Archive for the ‘Plastic Surgery’ Category

Acupuncturist Perspective for Pre & Post-surgical Management

Dear Readers,

Below you will find a guest blog post by Dylan Stein, MS, LAc . Dylan is an acupuncturist in New York City  specializing in men’s health, dermatology and pain management. He has written a short post here for my readers and also my patients about managing pain after surgery. I think you will like his suggestions.

Also, please visit his website to see if acupuncture might be of use to you.

Cosmetic surgery is an incredible advancement in the field of healthcare. So many people suffer from issues of low self-esteem and poor body image. Cosmetic surgery provides an opportunity to change this. There are a few ways you can prepare yourself and then manage unwanted symptoms naturally after surgery. The best things you can do to prepare for surgery are get adequate rest, eat a diet rich in vegetables and low in refined carbohydrates (high sugar snacks, baked goods made with white flour, and tropical fruits), and drink at least 8 glasses of water per day in the two weeks leading up to your surgery date. Sleep is a time for your body to heal and recoup lost resources. By getting at least 8 hours of sleep per night leading up to your surgery, you will have prepared yourself to start healing sooner.

A vegetable-rich diet will give your body the vitamins, minerals and anti-oxidants it needs to heal from surgery. As I tell my patients, try to eat the rainbow. This means make sure you’re getting all different colored vegetables, with an emphasis on the dark leafy greens. Add these extra vegetables to your existing meal plans. Also, try to eat refined sugars and simple carbohydrates (they digest quickly into sugar) infrequently. Sugars like this promote inflammation, which will slow or inhibit proper healing after surgery. If you’re craving fruit, try to eat organic berries, pears and even roasted sweet potatoes for a healthier version of a sugary snack. Drinking enough water each day is incredibly important. We’re lucky in New York to have excellent tap water. Consider getting a filter to remove the chlorine before drinking. Do not drink distilled water. Tap water, even unfiltered tap water, is preferable to water bottled in plastic, which can be full of chemicals, which disrupt your hormones. Adequate water intake will help your body flush out toxins and keep your body fluids at the right levels.

I teach all of my patients undergoing surgery three different acupressure techniques. Acupressure works similarly to acupuncture, but doesn’t involve needles since it’s a massage technique. Acupressure is very safe. The only contraindication is to avoid the first technique I mention below if you are pregnant. Because this kind of acupressure is so safe, you can do this a few times a day or even hourly to help manage your discomfort. The first technique is called Massaging the Four Gates. It uses a point on each hand and each foot. The hand points, known as Large Intestine 4, are between the thumb and index finger in the fleshy muscle of the web. This point has a resonance with the face, so it is particularly good for anyone who has had cosmetic surgery in that area. Coincidentally, it is also a great point for sinus headaches and toothaches for the same reason. The second point in this pair is called Liver 3, which lies in between the foot bones that connect to the first and second toes. If you touch this area, you will feel a depression in which the point lies. This coupled point pair strongly stops pain by regulating the Qi (the body’s energy) and blood of the entire body. Since the foot points are not very easy to reach on your own, you can focus on the hand points during self-massage. Massaging these points can be done gently or strongly, whatever feels most comfortable to you. You can even push and hold the points strongly if the pain is intense.

The second technique will help with pain, but it also helps with agitation or nervousness. This can be useful right before surgery if you’re feeling anxious or after surgery to help calm your nerves. This is acupressure ear massage. Gently pinch your ear between your thumb and forefinger and massage with small circles. Pay attention to the entire ear. Use just your forefinger to work into all the nooks and crannies. Be gentle, but firm. If you have very cold hands, this will be less useful, so either ask a friend with warm hands to do it or run your hands under warm water to take off the chill. The third technique is for post-surgical nausea, and is called Massaging the Inner Gate. It utilizes a point called Pericardium 6, which lies two inches or so above the inside wrist crease on the forearm, right in the middle of all the tendons that move the hand and fingers. Motion sickness bracelets stimulate the same point. Apply gentle, but firm, pressure to this point if you’re feeling nauseated. Coincidentally, this point may also be useful for morning sickness. If your doctor says it’s OK, you can also apply some lavender essential oil to this point to help control the nausea.

