Procedures
Did you know that 7-8/10 men suffer from a form of gynecomastia? If the 90s and 2000s until 2010 we could consider them as belonging to women from the point of view of aesthetic surgery in Romania, starting from 2010 men want to improve their physical appearance as well. If for women the fact that they have small or very small breasts can have a negative impact when they have to undress or wear a bathing suit, modern men have a problem when they are at the beach, swimming pool or at the gym and their chests show an unsightly protrusion, especially at the level of the areola, where the nipple (nipple) is convex. This feminine aspect of the chest, or in other words unattractive for a man, brings to the consultation those who want to look better.
I would like you to remember that I, as a professional, act on the basis of some desired aesthetics, which are presented to us through famous sculptures since antiquity. The god Adonis was considered the counterpart of the goddess Aphrodite, the god of beauty. Although he was initially considered the god of fertility, in Greek mythology, Adonis was in love with Aphrodite. He embodies the perfection of the male body, in which exactly as we can evaluate in the case of women, proportions are everything. The beauty or the rigors of the beauty of a man’s body are not templates from which we cannot get out, but the aesthetic units, such as the chest, shoulders, arms, abdomen, thighs, calves or back must be in harmony, pleasing to the eye. We often see in the public space men who are obsessed with the size of their arms, especially the bicep muscle, and when they go to the gym, they work much more only this region, causing an obvious disproportionality with the rest of the body elements.
Personally, I would prefer a man who has the necessary strength to prove that he is a man in front of a woman and who has the shape, not necessarily of a body builder, than a bag of muscles that is even more asymmetrical and unaesthetic. The chest must have a shape, a contour and a volume, but if these are not obvious, this is where I intervene, where I will explain where we have to remove, which are the areas we can not touch, where we could add how to make the transition between them.
Ideal candidates
It is absolutely obvious that the treatment of gynecomastia is done surgically and this will involve a patient in a perfect state of health or as good as possible, without decompensated chronic diseases or with necessary daily treatment, which can cause complications. Since we consider it an elective operation, the patient must understand how important it is that everything goes well. I would like you to imagine this kind of operation, just like a plane flight on a sunny day, without wind, without air currents, in a large plane, in which both the flight and the take-off and landing are I do almost without feeling anything. At the end of such a flight, in which you slept, were pampered by the flight staff, you land in the other corner of Europe and you don’t even realize that you have arrived. That’s how I and my team want things to go with you.
Chronic diseases such as diabetes, hypertension, thyroid diseases, chronic venous insufficiency, previous cerebral ischemia, previous venous thrombosis, etc., if any, must be compensated, that is, within the parameters accepted by both me and the anesthesiologist. This does not mean that we have not operated on patients with the problems mentioned above.
Over the years I have had and often have situations where some patients, although young, between 35 and 55 years old, who have chronic diseases, are under treatment, but for whom the risks of postoperative complications are very low or acceptable. Don’t forget, we undertake the procedure together and go through the stages forming a team, because this is the only way we reach an exceptional result.
The ideal candidate is you, when you have the patience to explain the whole process to you in order to understand it, you respect the steps both for the preparation of the operation and those for the recovery and even after you return home, we keep in touch to see that the process is carried out excellently during of time. If you have read all this far, I already thank you.
Preoperative preparation
As I said in the lines above, any operation, even an emergency one, requires preparation. If we are also preparing for an emergency operation, you realize that for a gynecomastia operation, the preparation is even more efficient, because it must be done carefully. I’m obsessed with making things go smoothly, that’s why I’d like you to take everything seriously too. Don’t be scared, it’s for your own good and I’m sure you understand that. Believe me, all my patients so far have appreciated my care for them and without any lack of modesty, I am interested in knowing and controlling even the smallest detail.
Let’s take a very simple example, a vacation you took almost a year before. I would say that it is important for you and I am convinced that you will want to prepare everything together with your family: luggage in which you can put everything you need (although you almost always forget something), money, tickets, how many stops you make if you will use the car, what you will visit, etc
In our case, I would like you to start by searching various online sites, articles or any publications, as much information as possible about gynecomastia.
