3 months post-op: significant residual Gland

[pdubbz]

I'm hoping to get some medical advice here. 
I'm 33 years old.  Always kept in shape.  But my chest never looked too good; however I did not have a bad case of gynecomastia.  In July of this year I began to notice that the condition was getting a little bit worse. 
So, I had gynecomastia surgery done at end of September.  the board certified plastic surgeon performed ultra-sonic lipo only - no excision. 
Anyway, it is now almost 3 months post-op.  there is significant breast gland and in fact it looks worse than it did pre-op; my nipples are hard and tender.  I can't even wear a t-shirt now.  I realize that unfortunately the procedure that was done, the doctor did not remove gland.  At a 2 month follow-up, the doctor said it was probably residual gland but could be still swelling. 
However I'm beginning to think that there might be some other underlying issue.  Why has the breast tissue gotten bigger in the last several months?  The only thing I can think of is that it's a side effect of finasteride.  I've been using propecia (1mg finasteride) for 5 years now.  But in March of this year I switched to generic Proscar (5mg finasteride), and my doctor instructed me to cut it into quarters.  Could it be this slight increase in dosage causing the gynecomastia??  A few weeks ago I stopped this medicine altogether. 
I'm going for an annual physical in early January; hope that will rule out any other medical conditions with blood work. 
As far as I can tell, I feel fully healed.  If this requires corrective surgery with Gland excision, would I have to wait a full 6 months??  Is it possible this is just part of the healing and the glands will shrink down? 

[Dr. Elliot Jacobs]

It is very difficult to discern whether your residual problem is due to inadequate remove of gland or stimulation with the use of Proscar, or both.

Using common sense, however, it would seem that at a minimum, there was inadequate removal of tissue.  Many times on this forum, one reads of patients whose surgeons plan on using ultrasonic lipo only -- and anticipating a good result.  And, as has been written many times on this forum by me and others, we have cautioned that ultra-sonic lipo, at best, will remove only fat and will not affect gland.  In many gyne cases, there is a need for an additional excision of gland during the procedure.  In those patients where this is not done, there is a high percentage of dissatisfied patients.

With reference to your own situation, would strongly recommend waiting at least six months from your surgery before contemplating additional revision surgery. 

Dr Jacobs

[George Pope, M.D.]

I agree with Dr. Jacobs that no additional surgery should be done for 6 months from the original procedure.  You have a number of things going on, and it's hard to say what is causing your problem.  One thing that it could be is scar tissue forming.  It sounds like you do have residual gland tissue present, but you mention that your nipples are hard (I assume you mean beneath the nipple/areola complex) and the problem is getting worse - tissue is getting larger.  That really sounds like you're developing some scar tissue. 

Be sure to keep all follow up appointments with your surgeon and follow instructions.  The good news is that revision surgery will most likely solve the problem.

Dr. Pope, MD

[Litlriki]

I join Drs. Jacobs and Pope in encouraging some patience.  As Dr. Jacobs pointed out, it's a common problem to see residual gland exposed by procedures involving liposuction only, and if the surrounding fat is removed, the prominent gland may become more apparent, making the end result worse than the pre-op appearance.  An early article in our primary journal by very reputable surgeons regarding the use of ultrasonic liposuction showed pre- and post-operative photos, and I recall thinking that at least one of the post-op photos looked like many of my pre-op patients with puffy nipples.  Nonetheless, you should give some time to see if the issue resolves, and if not, revision will correct the residual deformity.

Rick Silverman

[DrPensler]

I typically perform glandular excision in virtually all cases. If liposuction only is performed there is invariably swelling after surgery and  the swelling masks the gynecomastia. As the swelling recedes over a few months the gynecomastia  ( glandular component) which was not excised becomes more noticeable. The time course you describe fits perfectly with this. It would be helpful if you could provide some photos if you would like any additional thoughts.