My final tip for patients is not from the Chinese medicine repertoire, but from homeopathy. Before taking any medications or supplements, be sure to get your doctor’s OK. The use of a homeopathic remedy called Arnica Montana may be helpful to reduce swelling and bruising after surgery. The 30C concentration is usually adequate. Follow the directions on the label. Arnica is readily available in health food stores and some pharmacies.

Continuing the pre-surgery routines I mentioned above after surgery will also be useful to encourage healing.

I hope you found this information helpful. I wish you a speedy recovery.

Yours in health,

Dylan Stein, MS, LAc.
Dylan Stein Acupuncture
Follow Dylan on Twitter @citypuncture

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Gynecomastia and Body Dysmorphic Disorder

Body Dysmorphic Disorder (BDD) is a condition which is frequently on the minds of many plastic surgeons. In the U.S. it affects 2% of all men and 1% of all women. According to the Mayo Clinic, Body Dysmorphic Disorder is a chronic illness in which a patient fixates on a particular real or imagined physical flaw. In relation, to gynecomastia, each surgeon who performs this surgery has to consider the possibility of whether a prospective patient has a realistic body image in comparison with the average population. For a condition like gynecomastia, which is characterized by enlarged male breasts, it is possible for a man to fixate on the flaws in this particular area of the body. With the connotations related to how men with enlarged breasts perceive themselves on the gender spectrum, it is understandable that some men might fixate on this. According to Dr. Blau, who is a specialist in gynecomastia, he finds that he is especially wary of this when working with the body-building community. As bodybuilders need to be conscious of their physique on a consistent basis in order to remain competitive. To minimize the likelihood of operating on someone with Body Dysmorphic Disorder, plastic surgeons evaluate their patients psychologically in order to ensure that the surgery is really in the best interest of their patient.

Handling a gynecomastia patient with Body Dysmorphic Disorder is always a tricky situation for any physician. It takes a skillful physician, who has a lot of experience working with patients to learn how to communicate realistic expectations to patients. However, even after spending a great deal of time discussing what outcomes a patient can realistically expect, sometimes, patients whose results objectively look good to other still look like they are in great need of fixing from the perspective of the patient. At this juncture, the physician should discuss with the patient, the possibility of benefitting from counseling for Body Dysmorphic Disorder.

Body Dysmorphic Disorder needs to be taken seriously. Those with BDD can also experience unfortunate symptoms like depression, anxiety and suicidal ideation. Fortunately, BDD can be managed through medication and cognitive behavioral therapy. If you think you may be suffering from BDD, please consult your healthcare professional.

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Dr. Blau’s Practice Featured on TLC

Watch the story of Cristian, a patient who came into our practice for gynecomastia surgery. TLC  Tv got many proposals from various board certified plastic surgeons, but because of Dr. Blau`s reputation and expertise on male breast reduction surgery our proposal was accepted by The Learning Channel who came to our office in White Plains to document his story. Learn more about Cristian and Dr. Blau’s surgical techniques in our video below. We thankful to the Learning Channel for documenting a typical young person story concerning gynecomastia and hope that other prospective patients will identify with this documentary. The video shows pre-surgery and three and six months after surgery.

Dr. Blau on TLC

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Information on Gynecomastia Incisions by Dr. Mordcai Blau

When it comes to gynecomastia surgery, the choice of how the incision is made is crucial. In 1992, back when relatively less was known about best practices for gynecomastia removal, I decided to invite 100 patients to participate in an on-line comparison survey to find out more information about patient preferences for incisions. Of the 100 patients invited, 50 were those who were my patients and 50 were those who had gynecomastia surgery performed on them by other doctors. The two types of incision I wanted to compare were the lower axelar incision and lateral (under the armpit). I also wanted to find out more information about the advantage of one incision vs. multiple incisions. All of the patients’ incisions were between a year and a half to three years old.

