A professional man in his early 50’s who has been troubled by the feminine appearance of his chest. He has difficulty wearing fitted shirts and sweaters without this being visible and troubling for him. He is shown before and again, 5 weeks after “SAFE” liposuction. After the wetting solution is placed in the operating room, external ultrasound was applied to his chest. Then power assisted separation of the fat with a basket cannula was performed. Then liposuction was performed with cross tunneling from an incision at the areola and an incision in the upper chest. Then fat equalization was performed to smooth the area after aspiration. He is thrilled with his early result. The small red scars, one on each side of his upper chest, are at their most visible at 6 weeks. They will continue to fade and soften over the next 2 years.
A body builder in his early 20’s who is troubled by female breast development. While not extreme, this bothers him in some fitted shirts, as well as with his shirt off. He is shown before and again, 6 weeks following direct excision of the breast tissue combined with SAFE liposuction (suction aspiration/ fat equalization) using power assisted liposuction. The small scars on his chest from the liposuction are at their peak at 6 weeks and will now fade and soften over the next 2 years. He is thrilled with his early result.
A man in his late 30’s who is troubled by gynecomastia for many years. He was bothered in a bathing suit but also in close fitting shirts. He is shown before and again, 6 weeks after bilateral chest liposuction with a combination of external ultrasound assist and power-assisted liposuction, as well as direct excision of a walnut size area of actual breast tissue( 2 ounces from each side, about the size of a large walnut). He is thrilled with his improvement, and no longer has a feminine appearance to his breasts in a bathing suit or in fitted shirts. He will typically continue to have some additional shrinkage as swelling diminishes over the next 3-4 months.
A fitness instructor in her early 50’s who came in to evaluate her implants and also to address problems with her nipples. She initially had surgery 26 years earlier and reports significant bruising afterwards, followed by a fairly rapid development of hardness around her implants. The hardness of the implants (capsular contracture) made it uncomfortable to lie on her stomach. She was also bothered by “long nipples” that were overly prominent in her clothing. She wears silicone nipple shields to hide them. They are also very sensitive in the shower and against her clothing. Given the length of time since her original surgery I obtained an MRI which showed that both implants were ruptured.
Decisions to make: Replace or remove? She likes filling her bra without the padding and wants to replace the implants. Saline or silicone? Her tissues are thin, and she does not want the additional wrinkles and ripples which may be more noticeable with saline implants.Keep the implant above the muscle or place it below the muscle? She does not want to see motion of the implants when she tightens her pectoralis muscles (animation) and would prefer to keep the implants above the muscle. Our usual decision would be to place the implants in contact with fresh tissue in a new plane below the muscle but I felt that I might be able to make a new space between the implant capsule and the muscle ( a “neosubcapsular” space) so the implants would be in contact with fresh tissue but still above the muscle. Texture or smooth surface? Texture can decrease dropping and lateral shifting of the implant with time but can increase the risk of late seroma and pseudocapsule formation. Because she is so physically active, she would theoretically be more at risk for seroma and pseudocapsule with the texture so she elected for the tradeoffs of the smooth.
Size? She is 5 1 ½ and 118 lbs. Her operative report was obtained and listed a 175 cc implant on her left and an adjustable implant on her right but did not mention its size. After discussion of the options she elected for 250 cc implant on her left, which we sized her in the office by adding 75cc sizing shell to her existing breast so she could see how this looked in a bra. Our plan was to have a range of sizes available for the right side and to decide in the operating room.
Choice of nipple reduction procedure: The “standard” approach that is taught is to amputate the top of the nipple and let this heal in. Although this does reduce the height of the nipple papule it cannot reduce it’s diameter. We elected for a top hat flap procedure, which does not leave any raw areas to heal in and also reduces the diameter and height of the nipple papule. Remove and replace the implants immediately or leave them out for 3 months before replacing? Capsular contracture can be difficult to treat, and can havea high recurrence rate with immediate replacement of the implants- as high as 70% in some studies. The causes of capsular contracture are still being debated. A common cause may be biofilm, where bacteria gets on the implant and “walls itself off” (like tartar on your teeth that the dentist scrapes off) so that the body can’t fight it. In a situation like this, simply replacing the implant does not give the body a chance to clear the bacteria and the risk of it spreading to the new implant and causing a contracture is high. I have had the best success in these cases by leaving the implant out for 3 months prior to replacing it. But a hematoma (collection of excessive blood around the implant) can also stimulate a capsular contracture and given her history of significant bruising after her original surgery this seemed more likely in her case. I am not as worried then about immediate replacement of the implant and this is what she elected.
