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

The next step was removing the dense, fibrous male gynecomastia breast tissue with a pair of forceps and then, for removal, making an incision at the bottom of the breast tissue that sits atop the chest muscle.

That works but it also involves a scar, a longer breast surgery and a longer healing time – two to four months for most patients — as well as swelling and bruising.

Drains are usually involved, too, even though they are placed under the compression vest the patient must wear for up to four weeks.

I almost always perform liposuction during the same procedure and soon wondered if it was possible to combine the liposuction with surgical excision of the breast tissue.

The method offers several benefits. Because a liposuction instrument, or cannula, is thin – less than the width of a #2 pencil – a smaller entry hole through the skin, a “stab” wound, is used.

That helps reduce swelling, bruising and healing time which leads to a happier patient who can return sooner to his normal activities. In many cases, it can eliminate the need for any other incision on the chest.

The basic liposuction cannula tip is blunt and rounded. My version has a sharp tip, and is known as a “cobra” tip; it’s pointed and thin but not sharp, something like the prow of a ship that cuts its way through water. It can penetrate some breast tissue.

But thick, dense tough breast tissue cannot be liposuctioned — it must be excised with a scalpel.

About five years ago, I figured that by cutting a sharpened aperture into the tube of the cannula, I can remove a thin slice from the gland, let it be sucked into the cannula and out of the body.

The cannula I now use in most cases works very much like a cheese knife peeling off a thin slice of cheese. I push the cannula through the breast gland and then pull it back — so its sharp aperture removes a slice of breast gland.

Result?  Multiple to and from movements into and through the gland, removing it all – without that longer incision in the areola. It’s like “whittling” it down from the inside.

But, alas, in a few cases, the breast gland is as hard as a golf ball and my cheese-cutting instrument just, well, does not cut it!

So I use a scalpel and surgically excise that breast tissue.

While some pediatricians and even plastic surgeons are against it – thinking the lad may outgrow the condition – the teen patient’s life can be hellish if the condition does not go away. Others say the breasts may grow back after surgery. (They don’t!)

According to the American Society of Plastic Surgeons (ASPS), 14,203 patients between 13 and 19 went under the knife in 2008 for male breast reduction.

(2009 statistics will be available soon.)

While I’m not a psychologist, anybody who hears these lads’ stories would conclude some damage is being done at a critical time in a young man’s life when he should be building self-confidence, not having his image torn down daily.

For the teen with large breasts (or “man boobs” as they are cruelly known) teasing and finger pointing can also destroy his fledgling ability to relate to both boys and girls.

Recently a teen gynecomastia patient complained of school bullies flicking his breasts as if he were a girl. And here’s what he said about his social life, which is usually very active for any teenager: “I don’t like going out because it seems like everybody is staring at me.”

It turned out that Tim’s father also suffered as a teen with large breasts and did not want to see his son go through the same thing.

One boy, pictured below, was only 12 when he and his family came to see me about male breast reduction surgery.  (Read The Post-Standard article from  Syracuse, N.Y. about teens with gynecomastia .) The after picture was taken in February, 2010.

After surgery, the youngster was so motivated, he lost 35 pounds through diet and exercise!

In another case, a mother wrote about her son whose breasts started growing when he was only 10.

Some female classmates said it would not be cool to have a boyfriend with bigger breasts than they had! Naturally, the lad was crushed.

(Read the touching letter of the mother whose son had gynecomastia.)

I’ve performed male breast reduction surgery on over 175 teens and recommend it, if certain diagnostic criteria exists like:

• Stability for at least two years.

Breast size have not changed

• Being emotionally mature.

He must understand treatment is an operation, with all that entails.

(Read more about when teens should have gynecomastia surgery.)

The thinking seems to be a flabby chest will seem normal if the rest of the body is heavy, too.

Teen boys with large breasts often do exactly that, gaining as much weight as possible.

It’s not a good idea.

For one, it’s  hard on your body and your health. Keeping that excess weight into and through the 20s, creates a higher risk of developing type II diabetes, high blood pressure and perhaps sleep apnea.

Keeping that weight into your 30s and 40s, increases the risk of atherosclerosis, or arterial disease, which additionally puts you at risk of heart trouble.

Gaining weight also makes the job of the plastic surgeon job harder and the results of gynecomastia surgery less pleasing.

Here’s why:

Picking up a lot of weight stretches your skin and contributes to skin drooping and sagging if and when you get around to losing the excess weight. The skin loses its elasticity.

If you then opt for male breast reduction surgery, you’ll have more scars because more tissue and the lax, excessive skin must be removed from the chest.

So, if a patient has been heavy, the gynecomastia surgery to get a smooth, flat and contoured chest may require more than minimal scars.

Of course, in the best possible scenario, all patients would arrive on the day of surgery at their optimum weight.

But that doesn’t always happen. Time after time, patients tell me they are too embarrassed to exercise at the gym due to their so-called “man boobs”. (Gyms are especially rife with the cruel moniker, “bitch tits”.) And if they can’t exercise, they can’t lose the weight.

If an overweight patient requests gynecomastia surgery, I may go ahead — particularly for moderately overweight men — with the understanding I can only reduce the thickness of the chest to match the thickness of the surrounding tissues.

If I took too much tissue away from the chest, it would look concave in relation to the rest of the patient’s body.

The outcome? The patient is still overweight but with smaller and less conspicuous breasts.

Alas, the patient will look like a normally overweight man, with a small fold under his breasts…..instead of an overweight man with enlarged, female-like breasts.

Of course, it’s probably worse in the mind of patient because he imagines everybody is staring only at his chest.

For a teen, the first year of high school is tough.

Due to the huge wash of testosterone washing through his pubescent body for the first time, girls become tremendously important. But for teen girls, cruel remarks are unfortunately seen as being fully in order and even fun.

Except for the boy at which the zingers are aimed!

The standard teen remark is usually something about no girl wanting a boyfriend with bigger breasts than she has. Ouch!

Thus begins a long covering and concealing process, using large shirts, baggy sweat shirts, hoodies  and, sometimes, several layers of T-shirts, shirts and sweat shirts. Some guys even bind their chests with yards of Ace bandages or cover their “poofy” nipples with tape which can discolor the skin.

Factor in summer weather and you have one miserable kid.

At the pool or beach, you’ll find that same youngster swimming in a T-shirt — if he dares go into the water at all. Then, as soon as he gets out, he wraps his torso in a big thick towel or beach towel.

Almost all gynecomastia patients, unless they can find something darker, choose to wear black tops.  That color seems to best hide bulky or fleshy bulges.

Most wouldn’t be caught dead in white which tends to reveal almost all the body’s outlines.

As the guy with “man boobs” studies his condition more, he also discovers the compression garment which is actually intended for wear after surgery.

Nonetheless, some men will don a compression vest daily to flatten their breasts before dressing. The vests are made of elastic and compress the fatty tissues.

The downside: compression garments are hot!

Possible upside: the misery factor starts many guys thinking more seriously about diet and exercise. Many join a gym, work hard and lose weight — except in the one place they so devoutly wish to slim down: the chest and breasts.

Then, having tried literally everything, they start reading, learning and thinking about the next logical step:  male breast reduction surgery.

A few moments spent with typical gynecomastia surgery before and after pictures often brings him to a consultation with a plastic surgeon.

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.

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.”