Lateral incision under the armpit

This patient has an incision made under the areola

Some of the conclusions I drew, were that the vast majority of the plastic surgeons who utilize the lateral incision seem to agree that it is effective for liposuction only. A small amount reported that maybe only tiny amount of Gynecomastia can be proven (most of the G could stop in today.) For hard fill number of patients claim they involved sharp instrument they can scrap sore of the glandular time.
In contrasting the responses with my experience, I’ve found that I have personally tried all kind of instrumentation and could not remove even a small amount of breast tissue using the lateral approach. The rate of recurrence with the lateral approach was extremely high and probably between 10-35 %. This is due to the fact that gland removal incision is highly visible even though it may be shorter then axeolar incision. In this case, there is natural liner to hide the gynecomastia incision (in comparison to a line between the areola and the shins). However, my personal experience is that less than 1% of patients with lower areola incision have noticeable scars in comparison to almost all patients that have lateral scars. Utilization of only one incision for breast through which liposuction and gland removal is done in this process. Rarely less than 5% need a drain after subgranlar incision which may be in some cases and second after a third incision to one breast.

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Gynecomastia Patient Testimony

What’s the best proof that gynecomastia surgery can make a huge difference in a man’s life? A patient testimony. See one letter from our patient below to see how gynecomastia surgery has affected his life.

Dr. Blau

I had surgery with you last Friday. First I would like to thank you and your secretary for making this a great experience. I am today six days post op and I truly was gearing up for a much worse recovery period. I am happy to say that I feel no pain with just a slight bit of soarness/itchiness, which is similair to having done a few too many bench presses at the gym. As of now I am very happy with the result. I till now had never had an actual surgery excusing wisdom teeth and I am very happy to say it was not anything what I expected.

As far as progress I have been taking it easy..back to work but not doing any gym activity. I have noticed that the left aerola pertrudes a bit more than the right which I can notice when in a tight fitting t-shirt…I do not remember seeing it perturude as much when you took the bandage off so I am thinking it to be either a little fluid or swelling. I am hoping that it is just some excess fluid or swelling. I know it can take a while for everything to heal and the final picture to become evident. My only question would be if it would be advantageous to wear additional compression dressing to aid in this..beleive me I am happy to stay away from compression dressing if possible..I will be patient for healing. I am sure this has happened before. I have never been one for patience, but in this case I will make an exception. Either way I can say that after less than a week post-op I look totally different and do not feel the need to wear baggy t-shirts or long sleeve button downs in the heat of this very warm summer. For the few close friends I have shown it too they have all said I look totaly different. In any case I can say that the money I spent was worth it and that I wish I had done this many years ago. I cannot begin to explaint the relief of being rid of this after so many years. I truly feel totaly different from last week.

In closing thank you all for your time and patience. I am happy I made the long trip to your office. Your secretary has been great at answering my abundance of questions and keeping in contact. Thanks again to you and your entire staff for making this an easy experience. You guys rock!! If I know of anyone looking for a surgeon especially for gynecomastia I will send them to your office and tell them that it worth it!! Hope to hear from you soon and enjoy the rest of the summer..I have a feeling mine will be better than all previous.

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Gynecomastia Surgery: Describing the experience by Dr. Mordcai Blau

To prepare for the surgery, it is important to bear a few things in mind. When consulting with your surgeon, it is essential to disclose all medications, vitamins and herbal supplements taken on a regular basis in order to ensure that there are no harmful interactions with any medications prescribed for the surgery.Additionally, to avoid complications, the patient should discontinue using Aspirin, Ibuprofen, nutritional supplements, steroids.Some of these act as blood thinners and could cause problems with blood clotting. Please ask your surgeon for a full list of medications which could cause complications with blood clotting. Furthermore,the patient should stop smoking and drinking in excess two weeks prior to surgery as smoking and drinking in excess can lead to complications.

