The common misconception:

Many people have the idea that liposuction is a weight loss procedure. Actually, liposuction goes best when you are at, or near, your normal weight. The point of liposuction is not to reduce your weight but to remove bulges that may show through  clothing.

Liposuction is often done in connection with gynecomastia surgery. In most guys, there is some fatty tissue over the main chest muscle, the Pectoralis  major. That can be liposuctioned with good results but the dense, fibrous tissue lying under the nipple must be surgically excised.

Liposuction is also used in another procedure that men like, the Torsoplasty. Once many guys have a flat chest, they eyeball the rest of their torso more critically and decide the flabby stomach and love handles should also go.

(Check out some Torsoplasty and gynecomastia before and after pictures for yourself.)

Liposuction is done on those locations, big time. But only where the fat is what we doctors know as superficial, that is, lying just under the skin.

If you have a rotund pot or beer belly, that fat is too deep down around your internal organs for liposuction and you must remove that on your own – with serious workouts and a reasonable, low calorie diet.

Women most often request liposuction of:

• Thigh bulges
• Love handles
• Flabby upper arms

Now for the news I mentioned: For the first time, the International Society of Aesthetic Plastic Surgery (ISAPS) has compiled the numbers and types of cosmetic plastic surgeries done worldwide in 2009.

The most popular procedure in the world? You got it, liposuction! It accounts for18.8 percent of all plastic surgery done globally but is second in America. (Breast augmentation is in first place here.)

The world’s most popular procedures two through five are:

• Breast augmentation – 17%
• Upper or lower eyelift – 13.5%
• Nose jobs – 9.4%
• Tummy tuck – 7.3%

Here’s another statistic you might find interesting.

The top 5 nations for performing large numbers of plastic surgery procedures are:

1. United States
2. China
3. Brazil
4. India
5. Mexico.

Here is my interview on WCBS-TV’s “The Early Show”. Go to: http://www.cbsnews.com/stories/2010/08/09/earlyshow/health/main6756741.shtml

But it seems like the words of a mere plastic surgeon with 25 years experience treating gynecomastia doesn’t count for much, judging by the tons of advertising that feature a quick and cheap — but worthless — fix.

Some are real knee slappers!

I heard from some patients who were told that acupressure removes gynecomastia.

Acupressure  — a blending of “acupuncture” and “pressure” — is a complementary medical technique using pressure put on the acupuncture points by the hand, elbow, or with various devices.

Sorry, guys; it just does not work. Ditto turmeric and flax seeds.

(I was delighted to see that the turmeric and flax seed commercials for  curing gynecomastia were in the right section. The companion ad was “The Truth about the Nevada Triangle.”)

All the herbal cure ads alone would fill several box cars. I notice such products are always billed as safe and “natural”. We may have encountered an oxymoron here because, while snake bites are also 100 percent natural, they are far from safe.

I’m not naming the  products due to the lawyers lurking around the corner and because:

• It would take all day to create such a list and require more space than the Internet offers.

• I would love the opportunity to debate herbal manufacturers on the science of their claims but, that would also take far too much time away from my patients who need actual treatment for their condition.

So let’s just go with the basic, ultimate consumer-beware statement: no pill or herb removes true gynecomastia. Surgery is the only treatment.

Various work-out programs are also often put forth as a way to remove gynecomastia in teens and young men.  One program that advertises, “Lose Man Boobs Now” offers lots of sympathy and even starts to cover some of the same ground we’ve walked by telling how teens and men hide their condition. (Read our post on how some guys conceal their man boobs.)

One online Chinese herbal store (http://hnmrc.net) located in London, England, offers nine herbs which taken individually and in various combinations will allegedly cure gynecomastia.

The proof?  “11 total cases observed; 11 Fully recovered”.

But that’s all the site tells you about the cases. Let’s at least hope those nine herbs are also natural!

A comparison of breast operations done in a hospital and the same procedure done in private operating rooms show that smaller can be quicker and just as good.

Writing in the July, 2010, issue of The American Journal of Surgery, five surgeons found the ambulatory (“ambulatory” means the patient leaves after surgery) surgical center they use was closing.  So they would  perform surgery in a nearby hospital instead. (Read more about the breast operations study.)

Choosing to make lemonade from what seemed like lemons, the surgeons duly booked their patients into the hospital operating room and then decided to compare the hospital’s experience to an ambulatory surgical center.

