Quick Q re: puffy nip revisions after previous lipo or on slim patients?

[tonysoprano]

Just a quick one here, in regards to revision surgery for post-surgery puffies where the primary surgery was already excision+lipo, and where a significant amount of lipo was performed....

Maybe the best question for Dr Bermant or Dr Jacobs here?

I'm just curious as to the difference it would make if a patient is presenting for revision surgery for post-gyne-surgery puffy nips, where significant lipo was already performed, thus reducing the palette of fat remaining to sculpt into the void/for fat-flaps or what have you...

Not to say that there is no fat left or extremely little fat left, but rather that the level of fat remaining in the chest is now fairly modest, on top of the patient being in fairly good physical shape, with generally low-weight and fairly low (not single digit low or bodybuilder low, but still lower end) body fat %...

Would this make a revision for post-primary-surgery-puffies necessitating fat-flaps (or similar method) construction more complicated, or harder for the revision surgeon to perform? I mean, would it be better in such an instance if maybe the candidate for the revision op WASN'T in their best, most-athletic, tip-top, slimmest shape when  presenting for surgery ?

I know that too much fat previously removed can make a puffy-nips revision more difficult, and sometimes even impossible, but I'm just asking here if it's a case of the surgeon now just having less fat rather than more fat to play with/sculpt, if that now creates a more difficult task for the revision surgeon?? (As we are always hearing about a preference by surgeons for their patients to be as cut and in-shape as they can possibly get into prior to surgery....Would that also apply to those in-shape/slimmer patients who could probably stand to have a bit more chest fat available for revision-surgery sculpture?)

cheers Docs,

Tony

[DrBermant]

Just a quick one here, in regards to revision surgery for post-surgery puffies where the primary surgery was already excision+lipo, and where a significant amount of lipo was performed....

Maybe the best question for Dr Bermant or Dr Jacobs here?

I'm just curious as to the difference it would make if a patient is presenting for revision surgery for post-gyne-surgery puffy nips, where significant lipo was already performed, thus reducing the palette of fat remaining to sculpt into the void/for fat-flaps or what have you...

Not to say that there is no fat left or extremely little fat left, but rather that the level of fat remaining in the chest is now fairly modest, on top of the patient being in fairly good physical shape, with generally low-weight and fairly low (not single digit low or bodybuilder low, but still lower end) body fat %...

Would this make a revision for post-primary-surgery-puffies necessitating fat-flaps (or similar method) construction more complicated, or harder for the revision surgeon to perform? I mean, would it be better in such an instance if maybe the candidate for the revision op WASN'T in their best, most-athletic, tip-top, slimmest shape when  presenting for surgery ?

I know that too much fat previously removed can make a puffy-nips revision more difficult, and sometimes even impossible, but I'm just asking here if it's a case of the surgeon now just having less fat rather than more fat to play with/sculpt, if that now creates a more difficult task for the revision surgeon?? (As we are always hearing about a preference by surgeons for their patients to be as cut and in-shape as they can possibly get into prior to surgery....Would that also apply to those in-shape/slimmer patients who could probably stand to have a bit more chest fat available for revision-surgery sculpture?)

cheers Docs,

Tony

While in general, I have been talking here on this forum for years that weight loss before surgery is better than weight loss after, there are 2 exceptions. I work with many Bodybuilders with Gynecomastia and other athletes with extremely low body fat. For these individuals, I prefer to work on them in their off season body fat. Too little fat makes targeting gland first difficult. It is nice to have some local resources to work with.

The other exception is a patient with a missing tissue defect after surgery done elsewhere who also has a global fat component causing a contour problem. For the global problem it would be more predictable to get the weight off first and then do the surgery. Yet reduce the global fat and the local resources on the chest may be reduced. I teach these patients of the conflicting options going either way. Almost all patients for the Revision Gynecomastia Surgery opt to give me resources to work with first and then gamble how the changes will happen with further weight loss. There are exceptions to even this situation. Those with massive amount of global fat. Then the weight loss first again becomes a priority.

So you see, advice on any specific problem is best delivered during an individualized consultation or a Preliminary Remote Discussion where I can learn about the specifics of the problem and offer a specific solution. If interested, Jane is my office manager.  She can normally be reached at our office by phone Monday - Friday 9-5 Eastern Time at (804) 748-7737.

