Gynecomastia – Patient 148
A man in his early 30’s who had gynecomastia surgery 10 years somewhere else before but is still bothered by prominence of his nipple papules in clothing. He works in the travel industry and is lucky to be able to spend a lot of time at the beach and in summer clothes. His left nipple bothers him more than the right nipple. The left nipple papule is 6 mm in diameter and 7 mm high. His right nipple papule is 5 mm in diameter and 5 mm high. After discussions we decided to proceed with bilateral nipple papule reduction utilizing the nipple amputation technique under local anesthesia in the office. He is shown before and again, 6 weeks after correction.
Discussion: He appears that he may still have mild gynecomastia but this is not present with the “hands on the head” view and may be due to mild skin laxity but not additional tissue thickness which means that further surgery of the chest would not be helpful. His nipples do appear prominent. “Normal” measurements for the nipple papule have not been reported but in a female are generally considered to be 8 by 8 mm. My experience in males is that they prefer a flatter nipple to prevent prominence in clothing. Our patient is thrilled with the normal appearance of his nipples and no longer has prominence of the nipples visible in a thin shirt.
Gynecomastia – Patient 147
A college student in his early 20’s who first noticed female breast development at the age of 18. He was heavier, and reduced his weight by 50 lbs by stopping drinking soda, but the gynecomastia did not resolve. He wears compression shirts to hide the appearance of his chest in clothing and is uncomfortable with his shirt off. He is shown before and again, 4 ½ months after gynecomastia correction with power assisted/external ultrasound assisted liposuction using the S.A.F.E. technique ( Suction Aspiration Fat Equalization) combined with a direct excision of breast tissue from an incision around the lower border of his areola. He is thrilled to have a normal appearance.
Gynecomastia – Patient 146
A man with recurrent gynecomastia. He first presented at age 38 when he was 5’7 1/4 and 169 lbs. and had gynecomastia treatment by myself with external ultrasound assisted, power assisted liposuction combined with the direct excision of breast tissue through a periareolar (around the lower areola) incision with the specimen of breast tissue weighing 63 gms on the left and 70 gms on the right. He did well after surgery, with a good result at 5 months.
He returned to see me two years later.
He continued to smoke Marijuana (which can lead to gynecomastia) and also gained 15 lbs. and developed recurrence of gynecomastia, with new development of some firm breast tissue in the lateral lower breasts. This was a little surprising and not common in my experience, especially with direct excision of the breast tissue under the areola at the initial surgery. We returned to the operating room and performed liposuction again, along with the direct excision of 49 gms of breast tissue from the right and 40 gms of breast tissue from the left. The new breast tissue was located more laterally and inferiorly in the breast this time.
He again did well. He is seen again, 5 years after this second procedure. He reports having one treatment of cool sculpting to his upper chest for a little more refinement. He has lost one pound since his second surgery, but has been spending more time at the gym. His case illustrates a few points. Recurrence of gynecomastia is uncommon, but can happen, and may be impacted by gaining weight and significant marijuana usage. I have other patients who have continued to use marijuana without recurrence of their gynecomastia, so a recurrence like this has been uncommon in my experience. Weight gain after surgery can certainly contribute as well.
Gynecomastia – Patient 145
A man in his mid 30’s who has had gynecomastia since middle school. He describes developing breasts at 11-212. He was smoking marijuana at that time, and continues to smoke marijuana on a regular basis. Marijuana use has been associated with gynecomastia development in some studies.
He is bothered by the appearance of his chest with his shirt off and also in fitted shirts. He has worn compression garments to hide the appearance of his chest.
He is shown before and again, just 6 weeks after bilateral gynecomastia treatment with A modified S.A.F.E. technique combined with a direct excision of breast tissue through an incision around the areola. External ultrasound is used to soften the fat before the finned cannula is used to mechanically disrupt the fat. Then liposuction is performed through an incision behind the pectoralis muscle and beneath the areolar. Remaining breast tissue is excised through the periareolar incision and then the fatty layer is mechanically smoothed with the finned cannula.
