Aesthetic revision after gynecomastia surgery. Too much fat was removed: how can this be corrected? (Photo)

Question

I feel the surgeon has removed to much flat, this has compromised contour and skin tightness. I am planing a aesthetic revision surgery, where I am considering fat flaps, fat grafting and skin excision (either around the aerola or below the breast pockets) I am looking for advice, of how this can be corrected, and what methods may correct this. Is is a good idea to add in order to fix the fact that the skin is adhered to the muscle in the upper parts. Please help me figure out how to fix this

Larry S. Nichter, MD, MS, FACS · Answer

Your problem was most likely do to over resection of your breast tissue beneath your nipple. Revision gynecomastia surgery is often difficult and requires a well trained board certified plastic surgeon with experience in redo male breast surgery. An exam is critical to give you an opinion but most likely fat transfer and possibly local internal tissue rearrangement is required. The below link will direct you on how to find the best plastic surgeon.

Ronald Schuster, MD · Answer

I actually think that you may benefit from the removal of additional tissue using liposuction and Ultrasonic Liposuction. Your skin is not particularly tight and it looks like you could stand to lose a little weight. I think it would be particularly important to discuss your goals and show pictures of what you are striving for BEFORE you ahve any additional surgery. Good luck.

Richard H. Tholen, MD, FACS · Answer

Perhaps you had unrealistic expectations, but your skin is somewhat lax in areas where your surgeon did not operate, so this is more of a residual fat/skin elasticity issue than over-resection.That being said, you may benefit from additional liposculpture to further refine and improve the entire chest and upper abdomen area. This is best done after 6-12 months have elapsed, during which time you have dieted and exercised.Skin excision is not recommended--the scarring is much more of a cosmetic deformity than your present appearance, and you can never "take them back" if you decide that skin excision didn't really give you the desired look either. I have to make this [skin removal or not] assessment every week as I see female-to-male transgender patients who want their (small, medium, or large) breasts removed to create a masculine chest. Obviously, all prefer a keyhole preiareolar incision if possible, but many have breasts that are too large to achieve satisfactory results without skin excision and the resultant permanent scars. You probably don't need it (skin excision), and you DEFINITELY don't want it (scar). Where skin is adherent to the underlying muscles, fat grafting may indeed be the best solution. Click on the web reference link below to see my transgender mastectomies (most with skin excision scars, and a few with "keyhole" excisions. Then see one or more ABPS-certified plastic surgeons who do lots of gyno procedures for in-person examination and recommendations. Best wishes! Dr. Tholen

Gregory T. Lynam, MD · Answer

An exam needed but  it looks like you skin just did not shrink or tighten up as well as one would want. I utilize Vaser ultrasonic liposuction to enhance the skin shrinkage. You may always do more surgery but looking at your overall body contour  you may want to wait at least a year after surgery and continue to diet and exercise and see how things change over time. The potential scars or complications from more surgery may be significant as well as the cost. Good Luck,

