Where did you learn technique to prevent nipple indentation/ creator deformity?

[letsfixthis]

I have an open question to the doctors on this forum.

I have seen video from Dr. Jacobs and Dr. Cruise both showing that they intentionally leave a small amount of gland attached to the under the nipple area to provide support to prevent the nipple from becoming depressed into the body and a crease from occurring when the muscle is flexed.

I am looking at some pictures from qualified AMA board certified doctors who some pictures seem to have this nipple indentation and small amount of creator defect.

My question is this information learned? Was it something that was taught in school, in a book,medical journal, article while studying/training to be board certified or was it something you picked up on your own which is not published?

Secondly, how would you suggest that I approach this subject while going into consultation with a surgeon?

Should I come in with some kind of published document saying please make sure you do it like this or else I might be left with this deformity?

I do not want to come as I know better than you, know it all type however I also don't want to be left with a deformity for the rest of my life which could have been easily avoided using the correct technique.

Thanks. 

[DrPensler]

This is a important question. Most plastic surgeons have a rather minimal amount of exposure with gynecomastia as residents often in morbidly obese patients. These surgeons once done with their residency see a minimal number or no  individuals with gynecomastia over the course of their careers.Very few doctors in the United States see a substantial number of cases of gynecomastia over the course of their careers let  alone devote a majority of their practice to the problem.

At present the best answer to your question comes from that great 20th century philosopher Will Rogers who once aptly said "Good judgement comes from experience, and a lot of that comes from bad judgement."

[letsfixthis]

This is a important question. Most plastic surgeons have a rather minimal amount of exposure with gynecomastia as residents often in morbidly obese patients. These surgeons once done with their residency see a minimal number or no  individuals with gynecomastia over the course of their careers.Very few doctors in the United States see a substantial number of cases of gynecomastia over the course of their careers let  alone devote a majority of their practice to the problem.

At present the best answer to your question comes from that great 20th century philosopher Will Rogers who once aptly said "Good judgement comes from experience, and a lot of that comes from bad judgement."

Thank you for the response Dr. Pensler. You have confirmed what I was beginning to suspect.
Many things in the computer programing industry are like this where a self taught programer knows more about programing then someone with a degree in programing from a good college due to lack of documentation and instructions . It would be nice if this issue was at very least covered when getting board certified process. You would think all the extra years of training would dedicate maybe a few hour to gynecomastia and preventing a creator defect/nipple depression. Perhaps published this information in a medical journal for plastic surgery may help improve the profession.

Unfortunately, this makes things much more difficult for the patient trying to evaluate a good doctor to perform gynecomastia surgery.

Are you able to put into words or quantify what steps that a doctor should take to minimize the risk of a creator defect, nipple depression outcome ?

As a patient, I can look up doctors who have gone to good medical schools, have board certified by the American board of plastic surgery, talk about gynecomastia on their website, have no issue with the state medical board or good ratings on various groups however I simple don't know how to evaluate if the doctor knows how to prevent a creator defect.

They are likely to filter these picture from their before & after pictures and only display the patients who have had favorable outcomes.

I need a way to either test potential doctors or inform a doctor how to prevent a creator defect so I will not be one of the unlucky people with this post surgery deformity. I think we can all agree that its easier to prevent the problem from the beginning than try to fix it afterwards.

My sense is that there are maybe 3 ways that a creator defect can be prevented or minimized but please correct

1. Leaving a small amount of gland attacked to the underside of the areola to provide structural support
2. Creating fat flaps under the areola to provide structural support.
3. Feathering the fat under the area in such a way that there there is a level and even surface instead of a large crater.( However not sure if this method would prevent the nipple depression/crease from occurring)

Please tell me if I am wrong here or if I am right but missing elements?

[DrPensler]

Different techniques are useful in different patients not to mention various combinations of the different techniques.Also different surgeons find different techniques more effective. As a surgeon I would be to put it mildly, put off by a prospective patient instructing me on how to perform surgery and avoid complications.
Its a difficult problem I understand that.
As an aside you might enjoy reading the book Surgeon Under the Knife by William Nolan.

[letsfixthis]

Different techniques are useful in different patients not to mention various combinations of the different techniques.Also different surgeons find different techniques more effective. As a surgeon I would be to put it mildly, put off by a prospective patient instructing me on how to perform surgery and avoid complications.
Its a difficult problem I understand that.
As an aside you might enjoy reading the book Surgeon Under the Knife by William Nolan.

I can certainly see your point but its kind of a unique issue due to the lack of documentation on gynecomastia crater deformity complication.


Would you be mildly put off if a prospective patient said that he received a consultation with a few doctors and each previous doctor seem to have their own style and method to preventing creator deformity. One said they utilize fat flaps, another left a small amount of glad attached to the underside of the nipple for structural support, another surgeon said he would feather down the surrounding area so there was no creator for the areola to depress into.