Scars are at their thickest and reddest at 6 weeks and will now begin to fade and improve over the next 1-2 years. He is already thrilled with his improvement and is looking forward to going the beach this summer and wearing fitted shirts
Update: Our patient is now seen 8 months after surgery. His scars have continued to fade, and his swelling has resolved
Gynecomastia – Patient 144
A man in his early 30’s with gynecomastia. He first noted breast development at the age of 15-16. This bothers him with his shirt off and in fitted shirts. He wears additional shirts to camouflage the appearance of his chest. He does not have a history of marijuana or anabolic steroid usage. He has had endocrinology screening which is normal.
He is shown before and again, just 6 weeks after a modified S.A.F.E. technique using power assisted liposuction and external ultrasound assist, combined with a direct excision of breast tissue through an incision around his areola. The S.A.F.E. technique (Suction Aspiration Fat Equalization) uses a cannula with fins to mechanically loosen up the fat followed by power assisted liposuction to remove fat and then the finned cannula again to smooth or “Equalize” the remaining fat. In my hands this allows the most aggressive removal of fat with less chance of dimples and irregularities. I modify this technique by starting with external ultrasound to soften the fat. After the liposuction is performed I check the chest and if there is a distinct mass of breast tissue (as in his case) I excise this through an incision around the lower aspect of the areola. A gynecomastia vest is worn continuously for 6 weeks along with micro-pore tape. We have just removed his tape in the office. Although scars are typically the reddest and thickest at 6 weeks, he already has an excellent contour. He is thrilled to have a normal appearance of his chest again.
Gynecomastia – Patient 143
A man in his early 30’s who developed gynecomastia at puberty. He does not have a history of significant marijuana use or anabolic steroid use, both of which can cause gynecomastia. Studies report that as many as 30% of young boys will develop some growth of the breasts at puberty. In most cases this goes away on its own by 18 months. If it has not resolved by that time it typically is not going to go away on its own.
He is bothered by the appearance of his chest in fitted shirts and with his shirt off.
He is shown before and again, 6 weeks after Power-Assisted liposuction using a modified S.A.F.E. technique combined with direct excision of breast tissue though an incision around the lower part of the areola. In the S.A.F.E. technique ( the letters stand for S uction A spiration and F at E qualization) the procedure is typically performed under general anesthesia. Wetting solution, sometimes called “tumescent” solution is injected under the skin. This is a dilute solution containing some local anesthetic and epinephrine. Then I perform external ultrasound to soften the fat. Then a cannula with fins called a “Becker” cannula is used without suction to mechanically disrupt the fat. I prefer the Microaire power system that vibrates this cannula rapidly back and forth. This loosens up the fat cells that remain viable however. Then the “aspiration” or liposuction is performed using an incision under the arm as well as the incision around the areola. After excising any remaining breast tissue under the areola, the fat is “equalized” or smoothed by using the finned cannula again to smooth the remaining fat layer around. In this manner the most aggressive liposuction can be performed without as much of a risk of leaving dimples or irregularities. A compression vest is worn for 6 weeks.
Scars are at the pinkest and reddest at 6 weeks and then begin to fade and improve over the next 2 years. The peri-areolar scars are nearly imperceptible even at this time. The lateral access scars are typically the most visible early on, and I try and place these behind the border of the pectoralis muscle so they are not as noticeable. He will now wear topical silicone on the small access scars for the next 3-6 months. He is ready to go to the beach now at 6 weeks. Sunblock is recommended for the first 12 months because any scar that is exposed to the sun while it is still pink can turn brown. He is thrilled to finally have a normal chest.
Gynecomastia – Patient 142
A man in his early 20’s who has bilateral gynecomastia which started at the age of 16. He is right handed and muscular, with his right pectoralis muscle being larger and more prominent than his left. Arms up view demonstrates the prominent breast.
He was able to be treated with Power assisted liposuction using the S.A.F.E. technique ( Suction Aspiration Fat Equalization) with the removal of 550 of fat from each side of his chest. There was no palpable breast tissue present after the liposuction was completed so an excision of breast tissue through a peri-areolar incision was not needed. It is difficult to tell before surgery whether or not an excision of breast tissue will be needed so we typically plan for this and make the final decision in the operating room after the liposuction is complete. Liposuction will not remove breast tissue, so this is the advantage of being in the operating room rather than under local anesthesia in an office setting.