The next step would be to get in touch with at least 2 plastic surgeons who have or seem to have experience with gynecomastia surgeries and make an in-person consultation or an online consultation. There will be the first contact in which you will realize the experience of the doctor and his vision on gynecomastia, so that in the end you will realize what choice you will make.
If you choose me, I will do everything in my power not to disappoint you, because this operation will change your life.
If you have decided that I will be your doctor, I thank you for your trust and I already feel honored to take care of you. The first thing we will do will be to determine the date of the intervention, because everything revolves around that day. We will need a set of blood tests in which we will check that you do not have certain inflammations or infections that you may not know about, to check if the blood coagulates effectively, to see how the liver, kidneys are working, everything in general, nothing out of the ordinary. These are the analyzes that you have most likely already done, maybe several times in your life. If necessary, we will also do examinations such as a lung x-ray, cardiological consultation or other consultations from other fields, as the case may be. In addition to these, I will recommend you to do an ultrasound of the soft parts of the chest, where I will want you to go to an experienced radiologist if you are from a distance or I will send you to the radiologist I work with. During the ultrasound, I am interested in receiving information about the thickness of the fat layer, the size of each mammary gland and sometimes the thickness of the pectoral muscle. This helps both me and you to understand the necessary technique, which I will explain further and then during the consultation.
It will be necessary to think about how you will travel and if you will be accompanied. My recommendation would be to have a helper, because postoperatively I will instruct you not to move your arms away from your chest for a period of at least 2 weeks.
Therefore, accommodation that will require daily climbing of stairs, going shopping, lifting weights or driving are to be avoided.
The postoperative period to stay in Baia Mare if you are from far away, will be between 3 days and 2 weeks, of course depending on the technique required for your particular situation. Don’t worry, everything will be set in advance and I will explain what I recommend and how to do it, but if you have help for all those movements listed above, it will be much easier for you. If you are from another city or come from abroad, it will be necessary to book your accommodation in advance and I will tell you in advance for how many days, in order not to pay in advance and realize that such a long period of time was not necessary to stay in Baia Mare.
2-3 days before the operation, I will recommend you to wash yourself in the shower with a disinfectant solution all over the chest area, from the neck to near the navel and in the armpits, which you should leave on for 1-2 minutes and then you can rinse it with water.
This can be based on iodine or chlorhexidine or any other skin disinfection product you can find in the pharmacy. I recommend this to prepare the area on which I will work, to reduce the bacterial impregnation on the skin and thus reduce the risk of infection. It is an additional measure, but very effective.
Gynecomastia treatment
Ever since I was a resident and worked in the plastic surgery services where I trained in Germany and Italy and then with my father, I have not seen the modern treatment of gynecomastia. The general opinion is that gynecomastia is an abnormal increase in the size of the mammary gland, and if we remove it, it would be enough. I’m telling you it’s not like that, moreover, to get an excellent result, removing only the glands is too little. Nowadays, the modern treatment of gynecomastia involves a combination of liposculpture and mastectomy, sometimes possible in severe cases with the removal of excess skin.
Before moving on to the treatment itself, I would like to explain to you what we want to achieve from this operation. Any aesthetic operation requires as detailed and meticulous an evaluation as possible, which then presents the treatment strategy with the necessary techniques and, finally, what we expect as a result. In the case of gynecomastia, it is not just about removing the mammary glands, because they are abnormally enlarged and they should be removed. Here we are trying to get a sculpture of the chest, so that it looks attractive. So our desire is to reach a shape and contour of the chest so that it respects the rigors of beauty for men. For this, it is good to know that it is necessary to obtain some criteria:
- Let’s delimit the deltoid region (of the shoulder) from the pectoral one: for this I will practice liposuction and a specific liposculpture to create the future delto-pectoral groove by completely removing the fat from this level.