As most cases of gynecomastia are a mixture of true gynecomastia and psuedogynecomastia, most surgeries will include excision of the gland, which is associated with true gynecomastia, and liposuction, which is used to remove the fat which characterizes psuedogynecomastia. During the surgery, the patient will be placed under anesthesia, either intravenuously or with the use of local anesthesia. Once under anesthesia, a small incision is made under the areola and 90-95% of the enlarged gland is removed. To perform the liposuction a special instrument, called the cannula, sucks out the fat with negative pressure.

After surgery, you should expect some bruising and swelling after your procedure and any discomfort can typically be controlled with pain medication. If you experience, severe pain which is not normal, you should contact your surgeon immediately. It is also possible you may feel like you’ve lost sensation in your chest, however, this is not cause for alarm. This loss of sensastion is due to your nerves beginning to regenerate after surgery. Feeling and sensation should return to normal.
Bruising may last a week or more and swelling may take more than a month to fully subside and though each patient recovers at his own pace, most patients are up and walking around within a day of the surgery and return to work three-seven days following surgery.However, any physically strenuous activity such as jogging or heavy lifting, should be avoid for at least four to five weeks following surgery.
Five to seven days after surgery, you will need to return to your plastic surgeon’s office in order to have the stitches removed. Also, the patient will have to wear a dressing in order to compress the chest and ensure the best possible contour of the pectoral muscles.
While there will be scars, they are usually well hidden and become very inconspicuous as they fade and mature. Avoid exposing any scars to the sun for a minimum of six weeks as sunlight can cause scars to darken permanently. If you can’t avoid sun exposure, use a strong sun block. Swelling may take three months or more to fully subside and allow you to observe the improved contour of your chest, but you should attain a result you can love for a long time.

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Natural Blend Technique for Gynecomastia by Dr. Mordcai Blau

After working in the field for 25 years, Dr. Mordcai Blau created and perfected his technique of choice, which he refers to as the Natural Blend technique. The natural blend technique focuses on the male chest as a whole, not just the breast gland tissue. The Natural Blend technique is so comprehensive that Dr. Blau begins its implementation as early as the consultation stage. During the consultation process, he examines the particularities of each patient’s chest and devises a surgical plan based around the idiosyncrasies of each patient’s chest. He closely examines the amount of glandular tissue and excess skin. The patient’s age is also taken into consideration as this will affect the elasticity of the skin. He asserts, that these factors play a huge role in defining the shape of the patient’s chest. By examining this, along with the patient’s particular composition of adipose tissue, breast gland tissue, fibrous tissue, muscle and skin, Dr. Blau can adapt his surgical procedure to fit the natural contours of each patient’s body.
As an accomplished artist, Dr. Mordcai Blau pays close attention to the symmetry and proportions of each patient’s chest, knowing that the optimal result is a product of both a strong artistic sense, and extensive surgical knowledge. In addition, he is well-versed in anatomy and has held positions as an anatomy instructor at both Albert Einstein and NY Medical College. The right proportions of the chest can make an astounding impact on one’s overall appearance, and getting the right proportions and symmetry is Dr.Blau’s ultimate goal.
During the surgery, Dr. Blau begins to implement his strategy based on his observations during the consultation. As a true aesthetician, Dr. Mordcai Blau takes precaution to minimize the incision, which, in general, is less than one inch, and remove the exact portion of the breast gland necessary for optimal results. His copious notes in the consultation beforehand, informs his decision about how small he can make the incision and how much of the breast gland to remove. Removing the exact right amount of the breast gland is a critical component of this type of surgery. Using the natural blend technique which emphasizes adhering to the uniqueness of each patient’s body, this is especially true. Removing too much of the gland can result in a depression underneath the nipple-areola-complex, and removing too little could result in a reoccurrence. Excising the appropriate portion of the gland makes a huge difference in terms of the overall appearance of the chest, so using the natural blend technique is particularly useful in terms of removing the right amount of gland, which is usually between 95-98% of the gland. In his experience conducting thousands of surgeries, Dr. Blau has noticed that the breast gland tissue can appear in areas other than directly under the nipple-areola-complex. The thoroughness of the natural blend technique helps him to ensure that he does not miss any glandular tissue.
The next stage in the natural blend technique is to remove the fat tissue. Again, Dr. Mordcai Blau takes careful note of the appropriate amount of fat to remove on a case-by-case basis. For his patients who are bodybuilders, which comprises about 20-30% of his client-base, he removes glandular tissue only, since bodybuilders have such little body fat. Bodybuilders are particularly attentive to the shape of their chest as their competitive edge relies on the build of their chest. Dr. Blau sees this as a testament to the quality of his natural blend technique. Patients with psuedogynecomastia, which is characterized largely by a great deal of fat tissue, on the other hand, have to have a lot of adipose tissue removed. In the rare case in which gland excision and fat removal are not enough, Dr. Mordcai Blau will employ an adipose flap to create the ideal chest shape. This is more likely to be the case if it is a secondary surgery as opposed to a primary surgery. If there is a little depression or deformity, the adipose flap can be used to mold the fat into place to fix the depression or deformity. The flap is often a better option than a fat injection, as the adipose flap leaves one side of the fat attached to ensure blood supply.
By taking great care and paying attention to the unique features of each patient’s body, Dr. Mordcai Blau manages to create a surgical technique specific to their needs. Using the natural blend technique, many patients see results which, appropriately, suit their body quite naturally.

