Since establishing the Austin Gynecomastia Center many years ago, I have learned quite a lot about the diagnosis and treatment of gynecomastia, a benign but very troubling male condition. Surgery for gynecomastia was presented in my formal plastic surgical training in a confusing, somewhat subjective and arbitrary way. There were several classifications and algorithms that attempted to determine which form of treatment was best for the many varied presentations of gynecomastia.
Fortunately, through my experience I discovered that most forms of gynecomastia can be treated successfully in the same way with few complications and impressive results. It is actually quite straightforward and relatively easy! I have found that the a more challenging aspect of gynecomastia surgery is determining which patients would benefit from skin removal and relocation of the nipple-areola complexes to prevent loose skin after gynecomastia surgery.
To briefly review, the state-of-the-art treatment of gynecomastia consists of two small incisions, one typically in the axillary hair (underarm) and the other at the bottom of the areola border. Through these incisions and with the use of Vaser ultrasonic liposuction, I’m able to effectively treat a majority of patients regardless of size or appearance.
Open and Closed Gynecomastia Surgery
However, one category of patients that posed a challenge where those with very loose skin and an advanced case of gynecomastia. In these cases, standard treatment would not result in a satisfactory result as there was excess skin with wrinkling and folds due to poor skin elasticity (the ability of the skin to contract or tighten). These cases required skin excision across the chest and typically under the arms, with relocation of the nipple-areola complexes to the ideal position on the chest.
This led to the development of the concept of “open” and “closed” gynecomastia treatment. Open gynecomastia surgery involves the removal of skin and tissue and relocation of the nipple-areola complexes, which produces large scars across the chest and under the arms if needed. Closed gynecomastia surgery refers to the treatment of gynecomastia with minimal incisions and virtually no scarring.
Is Open or Closed Gynecomastia Surgery Needed?
As always, experience matters most in making this important decision. After operating on thousands of gynecomastia patients, it has become clear who needs an open approach and, more importantly, knowing who didn’t need the open approach! Permanent scars across the chest that could have been avoided is the last thing any patient wants. In fact, one of the most important skills I have learned is how to judge when a patient does not need skin removal, despite when many of my colleagues would likely suggest an open approach. The ability of the chest skin to retract to a normal or near-normal appearance should not be underestimated!
Patients who are more likely to need skin removal for loose skin after gynecomastia surgery are those with very large and saggy breasts. Often massive weight loss patients (over 100 pounds) need skin removal because there simply is no elasticity left in the skin and it simply won’t retract and redistribute after tissue removal. Age also affects skin elasticity, so older patients may need to have skin excised. Some of the ancillary techniques that I use, such as quilting sutures or wide undermining, have worked well to assist in skin redistribution after more challenging cases that help avoid the open approach.
Is the Decision of Open or Closed Final?
Hopefully your surgeon has the experience to make a good decision regarding whether to use the open or closed approach. If in doubt, know that it’s always possible to perform the closed approach first and if the skin doesn’t lay out as anticipated the open approach can be used through a secondary procedure later. Experience has shown me that most cases requiring an open approach are obvious, but there are those “in the grey zone” cases that are more challenging to judge how effective a closed approach would be. I will often give the patient the benefit of the doubt in these cases and elect to perform the closed approach.
The open approach requires much more skill and experience to perform satisfactorily. The proper placement of the final scar across the chest and the appropriate placement of the nipple-areola complex is critical to achieving the best result. I prefer placing the scar in the native crease under the chest area that, if necessary, extends horizontally into the underarm area towards the back. The nipple-areola placement (usually a free nipple graft technique) is just above the chest crease and quite lateral on the chest to avoid giving a “headlight” appearance. Although the scars can be extensive with the open approach, the result is typically very rewarding for the patient and satisfaction is quite high. No longer do they have to deal with the burden of large breasts and saggy tissue with loose skin. Open gynecomastia surgery is more extensive than the closed approach, so it does take longer to perform and has a longer recovery period. Drains are typically used in the open approach.
To be safe, I suggest that those patients who have been told that they require an open approach to consult with an experienced gynecomastia professional for a second opinion regarding skin removal to prevent loose skin after gynecomastia surgery. Once the open approach is complete there is no going back.
Be Confident in Your Surgeon
With decades of experience and thousands of procedures performed, you can be confident that you will get the best advice, care and results at the Austin Gynecomastia Center. Get my expert opinion about your gynecomastia with a free online consultation today.