Gynecomastia Consultation

Once you’ve found a few plastic surgeons you might be interested in working with, it’s time to arrange consultations.  These appointments with prospective surgeons are all-important.  In treating patients with gynecomastia in Manhattan, we find that those who are well informed and make the ultimate choice of plastic surgeon carefully are typically more satisfied with their results.

Here are some points to cover and consider during your consultations.  These are designed to help you decide who your surgeon should be.   (You will soon have many more questions about preparing for gynecomastia surgery, the procedure itself, recovery and risks.)

Gynecomastia Expertise

After making sure each plastic surgeon you consult is certified by the American Board of Plastic Surgery, you’ll want to explore their gynecomastia experience.  You should know that according to the American Society for Aesthetic Plastic Surgery, just over 18,000 male breast reduction procedures were performed in the U.S. in 2010.  That’s not a large number, so be prepared to find that many plastic surgeons have a limited track record with gynecomastia.

If you’re seeking an expert, ask how many male breast reduction surgeries each prospective surgeon performs every year and how many they have done during their career.  See how many before and after gynecomastia photos they have to show, request names of patients you can speak with.

Philosophy and Approach

Ask questions about your surgeon’s philosophy and approach to treating gynecomastia patients to see if it feels like a fit.  What type of anesthesia does he or she prefer to use and why?  If you want a different kind, is it available to you?  What credentials does the anesthesiologist have?  Does the surgeon treat the anesthesiologist as an important team member?

A critical factor to discuss is whether your surgeon is prepared to do excision and liposuction, as your physique may require.  In our experience, there are few cases in which liposuction only will do the job, and your surgeon should be prepared to use both methods of reduction.  Ask exactly how they go about achieving natural looking contours for their patients.

Nuts and Bolts

Don’t be afraid to inquire about patient satisfaction.  Under what circumstances are gynecomastia patients unhappy with the outcome of surgery?  How many of the surgeon’s patients have been dissatisfied?   What is the policy on revision surgery and scar treatment?

Does the surgeon respond directly to your questions – and review certain aspects of the operation that you are not clear on.  If a surgeon doesn’t reply to your questions in a consultation, can you be sure he or she will be responsive after surgery is performed?

Finally, trust your instincts in making the decision about who will be your gynecomastia surgeon.  If you’re not comfortable with one you interview, chances are they may not have listened closely to you. Perhaps they’ve made assumptions about your case, maybe their policies seem inflexible or it’s possible some of their answers have sounded evasive.

Whatever the reason, if you don’t “click” with a plastic surgeon, move on.  As we discuss gynecomastia with Manhattan patients, we remind them that male breast reduction is a somewhat specialized procedure.  You may have to look a little harder to find the surgeon who’s a fit for you, and you may even need to travel outside your hometown.  Your results will be worth the effort.

Male Breast Reduction Surgery, Before and After

Gynecomastia surgery is often done on men and boys who find themselves with a complex, extremely troubling genetic condition known as Klinfelter (also spelled “Klinefelter”) Syndrome.

About the only good news: plastic surgeons can usually tell those patients that insurance coverage for male breast reduction surgery for Klinfelter’s is often available.

(Read our previous post about getting insurance to cover gynecomastia surgery.)

The patient usually receives testosterone replacement because his body does not make enough.

Many times, especially in teens, the condition is discovered before a gynecomastia surgery is scheduled. A medical specialist known as an endocrinologist checks to make sure the lad’s hormones are within normal ranges.

But, alas, after healing from the surgery and finding a flatter and more masculine chest, the patient still must face a sea of medical woes.

Other effects of Klinfelter Syndrome on behavior and social adjustment in teens include:

• Shyness
• Low self-esteem
• Introversion
• Some attention deficit disorder

To a certain extent, some of the poor self-image is helped by having gynecomastia surgery — the breasts are no longer embarrassing.

Accompanying medical conditions include hand tremors, difficulty concentrating, restless sleep and a type of dyslexia, among others.

As adults, Klinefelter sufferers may show more aggression, reduced upper body strength, obesity, loss of libido, infertility and impotence. Experts also say they also may have higher risks of heart attacks, breast cancer, osteoporosis, and autoimmune disorders like type 1 diabetes.

The condition strikes in one of 500 to 1000 births.

About one third also have sufficiently enlarged “man boobs” to make them appropriate candidates for gynecomastia surgery.

