Video Transcript

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Dr. Delgado: As you saw from the exam you could see how loose the skin was and how much breast tissue that he has. There is a significant amount of nodule nodularity throughout the entire subcutaneous tissue area. So it’s going to be tough to sort of get a nice contour with all the irregularities but this is something that is an unusual type of case for gynecomastia. Due to the amount of extra skin, there’s no other option so what we’re going to do is do like a mastectomy like a woman would have almost and then reposition the nipple upward. So it would be a dramatic change for him. Okay, let me have it again please you can see from the pictures that what is going to help them a lot with the incision the underneath is the amount of hair that has. So it’s gonna camouflage quite nicely once it grows back. Hey, Brandi must put him up it’s gonna see how the tissue falls. The scene how the skin tapers out when he sits when he’s like standing up so this will help us to take out the proper amount of skin in the right position. Okay, Brandi, flat he’s got a lot of nodules I don’t know if you can see how it’s very irregular on his chest but there’s a lot of steroid-induced tissue glandular tissue that’s just spotted all over his chest not only here but kind of all over you can kind of see that irregular pattern. There that will not change we’re not really going after this tissue up through here at all or it would even make things even more irregular so as I said this isn’t a cancer procedure and taking out gland. But it is a cosmetic procedure this is what’s called tumescent fluid and this is to reduce the amount of bleeding that occurs while the surgery is being done the tissue is very hard and very firm again from all the scar tissue from the steroids and as you heard from his interview he’s been taking them constantly for quite a long time and he’s going to continue to take them as well which is not uncommon. The nipple size we’re going to make is about a centimeter and a half in diameter and this will be sewn on as a graft. That will be about the resulting size of the nipple. So we’re cutting this off as a full-thickness graft this is what steroid production does and hormone manipulation, it changes this to be a breast organ and you could see that tissue that fluid you can cig coming it out again. We’re going through the skin and the area that we defined earlier. We’re not going to injure the muscle we’re not going to go through tussle we’re going to respect the muscle. You can see the muscle underneath has a dark coloration and you can feel a fair amount of scarring and breast tissue. And we can see the muscle on the edge of the PEC right here. Well, this definitely isn’t normal tissue. Was scarified its firm, nodular and you can see all the scar tissue can see all the glandular tissue this is not a normal tissue is yellow all this white hard tissue is glandular induced by the steroids. So now I’ve undermined it a fair amount as you can see now what I do at this point is I want to anchor this position of this fold because if not the closure will tend to pull it up like this too much so I’m going to anchor it with the suturing all the way down. Okay, so that kind of anchors my fold there. So again just to go over this is where the nipple came out this is the incision to excise the skin we’re not quite sure how much we’re going to excise yet we won’t make that determination until we set him up and then this shows you how much of the undermining of the tissue the skin subcutaneous tissue we’ve done and you see the muscle laying down throughout this entire area. Notice there’s not a lot of bleeding what we inject in there helps control that so it makes it easy for me to operate and I’m going to do the same thing over here. Again cutting out the new nipple as a graft, and we’ll cut it off. I’m so you can see the fluid coming out, again and again, this is from the breast gland being stimulated so you can tell it’s very active. Sometimes men will lactate or milk will come out you can see it again here sometimes they’ll have pain. Okay, just to make sure okay good very good you can see the fluid coming out again. And again as I say this is all from the steroid use stimulating the tissue and this can be a statistic it can call cysts in the breast which probably some of this nodularity that you see and it can produce pain, it can potentially produce infection, as well. The edge of the pack is right here and guys want to see definition along this peck right here. we’re just going up nice and slowly. Okay let’s go ahead and anchor, I’ll take that suture. But if we don’t anchor this you don’t have control of this fold here we like to keep the scar and the fold symmetrical. Okay, so the next step is to have Dr. Gaynor set him up. What we want to do at this point is emulate a standing position see how gravity affects his chest. Looks pretty good I may take out a little bit more of this tissue here because he has muscle here very nicely I’m gonna take a little bit more out of this area here.

