Can PAL break up most of the gland?

[spaceace]

Another poster wrote that his surgeon, Dr. Lista, said that the PAL can usually break up most of the glandular tissue under the nipple and suck it out, without having to make the 'peri-areolar' incision'.  

It can actually break up the gland?  

Is it possible then that 'peri-areolar' incision'would not be necessary for very minor gyne.  I'm talking *very* small lump.

[DrBermant]

Another poster wrote that his surgeon, Dr. Lista, said that the PAL can usually break up most of the glandular tissue under the nipple and suck it out, without having to make the 'peri-areolar' incision'.  

It can actually break up the gland?  

Is it possible then that 'peri-areolar' incision'would not be necessary for very minor gyne.  I'm talking *very* small lump.

Liposuction Is Great for Sculpting Fat

Various types of ultrasonic and power assisted liposuction (UAL and PAL) have been around for quite sime time.  Each surgeon uses the tools and techniques he / she prefers.

There are studies claiming that ultrasonic liposuction does not break down gland cells, these were done to justify the safety in female liposuction breast reduction surgery.  Ultrasonic energy cannot be both ways, good for gland breakdown and safe not harming gland unless there is a difference between male and female breast gland tissue which has not been proven to my knowledge.

Tumescent liposuction is a form of anesthesia where fluid is placed in the tissues to be sculpted.  You can see very graphic pictures of the tumecent technique here.

Liposuction such as ultrasonic, VASER, power assisted, and sharp cutting cannula preferentially remove fat over gland.  Gland tends to exist under the nipple areola region.  When fingers of fat extend between fingers of gland, breast reduction can come from removing the fat and leaving gland behind.  On animation such as flexing the pectoral muscles or putting the arms over head, gland does not compress or move like fat.

When gynecomastia is from fat, liposuction works very well for contouring the chest.  I have seen many patients from other doctors who tried to use liposuction alone techniques that left gland behind that the patients just did not like for Revision Gynecomastia Chest Sculpture.

Here is an example of Revision Surgery after Liposuction alone.   Here is another revision after liposuction alone.

The problem is picking the right method for what actually is that patient's problem.  That is why I prefer my Dynamic Technique that permits what I find during surgery to guide my sculpture.

I have also seen patients with channel problems between remote access sites and the areola / nipple.  Scars, adhesions, and depressions can look terrible.  Check out the lateral (side views) and posterior oblique (side from the back views with and without muscle flexion here to see what I mean.

Ultrasonic liposuction uses energy to help emulsify fat.  Power assisted liposuction uses mechanical vibrating devices to rapidly move the cannula back and forth.  Both PAL and Ultrasonic methods have been around for several years.  Many do not prefer what they do to the tissue.  Others like what they offer.  Both still preferentially remove fat over gland.  Both make the work of the surgeon easier.  Some feel ultrasonic liposuction can cause more swelling, bruising, and the increase the need for drains.

For me however, they also both remove the feel of the tissue sculpture.  I like the much better control I get with my cannula selection and personally I do not like either ultrasonic nor power assisted techniques.  None of the cases on my website used either PAL or Ultrasonic techniques.  

As any artist, I take my cannula selection very seriously and have evolved what permits me to achieve my results.  I have considered and evaluated many, many technologies.  The many different types of cannula I use have their own advantages and qualities.  I pick a subset of these cannula that varies for the many different types of gynecomastia male chest sculpture that I see.

Gland removal by any technique can still leave a depression when  a major part of the problem is from gland.  For gland removal, I prefer the greater precision of removal under direct visualization and feel.  This also give me access to many more elements for my artistic palette of my Dynamic Technique to sculpt the remaining tissues.

This approach permits me to maximize the removal of the firm gland and sculpt the remaining fat.  How tissues move is important.  The human body is beautiful in animation.  That is why I show pictures of the chest with arms up, down, and with muscles tight / relaxed in addition to the results from multiple views.  Such analysis of the results as well as how tissues evolve, the possible need for drains, comfort level after surgery, are important factors in picking your doctor.  It is like an artist selecting a paint brush.  The results are what matters, not with what tool they sculpt.

Hope this helps,

Michael Bermant, MD
Learn More About Gynecomastia and Chest Sculpture

[MonarchX]

My doctor broke down my gland into small pieces and then sucked it out with regular liposction (with syringe suction, because no machine was present).

It was not fun, it took 5 hours, and it was VERY aggressive.  My surgeon was a perfectionist and let himself, his assistant, and me to feel the gland during the surgery and asked whehther I am satisfied.

When under local anaesthesia, you can FEEL the gland being scapred.  The fat comes out smoothly, but the gland gets STUCK in the cannula hole.  So, you just keep "sawing" it off (the canula should have a BIG hole with sharp edges!)

The original lump was like a clumped set of small hard beads size of a quarter and height of 2-3mm.  The remainder is a very smooth "hill" maybe 0.5mm in height, and 7-8mm in length.  

Its all about the surgeon I believe.  I have looked at lipousction books that my doctor has of the TOP surgeons in the world and their gynecomastia works looked terrible.

