Surgically closed incision

Complications are part and parcel of any cosmetic plastic surgery procedure – including gynecomastia surgery.

They can include, in order of severity: bleeding, irregular contours, cratering of the nipple, infections, and poor wound healing or scars.

But a couple of proven ways help decrease your odds of turning up with a pesky, time-consuming complication.

The first may not be obvious – but it involves the plastic surgeon. The secret is actually no secret at all: choose one who does a lot of gynecomastia surgery.

American medicine is very specialized today, so for example, even among heart surgeons, some specialize in surgery on heart valves while others concentrate on veins.

It’s no different in all of cosmetic plastic surgery: A surgeon who has performed a particular procedure many times over several decades disturbs less tissue and is more precise while doing his work.

It all actually starts before surgery.

For instance, it’s okay to ask a plastic surgeon during your first consult how many times he or she has done the procedure you want. Look for a doctor who performs that operation at least once weekly.

That translates into less bleeding, bruising and swelling because less tissue has been disturbed.

Even before you go see the surgeon for the first time, look at the before and after plastic surgery pictures on the doctor’s website. There should be many.

Much of complication avoidance is following –  to the letter — the doctor’s pre-and-post surgery instructions. For instance, halting aspirin or other blood thinning medications several weeks before surgery is very important. As is wearing the compression garment after surgery precisely as recommended by the surgeon.

Depending on your particular circumstances, the surgeon may want clearance by your personal physician, a physical or certain blood checks.

Why? All surgical patients must be healthy enough to undergo surgery.

Just before surgery, your surgeon may prescribe some antibiotics. These are preventive because the first cause of concern after any surgery is infection.

Personally, I have not – thankfully! — had a case of post-surgical infection for years.

Much of that is because my office surgical suite, is JCHAO (Joint Commission on Health Accreditation Organizations) certified and is as sterile – if not more so – than any hospital operating room you’ll ever find.

You should be in frequent touch with your doctor for the week leading up to surgery and make sure you are not ill just prior to surgery.

And don’t be surprised if your surgery is put off if you show up on the day of surgery with a cold, sinusitis, a skin infection like active acne or even a pimple on your chest.

Going ahead could be courting a serious infection!

My patients want to look better for the following reasons:

• Weight lifters want perfection
• Teens want to look like other teens
• 20 and 30-sometings want to look good shirtless
• 40 and 50-somethings want to look good in T-shirts

Plastic surgery has a concept known as realistic expectations. If you are 60-ish, a cosmetic plastic surgeon can perhaps make you look 45-ish. But 20? No way. That boat has sailed!

All procedures have various levels of what can actually be done, given the material presented to the surgeon.  Just as sculptor is limited by the material in which he works (you can do certain things with stone that you can’t do with wood) so too a plastic surgeon is limited in what he can do with the body and tissues of a patient.

Because an experienced surgeon has molded human flesh many times over – and has seen the changes healing can make – he or she has an excellent concept what can realistically be accomplished from surgery.

That same experience also gives a surgeon of many years experience an equally good  idea when the odds are stacked against you or, worse, when defeat may be about to be pulled from the jaws of victory.

Body builders are indeed a hardly lot who put in countless hours of grueling, exhausting training while living on a healthy but scant diet most people could not tolerate a couple of days.

Their yard stick is the mirror; they are judged on the degree of perfection shown in their bodies. Is it any wonder they often expect perfection?

Often, after gynecomastia surgery, weight lifters complain they can feel “something” under a nipple and demand a revision procedure. But I have to point out that 99 percent of onlookers don’t feel your chest – they look at it.  (In fact, most admire it greatly after the surgical fix!)

Then, I usually point out a 98 percent improvement is nonetheless very, very good. And, given all the elements involved, striving for a perfect improvement may actually drop the results down to 90 percent.

There is always an element of unpredicibility in surgery; infections are possible although I haven’t had one for years. (Knock on wood!)

I can also thank my operating room for that. (Read more about the exacting standards to which my gynecomastia surgery O.R. is held.)

A major part of finding a good advice about realistic expectations for male breast reduction surgery is finding a fully qualified surgeon.

A couple of tips:

• Make sure his or her board certification is from the American Board of Plastic Surgery

• Check for many before and after plastic surgery pictures

To start, we give patients a list of blood-thinning substances – headed by compounds that contain aspirin — that must be halted two weeks before surgery. Those items promote bleeding.

The patient and I also go over all the prescribed medications he may be taking with an eye toward continuing some and temporarily halting others.

Tobacco use must also be stopped because nicotine reduces the size of your blood vessels and interferes with both healing and the anesthesia process. That includes nicotine gum or patches. (Read more about smoking and plastic surgery.)

For the overweight, I usually recommend a weight loss of at least 25 pounds before surgery because it creates a much better result. Smaller amounts, say, five or 10 pounds really do not go very far in making the end result of male breast reduction surgery look that much better.

On the other hand, if weight loss and exercise in the gym is embarrassing, then “compromise” surgery at the current weight can be done.