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Different kinds of gynecomastia by Dr. Mordcai Blau

Did you know that there are three kinds of gynecomastia? There is pure true gynecomastia, which is caused by a large breast gland most common in athletes and body builders , there is peudogynecomastia, which is often cause by excessive weight but may also be hereditary and is characterized by fatty tissue deposits in the breast area, and the third one which is the most common kind of gynecomastia is a combination of enlarged breast tissue(breast gland) and Fatty tissue deposits.
Psuedogynecomastia is characterized by a large amount chest fat as opposed to excess breast tissue. . As the increase in chest fat may be hereditary or due to excessive weight it is important that the patient try to lose weight by managing diet and exercise before attempting surgery. If weight loss attempts do nothing to ameliorate the effects of gyneocomastia, then one should consider consulting a plastic surgeon. Pseudogynecomastia is often treated by using liposuction, in which negative pressure will suck out the excess fatty tissue. When the third, kind of gynecomastia which is a combination of both true and psuedogynecomastia is treated surgical treatment should be a combination of the breast gland excision (which is an essential to ensure a successful outcome) and liposuction of excess fatty tissue.

On the other hand, true gynecomastia, which is caused by excess breast gland(larger gland), results in a hard swelling underneath the nipple-areola complex, giving the appearance of a woman-like breast. The exact cause of true gynecomastia is not always known. However, researchers have determined some strong correlations. Gynecomastia can be found more frequently in males who consume high levels of marijuana or alcohol, or use a large amount of drugs like Digoxin Effexor, Motrin, Pepsides , foxglove and many other drugs. Smaller percentage of gynecomastia sufferers have low testosterone and higher levels of estrogen on average. It is also more prevalent in males who use steroids or steroids like substances. In order to treat true gynecomastia, the surgeon must excise most of the breast gland, tipically over 90% of the breast tissue.
According to Dr. Mordcai Blau, it is crucial to seek out a plastic surgeon with expertise in gynecomastia, as a surgeon who removes too little of the breast gland will result in a reoccurrence(According to the medical literature in 10-35% of the surgical patients) and a surgeon who removes excessive tissue may cause concavity of the nipple-areola complex. Consulting a plastic surgeon with little experience with gyneocomastia-related surgeries could result in a misdiagnosis and a resurgence of gynecomastia as the two are treated in somewhat differing manners. Using the incorrect ,or insufficient technique could result in the need for revision surgeries, and the symptoms can continue to persist, so it is important to understand the differences between the three.

