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Hello and welcome. Dr. Stephen Mulholland here on Toronto Canada with Plastic Surgery Talk. Welcome to our latest installment of our podcast series. This is one is on gynecomastia. Male gynecomastia. Male chest tissue. Male breast. An embarrassing problem with a very simple solution. If you find these podcasts entertaining, engaging, interesting and informative, please sign up, share and comment.
What is gynecomastia? What is male breast tissue. Gynecomastia is a fancy name for unwanted male breast shape and form. The content of that male breast can be one of two and sometimes a combination of two tissue types. It can be a fatty male breast, so it’s mainly adipose or it could be glandular, which is true glandular hypertofere. Increased glandular tissue forming the breast mound.
The causes of gynecomastia can be hereditary or acquired. The hereditary causes are stronger estrogen drive usually a hereditary predisposition to this gynecomastia. This glandular gynecomastia tends to be more gland and less fat because you inherited the curse of that estrogen [inaudible 00:01:24] fat. Now interestingly, the treatment for glandular hypertofere gynecomastia is going to be ascertaining the diagnosis.
So if you have a younger patient. Adolescent develops a little tanner stage one or two breast bud. The nipple areola complex is sticking out and you’re wondering, “Oh geez I hope my adolescent son doesn’t create male boobs”, and it could be a glandular issue. And so as a family physician or a specialist seeing these patients you want to hormone profiles. Sometimes the hormone profiles show a hypotesterosteroneism or a relative hyperestrogenism. You may do ultrasounds and other scans looking for syndromes or genetic syndromes or feminization, adrenal glands, reproductive organelles, pelvic ultrasounds, CT scan of the anterior pituitary.
These are more complex angronological endedocron screening for glandular hyperplasia usually in adolescents. Once you have an adult, a young male or middle aged male with gynecomastia you ask one simple questions, “Are you having any erectile disfunction? Are you having normal sex life with a normal erectile function?”. If the answer is yes you can usually rule out all the other causes of hypotestosteronism and relative hyperestrogenism. You still might do hormone profiles, but in general they then have a genetic jip of some glandular hyperctofy, and the rest are usually gonna be fatty impultrate or fatty breast in generally someone that has some subcutaneous fat as part of their genetic curse. And often comes with love handles, a little male pot and some fatty breast tissue that masquerades as a male breast.
And so fatty gynecomastia, glandular gynecomastia can often be two different causes, two different treatments, two different sources, but at the end of the day as plastics surgeons, aesthetic physicians, body contouring surgeons, the patients we see are generally those that have pure atapost gynecomastia and they just have chubby breasts that project and are embarrassing, or they have an add mixture of some glandular and some fatty tissue, and usually amenable to modern surgical liposuction technique.
And so you’ve got a male patient with gynecomastia and you do a pulpation and it feels a part glandular, a little hard disc behind the areola and then a lot of fatty tissue. And so they have a small B cup or C cup breast. Sometimes there’s some ptosis or droop, and so who’s a candidate then for modern gynecomastia surgery? When I say modern, more and more gynecomastia is managed without a scar. Without an incision. Without a true lollipop or anchor breast reduction surgery. Even cir cum areola or nipple are ler incisional momelar removal. That’s getting less and less common because our new technologies are amenable to non-surgical breast reduction techniques.
So who’s a candidate? A male patient with glandular or adipose gynecomastia breast enlargement who is medically well. Has no contrary indications to surgery and is accepting of the risks and the modest improvements and benefits and realistic about the outcomes that they can achieve. That’s the best candidate.
So what technique options do we have for male gynecomastia? We can divide them into excisional options and aspiration or suction based options. Under excision it can be periareolar, limited periareolar and glandular lamellar excision. It can be more extended excisional treatments such as cir cum areola or a smaller short scar lollipop excision with or without skin. And then suction techniques. Tomesamicrocanula non-thermal techniques are increasingly in the modern era. Some sort of thermal lipo contouring and coagulation where we liquefy and coagulate the gland and the fat. Elicit a strong contraction up to 40 percent contraction, and then remove the gland and the fat. And the leading technology for that is Body Tight. Body Tight male gynecomastia reduction surgery can often eliminate all the scars of excisional options.
Other more old school older technologies going back to 2006 to 2010 would be Smart lipo and Thermiarap (phonetic). Principally replaced by the more modern and successful Body Tight bipolar radiofrequency energy systems, which are gonna give you some optimal contraction as well as glandular and adipose lipocoagulation. And so the vast majority of patients, even with a class 2 ptosis, a little bit of droop, are gonna be candidates for limited incision, non-excisional, non-scarring Body Type procedure. The treatment is straight forward. It’s done under local anesthesia and the amount of contraction, rotation and elevation with reduction and glandular tissue leaves most patients extremely happy.
