Pull Through Procedure

Pull Through Procedure

Gynecomastia Surgery and the  “Pull Through Procedure”


Male breast reduction surgery for gynecomastia is performed in a variety of ways. The specific surgical technique depends on the “grade of gynecomastia” of the patient.  The pull-through procedure was developed by Paolo Giovanni Morselli from Italy who publish the original article in the European Journal of Plastic Surgery in 2012. The pull-through procedure has become very popular in the United States due to the small incision.

Gynecomastia surgery with before and after photo of the pull-through procedure


Pull Through Procedure Operation

The pull through procedure is performed by making a quarter-inch incision at the bottom of the areola.  Liposuction is performed to remove fat from around the breast gland.  The tissue is grasped by a special instrument and then pulled through the incision while freeing up the breast tissue from below the areola and above the muscle.  This is a blind procedure and not great access so the experience is required, especially to avoid a crater deformity.


Who is an ideal candidate?

The best candidates are grade 1 or 2 gynecomastia. These patients’ male breast enlargement is not too large and the gland can be removed and the fat blended without creating a crater deformity.

What is recovery?

If drains are used, they are removed in 2-3 days. You can drive a car and perform white-collar work in 5 days. Blue-collar work about 7-10 days. Modified exercise can begin in 2 weeks and full work-outs in 4-6 weeks.  A compression vest is worn for 4-6 weeks.

What is the cost of the “pull-through” procedure?

The expense of the surgery is explained in this cost link, but the cost is usually less due to less surgical time. So, looking at $6,000-$7,000 is a normal fee. Sometimes, local anesthesia is used and this would lower the cost.




The Unspoken Problem: Gynecomastia (aka Man Boobs) And Its Silent Sufferers

The Unspoken Problem: Gynecomastia (aka Man Boobs) And Its Silent Sufferers

The unspoken problem

Men or women, we all have insecurities.

Some of us dislike how our arms are a little too thin, while some of us dislike the way that our jawline isn’t as masculine as we wishy they were.

All of these insecurities usually come from our comparisons to ‘ideal’ figures presented on the media, and many of the times, these ‘ideals’ are actually just products of awesome Photoshop skills.

Regardless, we make efforts to improve our physical appearances – some through strict exercise regimes, some through undergoing aesthetic procedures, whatever works for each of us.

The latter is riddled with misconceptions, and the term “cosmetic surgery monster” tends to pop up as an insult, and many a times as an unfair exaggeration to the individuals who simply took an alternative route to improve their appearances.

But what if some of these surgeries were actually rooted in health issues?

Bulging belly

For example, a bulging belly is more of a health than aesthetic problem.

We’ve probably heard about those who undergo jaw surgery to reduce issues from strong under and overbites, and some who require rhinoplasty to fix breathing problems. However, not much is known about gynecomastia, also known as the medical condition of having male breasts.

In the US, male breast reduction surgeries made up around 27,456 in 2015, which represented a 35% growth since the year 2000. In Singapore itself, the numbers are definitely smaller, but there is no doubt that there are men seeking a solution for their problem.

We spoke to David (not his real name), a Singaporean in his mid-40s, and a silent sufferer of “man boobs” until his gynecomastia surgery.

When It Actually Becomes A Health Problem


“Man boobs” also have physical implications, like soreness.

“Man boobs” are commonly seen as an issue when guys are wearing shirts with a tighter fit, and the bulges aren’t in the right places. (Also a problem for women.)

For David, however, the extra fat in his chest was actually making him feel physically uncomfortable.

“I’ve always felt a little discomfort on my chest area in my early 20s but have always passed it off as nothing. It wasn’t until the discomfort started getting overbearing and disrupting my daily activities.”

He first assumed that it was a sign of heart problems, but checks with a doctor revealed no issues, so he turned to the most common trick in the bag – exercise.

While his regime did help him lose weight, the fats on his chest didn’t go away and the pain was still persisting. He even resorted to putting ice on the sore areas, but it only served as a temporary relief.

Putting A Name To The Condition And Its Solution

Unable to find a solution offline, and adding on to the fact that it’s not a common topic of discussion among Singaporean men, David had no choice but to search online for solutions.

He soon found out that what he had was gynecomastia, and eventually, stumbled upon Amaris B. Clinic, which presented an opportunity for him to finally get help for the embarrassing condition.

