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.