The doctor-authors pulled the records of 92 breast operation patients who had surgery in the ambulatory center between January 2004 and December 2005

Next, they studied the records of another 92 patients who had breast surgery in the hospital operating room, and also went home the same day. Moreover, the ages of the patients were similar.

The authors compared many aspects of surgery, including:

• Type and techniques of anesthesia
• Surgical procedures
• Recovery room events and activities
• The elapsed time from patient admission to the hospital to discharge

Results: There were very few surgical problems and a small number of infections in both the private clinic and the hospital.

Plus, recovery times were about the same for both groups.

The big difference? Time! The hospital took an average of 69 minutes longer.

Reasons why a hospital takes longer include:

• Nurses prep many patients, including outpatient and critically ill patients
• A private clinic has small and similar types of cases. But hospitals have more varied and complex cases.
• The preoperational area in a private clinic is closer to the operating room. Hospitals have endlessly long hallways.

Concluded the authors: “The..efficiency advantage of  a private operating room over a hospital has implications for patient and staff satisfaction, facility expense and surgeon productivity.”

If you would like to learn more about a top-rated, extremely sterile private operating room, read about the certified operating room in my office suite where I perform plastic surgery procedures of the breast, including:

• Breast reductions for men and women
• Breast augmentation for women
• Breast lift

A Better Size

You may already know me through this blog as a plastic surgery specialist who removes large male breasts through gynecomastia surgery.

But I also reduce the size of extremely large female breasts – and watch as the patients soon enjoy the medical benefits of the procedure.

It’s also a pleasure to know that, more times than not, health insurance will kick in and cover most of the procedure.

You must be wondering, though. Why cover it for women but not for men?

The list of health woes for a woman whose extremely heavy breasts may hang down to her belly button is pretty long, including:

• Back troubles
• Neck pain
• Shoulder discomfort
• Frequent infections of the skin beneath the breasts
• Breast pain

Insurance companies usually cover the procedure because eve they realize they will not have to expend funds to treat all those aches and pains in the future. Untreated, the condition can even lead to skeletal deformities.

However, the procedure for getting approval has become ever more demanding. (Read more about obtaining breast reduction coverage.)

Insurance coverage for a man or teen is much more difficult because the damage caused by overly large breasts is “only” psychological, and not physical. For a male, the procedure is usually considered cosmetic surgery.

Many times, a woman candidate for the procedure shows up in my office asking about breast reduction surgery and I immediately see that the weight of her bra straps has created notches in her shoulder blades. Surgery creates breasts that are smaller, lighter, firmer, balanced and lifted.

Many such women have tried losing weight, thinking the breasts will slim down, too.  Sometimes, they also try physical therapy and seek treatment for their various pains.

But the only real, lasting solution is surgery to reduce the size and weight of the breasts. Between the lines, I see many patients who enjoy moving their breasts from resting on their stomachs to  a position higher up on their chests where most womens’ breasts sit.

It makes daily life easier, too. With very large, or especially in gigantomastia cases, teen girls suffer extremely cruel remarks and behaviors from men and boys. After surgery, clothes fit better and exercise no longer causes breasts to flap around.

The trade-off for female breast reduction is long scars on the breast.

Of course, like all scars, they lighten and fade over time and are hidden by bras, swim wear and most tops.

Yearly, the professional plastic surgery societies like  the American Society for Aesthetic Plastic Surgery (ASAPS) crunch the numbers on the previous year so we know the ages of patients having all the popular cosmetic plastic surgeries – like face lift and breast augmentation – plus the numbers of each procedure completed, the cost of plastic surgery and so on.

For the most recent set of statistics – 2009 — all plastic surgery procedures and techniques declined by two percent over 2008’s statistics, due to the recession. Surgeries declined 17 percent while nonsurgical procedures went up almost a full percent.

Along with the decline in procedures went prices.

For gynecomastia surgery, the average cost of cosmetic plastic surgery during 2009 was $3,294, $116 less than the previous year.

Of course, the $3,294 is the average surgeon fee. Usually, you must add on charges for the operating facility and for the nurse anesthetist or a board-certified anesthesiologist, along with some other items incidental to the procedure like medications, pathology fees, compressions garments and so on.

Currently, interest in all types of cosmetic plastic surgery is increasing which brings us to another question over which economists are always scratching their wizened heads.

When are prices going back up?

We would imagine that as more patients inquire about, and go ahead with, man boob surgery or other procedures, the prices will rise.

So, could now be a good time for a bargain if you’ve already been thinking about gynecomastia plastic surgery? Will prices go up in 2010?

