Gynecomastia

You should only consider gynecomastia surgery surgery if you are in good general health and have matured both physically and emotionally. Men who have firm, elastic skin will achieve the best results from male breast surgery and will require less extensive surgical measures. Male breast surgery is recommended for patients who feel dissatisfied with their breast size and shape following completion of breast development. Patients who are seeking surgical correction of their breast appearance should consider clinical evaluation for the cause of their breast enlargement. Clinical evaluation is important as it can unveil more serious physiological disorders and as it can prevent recurrence. Patients who consume large amounts of alcohol, are prescribed steroids, or smoke marijuana must be counselled against risk of reoccurrence.

Depending on the amount of excess fat, glandular tissue, and skin that a patient has, liposuction, direct excision, or both may be necessary. For patients with minimal sagging skin, minimal glandular tissue, but excess fat, liposuction only may be sufficient. With liposuction, a small incision that is less than ½ a cm in length is created at the edge of the areola to insert a thin, hollow tube which breaks down and removes excess fat. However, most patients present with excess glandular tissue underlying the nipple areola which then requires extension of the infra areolar liposuction injection site to approximately a 1 inch incision in order to allow for removal of the excess glandular tissue in addition to liposuction of the excess fat. In severe cases of skin redundancy and male breast sagging, direct excision of redundant skin and excess fat is required in order to avoid a deflated and overly sagging breast that would result from liposuction alone. In these cases, surgical incisions are placed strategically to allow for final surgical incisions in the shape of a “male breast plate” often seen in steel armor photos. In these cases, it is also necessary to remove and resize the nipple areola complex prior to replacing them at a natural and youthful position by skin grafting techniques.

On your initial visit, your surgeon will evaluate your health status by obtaining blood work and encourage you to seek consultation by your primary care or endocrinology physician to consider a clinical work up for the cause of your enlarged breasts. Your surgeon may examine you to rule out obvious medical causes of breast enlargement, such as impaired liver function, use of estrogen-containing drugs or steroids, or obesity. If your breasts are enlarged due to medically threatening conditions, your surgery may be postponed.

If you are 40 years or older, have had a personal or family history of breast symptoms (tenderness, lumps, nipple discharge), or contain suspicious lesions following your breast examination, you will be asked to obtain a mammogram. The mammogram will not only rule out breast cancer it will also let your surgeon know what kind of breast composition needs to be treated which will dictate surgical techniques required for your surgery. If you are a smoker, you should quit for 1 month prior to your breast reduction surgery to minimize skin tissue compromise. In addition, it is prudent to quit smoking for 6 weeks following surgery to ensure well-healed surgical incision lines. Finally, you will need to arrange for a friend or a spouse to care for any small children who may need to be lifted since you will be sore for the first couple days following surgery.

Since your surgery may require general anesthesia you must take several precautions prior to surgery. First, you will have to avoid eating and drinking after midnight on the day before surgery. This precaution ensures that your stomach is clear of digested foods that could potentially be aspirated into your lungs during induction of anesthesia. Since, you will have anesthetic medications administered throughout the case; you will remain groggy for several hours and will require a ride to and from the surgery center. You should choose a caretaker who is conscientious and who can spend the first night with you.

Breast reduction in men usually yields permanent results unless patients experience significant weight gain or continue consumption of causative agents. You should expect permanent surgical scarring, but your surgeon will try to conceal the scars in natural contours of the breast. By providing a thorough preoperative workup, safe intraoperative course, and frequent postoperative visits, patients should expect a speedy recovery and return to a more aesthetically pleasing physique and more comfortable lifestyle. Men who undergo gynecomastia surgery are extremely satisfied with their flattened and better-contoured chest and gain immense self-confidence after surgery.

Depending on the method of breast reduction and type of anesthesia, gynecomastia surgery can be performed at a hospital, outpatient surgical facility, or office-based surgical facility. If general anesthesia is required, the surgery must be performed in an operating room that is part of a hospital institution or an outpatient surgery center. Patients operated on at an office-based operating room must verify that the office facility is accredited by a surgical accreditation body such as AAAASF.

Depending on the complexity of your surgery, your surgeon will either recommend intravenous sedation in combination with local anesthesia or general anesthesia. The type of sedation that you will require will be discussed with you by your plastic surgeon during the consultation for gynecomastia surgery.