Bill Bucar of Hamilton, Ontario, Canada, who is associated with the American Association for Klinefelter Sydrome Information and Support once surveyed 66 Klinefelter patients and found four discovered the condition over age 50 when they went to their doctors for other complaints like testicle injury or depression. The condition was revealed to another nine over age 40 while 10 found out about it after their 30^th birthday.

The remainder found out about it childhood, in their teens and in their 20s. One — who is now 16 — discovered the syndrome while still in the womb, between the 16^th and 20^th week, thanks to an amniocentesis test.

(Read more about Bucar’s study at the Gynecomastia.org website.)

We have operated on a number of Klinefelter patients.  One of the patients returned for follow-up with a brand new baby boy — who had been conceived with donated sperm.

Look at some gynecomastia before and after pictures

• Go back to work
• Return to their weight lifting routines

Most guys can return to sedentary work after about a week while still wearing compression vests which are  easily hidden under clothing.

Our patients wear a compression garment for four weeks 24/7 after surgery. For another two weeks, they wear the garments just at night.

We encourage you to slowly walk around the day after your gynecomastia surgery.  For the remainder of the first month, do nothing to increase your blood pressure or heart rate. Don’t do any lifting, aerobic exercise  or anything else that breaks a sweat.

Think all your conditioning and training is going down the drain while you heal? Not so — you’ll soon be back to your pre-surgery workout level.

Just wear the compression garments, avoid strenuous exercise for one month and you will have a nice looking chest for the rest of your life.  That’s a good bargain!

When you return to the gym four weeks after surgery, go easy on your chest.  It will feel tight and have a pulling sensation.  Gradually stretch your chest; within a few days it will feel normal.  If  swelling occurs after the gym, wear the compression garments overnight.

Oh, be sure to tell your plastic surgeon you’re getting back into the gym.

Gynecomastia surgeon – and body builder – Richard Silverman, M.D. was once asked for a safe routine after gynecomastia surgery.

He said, in part:

Basic rule: if a lift hurts, forget about it for another week.

At first,  lift light weights or use the machines and forgo any pec training.

By the sixth week, you can ease back into full body training, gradually increasing weights and reps.

If something just doesn’t seem right,  listen to your instincts. It probably isn’t right!

Just stop if you notice any pain, watch out for swelling, signs of infection or other problems around the surgical site(s).

Call your surgeon if you are really worried. We would much rather hear about a little thing that turned out to be nothing rather than deal late with a genuine problem that turned into a big thing.

(Read more about the advice of a body builder/gynecomastia surgeon.)

Danny Cahill, Before & After Losing 239 Pounds

Many gynecomastia patients are interested in general weight loss, so we thought you might like to know the untold side of the popular T.V. show, “Biggest Loser.”

After the weight loss competition, some contestants have a plastic surgery procedure known alternately as body shaping, body lifting and body contouring.

After a loss of 100 or 150 pounds, the procedure becomes desirable. When people experience massive weight loss (MWL), their skin has been stretched far beyond its ability to rebound. Then, surgery is necessary to remove the excess skin and trim up the body.

So far, those who have gone public with their plastic surgery include:

• 2009 season winner Danny Cahill lost 239 pounds

• Amy Cremen from 2008 in “Biggest Loser: Families” dropped 104 pounds

• Erik Chopin from season 2006’s “Biggest Loser” took off 214 pounds

Loose, hanging skin usually drapes from the arms, torso, abdomen and legs,  getting in the way of good hygiene, other health concerns and even fastening one’s pants. All that surplus skin also flaps around painfully during exercise.

Some MWL patients even complain that sitting is a pain in the keister — literally! Loose skin drooping from your bottom amounts to sitting on a slippery surface. Clothes don’t fit well either.

In Amy’s case, it was a new misery: “I was more uncomfortable in my new skinny body than in my heavy body….”

Erik Chopin, then 37, another “Biggest Loser”, dropped a whopping 124 pounds on the program and another 90 at home. Overall, Chopin shrank from 402 to a trim 193 pounds. Moreover, he scored a $250,000 prize for his efforts. (But he showed up on Oprah in 2009, miserable because he had regained 120 pounds.)

MWL patients must be willing to trade long scars on their bodies for losing the excess skin via the plastic surgeon’s knife. On arms, for instance, surgeons make a long incision on the arm’s underside from the armpit to elbow, trim away the loose skin and close the two edges.

Women often receive a breast lift as well. Other MWL patients loose the huge apron of stomach skin—medically known as a pannicus — that can droop to their knees through a belt lipectomy or circumferential abdominoplasty

The surgeon makes an incision all the way around the waist, trims away excess skin and suture the two sides.

