Having woman like breasts, known as gynecomastia, is a condition affecting almost 40% to 60% of all men, however it is rarely discussed. Several factors can cause male breasts, such as: drugs, genetics, steroid use, and aging. To alleviate embarrassment of this disorder, the option of gynecomastia surgery is available.
Correction of the male breast comprises of reduction of the fibrous fatty tissue and breast gland by surgical removal. Liposuction is used with this technique for blending and sculpting of the surrounding area. It may be necessary to excise excess skin in some situations. However, skin has the ability to contract and shrink after surgery; similar to the way a rubber band stretches and then goes back to its previous shape. Dr. Delgado takes advantage of this natural phenomenon and has build his techniques around the “contraction effect”. Dr. Delgado has found that the younger the patient the more contraction and the older the person the less contraction. Other factors that are significant to the “contraction effect” are significant weight loss or gain. This will stretch the tissue and affect the degree of skin contraction.
Also, a revision gynecomastia procedure will affect contraction due to the development of scar tissue. In addition, liposuction-causing heat such as Smart Lipo, Laser or Ultrasonic liposuction will affect skin contraction. This is an important element to determine the best technique to use.
Pseudo-gynecomastia is male breast enlargement due to fat accumulation. This can be treated successfully with liposuction. However, many cases of gynecomastia are treated as if it was pseudo-gynecomastia and the gland tissue remains. This accounts for many revision surgeries. Dr. Delgado’s gynecomastia practice consists of 40 percent revision surgeries and the most common reason is men who had liposuction only at their first surgery.
The essential elements for successful gynecomastia reduction surgery are male breast gland excision with liposuction. However, every case needs to be assessed individually as each case is unique. Dr. Miguel Delgado will spend a lot of time to explain his reasoning for your operative plan. In this “decision tree” he will want your input to customize your result.
There are various types of male breast enlargements. Some are as minor as “puffy” nipples, or as substantial a cup breast size of C or D. The treatment strategy and outcome will be different for each patient depending on their different situations. Most surgeries can be achieved in one stage and others will require two-stages. Dr. Delgado will be able to explain this in advance.
At the time of the first consultation, a thorough discussion of the advantages and disadvantages of male breast reduction surgery will occur. Dr. Delgado has hundreds pictures of patients before and then after surgery, courtesy of his patients. He will show you patients who are very similar to your situation. Dr. Delgado also has many videos of the gynecomastia surgical experience to view.
If you decide to proceed with surgery, a preoperative appointment will be scheduled approximately two weeks prior to your surgical date. Before you come in for this appointment, a surgical information booklet will be emailed or mailed to you. It will contain preoperative and postoperative instructions, and an extensive warning list of medications you must avoid for two weeks before and two weeks after surgery, as they may interfere with your surgery and healing process. If you are coming from out of state or a different country all of the preoperative labs and paper work will be completed in advance.
When you come in for your pre-operative appointment, we will discuss risks, complications and goals. A medical history will be noted, a physical will be done and you will be given prescriptions, as well as an order for the required blood test(s). Pre operative photographs will be taken and used at the time of surgery.
When choosing a gynecomastia surgeon, the most important quality to look for is extensive experience and expertise. It is equally important to see before and after pictures of the surgeon’s own patients. Ideally, you will be able to review a multitude of examples and a variety of cases to get a good understanding of Dr. Delgado’s surgery technique.
It is important that you find a plastic surgeon that is experienced and knowledgeable in gynecomastia surgery. Miguel A. Delgado, M.D., F.A.C.S., developed the “Gynecomastia Surgery Center of Excellence” and is based at Marin Cosmetic Surgery Center in Marin County, California. He has dedicated a large part of his practice to gynecomastia and has developed Gynecomastia.org and founder of The American Society of Gynecomastia Surgeons. Dr. Delgado is a gynecomastia specialist who has extensive training in male breast reduction surgery, with more than 25 years in cosmetic surgery.
__ DAY OF SURGERY
When the day of surgery arrives, it is natural to feel both anxious and excited. Even though being nervous is expected; Dr. Delgado’s team will do everything to make you comfortable. His expert surgical team has been with him many years and they perform at the highest level of standards in his state-of-the-art surgery center.
Just a word about the facility, Marin Cosmetic Surgery Center: The outpatient surgery center is in the Medical Office building of Novato Community Hospital, part of the Sutter Hospital campus. The facility is certified by the American Association for Accreditation of Ambulatory Surgical Facilities, Inc. (AAAASF) and Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the highest quality accreditation available in the United States. Dr. Delgado and his team are very proud of their facility and maintain the highest standards in the industry.
Dr. Gaynor is the anesthesiologist, and is renowned for his expertise in outpatient surgery. You will feel very comfortable under his care. His objective is always to make the entire surgical experience as pleasant and free of discomfort as possible.
__ SURGICAL PROCEDURE
Dr. Delgado’s surgical techniques are far from new for his treatment of gynecomastia. Innovative surgeons who came before him developed the techniques. Dr. Delgado refined the time tested tools for his own use, completing hundreds of such surgeries over the course of his career. His surgical techniques continue evolving as technology advances and more experience attained.