- We will establish the area that marks the upper thoracic region, the one immediately below the collarbones, from the central one, because we will not remove anything from the upper area. Here we want to leave the region with slightly more volume. At this level, following the options I present, some patients choose to increase the volume of the pectoral muscle by injecting their own fat, fat that I also collect from them, as part of chest liposuction. In this way we increase the volume of the muscle in the upper pole.
- It is necessary to redefine the transition between the chest and abdomen, by making the transition between the infrapectoral groove (the groove under the breast) and the lower region of the ribs. From an anatomical point of view, the thorax does not end in the infrapectoral groove. It continues lower, with the lower rib edges, and only then do we talk about the abdomen. The problem is when the patient has a significant fat deposit just above the lower rib cage. If we do not act on this area as well, if the liposuction stops at the level of the infrapectoral groove, we will give the impression that the abdomen actually starts here, when in fact it is not, causing the appearance of a very small chest and a very high abdomen. If we do not act on this region and the patient presents a visible fat deposit, it will look unaesthetic from the profile, as if the abdomen or in popular terms “belly” will start from there, which does not offer a good result. Exactly this area of the lower edges of the ribs is the transition between the chest and the abdomen and we must make sure that it is smooth.
- The lateral thoracic region and the one immediately below the armpit require special attention, because the rigors of aesthetics dictate that it be as excavated as possible. This is due to the fact that this is the only way we will create the protrusion of the lateral edge of the pectoral muscle, thus offering an enviable look. I would mention the fact that this can sometimes be the most important region on which I sometimes focus in the case of some patients in an extremely serious way, through an “aggressive” liposuction precisely to obtain this effect mentioned above. It is quite difficult to approach this area through liposuction, because the patient, lying on his back with his arms apart, takes his layer of fat outside and to carry out the procedure as efficiently as possible, a tailored experience is needed.
- Zone 0 or the epicenter as we often call it, is the most important region for the patient. This represents the central area, behind the areola, where most of the excess glandular and sometimes fat tissue can be seen. All the regions mentioned above and how we should approach them are closely related to the central area because if we were to remove only from here and forget the others, the result would be very weak or sometimes catastrophic. If you want, I can show you during the consultation, a presentation at a congress where I was invited to discuss the modern treatment of gynecomastia, where I show some unsuccessful cases and how it should have been done so that the result was not like this.</ li>
Therefore, the treatment will depend on your particular situation, namely: the amount and disposition of fat, the size of the glands, the position of the areolas, the possible existence of ptosis and excess skin, and last but not least, the quality of the skin.
Seeing over the years different patients, some with a chest with a lot of fat, others with enormous glands, others with excess and ptosis of the skin, and others in which all these are associated, I decided to establish a classification that I have not found -the one described so far and which helps me a lot both in the evaluation during the clinical examination, as well as in the explanations that I will give you at the consultation when we sit in front of the mirror and I will explain every little detail that I want to know him.
Types of Gynecomastia
So we are talking about 6 types of gynecomastia:
- So-called classical gynecomastia of the puffy nipple syndrome type: thin patient, without too much fat or possibly with a layer of fat around the mammary gland, but with a large mammary gland, which gives the protrusion of the areola. In Romanian it would be translated as “fluffy nipples”. For this type, the treatment would involve minimal liposculpture and subcutaneous mastectomy to remove the mammary glands. Many people ask me at congresses where I am invited and present papers with cases and techniques about gynecomastia, why I choose to do liposuction in these cases as well, because the patient is too thin and has no fat. The answer is to restore its shape and contour by rearranging the skin over the muscles. In these cases, I will not necessarily do a liposuction, but a redistribution of the skin, to avoid during the palpation, the area where the gland was removed. On the other hand, if we are talking about a patient who has no fat at all, i.e. skin and muscles and you can see his ribs, a skinny patient, who would only have excess glands, in this situation, we cannot talk about liposuction , but only a redistribution ( redrapping ) of the skin, if it were the case.
