A Plastic Surgeon Asks:
hi Dr. Bermant,
I would like to ask ur opinion about protruding nipple deformity management?
and if you have any articles corrospond to this sublect can u please send to me ?
thank u very much
& best regards
This should not be construed as medical advice. I am a retired Board Certified Plastic Surgeon.
I have dedicated more than 3 decades trying to deal with surgeon caused deformity male chest contouring after seeing this surgery in medical school done by a general surgeon, by what seemed to me methods that were not right for some reason. During my Plastic Surgery training I sought out the literature and watched techniques trying to understand what was being done right and wrong with this problem. While in practice I saw so many deformities on patients done by other surgeons, I started coining names, coming up with terms for Bad Surgery Methods grouping commonly seen mistakes such as Crater Defect Deformity
and Puffy Nipple Complication Deformity
and several others.
Now coming up to 16 years since starting, I tried to address such issues by building what may be the biggest resources available to the public about male breast sculpture either in print or online: my Gynecomastia Encyclopedia
I have seen newer sites, but those I have evaluated fail to address primary issues about contouring the individuals and I have done revision surgery cases on patients who came to me for help to fix problems after having surgery done by the doctor who had published their methods either online on in the Plastic Surgery literature. I have posted some of this Revision Gynecomastia Surgery
on my site so far. But some of the defects I was asked to help were so bad, I could no longer design a surgery to fix the nightmare created by the bad revision surgery I was then asked to fix as in this example of Extended Crater Deformity After New York Revision Gynecomastia Surgery
. A patient who had resources for my methods chose to use a closer doctor who then converted a crater with nearby resources to a much larger crater defect. Instead of filling in the defect of deficient tissue to provide a natural look while moving, those nearby resources were removed extending the hole to a much larger defect that also did not move.
The beauty and design of that last link lies at the crux of the matter. The current Plastic Surgery literature fails to adequately document the male chest contour problem and result depending on too limited information of Before and After Pictures. The still image one or two picture before and after fails to document the male chest contour on a structure that sits on top of the pectoralis muscle. How tissues compress when the muscle flexes means something relaxed looks totally different than when that person tightens the muscle if the scar remaining gland do not compress the same. In addition, if you only look at the problem or result standing upright arms at side, you miss problems seen when lifting arms up overhead or when bending over. This extended crater page compares how just the still photos alone, that at least adding additional views, some of the problem becomes visible not seen when limited looking at the arms at side muscle relaxed view. But the before and after videos reveal true nature of the deformity transforms to what the living patient looks at when looking into the mirror each morning. Listen to the patient's emotional discussion about the topic.
My quest to understand the problem in the literature ending up evolving into a series of tools like Using Before and After Pictures
, an outline of some of the resources I have built so far. For the male chest, the specfic tools eventually evolved into:
and on our forum:
I then used this more critical documentation system to analyze the path taken between the before and after picture to check Gynecomastia Bruising Swelling
, patient Comfort After Gynecomastia Surgery
, and assess my surgical plan estimate of gland vs fat in my Gynecomastia Gland Gallery
I also evolved my own system to Male Nipple Areola Exam
to better standardize measurements for my documentation. I took John Tebbits brilliant methodology for Rhinoplasty documentation and made my own system of patient education, history taking, examination, surgery method documentation, after surgery progress package. I used this to better understand the problem, what I had been done, and results. I used this to show the patient and learn about my own results for that case to continue to evolve each element. No matter how well I did, I then went back to consider what I could have done better. I would then change this form or that sheet as I found some point I could improve What became fascinating was comparing the components as I continued to evolve each over the years.
This became the basis for my Dynamic Technique Male Chest Contouring
which starts out well before the surgeon gets into the operating room. If the inexperienced surgeon starts there, they are doomed to failure on an unstable male chest tender from unaddressed underlying problems. This is another component of failure of the literature causing recurrence deformities: Gynecomastia Revision Forum - Should Surgery Prevent Recurrence? Growing Again
. I go into more details about Gynecomastia Surgery
on one of our Forum's Resources.
My male chest contouring resource is so large it has subsections to organize the various problem, surgical methods, documentation, experiences and so forth. There are hundreds of pages, thousands of before, during, after surgery pictures moves and videos. Male Chest Page Index
outlines this organization. Here is an entry point to the many before after galleries divided by problem such as Bodybuilder Gynecomastia Gallery
to organize by problem. What is neat about my encyclopedia is that on a gallery page, you can click on an image and get to the more complete documentation of that problem and solution.
Each web page if printed might use up many pages of paper so I do not know how to measure the size of this tool. There are many interactive pages and an integrated forum and resources designed for the public in general. Perhaps someone will help me bring this to the specific Surgeon level adding the additional knowledge I have in my head to the surgical technique level. I am doing this project on my own but perhaps there are ways to fund or find those who could assist me in this process since I have so many hours of videos and before and after pictures yet to bring to the equation about the education of this process.
To organize and continue this project after my retirement I also built the integrated Gynecomastia Forums
which also a massive undertaking and many subdivisions for the varous forms this contour problem takes. Here is the direct posting Gynecomastia Forum Boards
so I do not have to organize the many requests for help, the person with the question or surgeon who has an answer or tool can pick the best subsection to contribute. Check the bottom of the posting screens to see how the forum integrates with the encyclopedia to begin to understand the power of the package I designed to further the process of a better male chest contour after retirement and my life. I am trying to make a living process that challenges problems and results and still evolves beyond me. But like the literature, limited 1 or 2 pictures are just not enough, or there will be more looking for revision surgery after some other surgeon falls trap to incomplete literature dealing with the male chest and not addressing how the tissues move. I am exited about my digital operating room videos, forms, and other components, but lack the resources to instantly have them available. Perhaps someone some day will assist me in these efforts. I think the documentation is the heart of the matter. If a method is really better, it should also look that way in real life. But marketing hype and verbal hand waving seem to dominate the reality of problem analysis and good surgery. The art extends to a critical choice of suture, dressings, and the many details of technique you can see when looking at Big John's nasal work. That is what I extended, but to my own methods and analysis process for my sculpture.
This is not surgery for the casual effort or occasional operator. It is a demanding sculpture to make something that not only looks ok for the one or two views typical journal articles shows. The problem is better done primarily, and not needing multiple operations by someone conversant in the subtle issues involved that go way beyond any one article, any resource I have examined to date, course I have taken, meeting presentation, or education tool. That is why so many hours of effort have been expended on my part to remedy this issue.
The site continues to evolve and I am looking for those interested in contributing to a combined effort to make a better art form as I attempt to further take what remains in my head and get it out there for others to assess, evaluate, and evolve as I have done on the shoulders of the many giants of Plastic Surgery I learned from.
So sorry, beyond that I have no "articles" to send to you. The problem nor surgery sculpture are not well addressed that way without a significant chance of yet another unhappy patient ending up surfing the web to try to understand why their results did not look good while playing basketball.
Hope this helps,
Michael Bermant, MD
Retired Plastic SurgeonLearn More About Gynecomastia and Male Breast Reduction