Need advice on skin excision / breast lift method before surgery

[Joe_612]

Hello!

I'm 32, currently 90Kg, and considering gynecomastia surgery. I've consulted 4 highly experienced surgeons and all recommended liposuction+gland removal and some amount of skin excision; however, their highly different approaches confuse me and make it impossible to decide what to do:

- The 1st suggested large excision, with 2 scar lines coming out each side of the areolas.
- The 2nd and 3rd suggested a donut lift (which often get a bad rep on these boards).
- The 4th suggested a "lollipop" scar on my left breast (the largest one) and a donut lift on the right, saying a donut lift would be impossible on the left.

1) Any expert opinion will be appreciated, I simply cannot decide what to do - I can't tell whether it's severe / light enough to fit any as I'm not a professional. My breasts are quite large (especially the left) and my nipples are either on- or below the breast fold, so a donut lift might leave the nipples too low and skin too loose; on the other hand, the extreme option would leave me with a flat chest but incapable of taking my shirt off. What would you advise? I can really use some perspective.

2) Additionally, if I go with a donut lift and require revision surgery later (not enough skin was removed), will that still be possible?

Thanks in advance.

[Dr. Elliot Jacobs]

I have a philosophy in doing gynecomastia surgery:  get the best possible result with the least possible scars.

IMHO, you would not require ANY skin excision initially.  Just have lipo and excision and be patient for at least six months or more.  You would be absolutely shocked at how much skin tightening can occur spontaneously.

After six months, get together with your surgeon and discuss the situation.  The result may not be absolutely perfect but it might be perfectly acceptable to you -- and without major scars!  On the other hand, if you still want to improve things, there will be less extra skin to deal with because it will have tightened to some extent.  Less excess skin equals less scars in doing a slight tightening.

Good luck!

Dr Jacobs

[Joe_612]

Thank you for the reply, Dr. Elliot!

This reassures me to some extent that the less extreme options I was given aren't far fetched. Unfortunately, none of the surgeons I consulted has suggested a waiting period between the tissue removal and the skin excision.

Regarding the second question - is there any limitation to a revision surgery, if a donut lift was performed?

Thanks again!

[Dr. Elliot Jacobs]

is there any limitation to a revision surgery, if a donut lift was performed?

Yes, there MAY be some limitations -- it depends on how it is performed.  Speak to your surgeon about this.

On the other hand, if NO donut lift is performed initially, then you have ALL options available to you for a revision (if indeed that is needed -- it may not be).

Dr Jacobs

[DrPensler]

After a review of your photos I suspect the right will be fine without any skin resection.The left side may be fine without any skin resection of may  require a periareolar resection.I would recommend the periareolar resection if needed be done after surgery for the gynecomastia if necessary. 

[Dr. Schuster]

I will give you a different opinion though I highly respect those of the other surgeons who have answered. I think for the best, tightest result in one operation, I would recommend a more aggressive approach. This would include a larger resection of the lower breast skin and repositioning the nipple as a graft. It would leave you with a longer horizontal scar along the IMF but this usually heals extremely well. I would definitely avoid any vertical scar as in breast lifts performed for women ie. the lollipop approach. I am recommending this because in the photos it looks like your nipple is already below the crease. I have not found that skin shrinks upward enough and would risk irregularities. 

[Joe_612]

Thank you both as well, Dr. Schuster and Dr. Pensler, for your answers.

This is the problem I still face trying to make a decision; I'm still faced with extremely different approaches presented by highly experienced professionals. The more I think about it the more uncertain I become, as I'm not knowledgeable enough to tell which approach will best serve my case. It feels like any decision I'd eventually make will be a blind gamble...

Nonetheless, I thank you again for your advice!

[Dr. Elliot Jacobs]

Understand that you may be confused.You have just received somewhat conflicting views from top surgeons.  Bottom line is that these surgeons have all seen cases such as yours -- and in their hands, you would probably be OK with their own methods.

Realize that there is no one absolutely right or wrong way to approach your problem -- but all the described methods will probably provide you with an acceptable result.  No need to throw up your hands in defeat.

Good luck!

Dr Jacobs

[Litlriki]

Like Dr. Jacobs, I also try to get the best result with the least amount of scarring, and in patients who present with your appearance, I have had success with an aggressive resection procedure done with traditional liposuction and glandular excision through a peri-areolar short incision.  After complete resection, I use sticky backed foam ("Reston Foam"), which I stick to the chest on each side (this approach requires clipping of the chest hair) and leave in place to splint the skin for the first week post-op.  When this is removed, the nipples are typically in good position and the contour is much improved.  I then leave the skin to tighten, healing to progress, and if skin resection is required, that is addressed 9 to 12 months later.  Often, no further treatment is required.  Peri-areolar skin removal can be done with the initial procedure if it is clearly needed, or it can be done with a revision, at which time other adjustments can be made. The second procedure is typically in the office under local anesthetic.  
Regarding Dr. Schuster's post, I have done a procedure with a free nipple graft where a pedicle flap to support the nipple was not possible, but most of the time, if I use an approach like that mentioned by Dr. Schuster, I will use a small inferior pedicle flap to support the nipple, and this results in a long infra-mammary horizontal incision and a peri-areolar incision.  This does heal well, usually, and the scar can be acceptable with perfect scars (and hair to camouflage), but of course, there's more visible scars, and if scarring becomes an issue, it may be quite extensive.  
Once again--Find a well-qualified surgeon with whom you're comfortable, come up with a treatment plan you like, and you will get a good result!

[Dr. Schuster]

As you can see there is sometimes more than one way to skin a cat. This is exactly why an examination I so important. Photos do not always tell the whole story and can make a difference in recommendations. I agree with Dr. Jacobs that it is not a reason to quit if your gynecomastia really bothers you. Try getting some consultations in person. Choose some surgeon that you like their results and see what they recommend.

[becky]

You could have a two stage procedure which will limit the incision around the areola. I perform this procedure often. This will work well in your case with your age and the amount of hair that you have on your chest.