- Adipomastia or pseudo-gynecomastia – when the patient has an unaesthetic chest because he has a large or very large layer of fat, with normally developed glands. At the preoperative ultrasound, we can reveal the size of the glands and the patient can opt only for liposuction and liposculpture, without mastectomy, i.e. without removing the mammary glands. If you want my opinion, I would say that since we will perform the liposuction procedure and anyway we will create a “disturbance” on the whole area, a small incision at the lower level of the areolas, to remove the glands would be auspicious, because this way you will avoid a long-term re-intervention, in case the glands increase in volume. Don’t forget, they can increase in volume even further during life, even if they were normal until the time of the intervention. In this way, you avoid another intervention in the area, which would later become much more difficult due to the scarring after liposuction. Statistically, it very rarely happens to me that I only do liposuction and do not remove the mammary glands, but when the patient chooses this way, he knows what to expect.
- Here the patient presents a large amount of fat and a mammary gland of small volume, but with dimensions above normal, which causes discomfort on the areola. This type 3 of gynecomastia is the most frequently encountered and, like the technique, requires liposuction, liposculpture and subcutaneous mastectomy.
- Here the patient presents a moderate or reduced amount of fat and large or very large mammary glands. In the same way, there is a need for liposculpture with the most efficient removal of fat and subcutaneous mastectomy.
- In this case, we are talking about a moderate or large amount of fat, large mammary glands and excess skin with minimal or moderate ptosis of the areola. When there is such a feature, most of the time my recommendation is for the upper body lift. This means that we will perform liposuction and liposculpture on the areas mentioned above, but we will remove the excess skin together with the areola and the nipple, which we will later prepare and reposition in the new location. However, in the case of this type, there are sometimes borderline situations, where the patient has a large amount of fat, a large gland, but the skin may no longer have the necessary quality to be able to contract sufficiently. I want to repeat this crucial aspect, namely, everything depends on the quality of your skin. When the skin is not sufficiently toned, we removing the fat that practically represents a support of the skin, we can have a surprise, with an excess of remaining skin. This remaining excess can implicitly produce ptosis of the areola which will not look good. The conclusion is that personally, in these situations, I recommend 2 options to each patient: a. Let’s perform the procedure without removing the skin and let the patient wear that compression corset for a period of 6-12 months and after 1 year let’s evaluate the result. If he is happy with how he presents himself, nothing else is needed. If there is a disturbing excess of skin, we have the possibility to do a revision, through which I will only perform a lifting of the areola-nipple complex to the correct position. In this way we will avoid a long horizontal scar almost or even along the entire length of the infrapectoral groove and we will be left with a scar only around the areola. b. Let’s remove the excess skin from the beginning and freely restore the areola to the correct position, at the price of more extensive scars. Everything depends on the patient’s wishes and we will discuss this in detail at the consultation, so that you can make the best decision.
- Here the patient has excess fat and skin and significant ptosis of the areola, so the only option is for an upper body lift. So in this case, we will remove the excess fat through liposuction from the mentioned areas, the excess skin through an elliptical excision that will also include the areola-nipple complex, which we will reposition 3-4cm from the infrapectoral groove exactly like a breast graft free skin.
The anesthesia we perform for the treatment of gynecomastia is general. For us, the comfort of the patients is extremely important and we do not consider the attempts to perform the mentioned techniques with local anesthesia associated with superficial or deep sedation effective and comfortable for the patient. Just the idea that you will feel the cannula walking under the skin at the level of the chest is quite scary and we want to offer our patients the most comfortable journey. The duration of the procedure is between 2 and 5 hours, depending on the complexity, which involves the amount of fat and if it is necessary to remove the skin and reposition the areola.
Techniques for the treatment of gynecomastia
The technique that I prefer and have been performing successfully for many years involves hidden scars for types 1-5 of gynecomastia, which will not involve the removal of a possible excess of skin.
We start the procedure by infiltrating the modified Klein solution to soak the fat layer for liposuction and we do this through an access of less than 1 cm in the upper part of the pre-axillary fold (if you sit with your arm outstretched and stuck next to your chest, at the border area between the shoulder and the chest, you can see a groove or fold where the armpit starts a little below) and another one in the lower part of the areola, which will be extended anyway little to have access to the mammary glands.