My surgeon wanted to order PAL but it proved difficult to get before my surgery.

So, I would say YES, with PAL and aggressive liposuction you can remove 90% of the gland or so.

The reason many plastic surgeons perfer excision to gland is not because liposuction can't do it, but because its much more difficult.  

[beevis]

Dr. bermant ,Dr. list said in his Youtube video that it really doesnt matter if you lose weight before the surgery. I saw you about a year ago for a consult and you mentioned that the results would be better if i lost a little weight. i don´t appear over weight and my BMI is good. what is the benefit in terms of outcomes to be at a lower bodyfat percentage going into the operation?

cheers,

beevis

[headheldhigh01]

dr b, useful commentary.  aside from the technique question of cannulas, though, i assume in severe cases you still wind up doing lipo and excision both most of the time, and excision only for the dense gland cases? 

[DrBermant]

My doctor broke down my gland into small pieces and then sucked it out with regular liposction (with syringe suction, because no machine was present).

It was not fun, it took 5 hours, and it was VERY aggressive.  My surgeon was a perfectionist and let himself, his assistant, and me to feel the gland during the surgery and asked whehther I am satisfied.

When under local anaesthesia, you can FEEL the gland being scapred.  The fat comes out smoothly, but the gland gets STUCK in the cannula hole.  So, you just keep "sawing" it off (the canula should have a BIG hole with sharp edges!)

The original lump was like a clumped set of small hard beads size of a quarter and height of 2-3mm.  The remainder is a very smooth "hill" maybe 0.5mm in height, and 7-8mm in length. 

Its all about the surgeon I believe.  I have looked at lipousction books that my doctor has of the TOP surgeons in the world and their gynecomastia works looked terrible.

My surgeon wanted to order PAL but it proved difficult to get before my surgery.

So, I would say YES, with PAL and aggressive liposuction you can remove 90% of the gland or so.

The reason many plastic surgeons perfer excision to gland is not because liposuction can't do it, but because its much more difficult. 

Sculpting gland with liposuction is like trying to eat steak through a straw.  You can use liposuction to easily remove the fat from a steak, but the meat is better worked on with knives or scissors.  What happens more often with liposuction of the gland is that the fingers of fat between the fingers of gland come out first. This condenses the gland behind leaving a mess. 

The question is why bother trying to use liposuction alone on the gland.  Are the incisions better, smaller, or more hidden?  In my opinion no to all of them.  My typical areola scar is often much shorter than what some doctors need to fit their ultrasonic liposuction cannula.  I often am somewhere between 1.6 and 1.8 cm for each areola incision for standard gynecomastia.  Check out my Nipple Areola Gallery. The junction between the areola and chest is a great place to hide the scar for most men. Incisions at the arm pit (axilla) or lower chest just do not look as good, move as well, and I have seen some terrible crater defects where the zones between these remote sites and the region needing contouring have been badly changed.

Dr. bermant ,Dr. list said in his Youtube video that it really doesnt matter if you lose weight before the surgery. I saw you about a year ago for a consult and you mentioned that the results would be better if i lost a little weight. i don´t appear over weight and my BMI is good. what is the benefit in terms of outcomes to be at a lower bodyfat percentage going into the operation?

cheers,

beevis

I typically tell my patients that weight loss before surgery is better than weight loss after surgery.  Weight loss is a coarse tool. Plastic Surgery is better as a refinement tool.  You cannot pick where weight comes off from.  As a Surgical Sculptor, I prefer the coarse tool first, then the refinement.  Men typically put weight on first the chest and belly and take the fat off those area last.  Do the surgery first, and you are gambling where the fat comes off from with the weight loss.  If the patient is typical, and the chest fat does not come as well, it will look like a recurrence.  Another option is to suck all the fat, leaving a crater defect.  A Crater Deformity Complication Scar, even one widespread across the chest, still does not look good, does not move well, nor appears normal in animation.

Some men do not plan on losing weight.  When they tell me that they are happy at their current weight, compromise surgery is another option.  There are examples on my website where patients have chosen to compromise. They look better after surgery than before, but they still look overweight and not as good as those who choose to lose their weight first.  The problem is that you cannot take an excess weight contour problem and fix it with plastic surgery.  Unless the contouring is done globally, the small region treated can look terrible.

If you have questions about your specific situation, Jane is my office manager and will be glad to set up a time to continue our disucussion of your options.  She can normally be reached at our office by phone Monday - Friday 9-5 Eastern Time at (804) 748-7737.

dr b, useful commentary.  aside from the technique question of cannulas, though, i assume in severe cases you still wind up doing lipo and excision both most of the time, and excision only for the dense gland cases? 

Leaving the gland behind, tends to result in puffy nipple deformity.  Gland just does not move like fat.  That is why I prefer to target gland first and then sculpt the remaining fat.  Liposuction and excision are typical elements of my Dynamic Chest Sculpture Technique.  Almost all of my sculpture involves both elements and usually others.

Hope this helps,

Michael Bermant, MD
Learn More About Gynecomastia and Chest Sculpture

[mmaman]

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