However, the decision wasn’t as easily made as compared to, let’s say, getting help for an illness like flu.

He was wary about seeking help from a medical aesthetic clinic, especially since cosmetic surgeries are usually cast in a negative light.

“I wouldn’t call it a misconception, [but] more of a lack of understanding. I’ve always thought of aesthetics procedures as solely for vanity and never did I imagine that they could do more.”

However, being that it was a means that he could finally be rid of his suffering, he decided to book an appointment with Dr. Ivan Puah to see how things go.

“You can imagine it’s quite unnerving considering that I have no prior experience personally or by proxy of aesthetic procedures. But with encouragement and relentless persuasion from my wife, I decided to take the first step.”

[Press Release] Beauty Tourism is Causing A Rising Need For Surgical Revisions

[Press Release] Beauty Tourism is Causing A Rising Need For Surgical Revisions

[Press Release] Beauty Tourism is Causing A Rising Need For Surgical Revisions

SINGAPORE, March 17, 2020 /PRNewswire/ — Dr. Ivan Puah, Medical Director of Amaris B. Clinic, has noticed a rise in failed results, such as botched procedures in liposuction and gynecomastia surgery, among patients who had their cosmetic procedures done overseas. Dr. Puah, accredited by the Ministry of Health in Singapore to perform liposuction, cites Gangnam (South Korea), Johor Bahru (Malaysia) and Bangkok (Thailand) as being the more popular medical tourism destinations.

The primary reason for Beauty Tourism is the relatively lower cosmetic surgery and aesthetics treatment cost. The next top reason is that many medical tourists have the opportunity to explore the host city or country after getting their treatment done. However, the lack of stringent regulations and clinical standards is often overlooked or does not pose as a deterrent. These inadequacies often lead to the need for revisionary work and additional corrective treatments, which may lead to additional expenses.

According to Dr. Ivan Puah, frequent complaints of patients who went through such experience includes the lack of medical follow-up, miscommunication, improper preparation and incomplete procedure counselling. Despite these real unfortunate experiences, botched procedures have seen an alarming rise in 2019, as observed by Dr. Puah.

Beauty Tourism is Causing A Rising Need For Surgical Revisions

He also noted that some botched liposuction were experienced locally as well. Some of the common complications he has seen include:

  • uneven dents or depressions on treated areas due to overly aggressive liposuction techniques,
  • asymmetry or uneven lumps and bumps on the treated areas due to reasons such as a poor selection of patients (i.e. patients are not suitable for liposuction), lack of experience or skills of the doctors, and
  • excessive post-liposuction tissue scarring due to improper use of liposuction equipment, high-definition liposuction performed by poorly-trained doctors.

Dr. Ivan Puah has also seen a rise in complications resulting from high-definition liposuction procedures. The procedure, which creates a more defined musculature is a more specialised form of liposuction and should only be performed by a qualified and well-trained doctor. Excessive scarring and uneven skin textures can happen if it is not done properly or by a suitably-trained doctor. Nonetheless, calamities as such can be addressed and corrected with VASER Liposuction.

VASER Liposuction enables a doctor to sculpt and shape a patient’s physique more efficiently. It uses patented ultrasonic soundwave energy to liquefy unwanted fat cells in targeted areas, leaving surrounding important connective tissues and blood vessels undisturbed. Additionally, patients experience lesser downtime and discomfort. VASER Lipo is particularly competent in addressing botched liposuction results.

Botched procedures should not be left uncorrected or untreated as patients may suffer significant physical and psychological trauma after botched treatment. As such, corrective surgery when performed adequately can help these patients to improve their clinical condition and self-confidence.

The lack of stringent regulations poses issues such as in ascertaining the requirements to be met as imposed by such facilities or medical centres and their adequacies, among others. In Singapore, stringent guidelines are observed, enabling the relevant authorities to monitor the industry better to maintain a high safety standard.

Under the rules set out by the Ministry of Health Singapore (MOH), cosmetic tourism agencies and representative offices are not required to be licensed. However, they are not allowed to provide and conduct medical consultation services. Foreign doctors who want to conduct consultations with patients must first register themselves with the Singapore Medical Council and upon success, will then be issued with a practising certificate. As MOH does not have jurisdiction over medical and healthcare institutions overseas, medical tourists who encounter issues will have to seek legal recourse in the country where the procedures were done.