Hope this helps,

Michael Bermant, MD
Learn More About Gynecomastia and Male Breast Reduction

[tonysoprano]

Thanks Dr. B,

I guess for those of us considering revisions who have previously had a fair bit of lipo performed, or those that are in very good athletic shape, and even those that are just naturally skinny, it might be best for us types to be in pretty good shape for surgery, but not in too good shape Who would've thought?

I guess I'll make sure I don't get out of shape for a possible near-future revision, but will also stay wary of ending up in "too good physical shape", so I'm not limiting your (or any other doc's) already reduced local resources...
cheers doc,

Tony

[DrBermant]

Thanks Dr. B,

I guess for those of us considering revisions who have previously had a fair bit of lipo performed, or those that are in very good athletic shape, and even those that are just naturally skinny, it might be best for us types to be in pretty good shape for surgery, but not in too good shape Who would've thought?

I guess I'll make sure I don't get out of shape for a possible near-future revision, but will also stay wary of ending up in "too good physical shape", so I'm not limiting your (or any other doc's) already reduced local resources...
cheers doc,

Tony

Actually, getting yourself evaluated for more specific information during a consultation is the better way to plan for possible revision. As I outlined I see many different variation all the time. Each situation is different. Only after evaluating the entire picture can I offer specific advice for one of my patients. Other doctors offering specific advice in a forum are risking establishing a doctor patient relationship for which they can be held responsible. So before guessing what would be best, explore the specifics with the surgeon you are trusting your future revision sculpture. If you are looking for my help, Jane is my office manager and will be glad to explain how the process works.  She can normally be reached at our office by phone Monday - Friday 9-5 Eastern Time at (804) 748-7737.

Hope this helps,

Michael Bermant, MD
Learn More About Revision Gynecomastia and Chest Surgery

[Dr. Elliot Jacobs]

Would that also apply to those in-shape/slimmer patients who could probably stand to have a bit more chest fat available for revision-surgery sculpture?

You pose an interesting dilemma.  Apparently your have now slimmed down AND you have some type of crater deformity.  Therefore, there may not be sufficient surrounding fat to perform fat flaps to deal with the crater.  Yet, if you should gain weight, it will make the crater problem even worse.

In cases similar to yours, I have oftentimes found sufficient surrounding fat to be able to do some type of fat flap.  Sometimes I have to do a slight bit of lipo on the periphery to lower the surrounding tissues so that the depth of the crater is seemingly lessened. And sometimes I need to do fat grafting -- taking fat from another area of the body and injecting it into the crater (this may require several sessions -- depending on the depth of the crater).  And sometimes both flaps and grafts may be necessary.

And sometimes there is just nothing that can be done.

Obviously, each case is different -- so you would have to see a true gyne specialist to see what can be done.

Best of luck!

Dr Jacobs

[tonysoprano]

Thanks for the reply Docs,

Dr Bermant: I definitely realise that a proper consultation - remote or otherwise - is the best way possible to specifically address the subtleties  and differences in each individual case, and certainly do fully intend scheduling consultations a bit later in the year, when I am in closer proximity (and also in a closer financial position) to a potential surgery date...
On that note, would you suggest shaving all chest-hair off before snapping "standard" angles gyne-pictures for a possible remote consult?

Dr Jacobs: I have not slimmed down since my original surgery - that's not what I was implying. I am naturally of a generally slimmer build anyway, as well as having had a decent amount of lipo to the chest my first time round. That's what I was wondering about - In the hypothetical case of someone having a bit less chest fat than more. I also do not have a "crater deformity" per se (that's noticeable) here, but rather the problem in my case is post-surgery very puffy, pointy nipples (on an otherwise very flat-looking chest), most likely as a result of nothing being left underneath the areolas for the nipples to "attach to"...other than what my original p.s described as a tiny "button" of gland that he left behind the nips...(Unless "post-surgery puffy nips" come under the general banner of "crater deformities" )

Anyway, thank you both for the great feedback...

Obviously, I won't be looking to actively put on weight for the surgery ( I am a healthy, yet slender weight and well in-shape for a 30 year old man), but I may just ease up on the whole keeping fit/staying in-shape lifestyle in the last few months before a potential surgery date, just so that my revision p.s has adequate "local resources" available for possible fat-flap construction, or any other micro-lipo-sculpture needed to correct my puffys' situation...

