Gynecomastia Surgery

Not all surgeons have the same skills nor do they use the same techniques. Good surgery starts with careful documentation of the individual patient's problem. Then there must be careful documentation of before, recovery, and after surgery results. The actual operation must be meticulously documented. Then the results analyzed, critiqued, and methods improved. That is what Dr. Bermant employed over the years to evolve what he calls his Dynamic sculpture of the male chest. This is way more than just adopting what is done during the operation to what is found on the tissues.

Analysis of The Problem

His Dynamic Technique start out with an analysis and stabilization of the patient's problem. Surgery breast regrowth. Ignoring this critical concept usually results in recurrence. Dr. Bermant found that for analysis of the male breast, the normal history form was not enough. He designed his own Male Breast History form that has continued to evolve over the years of its use. Collecting such details permits a better understanding of that particular patient's cause for the breast growth and if the condition is stable or not.

Global Fat Contour Issues are assessed during the examination, Body Mass Index Calculation and a Body Fat Analysis. Men tend to put fat on first in be belly and chest regions. With weight loss, we take it off those regions last, this is part of normal Male Body Fat Distribution. Why do surgery first to "jump start" the process, then lose weight. If this weight comes off in typical male fashion, it will look like the gynecomastia has returned. Major weight loss can also result in loose skin issues.

In considering this contour issue as surgical sculpture, the wise sculptor picks the coarse tool first, and one of refinement last. In this case, losing weight is the coarse tool. Surgery is better at refinement.

Red Flag System

Over the years Dr. Bermant has worked with a number of Endocrinologists as to which patients should be then sent for an evaluation. This became his Red Flag System. If a patient has these red flags, surgery should not be the next step. Instead the patient should be evaluated by an experienced Endocrinologist first. If indicated, laboratory test ordered, and medical management started to stabilize the problem first.

Examination Male Chest

This analysis then continues with the exam of the male chest. Again done with forms he evolved over the years, Dr. Bermant takes careful measurements of the contour components of the male chest. Such measurement then can be used to document the degree of effectiveness of the surgical sculpture.

Size reduction of areola seen after surgery.

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Evolution of a Technique

Analyzing the literature, Dr. Bermant did not like the documentation of results offered. What can look good in a still picture, just was not the same a in life. For the male breast, it is that firm gland or scar component under the nipple areola structure. Learn more on our Male Breast Reduction Pictures Resource. Other articles just removed gland leaving deformity. The dominant method for this surgery was to perform liposuction and if the contour not not good enough, then go after the gland component. A shelving layer of gland was left behind to "support" the nipple.

Puffy Nipple Complication
Dr. Bermant was seeing so many unhappy patients done elsewhere with these techniques. What he saw convinced him the offending contour issue was the gland. It may not be cancer, but leaving the gland behind was creating contours that did not look good. For the chest to look good on animation, remaining gland becomes an issue. Gland just does not compress like fat. So when the chest skin is compressed against the muscle, such as with flexing, the nipples stuck out. The problem was that liposuction does not remove gland. Dr. Bermant could find no papers proving the gland was the element being removed in the literature. That was also his observation in the operating room on his own cases and the revision surgery he was performing on patients unhappy with surgery done elsewhere. Instead the liposuction was digging a hole for the remaining gland. He saw so many such patients that he coined his term Puffy Nipple Contour Complication After Surgery that describes this defect. Any technique that only looks good in a few static pictures, but not in real life was just not adequate.

Crater Defect
Another deformity was also coming in for help after surgery done elsewhere. The gland was removed but nothing was done to fill in the defect. Dr. Bermant coined another term Crater Complication Scar to describe this problem. Here is another variation: Bursa Crater Complication Deformity Floating Nipple .

Excessive Liposuction
Dr. Bermant also has been seeing patients with too much removed from the chest. The skin needs a thin layer of fat to act as lubrication during animation. Too much fat gone, and there is a Deformity Complication . Here is another Extensive Crater Deformity After Excessive Liposuction .

Big Nipple Areola Complication
Donut mastopexy, reducing a band of skin around the areola can produce a disaster when the forces are left unbalanced. The male areola tends to be much smaller in diameter than in women. Forces to keep that small size will defeat any not permanent solution.

Key Break with Tradition
Targeting the gland first was the big change. This meant that there were resources there not removed by liposuction that could be used to keep the nipple from collapsing. If starting with liposuction first, then some gland would need to be left behind or a crater would be created.

Dynamic Technique

This dynamic technique starts out by careful analysis of the problem, stabilizing the problem, working on coarser weight loss issues first, and then surgery. The surgery targets the gland first. Then uses an artist's assortment of surgical sculpting tools to contour the remaining tissues.

You can see a graphic Surgery Video - Dynamic Technique showing actual during surgery movie. Less graphic the operation starts with Chest Wall Markings and Plan. The surgery is done under Tumescent Anesthesia with Sedation.

The areola chest skin junction is a great place to hide a scar. The Gland is Removed through a very Short Scar Technique that often measures less than 16mm (0.6 inch). This takes more work than having multiple incisions. But the other sites for liposuction, lower chest, under arms, just do not look good unless the doctor demonstrates how "great" they look by showing pictures with arms at the sides (try playing basketball with arms at your sides). The gland is first separated from the nipple areola complex. The remaining gland and the fingers of glandular tissues extending through the fat are then targeted. This is done by feel to remove the firmer structures.

The next step depends on the size of the defect created by the removal. If big enough, nearby fat is mobilized on its blood supply and advanced into the defect. The first to describe this method as applying to gynecomastia reconstruction, Dr. Bermant calls this his Fat Flap Sculpture. Not all chest sculpture requires these flaps. If enough fat remains without the additional mobilization he skips directly to Sculpture Chest with Tumescent Liposuction. Once the coarse general contour has been achieved, fat flaps (if done) are then sutured together. The tissues are then further refined with Microcannula Liposuction and sutures.

Long or Big Nipple Reduction

Big nipple reduction can be done by itself without any work behind the areola. When long nipples are a component of the contour, Dr. Bermant prefers to perform surgery in stages. Operating behind the nipple damages the blood supply to this structure that he waits for the tissues to recover, typically at least 6 days after surgery. This is done under local anesthesia. After a wedge of nipple is removed, Suture Sculpt the remaining tissue into a shorter nipple structure. A thin Dressing then protects the wound.