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And this is cutting through tissue here the reason I’m doing this is to be more accurate in how much the tissue I take out if I just cut it I could be over or like under. I mean this is this is really the real important part here is to get everything lining it up right get everything cut out properly. If not it’s not going to look right. also, we find that people on steroids with you know all the muscles and stuff the blood flow is a lot more robust we’ve got a lot of arteries and veins just popping out of his tissue.

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So I’m going to take out a little bit right in through here. So you have got my peck line I really don’t need to take any more out. A lot of bodybuilders have a squarish almost peck here we’re gonna maintain that. One area I’m going to consider is if I want to reduce it a little bit here. and I think I probably do but you can see I’m just taking out small amounts but you can see this entire tissue over here has been cut out so once this is sewn up is going to look a lot nicer the the edge of the PEC is here his nipples gonna be out in this area here okay let’s switch sides.

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Okay, he’s bigger if you look at this side compared to that side. It’s just larger here and so we’re gonna have to accept some asymmetries trees here because of his bill opened up this area here. Okay, hooks so we’re gonna have to see what’s in here and reduce it some. So I’m right underneath this PEC now so I’m trying to thin this out so it can have a better angle. That’s a lot better, I’m gonna also take him off of the edges on both sides I’ll decide on this soon. Now he does have hair too so that may help me now that I’ve got everything you know trimmed I want to wash him out any kind of bleeding I have I want to control it now and you can see what we’ve done here. We can see how the muscle comes in here and we’ve got this nice and tight here. Okay, so I want a nice clean edge. Nice, straight line. The tissue gets thin, it gets thicker, then I get thinner. So we want to maintain that we don’t want to have it at one level because this accentuates his chest. Okay, that’s good now this is very hard tissue, very abnormal tissue. After this we’ll use what’s called quail sutures which are barbed you don’t need knots you see I’m sewing these in and I have to sew them in place with those you don’t they lock on their own gives a nicer closure. Okay, so let’s take out more of this tissue so we’ll take it out and try and get it as smooth. As we can it’s called a dog here so now we kind of flap it over and we see where it kind of peters out at and I think we’ve got it about right. A nice closure there we’re gonna put a drain in. So this will drain the fluid that will accumulate underneath this tissue it will tend to ooze, and we want to make sure that this flow comes out and doesn’t build up inside. So now we’re gonna put this quell suture in as we talked about earlier it locks as I put it in and I’ll show you how there are little barbs on here you can feel them and as you pull it through it locks the tissue in place and you don’t need a knot. It’s a great advance in this type of surgery you just tighten it up it locks in place and work really nicely. His recovery will be taking drive within a few days. His being a trainer he can probably help train in a week but not be active yet. Intense exercise is probably in four to six weeks. You really have to heal. He can go out to eat in a few days. Pain is not a real issue unless there is a bleeding issue. Which occurs in about 5% of patients. And if that happens we take the patient back and take care of it, it’s not a problem. This is a very tight closure now the scar is what everybody sees we want to have the absolute best scar we could possibly have for him there’s a variety of things we have for scar management one is silicone sheeting that’s put along the scar once it gets healed. The newer technology is called embrace and it’s a device that you actually used to put on a sheet that stays on for about ten days or so because you want to do as much as you can for scars early on. So again we want to get the edges as close together and as smooth as possible. you can see how the muscle comes in right here you really like that a lot in a shirt that will come out nicely his t-shirt tight shirt. Okay so that’s one side now he was a little bit bigger on the side so I may let me have some more I may take off a little bit of this very light sheen here. I think that’s fine. Dr. Gaynor runs the patient very light so he wakes up faster. He’s able to go home faster the anesthetic wears out of his body very quickly. And they feel a lot better or lot sooner and Dr. Gaynor is a pro at that right Dr. Gaynor?

Dr. Gaynor: Right, been together for 16 years!

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Dr. Delgado: Again, the drain who drained the extra fluid to comes out walking in my quest to just and let’s have a ruler at the pictures.

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