The technique chosen for each individual patient will depend on their unique situation. Obtaining the ideal male chest is the typical goal of the male patient. Depending on the patient’s anatomy will determine how possible this will be. It is important to Dr. Delgado to have the patient accept realistic expectations and goals during the consultation.
Dr. Delgado begins the procedure by injecting tumescent fluid, a solution made up of: lidocaine (a local anesthetic), salt water and epinephrine. As a “vasoconstrictor,” epinephrine significantly reduces bleeding, allowing Dr. Delgado great ease in which to operate. Taking 6 to 7 minutes to be effective, liposuction begins through a three-millimeter incision in the areola incision reducing the fat in the chest. The nipple areolar area is where liposuction is primarily performed, not where the bulk of the pectoralis muscle is located high up on the chest providing a masculine appearance.
In many cases, Dr. Delgado notes that some men have accumulated fat in the axillae, surrounding the armpit area. Many times, he finds this area will need aggressive liposuction in order to obtain a smooth contour with the chest area.
An incision is made next at the bottom half of the areola. Elevation of the skin is made from the underlying gland and fibro-fatty tissue. The important thing to this procedure is to emulate how the chest sits when the man is in a standing position and not lying flat. The appearance of the chest changes considerably from the horizontal position. This is critical, because it is in the standing position that we observe ourselves. The back of the surgical table is elevated to eighty degrees to achieve this during surgery. The fibro-fatty tissue and the gland are sculpted into a masculine form, using specialized razor sharp scissors. Dr. Delgado is aggressive in his approach, but takes his time to make the contour as perfect as possible.
Achieving the most skin contraction as possible is another important goal. A substantial quantity of subcutaneous tissue must be removed from the skin to accomplish this. By allowing the skin to shrink as much as possible, will result in the most natural appearance. The quality and amount of excess skin present, will determine to what degree the skin will contract.
At the end of the procedure, a drain is placed through a small armpit incision to create negative pressure in the open space and remove the fluid that naturally accumulates. This prevents the formation of a seroma, a buildup of bodily fluid underneath the skin. Should this occur, the fluid will need to be removed through needle aspiration. Once the drains are in position, special dressings will be placed with a compression garment. At the conclusion of surgery, the patient will be taken to the recovery room.
Seventy five to eighty percent of gynecomastia patients can be treated with this technique. More severe gynecomastia cases may require a minor lift at the time of the first procedure, or another secondary procedure may be scheduled to remove redundant skin through a periareolar lift.
With a minor lift a half-doughnut-shaped or crescent piece of skin is excised above the areola, lifting the skin upward reduces sagging under the nipple areola complex and reduces the appearance of the lower fold. This technique is excellent for a patient who does not have much loose skin. However, a disadvantage is a somewhat more visible scar at the top of the areola rather than the bottom.
A more aggressive procedure is the periareolar lift, whereby more skin is removed and tightening up the chest. This technique excises a doughnut of skin around the areola. The scar is only around the periareolar incision, blending in extremely well with time. The secondary procedure would be done four to six months after stage one and would only be used for severe cases. For such severe cases, Dr. Delgado will rarely perform a single-stage mastectomy, a technique that leaves an obvious scar going across the chest. This is sometimes used in massive weight loss patients.
__ After Surgery
Once the surgical procedure is completed, you will spend about an hour and a half in the recovery room, where you will be observed by the attending nurse. When fully awake and there is no indication of a problem of bleeding in the chest, a responsible friend or family member will be able to take you home. If you live more than one hour away, Dr. Delgado strongly advises you to stay at a local hotel for the first night. This will enable him to evaluate you at a moment’s notice if needed. If you were not staying nearby, and experienced an emergency, and needed immediate medical attention, your care would be out of his control and the hospital expenses would be highly unpredictable.
In two to three days you will have your first follow-up appointment to remove your drains. Sutures are removed one week after surgery, or if you are from out of state or the country Dr. Delgado will place more internal sutures and use fibrin glue. A compression vest is to be worn for 6 weeks, no exercise is allowed for 4 to 6 weeks, and depending on the type of work you do, you may be able to go back to work in 3 to 5 days. If you are from out of state or out of the country, we require that you stay at least 5 days. This is adequate time to deal with any issues and the others can be handled with email, phone calls and Skype.
__ Risks and Complications
Male breast reduction carries the usual surgical risks of infection, bleeding, and complications of anesthesia. One of the most common complications is bleeding under the skin. It used to happen in about 8-9% of patients, but we have improved our techniques and over the past three years we have a lower hematoma rate which is approximately 5-6%. If patients live more than an hour away, we advise them to stay at a local hotel.
Another complication is over or under resection of tissue. Under resection is treated with re-excision, but over resection will require fat flaps or fat injections. Gynecomastia surgery does leave incision scars around the nipple-areola complex, however fades with time to almost invisible. Occasionally, sensation of the nipple is reduced. The feeling may not return for up to six months.
Complications are a fact in the practice of medicine. Marin Cosmetic Surgery Center’s highly-trained surgical team, along with Miguel Delgado, M.D.’s vast experience with gynecomastia surgery, minimizes the risk of these complications. How they are managed is what determines the outcome.