Michael Law, MD · Answer

First let me say that I am sorry that you have had this experience with gynecomastia reduction surgery. Surgical reduction of gynecomastia seems as though it would be relatively simple and straightforward – just ‘remove the lump’ and the chest will look normal. But it is actually a deceptively challenging procedure that requires detailed preoperative evaluation and planning, a rational and stepwise surgical approach, and careful attention to detail in the operating room with assessment of chest contour several times over the course of the surgery with the patient in upright sitting position (as stepwise contour correction is performed).
There is always much more to consider than the overgrown breast tissue mass when treating primary (not previously operated) gynecomastia patients. One must pay close attention to the surrounding subcutaneous fat excess which is present in the majority of patients, as this must be treated – and treated in a manner that ‘feathers’ the breast tissue and fatty tissue removal peripherally so that there is no obvious demarcation between the area where tissue has been removed and the area where no tissue has been removed. Also, the chest skin must be carefully assessed in order to determine whether and to what degree it contributes to the preoperative appearance of breast tissue excess.
In my practice we see a fairly significant number of patients who have had gynecomastia surgery elsewhere and who find themselves with post-surgical chest contour problems. During preoperative assessment of these patients, it is important to determine how each of the following anatomic concerns contributes to the visible contour deformity:
Condition of the overlying skin, with particular attention to whether or not skin laxity and/or skin tethering is part of the problem
Degree to which breast tissue has been over-resected, and whether or not there are adjacent areas where breast tissue has been under-resected
Volume of fatty tissue excess (or areas of fatty tissue under-removal) peripheral to the area where breast tissue has been removed
Extent of post-surgical scarring which can tether skin and subcutaneous tissues, altering chest area appearance in neutral position and/or with arms raised
The good news is that the vast majority of these post-surgical contour problems can be corrected, and many of them can be corrected completely so that patients have a normal post-correction chest contour, with surgical scars that are inconspicuous or even completely invisible to the casual observer.
As mentioned above, the patient is assessed in upright sitting position after completion of each step of the surgical procedure, as this is the only way to confirm the degree of improvement that has been achieved – and what additional correction is still required. The O.R. table flexes at the waist, allowing the back of the table to be elevated until it is almost perpendicular to the lower half of the table. In this manner a patient under deep IV sedation or general anesthesia can be examined in upright position, which of course is the meaningful position for chest aesthetics.
Areas of residual breast tissue excess are marked while the patient is in upright position. These areas can be reduced by two means: by use of an arthroscopy shaver introduced via a tiny incision in the underarm area, and/or by direct excision using small incisions along the border of the areolas. Breast tissue is extremely dense, similar to cartilage in consistency, and therefore only very minimal amounts of breast tissue can be removed by means of liposuction.
Areas of persistent soft tissue depression can be restored by means of structural fat grafting, where fat is harvested by hand from areas of fat excess using small syringes (most commonly the flanks in gynecomastia patients) then processed and reinjected using small blunt cannulas. Areas with major soft tissue deficits / depressions may require solid fat and/or dermal-fat grafts in order to achieve complete contour correction.
The last issue that is assessed and treated is laxity in the overlying chest skin, which can permit some soft tissue contour problems to persist, at least to some degree, if it is not addressed. The dermis of areolar skin is much thinner than the dermis of the surrounding chest skin, which means that it has an inherently lesser ability to contract and smooth out following the correction of problems involving the underlying fat, breast tissue and scar tissue.
Secondary gynecomastia surgery patients frequently require excision of lax and redundant areolar skin. Alternately, removal of a crescent of the surrounding, non-areolar chest skin may achieve a normalization of the vertical areolar diameter, which tends to collapse and shorten in some patients following removal of subareolar breast tissue. As with primary gynecomastia surgery patients, every effort is made to limit the amount of skin excision that is performed, as surgical scars become ever more obvious as the amount of skin excision increases.
Your best bet for correction of a post-gynecomastia surgery contour abnormality is treatment in a practice that is experienced with this complex problem. Make sure your gynecomastia contour correction surgeon is a board-certified plastic surgeon, ideally an ASAPS member. Members of the American Society of Aesthetic Plastic Surgeons are board-certified, residency-trained plastic surgeons who have significant experience in cosmetic plastic surgery.
Also, make sure your board-certified surgeon can clearly explain to you their stepwise plan for chest area contour correction, ideally while drawing on your chest with dry erase markers to outline each step of the plan, and that they can show you side-by-side ‘before and after’ photographs of gynecomastia post-surgical contour correction cases that show clear improvements in chest contour with scars that are faint or invisible.

Michael Marion, MD · Answer

I am sorry your result is not what you had envisioned.  Overcorrection is a dreaded complication of this procedure and is the reason many will be conservative with the initial procedure and accept that an additional procedure may be needed to arrive at the desired result.  There are options to help, but more information (i.e. physical exam, how long since last procedure, etc) is required to make an informed recommendation.  Amongst the options are fat grafting or transfer to this area, removal of some of the surrounding, overhanging skin or a combination of these.  Best of luck.

Jeffrey Zwiren, MD · Answer

You problem may be more one of redundant skin than over excision of fat.  I would discuss your concerns with your plastic surgeon

Melinda Haws, MD, FACS · Answer

It is so difficult to give a solid answer based on internet pictures. It's much easier to evaluate your tissue thickness and skin laxity on physical exam. That being said, fat grafting can help areas where the skin is adherent to muscle or where things are too thin.  Skin resection may also be necessary depending on if there is excess skin. If you aren't satisfied with your current consultations then please see another board certified plastic surgeon with an interest in gynecomastia surgery. I hope this helps.

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