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.

We’ve already discussed how gynecomastia causes extreme embarrassment, social withdrawal and can ruin a person’s self-image, making him feel worthless.

Truth be told, there is plenty of pain to go around!

On one website supporting a petition asking insurance companies to cover gynecomastia surgery, you can see lives being held back.

For instance, Bruce blogged:

“I opted out of a promising military career because I would not disrobe…I suffer from depression and often isolate myself. (Health) insurance will pay for tummy tuck and breast reduction in women but not for gynecomastia. Would somebody explain why?”

Mark B. wrote:

“The emotional impact can lead to feelings of hopelessness, depression and thoughts of suicide…there is pain and tenderness when jogging..gynecomastia plastic surgery has nothing to do with cosmetics. All we want to do is live normal and productive lives.”

Giovanni V. added:

“It is not normal to have breast tissue if you are a man!”

Louis P shared:

“Having gynecomastia as a teen, I put on a lot of weight because I thought I could hide it…I’m now 40 and trying to lose the 100 pounds I put on…An adolescent boy should not have to suffer through what I did!”

Porta S. wrote:

“At age 15, my son’s breasts are larger than mine; he can easily fill a size B bra. This otherwise healthy, athletic boy has to deal with kids gasping in horror when changing clothes in gym.”

Chase, 18, blogged:

“I have not led a full life due to my gynecomastia and it kills me! I try not being depressed but I can’t help it. Insurance coverage would give me the second chance I so desperately need.”

Jim, 48 said:

“In high school, my girl friend said ‘What the hell is this?’ while we were swimming. To this day, I won’t take my shirt off in public.”

Dedan L. wrote:

“I developed gynecomastia at 13. Whether I was 135 or 235, it made no difference. Even at my largest and leanest, 215 and 8 percent body fat, I still wore a rash guard (a spandex athletic shirt) to the beach.”

Karen added:

“My 13-year-old son has gynecomastia; it’s heartbreaking to see him worry so much about how much breast shows through his shirt.”

56-year-old Paul blogged:

“I have considered taking razor blades and performing surgery on my man boobs. My entire life has been affected by gynecomastia.”

Many times, it comes down to a question of how the patient wants to look after surgery:

• With a shirt on
• Without a shirt

In some cases, all that’s needed to produce a flatter chest is liposuction.

The exception is when actual, glandular breast tissue – yes, mammary gland tissue — sits under the nipple; that type of tissue does not easily yield to liposuction and must be excised away.

That can usually be done through the areola – the dark areas surrounding the nipples – so the surgical scar is well concealed at the edge of the areola.

Liposuction requires only small puncture wounds about one-eighth inch long. Those scars soon fade.

If a young person has very large breasts, removal of the excess underlying tissue will allow the skin to shrink spontaneously – much like letting air out of a balloon.  So rarely, if ever, is additional skin removal required.

If there is residual skin, six to eight months after the original operation, then a much smaller second procedure (with fewer scars) can be done to remove the excess skin.

If an older person has lots of excess skin as well as breast tissue, then he can elect to have everything removed and tucked at one time.

But that results in a trade-off of scars (which fade) for a trimmer contour.  Alternatively, he can elect a two-stage procedure, as described in the previous paragraph.

Before your first consult with a plastic surgeon, you can get a rough idea what’s needed by the position of your nipples. If they are in the center of the chest muscles, liposuction and breast tissue removal may be just the ticket. That leaves about a one-inch scar in the lower part of your areola. It’s not very noticeable.

Shirts off guys, take delight!

But if the nipples are pointing south, some skin will also probably have to be removed. That can result in a longer scar above, around or through the areola and nipples. After healing, you’ll have a flatter chest and look good in a T-shirt.

But for shirts off-guys, take heart. Those longer scars don’t last forever; they lighten and fade over time.

Depending on the person’s particular case and how much fat, breast tissue and scars must be removed, scars can be located:

• From side to side above and below the areola into the chest
• Under the areola into the chest area in a U-shape
• Under the areola but well hidden in the fold where the breast mound meets the chest

In some cases with a lot of sagging skin, the areola is repositioned higher on the chest.

As you can imagine, the attitude in gyms among weight lifters is often overly masculine so male bodybuilders often refer to gynecomastia as having “bitch tits.”

You may also hear one or two complain about “man boobs” or the abbreviated phrase, “moobs.”

One New York City plastic surgeon had to constantly tell his answering service that callers asking about “bitch tits” were not being crude or impolite, but just using the language of the gym.

Because the mirror is the measuring tape of body building, many want absolute perfection in their bodies.

Consequently, they will go to extreme lengths to make sure those “ripped pecs, abs and lats” (Translation: highly developed chest, stomach and lateral muscles) show well through the skin.

But many often take a misstep and see a surgeon for only liposuction of chest fat.

In reality, many have cases of gynecomastia, quite often caused by the steroids they take to build larger muscles.

Usually, weight lifters have a very low body fat percentage, with some very dense breast tissue around and under the nipple.

But not always. We’ve seen some guys come in with solid white breast tissue as big as a softball.

What’s all this mean? A couple of things:

• Breast tissue is too dense to liposuction
• Breast tissue requires an incision in the brown area around the nipples
• But we do liposuction around the areola

That extra liposuction helps make the buffed up muscles shine through the skin more.

In a very few cases, some overweight body builders lost a lot of weight but were left with loose, hanging skin.

In those cases, we perform skin tightening and nipple relocation procedures.

Which can result in a perfect chest!

This bodybuilder had loose skin removed and his areoli lifted to a higher position.

(See more bodybuilder before and after Gynecomastia pictures.)