgery/procedures they've had (whether it be fat graft injections or fat flaps)? I'm obviously not a doctor, but I find Dr. Bermant's approach pretty convincing. If you research these forums/internet carefully, you'll find that there are some ppl who have actually had fat flap surgery with Dr. Bermant and are very happy with the results. Likewise there are several people on these forums that appear very unhappy with fat graft injections. Unfortunately Dr. Bermant is now retired and I'm interested in finding the best doctor and getting something done to finally be rid of this problem.

Has anyone actually had a successful fat flap revision surgery with any doctor apart from Dr. Bermant? There are several expert gynecomastia surgeons in the U.S. who I have no doubt are just as experienced and skilled as Dr. Bermant and could likely produce as good as a fat flap surgery outcome as he can (after all, some form of fat flap transfer/suture is usually done with initial gynecomastia surgery to even out the results). That said, as far as I can tell Dr. Bermant is the only surgeon who has not only performed several of these operations, but also documented them with pictures on his website. So I was just curious, has anyone actually had fat flap revision surgery with another doctor? Who was your doctor? Were you happy with the results? Any help would be appreciated. If anyone has had some type of revision procedure done please let us know as I'm sure there are others in the same boat would benefit from the information. Cheers!

[godspeed]

This section doesn't get enough attention which sucks.  I myself had surgery with a Dr who was on this board and did a horrible job and have a crater thats needs to be repaired.  Iv yet to see any really impressive crater repairs before and after pics.  Honestly iv only seen a handful of of before and after pics of crater repair and they weren't that impressive to say the least.  Iv been to a couple consults and iv yet to find a Dr who seems confident and knowledgeable in that dept.  I wasn't impressed with Bermants results but that's just my opinion but i do like his approach to fix the problem.

[gggg]

I sent you a PM godspeed

[Rocky76]

Same exact problems and questions here. It seams very difficult to locate much information any more about Dr. who specialize in crater deformities. I too am a victim of a NY Dr's overly aggressive lipo and excision. Has anyone gotten any more info on this?

[luka08]

I agree - this needs more discussion, because it seems to be the "issue" for quite a few people on the site. With Dr Bermant off the scene through retirement, there doesn't appear to be another surgeon focusing on the local flap technique for areola support correction - although one or two other US Gyne surgeons do mention local flaps as a technique now. Certainly nobody else is going in to as much detail about it.

I'm also not encouraged (so far) about what I have researched on fat grafting by injection as an alternative. The feedback on this approach appears very mixed, with a lot of it negative on results. The whole "stem cell effect" certainly sounds promising, but it doesn't appear as if there is any true control over fat cell survival or predictable results yet, with hard scar tissue a possible outcome?

Maybe we can encourage some of the experienced surgeons who post here to comment on what they honestly think about correcting the unsupported ("crater") areola outcome (by any means) and the local flap technique - how many times have they done it? What is their opinion on the success rate etc?

I think we're all grown up enough to realise that practice makes perfect with any craft, including certain surgery techniques. Surgeons can't be brilliant at everything and we've all learn't through our experiences about the realities of this kind of surgery and recovery from it - hence our research and caution with the next step.

You can't blame the surgeons for not wanting to say anything negative about their own experiences, but it would be really helpful for any surgeon who is attempting the flap procedure or crater correction to help their patients, to give honest feedback on their experiences with the techniques tried and what's realistically possible. I would certainly respect that and it would help to inform a lot of people in a positive way.

As for patients - I'm with you gggg - any stories or feedback?? And for those still searching, any feedback on consultations with certain surgeons? It would be good to pool any information, either on the board or via PM.

[Dr. Elliot Jacobs]

Revision surgery is difficult and challenging.  First problem is that, in addition to fat and breast tissue, there is now a third type of tissue present:  scar tissue.  Scar tissue is more difficult to work with, it doesn't allow for local anesthesia to spread easily between the tissues, and it is unpredictable as to how it will behave while surgery is being done. 

Then, an assessment has to be made as to what the actual problem is.  Is there a deficiency of tissue (ie a crater deformity) or perhaps not enough tissue was removed at the first procedure.  Common sense will tell you that it is easier to deal with residual excess tissue -- you can just remove it.  If, however, there is a deficiency of tissue (ie a crater), then one must assess if there is sufficient surrounding tissue which could be mobilized and freed up (remember, it may be held tight by scar tissue) and then sutured into the area of tissue deficiency.  These are called fat flaps -- and they work well when there is enough tissue.  If there is minimal surrounding tissue, then fat flaps do not work and one has to look for another alternative:  fat grafting.

Fat grafting has been making a big splash in plastic surgery these days.  It is being used, in large volumes, for breast reconstruction after mastectomy and for various cosmetic breast augmentations.  It definitely does work.  The problem in fat grafting into a crater deformity is that there is often very little space between the skin surface and the underlying muscle -- and oftentimes that space is filled with scar tissue, which has minimal blood supply.  One cannot just inject a blob of fat -- it won't live.  Fat has to be injected delicately in small amounts so that it can garner new blood supply from the surrounding areas.  That is why fat grafting to craters is tough -- and may need to be done in several stages in order to gradually build up the thickness of the fat.