Could be! Hey, we don’t have a crystal ball, either!

But if you combine a lowered price for surgery with other common discounts, you may realize quite a savings.

An all cash, paid-in-full arrangement is usually worth a three percent discount while agreeing to have your surgery during the doctor’s least busy time may be worth one to two percent. In many places, if you agree to fill in for patient whose surgery is canceled at the last moment, you could receive another one to five percent discount.

Best case scenario: 10 percent is nothing to sneeze at! That equals a possible savings of 329 smackers on the average ’09 gynecomastia surgery.

Surgical markings are where an open rhinoplasty begins

You may know me here mostly for gynecomastia surgery but I also do many other plastic surgery procedures.

One of my favorite and most frequently performed plastic surgery procedures is the “nose job” or rhinoplasty. Because a human nose is so small and intricate, with many interconnecting tissues, it is something like working on a living watch.

One of the first questions patients ask is about open and closed rhinoplasties. (Most of what we do is the closed).  I always explain that it is like a car repair:  lift the hood and repair the engine (open rhinoplasty) versus remove the front grill and repair the engine through a smaller opening (closed rhinoplasty).

When a cosmetic plastic surgeon starts a rhinoplasty procedure, there are two approaches. Those are:

• The open, or external, approach

Feel the tiny strip of skin that keeps your nostrils apart and note how small the area is. One finger tip can cover the place where surgeons start. An incision is made there and then the skin is lifted up and back to reveal the architecture of the nose.

• The closed technique

In this choice, the surgeon operates through the nostrils, without pulling back the skin of the nose. Some surgeons favor this approach although it requires extra training and is more demanding due to the small tolerances in the nose.

Also known as the endonasal approach, it offers some advantages, including allowing the surgeon to immediately visualize what the final result is going to look like.

When using the open technique, however, the nose skin must first be pulled back into place over the framework of the nose to get a concept what the nose’s outcome will be.

Another upside to the closed procedure: it heals faster. If the skin over the nose is lifted, the lymphatic drainage system is interrupted. That also causes more swelling.

Or, if the surgeon is not getting the results desired during a close procedure, he or she may go ahead and open the nose up for better visibility.  This is often done if there are severe distortions or asymmetries of the tip structures or if it is revision, or secondary, operation.

The thing is, if the surgeon starts with an open approach, he can’t go back to a closed and enjoy its particular benefits.

Which is best?

If you like the quicker healing of the closed approach, do the next logical thing and look at the surgeon’s before and after rhinoplasty pictures to make sure all the noses you see look natural, fitting and flatter the owners’ faces.

(Read more about a  rhinoplasty from Dr. Jacobs.)

Gynecomastia patient has one breast larger than the other

Occasionally, a patient comes into my office with one breast larger than the other and, to appear normal, wants gynecomastia surgery on just that one breast.

It’s a condition known in medicine as unilateral (meaning, one side only) gynecomastia which requires a unilateral mastectomy.

First, we make sure nothing else is happening — like a tumor.

But here’s the fly in the ointment: it is very difficult to operate on one breast and make it identical to the other. About the only way to accomplish the task is to perform surgery on both.

Otherwise, the outcome can be one breast that looks normal (the operated breast) but now the untouched breast may look odd — or even bigger in comparison.  And usually some excess tissue on the other breast also exists, but obviously not as much as the larger side.

So, most plastic surgeons want to perform surgery on both sides as well.

I usually recommend that both sides be done to provide the best and most optimal results possible.

While virtually all gynecomastia patients report being unhappy with their large, female-like breasts, having one breast that is far larger than the other only makes the problem worse.

Some body builders are extremely frustrated when they devote endless hours to weight lifting and then discover the large chest muscles they have developed only make the breast fat and tissue – known as “bitch tits” to them — stick out farther.

The one larger breast problem also occurs in teens and non-bodybuilding men.

Overall, you may be wondering how many men have – or will develop – any form of gynecomastia. If you look at the articles that have been written about the topic, it often depends on who counts.
Four M.D.s writing in a 1961 issue of the Journal of the American Medical Association (JAMA) reported that 65 percent of boys may have the problem but that it “typically resolves on its own.” (Also, typically, many do not!)

A military doctor, counting Navy patients on active duty in 1944 found eight percent had enlarged male breasts, or “man boobs.”

Other researchers, counting hospitalized men and  those in pathology labs, found about 40 percent have the condition with almost 60 percent of men over 70 having it.

