Gynecomastia Palm Desert

I see many male patients who complain of enlarged breast tissue- also called gynecomastia, who seek surgical treatment and correction.  The first questions I ask them is whether or not they take any medications that are known to cause gynecomastia such as Cimetidine, anabolic steroids,  Valium, AIDS medications, heart medications and some herbals.  Another known cause of gynecomastia is excessive marijuana and alcohol usage, heroine, methadone and amphetamine usage.  The first issue is to identify any medical etiology known to cause gynecomastia if there is one.  I will refer patients to see an Endocrinologist to rule out an endocrine cause such as tumor, hypogonadism, hyperthryoidism or other medical condition.  This specialist consult is covered by most insurances.  Any male with a family history of breast cancer and enlarged breast tissue should be considered to undergo a mammogram, since breast cancer in men, although very rare, is much more aggressive and should be caught as early as possible.  The vast majority of cases of gynecomastia are “ideopathic” in nature, which just means we don’t why it occurs, but the good news is that it is a benign process.  The surgical treatment for gynecomastia depends on the severity and nature of the enlarged breast.

For very mild cases of gynecomastia where the majority of excess tissue is fatty in nature, liposuction alone may be an adequate treatment.  Tumescent liposuction will flatten the breast that is diffusely enlarged due to fatty tissue.  The nature of one’s breast tissue can be determined during the physical exam.

For gynecomastia that is due to excess glandular tissue, usually a combination of liposuction in conjunction with an excisional procedure is required.  There may be a “breast bud” behind the areola- and this can be palpated during the exam.  The typical history is that a man’s breast size does not change with significant weight loss and/or weight-training.  Also, there may be some herniation of the breast tissue out through the areola causing a “pooching” out or puffiness of the areola that might also be excessively wide and enlarged.  The areola can also be reduced at the time of surgery.

If there is excess breast/chest skin that is mild, then you might be a candidate for laser-assisted liposuction.  Addition of the laser cannula prior to performing the liposuction does mainly 2 things:  1)  the laser helps break up the fibrous tissue and melt the breast fatty tissue and 2)  the heating up of the dermis internally from the inside helps with postop skin-retraction afterwards.  Often the laser-liposuction is used in conjunction with an excisional procedure.  The liposuction can also remove tissue laterally (the “tail” of the breast”)- tissue that goes around the sides of the chest beneath the axilla.

The excisional procedure is typically done with an incision that can be done partly around the areola (if the areola is of normal size) or from an incision that goes all the way around the areola (ie via a circumareolar mastopexy incision) if it requires reduction in size and correction of herniation.  Moderate cases of gynecomastia typically require both laser liposuction combined with an excisional procedure.

Severe cases of gynecomastia may require a more extensive excisional procedure called a “male breast reduction” if there is a lot of extra, hanging breast skin and the nipple drops down below the level of the inframammary fold (called excessive “ptosis” of the breast).  In these cases, it may be necessary to create a scar that goes down the center of the breast and/or a scar that follows the inframammary fold beneath the breast.  This operation is necessary when there is just too much skin that requires removal to make the breast flat.

Recovery from gynecomastia surgery depends on the amount of surgery performed.  After liposuction, it is important to wear a tight-fitting chest post-surgical garment for about 4 weeks- or until the chest is no longer swollen.  Immediately after surgery, there will be some swelling and bruising, however the flattened appearance of the chest will be immediate and the results will only improve over time.  There is a small chance that there may be changes in sensation to the nipple.  Immediately after surgery, I place a special foam (called Reston Foam) over the chest skin to help with the results, then place you in your compression garment.  This is generally changed about 2 days postop- after which, you will go home, shower, then place antibiotic ointment over your incisions and put on a fresh garment.  For this reason, I have all liposuction patients purchase at least 2 garments so that you always have a clean, fresh one to change into.  The garments require hand-washing and air-drying- so it is imperative to have at least 2 on hand at all times.  You will be sore for the first several days and this will improve over the first week.  I generally recommend patients take off at least 4 to 5 days off work and a week before returning to any more strenuous types of work.  You can wear your compression garment at work.  Bruising and swelling should be resolving by the second week.  You should feel like your old self again by the third week.  You may return to regular exercise once you are no longer swollen or tender.  Again, results are immediate, only improve with time, and there is an extremely high “satisfaction” rate with this procedure!

