As 2012 comes to a close, we’d like to evaluate the journey our practice has gone through in the past year and highlight some of our accomplishments.
The practice recently submitted statistics to the American Society of Plastic Surgeons on the number of surgeries done over the past year. In 2012, Dr. Blau performed 317 gynecomastia, or male breast reduction surgeries, which was over 95% of the total procedures performed at his practice. Considering that on average, each plastic surgeon only performs 2-3 surgeries of this nature a year, it is quite impressive. Only a handful of other surgeons worldwide perform more than 100 male breast reduction surgeries each year. Of these surgeries about 100 were performed from patients residing outside of the country. Dr. Mordcai Blau and his staff make concerted effort to cater to international patients by providing extensive information on staying in the White Plains area and by providing individualized instructional packets designed for each patient based on his individual needs far in advance of the surgery to ensure each patient is prepared. His staff was more than happy to do this for all 317 gynecomastia patients, regardless of whether they came from out of state, out of the country, or right in town.
Since Dr. Mordcai Blau is an expert who specializes in gynecomastia surgery, he often gets many patients who require revisions from previous gynecomastia surgeries. In 2012, 100 of Dr. Blau’s surgeries were revisions. Throughout the year, Dr. Blau has found that patients have generally been satisfied and that none of his gynecomastia patients experienced a recurrence. He has found that his signature technique, the Natural Blend technique, which requires careful consideration of the contours of each individual patient’s body prior to surgery, contributes to the success of his surgeries. As an artist who has had his work showcased in several exhibitions throughout the U.S. and Europe, the Natural Blend technique combines Dr. Blau’s skills as an artist and a surgeon and helps him to map out his surgical plan to create a natural-looking contour in which the skin drapes naturally over the chest. Dr. Blau finds that this technique works especially well for bodybuilders, who represent a large portion of his gynecomastia patients. The fact that such a large percentage of his practice is comprised of bodybuilders serves as a testament to Dr. Blau and his surgical techniques as this group holds a much higher standard for physical appearance than the average patient. In an effort to further improve upon aesthetics, Dr. Mordcai Blau followed cues from his patients’ wishes and has also developed nipple reduction surgery in order create an appearance of the chest which is more typical. To see the results of his work, browse through his collection of 2,500 before and after photos.
Among his other accomplishments in 2012, Dr. Blau was featured on The Learning Channel (TLC). In the segment, the film crew followed the journey of one of his patient’s Cristian, from his early struggles with gynecomastia to his results from his gynecomastia surgery. This segment helps shed light on the problems commonly faced by those with gynecomastia.
Also in 2012, Dr. Mordcai Blau has started working on compiling his surgical knowledge of gynecomastia into a book. He hopes that this compilation of experience working on patients with gynecomastia will help inform the public and other plastic surgeons about best techniques and practices for male breast reduction surgery. He hopes to incorporate successes from 2013 into his book.
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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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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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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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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
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
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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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)
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. (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 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.(11)
Liposuction surgery (lipoplasty), is performed to remove unwanted localized fat deposits. The ideal candidates for this procedure are patients with localized fat accumulation who have been unable to reduce these areas through diet and exercise. The reduction of adipocyte (fat cell) volume can be accomplished by diet (energy intake restriction) and exercise (directly – through work performed, indirectly – through increased BMR). These methods work by inducing a prolonged catabolic state that promotes lipolosis, and gluconeogenesis. One can lose a significant amount of body fat, through mobilizing the 9 kcal/g energy store in adipose tissue but still have a significant local accumulation specific to a body part or area. Contrary to the common misconception, exercises targeted to a specific muscle group or body area will not reduce the body fat local to the specific area. Lipoplasty removes adipose cells present as opposed to reducing individual cell volume, like is seen with a negative energy balance. It is for this reason, lipoplasty applied specific adipose stores may offer aesthetically pleasing results.
Lipoplasty procedures including LVL (large volume lipoplasty), are not substitutes for diet and exercise, as research and primary literature have shown that lipoplasty does not reduce the metabolic risk factors for coronary heart disease, or improve insulin sensitivity.
Fat excess or deficiency can have adverse effects on endocrine function. Since significant adipose tissue removal can be achieved through lipoplasty, the procedure should be taken seriously. Adipose tissue is integrally involved in coordinating a variety of biological processes including energy metabolism, neuroendocrine function, and immune function. Adipose tissue is a major site for metabolism of sex steroids and is active in both efferent and afferent signaling. Two major efferent signals produced by adipose tissue are adipsin, and leptin (endocrine factors). Adipose tissue is known to express and secrete a variety of bioactive peptides (adipokines), which act at both the local (autocrine/paracrine) and systemic (endocrine) level. Adipose tissue expresses numerous receptors that allow it to respond to afferent signals from traditional hormone systems as well as the (CNS).
Tumescent liposuction consists of injection of fluid into a specific area as preparation for liposuction surgery. This procedure sometimes helps to reduce the bleeding and facilitate the liposuction surgery. A common method of preparing tumescent solution involves the use of a 3 L bag of lactated Ringer’s solution to which 2% lidocaine 75 ml is added yielding a concentration of 0.05% lidocaine. Next, 1:1000 epinephrine 3 mL is added, resulting in a 1:1,000,000 concentration of epinephrine. The Ringer’s lactate contains 28 mEq/L of bicarbonate ion and has a resultant pH of approximately 6.5. The system is pressurized to approximately 200mm Hg. A suction tube is inserted through a small incision. The surgeon minimizes the incision scar visibility, whenever possible, by placing the incision within and parallel to skin creases on the body.
Multiple modalities for the removal of adipose tissue exist in lipoplasty. SL (syringe lipoplasty), SAL (suction assisted lipoplasty), PAL (power assisted lipoplasty), and UAL (ultrasound assisted lipoplasty), are such modalities. Limitations of traditional lipoplasty (SL / SAL), when performed on fibrotic areas, such as the back, flanks, and gynecomastia, or in secondary or LVL procedures, encouraged the development of energy-efficient devices that allow greater precision and require less physical effort to use. The introduction of UAL, PAL, VAL (Vaser-assisted lipoplasty) resulted in less trauma to the patient, as evidenced by decreased ecchymoses. According to Dr. Mordcai Blau, the surgeon will select the appropriate method, or combination thereof, as appropriate for the anatomy of the area and the tissue removal quantity required.
Areas where the liposuction procedure can be beneficial are the neck, arms, abdomen, waist, back, thighs and knees.
Figure. Lipoplasty preformed on the waist and thighs. This patient is an example of an ideal candidate, in whom, diet and exercise were not adequate to markedly reduce the size of the adipose tissue, heavily distributed in the waist and thighs.
Figure. Lipoplasty of the waist and back. A significant reduction in waist size was achieved by removing adipocyte stores in the waist and lower back. The “love handles” as patients sometimes refer to the adipose tissue located superficial to the external abdominal oblique, internal abdominal oblique, gluteus medius, and tensor fasciae latae muscles.
Figure. A Profile view of a young female, with an adipose tissue store located superficial to the digastric, mylohyoid, and stylohyoid muscles. The postoperative view taken at 1-years time, displays a feminine neck contour, with no skin redundancy. The patients skin elasticity was excellent, which enabled the skin to adjust to the new neck contour after the appropriate volume of adipose tissue was removed.
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