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Important Information about Gynecomastia by Dr. Mordcai Blau

What is Gynecomastia?
Gynecomastia is enlargement of the male breast. It is important to distinguish the enlargement present in gynecomastia from the adaptive response induced by resistance training (hypertrophy) of the pectoralis muscles. Gynecomastia is firm subareolar tissue and or diffuse fibroglandular tissue aggregating behind the nipple.

Facts about Gynecomastia?

Gynecomastia is present in 30% to 50% of healthy adult men. There are three times that males are most susceptible to developing gynecomastia. The neonatal period (infant), during puberty, and the age of fifty onward are the most vulnerable to developing the condition. Obesity greatly increases the chances of developing gynecomastia. Other factors that can increase the chances of developing gynecomastia are: genetic predisposition, smoking, drinking, prolonged high stress levels, physical inactivity, and drug use. The potential to develop gynecomastia with any combination of the aforementioned factors is directly proportional to age.

Ultimate cause of Gynecomastia

Males normally possess the equipment (glands + tissue) but lack the means (hormonal profile) to develop breasts. Most cases of gynecomastia result from an imbalance between estrogenic and androgenic effects on breast tissue. Estrogens stimulate breast tissue growth while androgens inhibit it. While there are many mechanisms caused by factors previously mentioned, most of their potential to induce gynecomastia is from ability to disrupt the estrogen / androgen balance present in healthy males.

Significance!
Gynecomastia though not an immediately life threatening condition, can have negative effects on the quality of life of a patent. A male with gynecomastia can experience behavioral health changes serious enough to effects his social, mental, physical and thus overall health. A few examples of this are feelings of anxiety, psychosocial discomfort, and a chronic fear of breast cancer.

Will Gynecomastia naturally go away?

Gynecomastia during the neonatal period normally regresses spontaneously requiring no treatment. Gynecomastia in puberty commonly is asymptomatic and regresses spontaneously. Gynecomastia that has not spontaneously regressed from puberty will likely not do so. The only effective treatment is for this case is surgery. Gynecomastia onset in adulthood from: stress, drugs, refeeding following starvation (prolonged catabolic states), and obesity will likely not regress. Adult onset gynecomastia requires surgery for effective treatment.

Do I have gynecomastia? I have puffy looking nipples…..
It is common that overweight men may feel they have gynecomastia because of the protruding appearance of their nipples and chest area. It is possible that many of these cases are pseudogynecomastia. Pseudogynecomastia results from having excessive body fat. The fatty breasts behind the areola and chest area are swollen adipocytes (fat cells) and are a result of sustained energy input (diet), exceeding output (metabolic demands). Body fat is not site specific and its storage distribution throughout the body varies genetically. Pseudogynecomastia can be treated effectively with exercises and diet. It is important to emphasize that carrying excessive amounts of body fat increases the risk of developing real gynecomastia that is only effectively treated by surgery.

Both Nipples? One Nipple?

Gynecomastia is commonly bilateral and symmetric (both glandular mammilary tissue deposits are of equal size). Gynecomastia can also be unilateral (asymmetric tissue deposits).

Treatment

Surgery is the only effective treatment for gynecomastia that has not spontaneously regresses during puberty or that is adult onset. The surgical method is to remove the glandular tissue through a periareolar incision. A lipectomy may or may not be necessary as determined by the surgeon. The surgical procedure requires skill and experience by the surgeon. Finding the right surgeon will determine the success of the treatment and meeting your personal expectations.


