Hi I’m Dr. Delgado and I’m here to talk about gynecomastia surgery. “What is gynecomastia?” is one of the most common questions I get. Female breasts on a man is basically what it is and it. It commonly occurs during puberty and adolescence when the hormones are surging and changing and men get their secondary characteristics like hair growth, etcetera. Most of the time the gynecomastia goes away, but for a fair amount of patients it stays on with them throughout their entire life. If it stays the only treatment for is surgery itself. Gynecomastia can also be known as pseudo gynecomastia. That’s fat accumulation. That doesn’t occur doing adolescence, that just occurs as men gain weight more and more and more and it shows in their chests. This can be treated with liposuction alone and get a very good outcome. But true gynecomastia needs to have gland excision or you will not remedy the issue. I’d like to go over some typical cases, some of the more standard cases, and some of the more complicated cases to explain some of the broad spectrum of what gynecomastia surgery can do for you.
True gynecomastia is breast gland on a man, as I mentioned earlier. And I wanted to point it out to a specimen of an actual patient. And you can see the white portion is breast gland. The yellow portion is the fat. Obviously liposuction is not going to remove the breast gland. Under any circumstance you are not going to get extraction of this breast gland with liposuction, smart liposuction, ultrasonic liposuction, VASER, any of them. It will not reduce this glandular tissue, it must be excised. Now, in men the component of breast tissue to fat changes from person to person. Some has more glands, some has more fat, but if you have true gynecomastia you have a component of breast gland. And to get a good result with a nice contour the breast gland needs to be removed, and I cannot emphasize that more because forty percent of my gynecomastia practice is revision surgery from patients that are not happy from other practices. One of the most common reason why…the most common reason why is a doctor feels that they can remove it by liposuction only. Doesn’t work. You take out the fat around it and often times this gland now becomes more prominent so you can actually have a worse appearance than a better appearance. So make sure that when you consult your plastic surgeon that you have a discussion about the glandular component of your gynecomastia.
This is one of the more common types of patients I see. Is a man in his 20s or 30s that have enlarged breasts such as this, about an A cup. You notice that it has the shape of a woman’s breast, the areolas are larger. And for this young man is psychologically, it’s devastating. So this is not only a cosmetic procedure but it is a psychological procedure as well because men’s self-esteem is greatly affected by having enlarged breasts. They don’t take off their shirts, they have problems with relationships, they have problems with the clothes that they select, so these are the typical problems that a male has with an enlarged chest. Luckily, surgery, as you can see here from the close up picture, works fantastic. As you can see, the chest now is flattened, the protuberance is reduced, and the areolas shrink down. As you can see his areolas has shrunk down to probably about half. This young man can wear a t-shirt comfortably, he can go out on the beach, swim comfortably now. This is a life-changing procedure for this young man. You can see it on the oblique view that there is no protrusions, but nicely contoured. And you can see it from the opposite way as well. This is the typical patient that I see. One that is very straightforward once you get a very good outcome .
This is another example of a gynecomastia case that is very typical in my practice. This young man is a little bit larger than the previous one. He has a stretched-out areola. He has hair which helps camouflage to the overall appearance of the gynecomastia. Afterwards you can see, and most of these post-op patients are seen, or pictures are taken at six weeks, eight weeks because they travel or that they don’t like coming in a lot. So these incisions, even though they look good now, they get a lot better as well. But you see flat, better contour. Notice again how the areolas shrink. People ask me, “well why is my areola a different color?” What happens is the pigment in the areola now becomes more concentrated in the circular pattern, so it becomes darker. There really isn’t anything wrong with this areola, it’s natural but the colors now are just more concentrated. So it’s normal, it’s a normal appearance. And again we see here a nice oblique contour, nice flat areola, reduced. And we see it in this fashion again here. Now again this young man’s life is limited for him. He cannot play shirt versus skins in high school. They don’t go out to the swim team. These people become victimized from their gynecomastia. And that’s why this procedure is such a dramatic improvement on a man’s life. Going from here to here is a life-changing experience and I’ve seen it many many times.
This is another gynecomastia case, so I’m getting more extreme as I go along. So you can see his chest is very full, this is probably about a B-plus in cup size. One of the most important things about this procedure in the technique that I use is that we use the power of skin contracture. The power of skin contracture is tremendous. It’s better when you’re young, It’s worse when you’re older. So the earlier you have this performed the better your skin is going to react and shrink and recontour back to the chest. So if you have true gynecomastia and it’s something that you want to deal with surgically, having it performed earlier than later is by all means the best solution. As you can see from his pictures here, his skin is shrunk down tremendously. You notice that there is a birthmark in this location. It’s actually underneath the breast right in this location here. So it’s amazing to see how all that now has flattened out. You can see on the oblique view his chest, breasts gland is overhanging, there’s some sagging into it, and now afterwards look at how the skin has just just tightened up. This is really tremendous in terms of the body’s ability to shrink. However if you have massive weight loss, if you’re really obese, you have hanging skin, this is a more complicated case and other techniques would be required to get a nice outcome. But in this particular case you can see that this young man goes from being very imprisoned by his chest to one of being completely free.