The answer to these questions is up to each individual woman.  For starters, any woman aged younger than 22 years old is only a candidate for saline.  There is no hard data to support this age- it is only an arbitrary age that the two main implant manufacturers in the US (Mentor and Allergan), have established in their studies.  This age makes no sense to me since you need only be 18 years old to sign an adult informed consent or serve in the military, and be only 21 years old to meet the legal drinking age.  But “ce la vie…”

Saline implants are tried and true.  They are silicone shells that are then filled intraoperatively with sterile saline during the operation and quite safe.  If they deflate, then only sterile saline leaks out into the body and gets absorbed safely into your system.  If a deflation occurs, it is like a “flat tire” and you will notice right away and call your plastic surgeon immediately to have a new one placed.  Both manufacturers have good standard warranties regarding both their saline and silicone implants.  However, the down-sides to saline include a more rigid type of device in that the saline implants seem to “hold their shape”- particularly in the upper pole of the breast more rigidly than do silicone.  Saline implants can tend to feel more like “water balloons” and less natural.  Some have reported a “sloshing” noice audible and noticeable in high altitudes (such as during skiing trips).  I tend to steer away from saline implants in very thin patients- particularly patients who have visible ribs in their upper chest, as saline implants can be much more visible and palpable in this area.  Women who have broader chests and a fair amount of their own, native breast and soft-tissue tend to have more natural-appearing results with saline implants.  Saline implants are a good choice in women who have significant asymmetry of their breasts, as the implants can be inflated during surgery to more precisely match in volume.  Silicone implants have fixed volumes, thus asymmetric breasts may remain overall improved, however remain asymmetric after surgery if silicone implants are chosen.  Also, very young patients with a more limited budget who expect to exchange out their implants sometime over the course of their lifetime may be good candidates for saline.  Which brings us to the next commonly-asked question…

” Do I have to replace my implants after 10 years?”  This 10-year mark is a myth and the real answer is… you only need to exchange your implants if and when you have a problem with them.  I have encountered patients who have a problem with their implants after only a short period of time (due to capsular contracture, deflation or desiring a size or site-change) and women who haven’t had a problem with their implants in over 20 years or so.  It is recommended by each implant manufacturer that you replace your implants if they become ruptured.  I often make the analogy to women patients to think of their new breast implants similarly to a new car.  You wouldn’t expect anything to go wrong with the engine of your new car within the first few years.  However, after 7 to 10 years of owning your car… the chances that you may have something major go wrong with the car or engine increases greatly.  However, you only need to get a new car if either you have a major problem with your old car, or you wish to just get a new and better car.  Such is the case with breast implants.

“Which is safer- saline or silicone?”  Well, the answer is that both device have proven safe and effective.  That is why the FDA has re-approved silicone implants and saline implants remain on the market.  The previous belief that silicone implants cause auto-immune disorders and systemic problems has proven untrue in clinical studies.  If your silicone implants rupture, there is a chance that the silicone can travel regionally to the level of your axillary lymph nodes (similar to the path that cells travel in breast cancer) and cause silicone granulomas or axillary silicone granulomas.  These are typically permanent.  Also, women can expect to potentially require an MRI study to adequately diagnose a ruptured silicone implant and/or properly assess their breast tissue for pathology, and therefore must be prepared for this possible eventuality.

“Which do you recommend… saline or silicone implants?”  Well, this question is again based on each woman’s preference.  If a woman is at all fearful of the potential sequelae of ruptured silicone implants, then saline remains a very safe choice.  However, typically women who emphasize a desire for very “natural looking and feeling” breast implants will more likely be more satisfied with silicone devices as their shape and texture mimics actual breast tissue.  Thus, I recommend both saline and silicone, and the choice is solely up to the woman choosing her implants.

Here is another article from Dr. Q on demanding the best possible outcomes on breast surgery. Please follow this link http://www.plasticsurgerypractice.com/issues/articles/2010-10_02.asp.

If you have a chance please read an article co-written by Dr Q. on the safety and efficacy of breast augmentation and mastopexy (breast lift)

Is one-stage breast augmentation with mastopexy safe and effective? A review of 186 primary cases — Aesthetic Surgery Journal November 2006

W. Grant Stevens, MD, David A Stoker, MD, Mark E. Freeman, MD, Suzanne M. Quardt, MD, Elliot M. Hirsch, MD, Robert Cohen, MD

We are happy to announce the Dr Q’s VIP Club. Please go to http://palmdesertplasticsurgery.com/vip-club/ fill out the form and you will receive your $500 saving card to be used towards all services Dr Q provides.

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