Thanks again,

Tony

[DrBermant]

Thanks for the reply Docs,

Dr Bermant: I definitely realise that a proper consultation - remote or otherwise - is the best way possible to specifically address the subtleties  and differences in each individual case, and certainly do fully intend scheduling consultations a bit later in the year, when I am in closer proximity (and also in a closer financial position) to a potential surgery date...
On that note, would you suggest shaving all chest-hair off before snapping "standard" angles gyne-pictures for a possible remote consult?

Anyway, thank you both for the great feedback...

Obviously, I won't be looking to actively put on weight for the surgery ( I am a healthy, yet slender weight and well in-shape for a 30 year old man), but I may just ease up on the whole keeping fit/staying in-shape lifestyle in the last few months before a potential surgery date, just so that my revision p.s has adequate "local resources" available for possible fat-flap construction, or any other micro-lipo-sculpture needed to correct my puffys' situation...

Thanks again,

Tony

No, I do not normally recommend shaving the chest for documentation with rare exceptions. For the many years of patients having remote discussions, I have yet to make that type of recommendation. The shaving I perform the day of surgery for my patients is for their comfort in removing the protective dressings after surgery and to better keep those dressings functional for the time they are needed.

Michael Bermant, M.D.

[tonysoprano]

Would having a very thick growth of dense,long black chest hair (which definitely seems to obscure the general contour of the chest - at least to my own eyes) be one of those exceptions ?

I tend to shave my chest every few weeks anyway, just to keep is neat-looking and closely cropped, otherwise it can get pretty unruly. I mean would you recommend AGAINST shaving the chest for photo documentation for a remote consult.?

[DrBermant]

Would having a very thick growth of dense,long black chest hair (which definitely seems to obscure the general contour of the chest - at least to my own eyes) be one of those exceptions ?

I tend to shave my chest every few weeks anyway, just to keep is neat-looking and closely cropped, otherwise it can get pretty unruly. I mean would you recommend AGAINST shaving the chest for photo documentation for a remote consult.?

Actually no, I take care of many bodybuilders, athletes, actors, models and others who prefer a shaved chest look. For my remotes I generally do not ask my patients to stop shaving or to shave. Exceptions would more fit contour irregularities or scars that the patient tells me are hidden unless the chest is shaved. If a photo hides the problem, then it does not work well for an evaluation of the problem. The bottom line for remote discussion based on pictures, if the images do not show the problem, then a discussion on something that can not be seen on the images makes little sense. Then the options include taking different pictures, shaving (not something I have needed to ask patients to do to date), or coming into the office to be examined in person.

Shaving before surgery is a different matter. Shaving before surgery, unless it is done just before the operation (I do mine on the operating table), raises risk factors for infection many fold. So for the patients who shave their chests, I ask them to stop shaving their chest before surgery.

Michael Bermant, M.D.

[tonysoprano]

Thanks Dr.B,

I'll probably shave before taking pictures for any remote discussions to take place in the coming months, just to give the best views possible of the problem. I'm really hoping the remote consult. will provide a sufficient depiction of the issues present with my chest, so as not to necessitate an in-person, separate trip for an office consult in addition to the surgery trip I would be making too.

Although even if the pics are able to illustrate 80 or 90% of the problems and issues with my chest, there is still a day-before pre-op consult in-office anyway, which would complete the other dimensions of the picture for you anyway, right?
I would think that so long as most of the problem/s can be illustrated via pics and the remote consult., that anything more that wasn't entirely noticeable in the pics, or was, perhaps, made to look minimised by the nature of the remote consult., and the limitations of 1-D photographs, could then be accounted for and fully evaluated at the day-before-surgery consultation - of course, to better complete the overview of the chest problem presented by the patient (as best as one is able to through pics) during the prior remote discussion...

Since I have seen many cases milder than mine, many of whom probably undertook the remote consult. option before surgery, who were probably still able to clearly depict the nature of their problem/s accurately through a remote consult, then I'm thinking that for my case, the remote option would probably suffice too - at least in painting an initial - albeit less precise - picture of the issue/s of my chest, before surgery.... ?)

Am I on the right track here with my thinking Dr.B ?