A ‘crater’ or indentation where breast tissue has been removed generally results from a combination of over-resection of breast tissue and the formation of scar tissue (which is part of the normal healing process) which tethers and distorts the skin. Correction of this post-operative complication consists of treatment of both issues: release of scar tissue, and grafting of living tissue to fill the space and correct the indentation. The injection of a temporary filler such as hyaluronic acid is not a practical alternative. Without releasing the scar tissue, the contour problem cannot be corrected. And injection of a hyaluronic acid filler, even if it was capable of improving the indentation, would provide only a temporary correction that would have to be repeated every few months. Structural fat grafting can be effective at correcting some post-gynecomastia surgery contour problems, but primarily in the peripheral part of the male breast/chest area, where overly aggressive liposuction may leave surface contour irregularities. Structural fat grafting refers to the harvesting of fat from a remote location (flanks, for instance) by aspiration. The aspirated fat is centrifuged, processed and reinjected using blunt cannulas to restore a normal contour. To release scar tissue in these areas, cannulas are available with a V-shaped cutting edge which can be passed through tethering scar bands which would otherwise prevent expansion of an indented area. In the central area of the breast, below and immediately adjacent to the areola, excess fibrous breast tissue is primarily removed by direct excision. Direct excision of fibrous breast tissue, along with the deposition of scar tissue as the surgical site heals, is what most commonly leads to indentations or ‘craters’ involving the areola, sometimes with significant distortion and irregularity of the areolar anatomy and indentations in the adjacent chest/breast skin. The lasting correction of areolar indentations and irregularities requires experience and expertise, and at times more than one surgical procedure to achieve an aesthetically ideal appearance, so make sure that you seek treatment from a board-certified plastic surgeon who has dealt successfully with this challenging issue before. These surgical procedures generally involve the following steps, most or all of which can be accomplished through an incision or incisions at the areolar border: 1.Release of tethered skin and subcutaneous tissue by sharp dissection (scissor release or sharp cannula release).2.Levelling of any areas of soft tissue over-projection.3.Placement of solid soft tissue grafts such as dermal-fat grafts, fascial grafts and solid fat grafts (harvested from another location on the body) to restore normal surface contour to indented areas.4.Removal of any areolar skin excess contributing to surface contour irregularity.5.Structural fat grafting of associated peripheral contour irregularities.The success of solid tissues such as dermis/fat, fascia and solid fat at restoring normal contours depends upon revascularization of the grafted material. If the majority of the grafted tissue gains a new blood supply, then contour may be normalized in a single surgical procedure. Partial survival of grafted material, which in more likely for large grafts required for larger defects, may necessitate an additional surgical procedure or procedures. Our postoperative protocol for return to physical activity is as follows: casual walking only for weeks 1 and 2, light aerobic exercise (elliptical trainer at a moderate pace, etc) for weeks 3 and 4, light weight training and impact exercise (running) for weeks 5 and 6, and a gradual return to full effort exercise over weeks 7 and 8.