Regardless of the surgical technique, patients will experience bruising, swelling and discomfort for the first few days after surgery. Pain medication and antibiotics will be prescribed by your physician to address these problems. After surgery, you must wear an elastic pressure garment for 1 to 2 weeks at all times and for two more weeks only at nights. Stitches are all internal and external tapes remain in place for one month. Generalized swelling will resolve over the first month. Strenuous activities such as heavy lifting should be avoided for about 4 weeks, but patients can usually return to work and resume light activities within 7 to 10 days after surgery.

Patients can usually return to work in 7 to 10 days if their job does not include heavy physical stress. Patients with more strenuous jobs will require 4 weeks prior to returning to work.

a) Numbness: Swelling after surgery usually results in loss of feeling in the breast and nipple area during the first several weeks. This impairment is typically temporary and resolves within a few months.

b) Scarring: Incisions may be lumpy and red for a few months, but incisions become less apparent over time and can even fade to thin white lines. In general due to improvements in suture quality, patients can expect superior results today when compared to just a decade ago. It is important to acknowledge that smoking impedes the healing process and will result in more prominent surgical scars in patients who smoke.

c) Breast/Nipple asymmetry: Breasts may not be the same size and shape and nipples could be positioned unevenly depending on the degree of preoperative asymmetry. Furthermore, when liposuction is used, you may experience uneven contouring or skin redundancy that should tighten over time.

a) Hematoma: Hematoma refers to the accumulation of blood in the early postoperative period which pools into a dissected pocket. Hematomas provide a perfect medium for harboring growth of bacteria. In fact, if the patient has an infection anywhere in the body, the bacteria will travel through the blood stream and resettle in the hematoma; this can lead to an infection and subsequent wound development. In order to avoid a hematoma, drains can be placed in surgery so that any fluid accumulation can be drained. In addition, patients are evaluated preoperatively to make sure that they do not have a blood clotting deficiency. Finally, patients are asked to wear a breast compression garment at all times for the 1st two weeks to prevent hematoma formation.

b) Seroma: Seroma formation refers to the accumulation of plasma fluid in pockets created by surgical elevation of the soft tissue and disruption of vessels. This fluid may accumulate if the patient’s blood count is low and/or the patient’s nutrition poor. When nutrition is poor, protein levels in the blood are diminished which promotes leakage of this plasma fluid out of vessels. This fluid can be a nuisance to patients often requiring several aspirations in the office prior to its resolution. More importantly, these plasma fluid pockets may harbor bacterial growth and result in a clinical infection. Drains can be placed in surgery and are very effective in preventing seroma formation. Additionally, patients are asked to wear a breast compression garment over the 1st two weeks to prevent seroma formation.

c) Infection: An infection can occur after gynecomastia surgery and result in disruption of surgical incision lines and may leave the patient with an open breast wound. Prolonged antibiotics may be required to fight an infection and to prevent further extension of the infection. Risk of infections are avoided by using sterile technique, using intra-operative antibiotics, and sealing all incisions sites so that bacteria can’t get in through external contact. In addition, infections are less likely in patients who don’t smoke cigarettes or in smokers who quit smoking for at least 1 month prior to surgery.

d) Pulmonary embolism: Blood clots may form in leg veins during any surgery when the patient is under general anesthesia. Patients with a leg vein clot will complain postoperatively of pain in their calves. Patient’s with this complaint should be taken seriously and treated if a vein clot is diagnosed. Early treatment of patients with a deep leg vein will avoid migration of leg vein clot to the heart and lungs causing pulmonary embolism. Even though pulmonary emboli are rare, pulmonary emboli are the leading cause of death after surgery. Pulmonary emboli must be detected early by performing a CT Scan and should be treated urgently.

e) Skin edge compromise/death: The skin incision can be disrupted if the skin edge is vascularly compromised and/or dies or if there is local infection. This complication is best avoided by counseling patients on the terrible consequences of nicotine in cigarettes. Nicotine will literally clog all the small vessels found in the skin, which are critical for the delivery of nutrients and healing of the skin edge. Male breast surgery patients are usually mandated to quit smoking for at least 1 month prior to surgery. In addition, uncontrolled diabetes can lead to the undesired sloughing of the skin. Diabetic patients are urged to be vigilant about controlling their blood sugar levels prior to surgery. If patients develop an open wound, they will require prolonged local wound care with frequent dressing changes. Unfortunately, any delays in healing of the skin edges will compromise your aesthetic outcome.