Surgery: Her old scars were two fingerbreadths above her existing inframammary fold and were felt to be too high and had not healed satisfactorily. I felt it best to place new incisions in the proper location along her existing inframammary fold and this was discussed and approved by her. I was fortunately able to develop a neosubcapsular pocket, below the old breast capsule but above the muscle. In this way the implants could be kept in the subglandular position as per the patients request, but in a new “space” in a fresh plane of tissue. The ruptured implants were removed. The 250 cc round smooth moderate profile plus silicone gel implant was placed on her left, and was best matched with a 275 cc round smooth moderate profile silicone gel implant on her right. She is now seen nearly 3 months after surgery. Although it is early, her breasts have remained soft and she can now lie comfortably on her stomach. She has not lost nipple sensation, but no longer has the hypersensitivity in the shower and from her clothing.
A man in his late 50’s with breast development since his early teens. He is troubled by the appearance of his chest at the beach, but also in some shirts. He has not used marijuana or anabolic steroids, two common caused of male breast development, and his cause is considered “idiopathic” – which means that doctors don’t know the cause. This is probably the most common scenario. Some medical studies suggest that 30% or more of males may have some female appearing breast development around the time of puberty but in most cases it goes away. If it is not gone by 18 months, then it is probably not going to resolve. He is shown before and again, 6 weeks after gynecomastia treatment with a SAFElipo. His small incisions are still red at this point but will fade as he heals over the next 6-12 months. He is already pleased with the improvement in his contour. Typically skin is felt to continue to shrink and contract over the next 6 months. The “S.A.F.E.” method described by Dr. Simeon Wall gives more effectiveness with fewer irregularities than thermal-based technologies such as laser-assisted liposuction or internal ultrasound-assisted liposuction. These thermal technologies can damage the fat cell and coagulate the tissues surrounding the fat, and can lead to more irregularities in the skin. With SAFElipo, a three step process is followed: S eparation, fat A spiration and F at E qualization. In the first step a special probe is used to mechanically separate the fat cells. This is often done with a power assisted device that vibrates back and forth. Then fat aspiration is performed but can be less aggressive than standard techniques because the fat cells have already been separated. After suctioning, the area may feel smooth, but can still have some irregular areas of fat that are thicker and thinner. The mechanical probe is then used for Fat Equalization, to help reposition the fat deposits and smooth them out. Using this technique can give a smoother result, and helps to preserve the fat cells that are left behind.
A very early followup in a college student with unilateral (one sided) gynecomastia. He is shown before and again, 5 1/2 weeks after a combination of external assisted, power assisted liposuction of the right chest/breast combined with direct excision. Scars typically thicken for 6 weeks and then start to soften and lighten over the next two years. He already has an excellent contour and correction, no longer having a “feminine” appearing breast. No skin excision was necessary.
An 18 yo college student with idiopathic gynecomastia (idiopathic means that the cause is unknown). He is shown 5 weeks after a combination of direct excision and mechanically assisted/ external ultrasound assisted liposuction. The imprint from the silicone pads that we have recommended that he wear to help with scarring is seen in the after photos. He already has an excellent contour, and the scars should continue to fade over the next 6 months.
A man in his late 20’s is troubled by prominent breasts (gynecomastia) as well as prominent nipple papules. This really bothered him at the beach, and also when wearing shirts. As in many of my cases here in Boston, he has had this since puberty. He denies significant marijuana use or anabolic steroids, which have both been known to cause gynecomastia (male breast development). In his case we would list the cause as “idiopathic”, which is a fancy word for “the cause is not known”. As much as 30% of young males can have some breast development at the time of puberty, but in the majority of these men, it resolves spontaneously. If it has not gone away by 18 months, however, it is probably not going to go away without surgery. At first glance, his gynecomastia and nipple prominence may not seem too noticeable, but an oblique (3/4) view and side view tell the story. He is shown before, and again, 6 weeks after a combination of a nipple papule reduction with a “top hat flap”, combined with external ultrasound assisted liposuction of his chest and a direct excision of a small button of breast tissue through an incision around his areola. The keloids in the middle of his chest are preexisting from acne scars, and were treated at the time of his surgery with the injection of Kenalog, a type of steroid that can soften and flatten scars. His tattoos are blurred for his privacy, the photos are otherwise unretouched.