Example # 1 – Mild Case of Gynecomastia

Patient with bilateral symmetric gynecomastia
Surgeon: Dr. Mordcai Blau
Post-Operative Photo: 1 year

Mild Gynecomastia Before Photo

Mild Gynecomastia After Photo

Cosmetically: There are no visible scars present from the incisions. The size of both nipples was reduced as a result not being stretched over the breast tissue. The natural contour of the nipples resting on the chest has been restored. There are no protrusions or depressions present in the surgically corrected area.

Example #2 – Severe Case of Gynecomastia

Patient with bilateral symmetric gynecomastia
Surgeon: Dr. Mordcai Blau
Post-Operative Photo: 1 year

Severe Gynecomastia Before Photo

Severe Gynecomastia After Photo

Cosmetically: Patient was concerned that scar tissue would be a serious issue with his dark skin complexion. There is no visible scar and his severe case of gynecomastia was corrected, achieving a natural smooth contour of the chest.

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Anatomy Relevant to the Surgical Correction of Gynecomastia by Dr. Mordcai Blau

The blood supply to the cutaneous tissue in the anterior chest area, including the NAC (nipple-areola complex), is from the anterior perforators arising from the internal thoracic artery, and the  musculocutaneous perforators arising from pectoral branch of thoracoacromial axis.  The cutaneous tissue located laterally, to lateral cephalic of the NAC,  is supplied by the superficial thoracic artery. Lateral cephalic from the superficial thoracic artery cutaneous supply, the cutaneous tissue located on the ventral portion of the axilla continuing to the medial, proximal portion of the biceps brachii, is supplied by the anterior circumflex humeral artery.  Located inferiorly to the clavicle, on the lateral portion of the upper pectoralis area, the cutaneous tissue is supplied from the direct cutaneous branch arising from the thoracoacromial axis.

Figure 1.  Anterior aspect of the anatomical territories of cutaneous blood vessels on the anterior trunk. (Adapted from) (1)

Figure 1. Anterior aspect of the anatomical territories of cutaneous blood vessels on the anterior trunk. (Adapted from) (1)

The fascia relevant to gynecomastia surgery are the superficial fascia, and the deep fascia.  The superficial fascia, consist of adipose tissue loosely attached to the skin.  Small blood vessels and nerves perforate the superficial fascia to supply the skin. (2)  The gynecomastia fibroglandular tissue is found within the superficial fascia, as is true with the female breast.  The deep fascia is a tough and fibrous membrane that allows some movement of the structures over one another. (2) The deep fascia investing the pectoralis major muscle is relatively thin, but polar, stronger and more distinct in the upper pole of the muscle. (2)

Figure 2.  Anatomical diagram of the left anterior chest. (2)

Figure 2. Anatomical diagram of the left anterior chest. (3)

The male NAC, like females, is susceptible to hypertrophic scarring as a result of the high tensile forces present. (2) The NAC is more susceptible to hypo and hyperpigmentation, onset by surgical wound, than the thin hirsute skin that covers most of the body.  This is due to the greater degree of melanization in the NAC. (4) Physical examination is performed to evaluate the breast for any dominant masses, nipple discharge, or lymphadenopathy. (2)  Patients with gynecomastia were found to have an increased incidence of testicular tumors (5), warranting examination of the testacies.  Factors influencing which operative procedure a patient will require are, skin redundancy, the amount of adipose tissue present, the amount of glandular tissue present, and the diameter of the NAC. Mild cases of gynecomastia can be corrected by intraareolar incisions (infraareolar, cresentareolar), circumareolar, endoscopic approaches, and transaxillary approaches. (6)  Moderate cases of gynecomastia can be addressed with the donut mastopexy. (2,7,8)  Extreme cases of gynecomastia can be corrected with a vertical scar mastopexy, wise pattern mastopexy, or IMF approach (9,10).  Gynecomastia operations need to be designed specifically to address the amount of skin excess, glandular breast tissue, fatty tissue, degree of breast ptosis, and the size of the NAC. (2)  Each component should be considered separately to optimize the outcome.(2) An example of a single component to consider when planning a surgical approach is the NAC size.  The diameter of the NAC will decrease after the removal of the glandular tissue, as a result of contraction, in absence of pressure from underlying tissue volume.  Excessively large NACs sometimes require a circumareolar excision, to achieve a reduction in nipple diameter. Based on Dr. Mordcai Blau’s observations, this method comes at the expense of aesthetics, as there is a greater potential for more apparent scarring.  An extensive knowledge and understanding of the anatomy relevant to gynecomastia facilitates better aesthetics in procedural outcomes.