One of the statistics I like the best is by Merl Yost, a psychoanalyst, gynecomastia patient, author of a book on gynecomastia and operator of the excellent website, Gynecomastia.org.

Yost wrote in a 2006 article for Men’s Health that about 91 percent of gynecomastia surgery patients were happy and would recommend the procedure to a friend.

All of which brings us to our next post: of the nine percent who were not happy, some had revision gynecomastia surgery.

Same patient as above after gynecomastia surgery

Body Builder Before Surgery

A professor of plastic surgery once explained that, not two, but three parties are actually involved in any cosmetic plastic surgery: the patient and the surgeon, of course, but Mother Nature and the healing process are also lending a hand.

Mother Nature stays in the mix quite a while afterwards — because any surgery is actually a very carefully controlled injury.

And because I never know precisely what the healing process is going to do, I can’t say with 100 percent certainly how any patient is going to finally heal.

But, please, give me this – I can improve things within a 90 to 98 percent certainty. And those aren’t bad odds!This controlled injury process we know as surgery also involves a trade off; in these cases, a flatter, more masculine chest for a few scars which do lighten into virtual nothingness over time.

After surgery

I often tell my gynecomastia patients that all men have some actual breast tissue. Male breast reduction is only indicated when that tissue is excessive and something resembling female breasts start to appear on a man’s chest.

In most cases, plastic surgeons remove both fat and glandular breast tissue. And, given a skilled surgeon, the outcome is normally a vastly improved chest that looks great in a tee shirt or with no shirt at all.

Nonetheless, the gripe most frequently heard is: “But, doctor, I can feel something under my nipples.”

No doubt. Something is probably there — perhaps scar tissue, firm fat or some very small amounts of glandular breast tissue. Even buffed out weight lifters may have a small layer of fat within their breasts.

But plastic surgery is judged by appearance. Indeed, how many people test the outcome of your surgery by poking and prodding at your chest? Not many, I would bet.

All this is considered within the realm of “realistic expectations.” It’s actually an issue in all of cosmetic plastic surgery.

If you would glance at our before and after gynecomastia surgery pictures, you can see patients who received a huge improvement in the appearance of their chest.

While those rejuvenations may not be 100 percent perfect, most are more than glad to have upwards of a 98 percent betterment.

The rub happens when a vastly improved patient – on the order of 93 to 98 percent better — wants perfection and asks for a revision surgery.

(Read more about revision gynecomastia surgery.)

After Gynecomastia Surgery

So many patients ask what happens after a male breast reduction procedure, I prepared a handout listing virtually all the questions that are most frequently asked. (FAQs.)

(I also have a handout instructing patients what to do before surgery.)

After any cosmetic plastic surgery procedure, the main concerns are:

• Infections
• Bleeding
• Fluid collections

The chest is usually – temporarily – swollen and slightly bruised at the surgery site. So you won’t be able to see the results of the surgery right away.

You may also be aware of some numbness, tingling, itching or mild burning that goes away after a few weeks.

Usually, I tell patients their chests will feel like they’ve done a very heavy chest workout like 300 push-ups.

A tight fitting compression vest is vital to stop fluid or pools of blood building up under the skin. Rarely, you may have some surgical drains under the vest.

And here’s where you have to be your own plastic surgeon and make yourself do what’s in your own best interest: wear the compression vest 24 hours daily, seven days a week except for showering.

And we’re talking three to four weeks after surgery. Not to worry; a compression vest fits nicely under your street clothes.

Here are some rare, but possible, post surgery symptoms for which you should get back to me or my staff immediately:

• Severe discharge, redness, tenderness or pain at the surgical site
• One side much more swollen
• Muscle aches beyond soreness
• Nausea
• An overall ill feeling with fever

Most guys are able to go back to sitting activities like desk work in two to three days.

More hardy exercise or sports can usually be resumed after about three to four weeks. But you’ll have to wait three to six months to see the full results of surgery on your chest.

Another rare, possible but totally unpredictable side effect is scar development on the chest or directly under the nipple any time after surgery. I’ll treat those at no extra charge for up to a year after your surgery.

Looking at the long term, the bulging, female-like breast tissue that was causing you so much embarrassment will not return. However, if you gain a lot of weight, some fat will appear on your chest.

But look on the bright side: if you protect your surgical investment, consume a sensible low-fat diet and continue with a reasonable exercise plan, you will only enhance the results of gynecomastia surgery!

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!