Had Ultrasound....So What is it?

[David1991]

So oddly enough I saw someone post almost this exact issue (even including getting an ultrasound!) a few days ago.

Basically, I had gyno surgery 8 months ago. Hasn't changed in awhile. Mostly good result but still definitely some puffiness particularly on the left side when relaxed.

I got an ultrasound done two days ago and we got to compare my pre-surgery ultrasound to my post-surgery ultrasound. What we saw in the pre-surgery one was a bunch of dark, thick, striated muscle, then a bit of white/lighter fat, then the dark glad which was 2.5cm across and maybe 3-5mm thick, then lighter skin. Whereas in the post-surgery ultrasound you could see the muscle, but it was all white, about 1mm of fat and the same lighter color of skin.

This is basically how it was on both sides and she said she couldn't even detect any glad.

So in that sense I guess I'm glad that all the gland is apparently gone. What confuses me then is the puffiness and whiteness that can still be seen when looking at my nipples when relaxed. The left side is the puffier side and has soft/squishy tissue I can grab...not sure if that's fat or what. But what's also weird is the right side has very clear scar tissue that you can grab going from about 1cm towards the center of my chest to about 2-3cm towards my armpit (was not there prior to surgery). If this is clearly felt then why was there no distinguishable appearance of it in the ultrasound? I thought the scar tissue would show up as being darker? Which of course makes me wonder about any glad just not showing up.

In any case if it is scar tissue I'd think the right side could at least get a bit improved although my doctor didn't even want to give me kenalog. Left side is just soft though so Idk what that's about.

Anyway I attached 2 before and 2 after shots so you could see the little bit of white I'm referring too. I would upload the ultrasounds but I don't have a copy of the new one.  

[Dr. Elliot Jacobs]

From the clinical description, you probably have some scar tissue that developed under the areola rather than residual gland.  If this is the case, then you should discuss possible treatment with cortisone (Kenalog) to try to dissolve the scar tissue and improve the puffiness.  Would shy away from going back in surgically to remove scar tissue -- the result would be more scar tissue.

Dr Jacobs

[David1991]

From the clinical description, you probably have some scar tissue that developed under the areola rather than residual gland.  If this is the case, then you should discuss possible treatment with cortisone (Kenalog) to try to dissolve the scar tissue and improve the puffiness.  Would shy away from going back in surgically to remove scar tissue -- the result would be more scar tissue.

Dr Jacobs

Hey Dr. Jacobs,

Yes I would think going in for more surgery wouldn't be the best idea if it's just scar tissue. The reason I wanted to go back for revision surgery before was because I was pretty sure there was gland left

My surgeon didn't want to go do kenalog injections last visit because he felt it could cause more problems than it would solve (e.g. a divot or discoloration) but I can clearly feel 2-3 harder areas, I would assume a skilled cosmetic surgeon could get put it in these areas without much difficult.

I do have 2 follow up questions if you don't mind:

1. I saw the ultrasound being done on my myself and the radiologist said she could detect no gland (this was done at a breast imaging center so I imagine she is very experienced with this) so I guess there just isn't. Although if I squeeze the nipple I can get a little bit of fluid to come out ( ) so there must be a tiny amount left. In any case....with the scar tissue being so hard and easily felt on the right side why was this not seen on the ultrasound? She said she didn't see the scar tissue or a difference indicating anything but fat and skin really (and I saw the same) so if she didn't pick up the scar tissue maybe she didn't pick up some gland?

2. Since the left side does not have these hard areas but rather a softer/glandular/"mushy" feel I'm not sure what it is, but if it's scar tissue or even fat could kenalog be as equally effective there for the puffiness as it would be for the right (less puffy) side with the hard scar tissue?

[David1991]

OK here are the "pre" ultrasounds. As you can see there are significant masses of gland showing.

I do not have the "post" ultrasounds yet unfortunately, but when I looked at them you had the same dark striated muscle but then just white above it of fat and skin. No distinguishable differences.

So I do not understand why I'm looking down at my chest right now and can see these puffy nipples. Or why I feel this little pea sized bump on the left side.