Figure 3.  A lateral, inferior infraareolar incision of the  NAC.  The view is parallel to the coronal plane.

Figure 3. A lateral, inferior infraareolar incision of the NAC. The view is parallel to the coronal plane.

Figure 4.  Diagram of the NAC innervation.  An infraareolar incision is labeled in black.  This incision is most often appropriate for grades I and IIa, IIb (grades defined by Simon et al.). (5)

Figure 4. Diagram of the NAC innervation. An infraareolar incision is labeled in black. This incision is most often appropriate for grades I and IIa, IIb (grades defined by Simon et al.). (5)

References

1. Cormack, GC and Lamberty, BGH. The Arterial Anatomy of Skin Flaps. 2nd Edition. Edinburgh : Churchill Livingstone, 1994.
2. Bahman, Guyuron, Eriksson, Elof and Persing, John A. PLASTIC SURGERY INDICATIONS AND PRACTICE. [ed.] Kevin C Chung, et al. s.l. : Elsevier Inc., 2009. Vol. I and II.
3. Gray, Henry. Gray’s Anatomy. 15th Edition. New York : Barns & Novle Books, 1901, 1995.
4. Standring, Susan. Gray’s Anatomy The Anatomical Basis of Clinical Practice. 40. s.l. : Churchill Livingstone ELSEVIER, 2008. p. xxiii. 978-0-443-06684-9.
5. Testicular tumours presenting as gynaecomastia. Daniels, IR and Layer, GT. 29, 2003, Eur J Surg Oncol, pp. 437-439.
6. A transaxillary incision for gynecomastia. Balch, CR. 61, 1978, Plast Reconstruct Surg, Vol. 1, pp. 13-16.
7. Concentric circle operation for massive gynecomastia to excise the redundant skin. Davidson, BA. 63, 1979, Plast Reconstruct Surg , Vol. 3, pp. 350-354.
8. Eccentric skin resection and purse-string closure for skin reduction with mastectomy for gynecomastia. Smoot, EC 3rd. 41, 1998, Ann Plast Surg, Vol. 4, pp. 378-383.
9. Correction of gynecomastia with an inframammary incision and subsequent scar. Beraka, GJ. 96, 1995, Plast Reconstruct Surg, Vol. 7, pp. 1753-1754.
10. Correction of extreme gynaecomastia. Wray, RC Jr, Hoopes, JE and Davis, GM. 27, 1974, Brit J Plast Surg, Vol. 1, pp. 39-41.
11. Classification and surgical correction of gynecomastia. Simon, BE, Hoffman, S and Kahn, S. 1973, Plast Reconstr Surg, Vol. 51, pp. 48-52.

Figure 5. Bilateral fibro-sclerotic glandular tissue excised through an infraareolar incision.  Glands were released by sharp dissection.  Visual inspection elucidates a small percent of adipose tissue present.  Lipoplasty was not applied for the purpose of evening the contour of the chest periareolar-NAC area, due to the patients low percent body fat.  A 1.5" capped needle is placed medial to the left gland.

Figure 5. Bilateral fibro-sclerotic glandular tissue excised through an infraareolar incision. Glands were released by sharp dissection. Visual inspection elucidates a small percent of adipose tissue present. Lipoplasty was not applied for the purpose of evening the contour of the chest periareolar-NAC area, due to the patients low percent body fat.(11)

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