In this particular case this is a middle-aged man and you can tell from his skin there’s some droopiness to it. It’s not a cone sticking straight out but he’s got some laxity and and that’s what happens with age. They tend to have laxity and they droop. So I know in this particular case the skin is not going to contract that well. Not like the other cases I showed you. A nice technique for a person like this is you notice how low his nipples are. In this case we did a superior crescent lift where we make an incision above the areola opposed to the other cases, we do it underneath. In this case we’re doing a superior crescent lift on top, cutting out a like halfmoon shape of skin, taking out the gland and fat inside, and lifting it up and sewing it up higher to a new location, as you see here. Now, you see the goal is to get rid of this fold. Or to have the fold as minimal as you can. And that’s been accomplished here, the incision looks really clean. Its healing very nicely. You can see on the oblique view now the skin is like hanging due to laxity, and as I said, it’s just not going to contract that well. So the the superior crescent lift has really solved that issue in a very nice way. You can see there’s no overhang, there’s a nice contour there. And on this oblique view, too, you can see how this is just sagging. This is not going to do great. Superior crescent lift, we get a nice contour. And for this man, t-shirts, easily you can take off your shirt once things are well healed and blend in very well . That usually takes about six months or so.
I’d like to go into some of the more complex cases now. This young man is 14 years old. I see a lot of young men with very, very concerned parents asking is this going to go away? When’s the best time to have it? My son is devastated. He doesn’t go out. He doesn’t compete in sports. The kid’s become a recluse. His self-esteem as is negligible. For young men, I really try to work with their pediatricians and their endocrinologist to try to have a joint decision on when’s the best time to operate. Obviously in a man like this,14 years old, this is not going to go away on its own. Usually if a person gets gynecomastia doing puberty, as a general statement, if it’s not gone in about two years it probably won’t go away. In this particular patient there’s no reason to wait. As soon as a person has psychological impact on their lives it’s worth considering at that point. I’d like to also point out that when you’re young like this, even though his chest is really hanging down as you see, the power of youth and skin contracture is tremendous if the technique is performed properly. Your gynecomastia surgeon has to know how to perform these procedures. It takes a lot of experience, it takes pushing the envelope. some like in his case when you can, when you can’t so, there’s a lot of experience that goes into gonna gynecomastia surgery. And often it’s not really taught and read in residency very often at all. And its something that is learned with experience. I’ve been doing it for about 25 years. I came out as a young man saying I want to do something that no one else is doing. 25 years ago, gynecomastia, nobody was doing and I embraced the opportunity to become the expert that I am today. As you look at this young man, he has had no skin excised whatsoever, none at all. This skin has shrunk up to a thousand percent. On one side he’s completely flat. On the other side he has a small amount of laxity in this area that can be handled with what’s called a periareolar lift. This goes to show you the younger you have it done, the better outcome you’ll have, the less skin issues that you will have. You can see on this young man, profile he goes from a C to D cup to a flat chest that has a masculine contour. The same thing in this location here where he’s hanging quite significantly and now everything, you know, has significantly tightened up. I get letters from the parents of these young men and it’s some of the brightest parts of my career, when they tell me how their sons have changed, how their outgoing now, they’re president of their class, they’re dating now, this is this gives me a great honor and pleasure to be able to help a young man develop into his true potential in life.
This is another more extreme case. This person’s skin isn’t quite as resilient. Less elasticity to it, sometimes as you get, you know, heavier it breaks the skin down. In this case you can see how he is older and you can just see how it’s a little bit more loose. In this type of case I tell a person we can achieve flatness and you can certainly see that there is flatness. However the skin, you can only control so much. So the consideration is, do you put a big scar across a man’s chest? Which is almost as worse as having this because he’s not going to take off a shirt. The idea is you want to have a very concealed scar. That’s the ideal scenario for a man having gynecomastia surgery. The less scarring, the better. In this particular case, I know I’m going to have loose skin and I tell a patient, look you will have a flat contour but your skin is going to be loose and you will need a secondary procedure. Now it’s not a complication, it’s just a staged procedure. It has to be a staged procedure because of how the skin is naturally. As you can see on the side view, you can see how full he is. Nice and flat, skin is loose, you can see on the view as well that the laxity of skin creates skin laxity after the gland and fatty tissue is removed. So in this particular case we would do what’s called a pare areolar lift where we cut out a doughnut of skin around the areola and purse string it down closed around the areola. Now this technique cannot be done for five or six months after the primary technique because the blood flow now has to grow in from underneath.