But how is the Body Type gynecomastia procedure performed? You mark out the patients area of hypertrophy. Of adipose excess where the glandular elements are. We use infiltration anesthesia. Generally most of these in my office I do under oral sedation, a little arasopan, maybe some toradal nonsteroidal anti-inflammatories. Some oral antibiotic and then we infiltrate with double strength cline solution. A wetting technique into both glandular areas and infiltrate the gland and the fat.
Then we do Body Type thermo coagulation. We use the 2.47 centimeter device. Our settings are 40 degrees external, 70 degrees internal and we provide enough coagulation to heat the deep layers to 70 degrees and get the skin up to 38 to 40 degrees Celsius. Usually about six to eight kilojoules per breast. That takes maybe 10 minutes. Once we’ve done the thermal heating and coagulation ensuring that 40 percent area contraction over the ensuing six to 12 months, we’ve liquified the fat, the small vessels and the gland. It does liquefy a gland. Radio frequency internal electrodes and probes will liquefy the gland to make it asperatable.
Then we go in with any aspiration technique you like to use. It can be suction assisted microcannula. It can be PAL, Power Assisted. I like to use power assisted 3.7 or 4.0 milometer mercede tip cannulas. We do power assisted removal of the gland and the adipose tissue, and then I’ll use some small SAL cannulas and do a little bit of refinement. You make sure you get enough aspiration of that glandular tissue under the nipple areler complex to have a nice even pinch and roll test throughout the aspiration zone.
I’ll sometimes then go back after the heating, sorry after the aspiration and do second heating. Heat the skin and the residual gland and the FSN connecting the peck major to the skin one more time up to 70 degrees internal and 38 degrees external, 38 to 40 degrees, and then we’ve done our contouring.
I do us a drain. I use small seven milometer JP drain inserted under the glandular tissue coming out the exela on each side, and that drain stays in usually five to seven days, or until there’s three consecutive days with less than 20 cc’s in 24 hours. We do use a garment, so a tank top, a limited garment or an open neck short bicipital garment with good chest compression, and we use foam. Epifoam. Silicone backed foam on top of the chest, under the garment with the drains underneath. We do the foam and the garment for about two weeks, and then residual garmenting for the residual four weeks of that six weeks garmenting requirement.
The drains will often come out within three to five days from when those less than 20 cc’s on each side for three consecutive days. So six weeks of garmenting, usually back to work in a sedentary job environment in five to seven days. Back in the gym doing peck workouts, peck flies, bench press, aggressive upper shoulder girdle activity in four to six weeks.
How long will the results of Body Tight liposuction of gynecomastia breast reduction last? How long will male gynecomastia reduction last? Generally, the fat reduction if patients maintain their surgical weight. They don’t get chubby or put on weight again. They’re not gonna get any more glandular collections, so the glandular sub or real tissue is gone forever, and the fat we removed through Body Tight lipo is gone forever as long as they don’t put on weight. And so the results of the contouring reduction are forever. Lifelong with a proviso patients cannot put on significant weight. So stay within 10 pounds of your surgical weight you should have a life long improvement.
The skin tightening we get from Body Tight. That 35 to 40 percent we get over one year generally is long lasting, but as you get older the male integulent tends to get lax. 60’s and 70’s the belly gets a little lax. The skin of the chest and the arm, so you may experience some ongoing laxity in your chest wall as you get older. And so we do recommend ongoing maintenance treatments that are bulk heating thermal in nature to maintain and enhance the tightening. So bulkating radio frequency devices such as the Forma, the Forma Plus, Venus Freeze, Pelavay, Temperature Envy. The moving bulkating radio frequency devices that maintain collagen content are recommended about once every three months on the chest tissue following Body Tight lipo gynecomastia reduction in males. And you get lifelong pleasing contour improvement with tight skin is the result.
The recovery following Body Tight lipo gynecomastia male breast reduction is fairly quick. You can expect one week back to return to work for a sedentary job. So you do your procedure. Usually lasts about two hours. You go home two hours later. You get your drains out on day three to day five. You’re garmented. You’re wearing your foam under the garment. You can wear it while work, a shirt or a sweater or a hoodie or a work environment work shirt after one week. So usually return to work in one week.
Light activities in the gym for instance working on your quads, your lower legs, maybe abdominals at three weeks. Stair climber elliptical three weeks. Back in the gym doing jogging, peck work, peck flies, bench press at six weeks. So one week return to a sedentary job. If you’re a laborer, construction worker, heavy worker you’re gonna need modified duties or back to work in two to three weeks depending on how heavy a lifting you need to do.