[DrPensler]

Can I have some dates for the photos?

[David1991]

Can I have some dates for the photos?

The before pictures are from 12/2011
The after pictures are from 6/2014 so 2.5 years later (6 months after surgery)

Before Ultrasound pictures are from around 10/2011 I believe


I just got the "after" ultrasounds but apparently the file size is too large :\

Out of curiosity why are you wondering about the dates?
I appreciate the input

[DrPensler]

If the dates of the photos are relatively close there is swelling and there should be reduction of the swelling with time.The longer the time differential the possibility of postoperative swelling would be diminished.At a year and a half I would return to your surgeon or get a second opinion.

[David1991]

If the dates of the photos are relatively close there is swelling and there should be reduction of the swelling with time.The longer the time differential the possibility of postoperative swelling would be diminished.At a year and a half I would return to your surgeon or get a second opinion.

Well the first ones are pre-surgery, 2 years beforehand. The "after" pictures are 7 months or so post-surgery, so I doubt there would be any swelling.

I guess more what I was wondering was, if the ultrasound is showing no gland, how could it still look like that. I guess you are saying swelling is a possibility but could it still be 7 months post-op? It hasn't changed in many months honestly.

[David1991]

Looks like I was able to post the post-surgery ones. In the one above I do see a slight darker oval area to the left side...wondering if that's some residual gland? And if so, why the radiologist at the breast center didn't notice it / report it.

[Dr. Elliot Jacobs]

One of the things to consider is the technique that was utilized during the surgery.  Many surgeons think that if you just go in a remove the excess underlying tissue, that the puffiness will disappear.  the problem is that just localized excision of the tissue will leave the puffy skin with nowhere to go -- except to puff out again.

When I deal with puffy nipples, I make sure to undermine the surrounding skin as well (it makes it a bigger operation -- but well worth it).  The undermined skin will allow the puffy skin to re-distribute across the chest and then to remain flat.  This has absolutely nothing to do with ultrasound, etc -- it is simply surgical technique.

If what I described is the root cause of your problem, then you would require some additional surgery to allow the skin to re-distribute.

Dr Jacobs

[DrPensler]

Ok so the photos are 7 moths after surgery not 2 years. Those times are very different than the assumption that the photos are years after surgery.If you are roughly six months after surgery there will likely continue to be some changes.

[David1991]

One of the things to consider is the technique that was utilized during the surgery.  Many surgeons think that if you just go in a remove the excess underlying tissue, that the puffiness will disappear.  the problem is that just localized excision of the tissue will leave the puffy skin with nowhere to go -- except to puff out again.

When I deal with puffy nipples, I make sure to undermine the surrounding skin as well (it makes it a bigger operation -- but well worth it).  The undermined skin will allow the puffy skin to re-distribute across the chest and then to remain flat.  This has absolutely nothing to do with ultrasound, etc -- it is simply surgical technique.

If what I described is the root cause of your problem, then you would require some additional surgery to allow the skin to re-distribute.

Dr Jacobs

Hey Dr. Jacobs,

So if there is just remaining skin puffiness left over, would this not eventually reduce if there was an extended period of no gland/tissue there? Somewhat like when an overweight person loses fat and the skin shrinks?

If that additional surgery was done, can it be done alone for a cheaper cost or would it be as expensive as a full gyno surgery again?

While I'm not completely sure what you mean by "undermining the surrounding skin" I do believe my doctor only took the gland and surrounding fat out, nothing with the skin.

Lastly, looking at the "after" ultrasounds (I'll post one more here of the left side) would you agree that all of the actual gland is removed?

[David1991]

Ok so the photos are 7 moths after surgery not 2 years. Those times are very different than the assumption that the photos are years after surgery.If you are roughly six months after surgery there will likely continue to be some changes.

Hey Dr. Pensler,

I don't think I said the post-surgery photos were years after surgery, if I did I mis-spoke, but yes it's ~7 months. My surgeon said he didn't think things would change much at this point (they haven't in a few months) but who knows. I hope so.