Scars to tend fade and lighten over about a year.

Here are the top five that I most hear, and answer, most frequently.

1.      Gynecomastia’s cause

The condition, which most often begins during puberty, may be caused by unbalanced hormones, as a side effect from the use of certain drugs, or it may be due to an undiagnosed medical condition. There may be a strong genetic component as well. Sometimes, large male breasts occur for no one particular reason at all. The important thing is that 40 to 60 percent of teens and men have it. Virtually all hate it.

2.      Overweight

As a man gains unhealthy amounts of weight, his breasts may also grow. This is a double whammy:  fat is preferentially deposited on the chest.  In addition, excess fat on the body shifts the metabolism to make more estrogen, which in turn stimulates the breast tissue to grow on the chest. In essence, gaining weight results in more fat AND breast tissue on the chest.

The fly in the ointment is that the breast skin will probably not tighten by itself if weight is lost.  The breast will simply droop.

3.      Gynecomastia induced behavior

Virtually all men and teens will go to some lengths to hide or mask the condition by wearing bulky clothes, walking hunched over, avoiding certain activities like swimming, going to the beach and “skins and shirts” basketball games. Some men and boys will deliberately gain weight so that their abdomen is more prominent than their chest. (Unfortunately, in our society, obesity is more acceptable than gynecomastia).  Most hate the cruel nick-name “Man boobs.”

4.      Treatments

Despite an ocean of advertisements about pills, lotions, creams, herbs and other concoctions that claim to eliminate gynecomastia, the only proven treatment is plastic surgery. It’s because true gynecomastia involves a very dense and tough layer of actual breast tissue beneath the nipple. It can’t be liposuction away (although other areas of the breast are liposuctioned during the procedure) and the only possible remedy is surgical removal.

5.      How many such operations have been done?

While gynecomastia surgery is technically difficult and demanding, there are quite a few board-certified plastic surgeons who have mastered it; about 17,000 operations were done in 2009, according to the American Society for Aesthetic Plastic Surgery.

It’s absolutely not a procedure for neophytes but you should be in good hands if you can locate a plastic surgeon who has many years of experience. (Hint: find one with many — as in hundreds– of before and after gynecomastia surgery pictures.)

Although it’s not likely you’ll need one, look for a surgeon who has hospital privileges.

Hospitals are expert in knowing which surgeons produce top work but none will stay in business if they extend privileges to undertrained surgeons.

Unhappy Patient

A concept I often explain to patients is known officially as realistic expectations.

The concept? Any plastic surgeon can make the appearance of a normal person much, much better.

But not perfect. In any surgery, the trade off for the benefit you receive is some type of scar. In essence, patients must be realistic about what surgery can achieve.

In a sudden attack of appendicitis, not only is your health, but your very life at stake. So most do not complain about the large scar left on your lower right abdomen.

Scars from cosmetic plastic surgery operations are hidden behind the ears, under the chin or in natural  creases like where the eyelid folds.

Nonetheless, many patients have the idea that gynecomastia surgery can create perfect chests.

To create a flat, taunt muscular-looking chest, excess fat and some actual breast tissue must come out via surgery. And that requires a few scars which fade over a year or so.

Liposuction leaves a tiny scar, perhaps a ¼ inch mark, that soon heals and is virtually unnoticeable. The actual breast tissue, however, is too dense and thick to be liposuctioned so it must be surgically removed. But the scar is hidden as well as possible – usually around the edge of the areola — and also lightens, virtually disappearing in a year.

That scar reminds us that surgery is a controlled injury.

Don’t forget, another entity besides patient and doctor is involved – Mother Nature.

Statistically, in one percent of cases, Mother Nature causes an infection, a not-so-greatly healed scar or some other medical mischief that requires further care.

But in the huge majority of cases, we are able to attain a very significant improvement in a case of so-called “man boobs.” Just take a look at some before and after gynecomastia pictures.

Granted, the afters were taken up to a year after surgery so scars have healed considerably, but I’m willing to bet dollars to doughnuts your eye sees only the  major improvements.

Before getting angry about the results of plastic surgery, try:

• Technique 1 : look at your before pictures again and compare those to your current appearance.

That usually resolves any misgivings.

• Technique #2: try a second opinion.

Show your results to a third, highly experienced, but neutral, gynecomastia surgeon. Chances are, he or she will respond, “Count your blessings!”

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!

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.)

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.)