And sometimes, unfortunately, there is nothing that can be done.

In football, there is a saying:  "The best offense is a good defense."  For prospective gyne surgery patients, the "best defense" is to seek a surgeon who is very experienced in gyne surgery so that the problem never occurs in the first place.

Dr Jacobs

[Paa_Paw]

It should be kept in mind that most men who are happy with their result quickly lose interest in this site so they are not here to respond. Those who are not happy are therefore present in comparatively larger numbers and they can be quite vocal.

[Rocky76]

Dr. Elliot Jacobs,

I had sent you an email to your professional address for further information last week. Did you ever receive it?

[Dr. Elliot Jacobs]

I don't believe I received it.  I ordinarily respond to an inquiry within 24 hours or so.

Best way is to go to my website, (in my signature below) and fill out a contact form.  Include a reference to gynecomastia.org so that I will know it is you -- and I will get back to you ASAP.

Thanks

Dr Jacobs

[luka08]

Dr Jacobs - Good post, thanks for contributing.

I'm wondering what the take up is on this local flap procedure for correction?

Dr Jacobs - you obviously perform a lot of gyne surgery, so have you seen a lot of cases where you have used this technique? I'm not suggesting to correct your own first up procedures, of course - which I am sure are very cautious in this respect!

It's just that, with the exception of the recently retired Dr Bermant, you don't hear surgeons talking much about it or putting information on the website.
As a Dr who specialises in Gyne surgery, I would be really interested to know how many patients you see and use this kind of revision procedure on? Have you been doing it for a long time, or has there been a recent increase etc?

I'm interested to know because, as the nature of this thread suggests, there are clearly some people unhappy with this side effect of their operation who are wondering whether anyone is focusing on it and why no surgeon is talking much about it?
Is it because not many patients are coming forward or because the technique is not easily performed or has a low improvement rate or maybe because surgeons are reluctant to try and correct over excision, because it's more difficult?

You can understand any surgeon not wanting to perform something unless they felt the odds were very good they can make a real improvement.

Thanks.

[Dr. Elliot Jacobs]

You are asking too many vague questions.

I cannot answer for other gyne surgeons.  But for me, I use fat flaps on revision cases whenever appropriate.  I do maybe 2-3 revision cases per month (other surgeon's cases)-- sometimes more.  Not all of them require fat flaps.

I frequently use fat flaps during my own primary gyne cases -- but not all of them.  I take every precaution possible during my own cases to avoid a crater deformity and as a result, I very rarely have a problem.

It is very difficult to document (photographically) the results of revision surgery.  Most crater deformities are shallow -- and the slightest difference in photographic technique (shadowing, etc) can either accentuate or negate the results of the revision operation.  In essence, photos of revision surgery are very subtle -- they are not like the major changes seen in before and after gyne photos that one can see on many websites.  However, the patients themselves see the improvements and are pleased.

Dr Jacobs

[jusken]

Thanks for stepping in Dr. Elliot Jacobs.

I've been dealing with a so-called 'crater deformity' for years now and have remained hopeful to the 'Stem Cell Breast Augmentation' procedures.  I'm almost certain I don't have enough surrounding tissue for the fat-flap procedure... so that is probably not an option.  This new stem cell fat procedure is being proposed on women, mastectomy patients more specifically, with all of their breast tissue removed as well.  So the issue of not enough blood supply might be solved with this procedure.

Unfortunately, progress seems to be slow-going.  Some doctors have been using it for a long time now and I've been tempted to go in for a consult.  The trouble is it would probably be a waste of time. It seems like it might be a long time before a doctor with lots of gynecomastia surgery experience becomes trained and familiar with this procedure as it is currently linked primarily to women suffering mastectomy operations.

Any professional opinions would be great from an active doctor here.  Perhaps you know something about stem-cell fat procedures Dr. Elliot Jacobs?  Not to be confused with traditional fat-grafting, so I've read.

[Dr. Elliot Jacobs]

There is now a lot of hype about stem cells in every medical field -- and plastic surgery is no exception.

It is well known that fat (adipose tissue) is actually very rich in adult stem cells.  No one knows exactly how they work but it is believed that they "improve" the results of traditional fat grafting. 

There is really nothing different about stem cell fat grafting.  Please let me explain.  Fat grafting involves harvesting fat from one area of the body, cleaning and preparing it, and then re-injecting it into another part of the body.  One of the steps in preparing the fat for grafting is to centrifuge it.  Then, the intact fat separates from the blood below and the liquid fat above.  The blood and liquid fat are removed, leaving pure yellow-white fat which is ready for grafting.  Stem cells, being slightly heavier, tend to congregate in the lower 1/3 of the pure, cleansed fat.  So some docs are now just using the lower 1/3 of the cleansed fat for fat grafting -- and calling it "stem cell fat grafting."  To date, no-one has proven that it is in any way better than regular fat grafting -- but it is a way for some docs to hype a novel technique and attract patients and, by the way, charge a lot for the procedure.

Fat grafting for crater deformities can be done.  It depends on the depth and severity of the crater.  And it may have to be done in several stages -- not just in one operation.

Dr Jacobs