Then asked you what method do find superior or if you had your own method to prevent creator deformity?

I am sure there is a way to convey the information tactfully without coming across as a jerk.

The best thing a patient can possible do is to find a good doctor. I don't know what a good answer sounds from a bad answer on this issue.

If I can pose a wild and crazy hypothetical question based on your suggested book were a doctor experience as a patient. "Surgeon Under the Knife by William Nolan." What if you had gynecomastia and you could not perform the operation yourself but you were evaluation other doctors to see if they knew enough so the creator defect would not happen.

What type of answer would you be looking for to put your mind at ease? In other words, what would be a satisfactory answer for you choose one doctor over another if you were worried about crater deformity? 

Thank you again for the words of wisdom. I am going to have to check out that book you recommended, it sounds very interesting. ( I always heard that Doctors make the worst patients)

[DrPensler]

No question when it comes to me our my family regarding surgery is out of bounds and I would extend the same courtesy to any patient. The way you framed your questions here is totally fine.
As far as the choice of one doctor over another that's a tough one, that's why you would like the book.

[Litlriki]

It can always be a challenge to find the best surgeon who meets your needs, and this is for any procedure.  Ideally, if you start with surgeons who take a particular interest in gynecomastia, the issue of expertise is at least partially alleviated, presuming you have good references (associates who have had the surgery, feedback from on-line sources, review of websites, etc.).  That doesn't mean that every surgeon with expertise will be the right surgeon for you. At that point, personality, attitude, accessibility and other aspects gain importance.  Ideally, you should come away from your consultation with a degree of confidence in your surgeon, just as you might feel confident about a programmer who can help you with a problem on your computer.  (We face the same situation when we have a computer crash or so on--who do you trust?!) 

In the end, it's not just an issue of avoiding a crater deformity, since that can occur with any surgeon, including the experts.  But it's less likely to occur in surgeons who perform a reasonable number of these procedures, and because we probably see more revisions from occasional gynecomastia surgeons, we are likely more adept at correcting these problems.  Even when I lecture about gynecomastia, I don't spend an excess of time on technique--that's something that's learned in the operating room.  So no matter how many times a surgeon reads about ways to avoid a crater deformity, experience is probably more important at actually avoiding problems.

Rick Silverman

[letsfixthis]

No question when it comes to me our my family regarding surgery is out of bounds and I would extend the same courtesy to any patient. The way you framed your questions here is totally fine.
As far as the choice of one doctor over another that's a tough one, that's why you would like the book.

I think we may have had a bit of a miscommunication.

I know you suggested a book called  "Surgeon Under the Knife by William Nolan." although I have not read the book, I believe the encompassing theme is a surgeon experience in a role reversal in where he is forced to see things from the other side.

While on the general theme of the book you suggested, all I was asking is if you were in my shoes, how would you go about evaluating the qualifications of a doctor especially since the issue of creator deformity seem to be a complex one difficult to understand.

This certainly was not meant as some kind of insult,denigrate or attack on your family. I can assure you that no malice was intended.  Just trying to ask what you would do in my shoes as far as evaluating answers to avoid creator defect. In terms of decision making process, best technique, qualifications,key words or phrases to look out for,etc.. when trying to evaluate how good a surgeon skills are (not looking for information on your family members) 

I hope may help clear things up.

Thanks.

[letsfixthis]

It can always be a challenge to find the best surgeon who meets your needs, and this is for any procedure.  Ideally, if you start with surgeons who take a particular interest in gynecomastia, the issue of expertise is at least partially alleviated, presuming you have good references (associates who have had the surgery, feedback from on-line sources, review of websites, etc.).  That doesn't mean that every surgeon with expertise will be the right surgeon for you. At that point, personality, attitude, accessibility and other aspects gain importance.  Ideally, you should come away from your consultation with a degree of confidence in your surgeon, just as you might feel confident about a programmer who can help you with a problem on your computer.  (We face the same situation when we have a computer crash or so on--who do you trust?!) 

In the end, it's not just an issue of avoiding a crater deformity, since that can occur with any surgeon, including the experts.  But it's less likely to occur in surgeons who perform a reasonable number of these procedures, and because we probably see more revisions from occasional gynecomastia surgeons, we are likely more adept at correcting these problems.  Even when I lecture about gynecomastia, I don't spend an excess of time on technique--that's something that's learned in the operating room.  So no matter how many times a surgeon reads about ways to avoid a crater deformity, experience is probably more important at actually avoiding problems.

Rick Silverman

Thank you.

I appreciate your honestly in telling me that this defect can happen with even the best surgeons. I was starting to wonder why no one would give me a straight answer and I think what you said explains a lot.