This is the same patient after he’s had a peri areolar lift so he went from this to the previous picture I showed you with the lax skin and loose skin. And now he’s had what’s called a peri areolar lift, where a doughnut of his skin is cut out around it, closed, sutured with the permanent suture, and the skin tightened. And you can see now he’s got a more improved appearance. This is probably about a two months follow-up but you can see how much better his chest looks, and over time he’ll be able to take off his shirt. Men that have hair, it’s a lot easier, it is a lot simpler because it camouflages your chest. When you’re hairless you have to be more conscientious about your techniques, there’s less room for error. And this young man is going to do very, very well over time. You can imagine how happy he is.
This is another extreme case and I see very, very complicated cases. And this young man is a very challenging case. As you can see his chest is probably about a D-cup. His areolas are very extended and stretched out. He’s not really overweight but he has true gynecomastia. In this scenario I know he’s going to have a skin issue afterwards. There is no question about it, that you’re not going to get that much contraction as the other younger person I saw, especially when you have an areola this large. The areola contractility fibers aren’t nearly as as strong and thick as the skin itself. However this is the first procedure, he still got a lot of contraction. A tremendous amount of contraction. But he still has laxity of skin as you see here, but note his areola did shrink down. It probably shrunk down by about half. The skin probably shrunk down three times that, but because he’s so large to start with the skin just gets to a point and stops. This is a case that we would do a peri areolar lift. Again, as you can see from the side you’ve got loose skin. He’s flat, his chest is flat, he can wear a t-shirt but not quite comfortable with the folding and I understand that. As you can see here, you can see afterwards. So as I say a peri areolar lift is the ideal procedure.
This is the same patient after a peri areolar lift. Ss you can see now there’s an incision around the areola completely. He was from from out of town, so this is about 8 days afterwards, so he’s still healing. And you can see how the skin is now a lot tighter, these wrinkles, as things heal, flatten out. There could be a slight crease there at the end, but they usually flatten out pretty well. But you can just see the power of the two-stage procedure. I can guarantee you, many plastic surgeons that you would go to would would advise cutting the skin off with excision of both breast gland and fat. Guaranteed. With this technique, the two-stage procedure, you can actually excise the tissue inside, take advantage of the skin contracture, the younger you are the better it is, the older you are the worse it is. Taking the advantage of that and then go to a peri areolar lift and try to tighten it up as much as you can. And this, I would say is an excellent outcome because his scar is limited to around his areola which blends in overtime anyway. So the 2 stage procedure for severe gynecomastia can be a very very powerful tool.
I’d like to also share one of the best techniques in gynecomastia surgery that’s been around for quite a while. It’s called the pull through technique. This is a minimally invasive technique for men that has mild gynecomastia,, mild may be slightly moderate gynecomastia. The technique is going in through about a 4-5 millimeter incision using blind dissection tactics and the endoscope to go in and look and cauterize the bleeders of that nature and to create a good contour. But the pull through is when you actually grab the tissue and you pull through that tiny incision that you made, such the pull through technique. As you look at this picture here of this young man, we show you the before and the after picture which is an excellent outcome. And you see the very small incision. And you see the tissue being pulled through completely. It’s very dramatic. The one thing that you have to be very conscientious of this technique is that you don’t get a crater deformity that you can get if you don’t blend it in after you take out this tissue. As you see here afterwards we put the gland on both areola is to show the glandular component in this man’s case. In his true gynecomastia. And the fact that we were able to get such a large piece of tissue out from just a tiny incision. This again is called the pull through technique. It’s very effective as a minimal invasive technique on a select patient population.
This is a picture of another pull through procedure. I wanted to point out the incision and how minimal it looks. This young man has had to pull through. The incision is right on the on the side here. And as you can see, even though it’s a young scar of about three weeks, you can see that you can hardly see it now and certainly in months to come it will disappear even more.
I hope all this information has been very helpful for you. Gynecomastia surgery is a passion of mine. I’ve been doing it for about 25 years. I’m doing more and more each year, about 130 140 each year. I do a lot of the more complicated cases, the revisions as I said, about forty percent. I have people coming from all over the country as well as around the world. I’m a an expert in this technique. I study it and I welcome you to call our practice for a consultation either in person or a virtual consultation. Thank you very much.