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