He is shown before and again, nearly 5 months after surgery. His pectoralis muscles are now able to be seen under the skin and he no longer has a feminine appearing chest. The S.A.F.E. technique uses a liposuction cannula with fins to mechanically break up the fat. This is used before suction is applied. Then the liposuction is performed with a traditional cannula. The fat cells are looser and easier to remove more precisely but any remaining fat is still viable. After liposuction is completed, then the fat is “equalized” again with the finned cannula to break up the remaining fat and move it around, giving a smoother final layer.
Gynecomastia – Patient 141
An early ( 6 week) follow-up on a man in his early 30’s who first noted gynecomastia in his mid 20’s. He has had negative endocrinology testing and a negative testicular exam (testicular tumors can be one cause of gynecomastia). He is bothered by the appearance of his chest with his shirt off but also in fitted shirts and golf shirts. He wears extra shirts to camouflage his chest. He did take over the counter supplements for weight lifting, and that may have been the cause. He is 5’ 11” and 166 lbs and is shown just before and again, 6 weeks after Power Assisted liposuction of his chest using the S.A.F.E. technique ( S uction A spiration F at E qualization). After liposuction fluid is placed in the chest, then external ultrasound is applied to soften the fat. Then a cannula with fins is used first without suction to mechanically disrupt the fat. Then liposuction with a normal liposuction cannula is used. Any residual breast tissue that remains is excised through an incision around the areola- in his case about ½ ounce of tissue was excised from each side. Then the finned cannula is used again to smooth and equalize the remaining fat. Scars are at their thickest and reddest at the 6-week mark and he has been wearing paper tape to protect his incisions. We can see a little redness of the skin from the tape and from the scars, which will now fade over the next 6-12 months. The hands on head view shows the excellent contour that has been obtained and brings the gynecomastia into view before and shows the complete resolution after his surgery. He told me that he is so happy and relieved to have a normal appearing chest again. A tattoo on his arm has been blurred for his privacy. The photos are otherwise not retouched.
Update: Our patient is now seen 8 months after surgery. His contour remains excellent and his scars have continued to fade. He tells me that his only wish is that he had done this sooner. He is thrilled to be able to take his shirt off at the beach and look normal. And he is no longer bothered by the appearance of his chest in fitted shirts.
Gynecomastia – Patient 140
A 33 yo engineer who is bothered by a female appearing chest since his 20’s. Despite some recent weight loss, he is still bothered by the appearance of his chest in fitted shirts and with his shirt off. He wears extra shirts to camouflage the appearance, He is shown just before and again, 4 months after External ultrasound assisted, Power assisted liposuction using the S.A.F.E. technique (Suction Aspiration and Fat equalization) combined with a direct excision of breast tissue through a peri-areolar incision. He is thrilled with his early result, and is no longer bothered by the appearance of his chest with his shirts on or off.
Gynecomastia – Patient 139
A man in his early 30’s who is bothered by female breast development. He did not finish growing in height until his sophomore year of college. He noted female breast development starting after college. His endocrinology workup was normal and he does not have a testicular mass on the examination by his physician. He is bothered by the appearance of his chest with his shirt off but also in some shirts. He did not have a history of significant marijuana use or anabolic steroids. The cause of his gynecomastia is “idiopathic” which is a fancy word for unknown.
He is shown before and again, 5 months after power assisted liposuction with external ultrasound assist using the SAFE technique ( Suction Aspiration Fat Equalization) combined with direct excision of breast tissue through a peri-areolar incision.
At 10 months, our patients scars have continued to fade. Hands on head view shows perfect contour of the chest from the S.A.F.E. liposuction combined with the direct excision. It may be tempting to consider only a direct excision without the S.A.F.E. technique- but in my experience it is difficult to perform a direct excision without the liposuction and obtain a smooth surface as we have done here. Even when there is not a large amount of fat, the undermining with the special cannula initially helps to separate the mass of breast tissue so that is technically easier to smoothly excise it without leaving irregularities of the overlying skin. Then after the excision the fat equalization portion of the S.A.F.E. technique further smooths the overlying layer of fat. In this way we have managed to avoid contour irregularities of the subcutaneous layer.