We work on patients’ diets, too. We ask patients to leave any fad or unusual diets and concentrate on a standard eating plan concentrating on protein, Vitamin C and Zinc which can help in healing after the operation.

Vegetarians are urged to increase their protein intake before and after surgery; protein shakes help.

There’s no need to shave the chest before surgery. However, some patients want to do that anyhow so I ask them to shave it several days before and not just the night before surgery.

Just prior to surgery, I’ll mark your chest with surgical ink and will take medical photographs.

(Read more about the actual gynecomastia surgery.)

Afterwards, some cases require surgical drains – a decision that is made during the operation. The drains remove any buildup of blood or other fluids. I tend to think of them as safety valves for some cases.

The actual drain is nothing more than a plastic tube left inside a surgical wound and exiting through a tiny hole in the skin.

Drains are usually attached to a squeezable blub known as a “grenade” (because it looks like the real thing). Its purpose? To provide a small vacuum to suction out fluids.

Because drains penetrate the skin, showers are not allowed while the devices are in place. The patient is usually continued on antibiotics, too. The drains are removed in one to two days.

If a compression vest is being used, it goes on over the drains. (See gynecomastia surgery FAQs)

Virtually all surgeries are outpatient procedures which mean you can go home the same day.

But you need somebody to drive you here to my office, then home and to remain with you overnight – just in case — until I can see you again the next morning.

That may have been the case many years ago, but the world of sedation anesthesia now used in plastic surgery is more kind and gentle, thanks to a product you have perhaps read about.

That product, Propofol (trade name: Diprivan) used in the right hands and right places – specifically, used by an anesthesiologist M.D. or nurse anesthetist in a hospital or ambulatory surgical center – is a wonderful and unique anesthetic drug that has revolutionized office-based surgery.

Nonetheless, Propofol was abused in connection with the unfortunate death of Michael Jackson who called it “his milk” due to its milky white color.

That does not mean Propofol is safe to use at home, away from monitoring equipment and emergency equipment and, most especially, in hands not specifically trained in its use.

If we are to believe news reports, Propofol was used to lull Michael Jackson to sleep every night at his home.

But the drug was never intended nor designed for that use. Moreover, we don’t know how large the doses were nor how often they were administered.

(Side note: medical treatment in the absence of records is malpractice.)

Propofol is known as an hypnotic because it quickly induces sleep and then allows for a very fast recovery after cosmetic surgery with virtually no hangover, nausea, grogginess, sore throat or other undesirable side effects.

Among anesthetic drugs, Propofol is remarkable for clearing itself from the body extremely rapidly.

I commonly use it in my office, along with some other small doses of carefully selected medications. For gynecomastia surgery and other plastic surgery procedures, Propofol is administered by an anesthesiologist with whom I have worked for the last two decades.

Patients virtually always go into a relaxed sleep and have no memory of the procedure, experience no pain and gently wake up just as I’m placing the last stitch. Usually, the patient pleasantly chats with me as the bandages are being placed.

So if you have read about the circumstances of Michael Jackson’s case, don’t conclude Propofol is dangerous for use in an upcoming surgery.

In the right hands and setting, this drug works wonders!

To date, I have conferred with about 500 patients over the phone, through the regular mail and email and completed surgery — all without a hitch.

To expedite the process, my patient coordinator Jennifer (Jennifer@drelliotjacobs.com) will send you a form detailing the type of information and photos I need from you before we can speak on the phone.

I will then proceed to a presumptive diagnosis and suggested surgical treatment plan. You will need to have some medical tests prior to surgery – the results should be faxed to us two weeks before surgery.

But it’s not all phoned in! We will meet in my office the day before surgery and go over everything in detail, including the gynecomastia surgery cost; I will answer all of your questions at that point.

Here is what I would like to see in some digital photos of you (in jpeg. format).

To take the most informative pictures:

• Choose a background with one color. An ordinary wall works well
• Make sure it is well lighted with no shadows
• Have another person take the pictures
• Use a camera that will focus but not one with a wide angle lens; that warps the image too much
• If you’re interested in gynecomastia surgery, fill the viewfinder frame  from the shoulder bones to the belly button.
• Take a series of pictures without a shirt and with your thumbs gently linked together behind your back – one from the front, then a ¾ view from each side and one of the chest in both right and left profile.
• Then take one from the front with your arms straight out
• Don’t suck in your stomach; just be pictured as you naturally hold yourself

Some states – but not New York — now require cosmetic plastic surgery patients to have a physical before the rejuvenation surgery.

Here is my own policy about physicals before surgery:

• For teens and healthy patients up to about age 30: usually no physical required; I only need urine and blood tests.

• For guys over 40, a physical exam, cardiogram and the two tests mentioned above.

• Over 60, I require a physical, cardiogram and stress tests along with urine and blood tests.

We will also help with arrangements for your travel and NYC lodging.

Because October is Breast Cancer Awareness month, there is publicity everywhere about the need for women to keep current with breast exams and finding a cure for the dreaded female version of breast cancer.