Will my skin sag after gynecomastia surgery?

Will my skin sag after gynecomastia surgery?

Will my skin sag after gynecomastia surgery?

Most of the patients have degrees of gynecomastia that are not excessively saggy, and so in these instances, the skin elasticity will ensure that the skin snaps appropriately into a more aesthetically pleasing position.

Due to the high volume of patients I see regarding their gynecomastia concerns over the years, I have designed a customised 4-step gynecomastia surgery program called 4D Chest Remodelling. It reduces fat tissues and removes excess glandular tissues while stimulating the production of subdermal collagen to induce tissue remodelling and production of new collagen and elastin.”

Unlike the standard gynecomastia surgery, 4D Chest Remodelling is a more complex treatment modality especially planned for those whose ultimate objective is to achieve flatter and sculpted chest using high definition body sculpting technique.

Step 1: Gynecomastia Surgery
Gynecomastia is commonly caused by hormone imbalance and is the result of excess glandular and/or fatty breast tissues in men. It comes in a variety of degrees from the very mild to significant enlargement. Gynecomastia surgery is still the best option to address the issue effectively.

Step 2: Fat Tissue Removal
For those who not only have enlarged glands issue but also fat accumulation, fat reduction will be carried out. VASER® Lipo is a less invasive form of liposuction. Unlike the standard liposuction, it can precisely target problem areas without causing damage to surrounding tissues. This leaves a more contoured and defined appearance.

Step 3: Subdermal Collagen Production Stimulation with VASER® Lipo
Collagen is important as it gives structure to our skin, bones and all other connective tissue. VASER® Lipo is not only effective in removing excess fat; it also stimulates collagen production and skin retraction resulting in smoother skin.

Step 4: Nipple Reduction in 4D Chest Remodelling
Gynecomastia patients also may experience nipple issues. 4D Chest Remodelling® can help reduce their sizes for a more symmetrical nipple-areola creating a more masculine appearance.

4D Chest Remodelling will significantly lower the risk of saggy skin after gynecomastia surgery

Do I have Pseudogynecomastia?

Do I have Pseudogynecomastia?

Do I have Pseudogynecomastia?

Gynecomastia is common among adolescent boys and middle-aged, including older men. Hormonal imbalance, medication side effects and declining testosterone levels are the usual suspects.

Pseudogynecomastia, on the other hand, can happen to men regardless of age group. This condition is usually brought on by the presence of excess fat primarily in the chest area. However, due to their similarity in appearance – the best method of confirmation is via a doctor’s assessment.

Low Metabolism & Body Fat

Poor dietary habits and lifestyle choices easily contribute to a host of issues, including weight gain and the accumulation of excess fat. Excess fat often results in slower metabolism and testosterone levels and the production of aromatase. The aromatase enzyme converts testosterone to estrogen.

Men produce estrogen, albeit at a lower level compared to women. When a man’s body produces excess estrogen, the more the likelihood that excess fat will be stored. An area where this excess is usually more prevalent would be that of the chest or breast. This is what commonly causes pseudogynecomastia.

When the body produces excess estrogen, the more the likelihood that excess fat will be stored. Fat also causes the body to produce the aromatase enzyme. This enzyme converts testosterone into estrogen and is responsible for slowing down metabolism, which slows down the body’s ability to burn fat – you will lose fat but in lesser amounts. If not addressed, this can lead to more fat being stored causing an imbalance to the body’s hormone level.

An increased estrogen level in men also results in loss of muscle mass, fatigue and mood swings.

Low Testosterone

Low testosterone levels cause an increase in fat storage as the body’s fat-burning capability is reduced. This results in weight gain and the production of excess estrogen. One common sign of low testosterone sign is a decrease in libido. Frequent fatigue is also a sign in men.

Do I have Pseudogynecomastia?

There are simple self-check methods that one can carry out. For example:

• Appearance: Does your chest area look evenly enlarged?
• Excess fat: Is your exercise or workout routine not addressing the excess fat around the chest?
• Pain: Is it painful or does the area around the areolas when touched? (this could be a sign of gynecomastia)

The above list is not confirmation indicators. A trip to the doctor’s for a qualified assessment is highly recommended. Do take note that it is possible for an individual to suffer from both gynecomastia and pseudogynecomastia.