Lower chest/nipple depression after gynecomastia surgery. What are my options? (Photo)

Question

I had gynecomastia surgery in 2010... and have severe indentations on bottom half of breast/chest area ... I had gastric sleeve so body fat is pretty negligible at this point and do not have enough fat for fat transfers per a surgeon ... what are my options ?

John Reilly, MD, FACS · Answer

Hello, I am sorry you haven't yet achieved the outcome you desired.
The photos can not tell the entire story. Is the bottom too flat or the top too full? You can have an area of over resection below an area of under resection. If the upper chest is under resected a bit of liposuction can make the areas more harmonious as there is usually a bit more fat available to liposuction in that area.If the nipple and areolae are depressed, fillers would be costly and only temporary whereas a fat injection and scar release can provide a permanent fix. Good luck.

Michael Law, MD · Answer

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).
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.
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. I have performed fat grafting on models, professional athletes and others with very limited body fat. The amount of fat required for this procedure is not significant, so it is likely that you could be a good candidate. 
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.

Parit A. Patel, MD, FACS · Answer

Thank you for your question and photos.  I am sorry you are not happy with your results.  After gynecomastia surgery you can see asymmetries in specific areas if too much fat or breast tissue is removed relative to other areas.  To improve symmetry, you would be a candidate for fat transfer or filler placement.  It is hard to determine if you have enough fat for a fat transfer without an in office consultation.  I recommend finding a plastic surgeon certified by the American Board of Plastic surgery for an in office consultation to guid you.  Good luck and I hope this helps.

Nicholas Galardi, MD · Answer

Thank you for your questions and your photos. It is hard to tell from your photos which procedure(s) would best help you achieve your goals. Your best option would be to schedule an in person consultation with a Plastic Surgeon. During this consultation the surgeon will be able to provide you with their professional opinion based on their own observations. Good Luck.

Jay M. Pensler, MD - Account Suspended · Answer

Overresection is a difficult problem particularly in patients with decreased skin elasticity. Often the results are less than optimal. There are several techniques that may be used in conjunction or independently. The skin may be redraped over the chest to spread the slack over a wider area making it less noticeable . The redraping can  be done in conjunction with fat grafting or a lift to help.

J. Michael Morrissey, MD (in memoriam) · Answer

Thank you for your question and photos. Over resection can sometimes be a problem in gynecomastia surgery resulting in a depression of the nipple. We typically wait at least 6-8 months after surgery to see how things settle out. Sometimes muscle development of the pec can help with the contour. If not, a filler or fat graft may be necessary to improve the contour. Keep in contact with your surgeon and express your concernsBest wishes, Dr. Morrissey

Melih Erogul, MD (retired) · Answer

Hi and welcome to our forum!
From your photos, I see the depressions of the infraareolar area compatible with soft tissue loss.
The best choice in this situation would be transfer of autologous fat. The amount of fat required would only be a few hundred cc. We can usually find enough. You may wish to obtain a second opinion.
But, if no fat is available, other options are mostly temporary, including injection of soft tissue fillers. In severe cases, permanent  silicone prosthetics can be custom made and placed in the soft tissues. 
Best wishes...

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