Even pro football teams are wearing pink shoes to help everybody keep breast cancer awareness foremost in mind.

Statistics show that, for every 100 cases of female breast cancer, one strikes a male.

Despite the long odds, I’m vigilant about it when diagnosing new patients although I haven’t seen a case in my practice yet.

The patients who are concerned about it are relieved when I tell them having gynecomastia does not make a teen or man any more predisposed to male breast cancer.

One thing of interest, I have noted, though, is that after a male breast cancer patient has been treated, they often are found to have the BRCA1 gene – the very same one that women are so on guard about. Usually, there is some family component to a male having the gene.

The red warning flags for male breast cancer would be a man who:

• Is over 40
• Has breast growth only on one side
• Experiences breast pain or tenderness
• Has any type of discharge from the nipple
• Notices retraction of the nipple
• Observes changes in the appearance of his skin

Serious changes include fine skin dimpling like on an orange rind.

An experienced gynecomastia surgeon can usually tell the difference between a male who is a candidate for male breast reduction and actual breast cancer.

However, if he isn’t sure, the thing to do is arrange for a biopsy of some tissue of the affected area.

Just as in female cases, the earlier the condition is diagnosed and treated, the better things work out in the long run.

Consider the example of Peter Criss, the original drummer for the rock band, KISS. He was diagnosed and treated in ’08 and says he is cancer-free today, thanks to early diagnosis.

It’s worth mentioning because I have observed quite a few 18-year-olds who are all up in arms about having breast cancer when they are actually afflicted with run-of-the-mill gynecomastia.

Paperwork!

I think you’ll agree it’s a scattershot approach.

Here’s one from Harvard Pilgrim Health Care

Company policy:

• Covers those 16 and over
• Must have a gynecomastia diagnosis after a physical
• Signs and symptoms have persisted for at least 12 months despite

treatment of any underlying cause.

• Must be followed by an MD for at least 12 months

Documentation required:

• Medical records of the presence, extent and duration of gynecomastia
• Pre-operative photos
• Medical history including pharmacy records, chromosome analysis and drug screens.
• Proof of specialist care by a surgeon or endocrinologist to i.d. and treat any underlying condition.

(A chromosome test reveals if the patient has any genetic illness that causes gynecomastia. Hence, the need for an endocrinologist who also tests the patient to see if hormones are responsible.)

Reasons to go ahead with the gynecomastia plastic surgery:

• A dominant breast mass
• Gynecomastia on both sides
• Non-reversible gynecomastia due to medications prescribed to treat a medical condition or illness.
• Klinefelter’s Syndrome
• Grade III or IV gynecomastia for at least a year.

Exclusions:

• Under age 16
• Drug screen evidence of substance abuse
• BMI greater than 30, indicating obesity

The primary reason for granting coverage for surgery is psychological distress.

Nonetheless, most health plans contain a Catch-22 clause that specifically excludes any cosmetic treatments (like male breast reduction) that:

• Improves appearance
• Is performed for psycho-social reasons

Next: Many experts have put their heads together and recommended a common sense checklist for granting gynecomastia surgery.

That suggested checklist also screens for other reasons – like street drugs –  that a may cause gynecomastia.

It also considers the psychological and physical damage that happens  over time to a guy with man boobs.

Joys of smoking

Many times, when looking at the list of the things patients must do before plastic surgery, some smokers are dismayed to find they must give up the habit at least three to four weeks before the procedure and continuing on through some weeks after the procedure.

Plastic surgeons are not being politically correct. Our concern is about the substances in tobacco that conflict with good medical practice and plastic surgery outcomes.

For starters, nicotine injures the blood vessels and makes them constrict. That means less blood can flow to points in the body where it’s needed.

And one instance when a free flow of blood is most needed is right after surgery that requires longer incisions. Blood is very necessary for proper healing because blood carries vital nutrients and oxygen to the wound site.

Why? If the blood flow is limited, healing can be so delayed the tissue on both sides of an incision can actually die – this leads to very poor scars. Smokers are also at a much higher risk under anesthesia.

Other undesirable side effects include:

• Increased risk of infection
• Longer-lasting bruises
• Raised, red scars

On the other hand, I realize how addicting smoking is and that you may be in some discomfort. You can’t use Nicorette because it also contains nicotine but you can get a prescription for Chantix or Wellbutrin.

That’s why I applaud efforts of plastic surgeons around the nation who actually use carrots, and fewer sticks, to provide additional motivation to giving up the habit, at least long enough to allow for a good outcome to your surgery.

For instance, one board-certified New England plastic surgeon offers fee discounts for patients who give up smoking permanently and lose weight. And it’s all on the record – patients there must submit urine samples before surgery!

A California plastic surgeon, Darshan Shaw, M.D. was featured in our local newspaper, The New York Times, when he started offering non-smoking prescriptions to patients who could only have their surgery after permanently giving up the habit for good.

That creates more healthy patients and a better-than-average-shot at an excellent outcome to rejuvenation surgery.