Body Tight lipo and male gynecomastia reduction is uncomfortable. More like a bruised discomfort like you worked out in the gym and the next day of that lactic acidosis, a little stiff, a little sore, but no terribly painful. So I would tell most guys it’s about a four out of 10 type of pain. More like a muscle ache or discomfort in a bruise. So reasonably tolerable. Usually don’t need narcotics post-op. It’s not that painful. We use non steroidal anti-inflammatories like toradal, which is Ketorolac above Celebrex, above Nap rosin in terms of nonsteroidal strength. And usually you could be back to a sedentary job and a desk within five to seven days when your drain is out, and discomfort is more of the adjective I deploy rather than painful. It’s uncomfortable and discomfort that you experience in the name of a flat chest, so usually more than worth it.
One of the things that turns many, many male patients off who have gynecomastia they go online and they see all of these breast reduction scars. The circumareolar, the lollipop scar, the anchor scar and if you get any kind of keloid scar forming or raised unattractive red scars or wide spread scars, you’ll be just as self conscious with the scars as you were with the gynecomastia, so some guys just say, “Ah I’ll live with what I’ve got”. The nice thing about Body Tight lipo gynecomastia breast reduction is the scars are tiny. Two three to four milometer well placed access ports on either side of the breast. Invisible if you’ve got some hair to your chest, and generally well tolerated even if you have hairless skin on your chest because we can do laser treatments on the scar. We can inject the scar. We can modify the scar qualities that leave most guys completely either unaware or certainly not self conscious about the access ports we need to perform the Body Tight breast reduction lipo procedure.
Body Tight Lipo gynecomastia breast reduction is not risk free, but it’s greatly risk diminished. It’s performed under local anesthesia so you don’t need a general anesthetic. It’s done with local freezing and so the risk of having painful or risk nerve blocks, again is eliminated. It’s done as an outpatient so you’re not staying in a hospital. The risk of bad infections from highly resistant organisms is extremely low if not zero. The risk of having some reaction to aggressive general anesthesia and arrhythmias or cardiac pulmonary complications are low. The risk of a blood clot and a pulmonary embolism is very low because you’re active very quickly. So I would say your risk of a serious medical complication is not zero, but pretty close to zero with outpatient ambulatory Body Tight lipo gynecomastia breast reduction. The basic risk. The risk of infection that’s usually treatable. The risk of a mark or a scar. The risk of a symmetry, one breast is flat, one’s a little fuller. The risk of fluid collection called seroma. All these are annoying, but manageable and they are in the order of two or three percent.
So in terms of accepting a procedure most guys find this very acceptable. In 90 to 95 percent of all patients experienced no complications and had a predictable recovery and back to work within a week. And generally within a month you could go on a vacation, have a flat chest and not be vexed by the curse and the embarrassment of male breasts.
Very common question I get from male gynecomastia patients. “Doc, can I do something else with this? I’m already having the recovery?”. It’s a natural to combine with other procedures. Of course if you’re doing Body Tight lipo gynecomastia reduction here, if you have a little love handle, a little pot, a little double chin, we can do Body Tight on other body areas. We can give you a better figure, a more athletic looking shape, more toned, more cut. So additional Body Tight lipo reduction procedures, you can combine Body Tight gynecomastia lipo reduction with laser hair removal. You can combine it with Botox with injectable soft tissue fillers. You can combine it with little mini lifts. Little mini neck lift or guy lift with a rhino plasti. So yes you can combine it with other surgeries. The most common combination is just Body Tight lipo on other body areas to get even better contour in other areas other than your chest.
Okay, now for the big finale. “Doc, how much is this? I love the before and afters. I love the concept. I love what we can do with this Body Tight without scars. What’s the cost?”. So the average selling price or price point for gynecomastia reduction, depending on the city, depending on the market, depending on the surgeon, depending on the price point of that practice it’s gonna be somewhere between six and fifteen thousand dollars for male gynecomastia reduction. Now the value add to having a scar less approach with Body Tight thermo coagulation and tightening without an areola incision actually makes that more valuable and sometimes you can charge more. The average selling price in my practice for Body Tight lipo gynecomastia reduction about nine or ten thousand dollars. I can do that in about two hours. Patients are super happy because they get tight, flat skin without laxity and without ptosis and without the debilitating and often very embarrassing and disfiguring scars of breast reduction and masto pexis.
So this is an example of where technology and innovation in modes Body Tight with bipolar radio frequency thermo coagulation has made a significant difference in the clinical opportunities I can offer to patients with the scar less breast reduction, which for males, because we often are shirtless or topless which is one of the reasons you’re doing it, is critical to the success of any procedure you’re gonna be offering patients. A scar less Body Tight gynecomastia breast reduction.
Again, thank you for joining me. Dr. Stephen Mullholland here in Toronto Canada on Plastic Surgery Talk with our latest installment of our podcast series which is on gynecomastia, specifically Body Tight lipo reduction of gynecomastia. I hope you have found this enjoyable, entertaining and informative and if you’ve had please sign up, share and comment. We’ll see you next time.