The next stage of liposuction is the separation of fat because here it is extremely hard and fibrous, especially the one around the mammary glands. For separation, I use a special cannula that vibrates and will transform the fat into a compound like a smoothie, which can then be extracted by suction much more easily and efficiently.
Liposuction is a procedure that at first glance seems quite simple because inserting a cannula under the skin and suctioning the fat is not a big deal. After more than 1000 extensive liposuctions with large amounts of fat removed, I can tell you that liposuction is not a simple procedure at all. I notice many plastic surgeons who, almost immediately after the infiltration of the Klein solution, rush to suction the fat because, knowing that they have a long procedure ahead of them, they want to reduce the operative time, but this is not a good idea.
Liposuction does not mean how much fat you can remove as quickly as possible, but it means how much fat you leave in place and how you leave it in place. Under the skin, the fat has 2 layers: a superficial one, which is located above the superficial fascia and a deep one, located below the superficial fascia. The superficial one has 3 layers in turn. In a conventional liposuction, we must harvest as much as we can only from the deep layer, to keep a support for the skin and to protect against contour irregularities and deformities. When we want or are asked to be more “aggressive” in a positive way, we can also enter the superficial layer of fat so as to thin the contour even more, but it is crucial to pay attention to avoid the appearance of deformities and of contour asymmetries. We can intentionally remove all the fat from certain areas, where we want to get those indentations specific to the transition zones between muscle groups. In the case of the chest, it would be the deltopectoral groove, where we want to emphasize the transition between the shoulders and the chest.
I finish the liposuction with fat redistribution, which is a technique specific to liposculpture in which I make sure that the layer of fat remaining under the skin is uniform and there are no contour differences, irregularities or deformities. The 2 approaches help me to offer a 3D frame of the chest liposuction, because the cannula paths will intertwine in the form of a 360 degree network and in this way we will obtain a uniform result.
The next stage is the subcutaneous mastectomy, which I perform by extending the incision from the lower part of the areola, in order to reach a proper access from 5 o’clock to 7 o’clock or from 4 o’clock to 8 o’clock, if we consider the areola to be a clock.
Through this approach, I manage to remove the mammary gland, which sometimes has dimensions of more than 10 cm. The incision will be placed in the lower part of the areola, slightly above the transition between the hyperpigmented area of the areola and the skin, in order to be as hidden and unnoticed as possible. It happens very rarely, but sometimes it is necessary to extend this incision in the Omega-type skin area, when the size of the glands is very large and the areola is small. Usually when we have large glands, we also have a large areola, but there are rare cases when due to the small areola we do not have enough window to be able to approach the gland and then it is necessary to extend the incision.
When an upper body lift with free repositioning of the areola is necessary, the skin ellipse and the gland together with the areola are removed en bloc, the scar being positioned exactly in the future inframammary groove, along it, sometimes even up to the armpit. The areola with the nipple will be placed in the new position that we establish intraoperatively. You can find all these details in the explanatory videos on the YouTube channel and I will show and explain them during the consultation.
After removing the mammary glands, the next step is the support of the areola, which is particularly important. There are many doctors who support the fact that it is necessary to keep a portion of the gland under the areola, in order to support the areola so that it does not appear indented and uneven. I do not recommend this approach, because I believe that we must remove the gland completely, in order not to risk a recurrence in the future.
You must know that the development of the mammary glands over time can be continuous and can give birth to real “monsters”. That’s why the rule is to remove the glands completely, so that gynecomastia does not occur anymore. Therefore, I completely remove the glands and to support the areola I will create some internal flaps (own tissues formed by fascia and fat) which I will suture latero-medially (from left to right or vice versa) and cranio-caudally (from above) down) and thus I will create a blanket of own tissue under the areola that will support it. These flaps must be checked to be strong enough to withstand the subsequent tensile forces and uniform so that no irregularities are felt around and under the areola. It is important to know that during the intervention you will be with your arms outstretched and lateral to your chest, so that these sutures will be done under some tension, and postoperatively when you will remain with your arms by your side there will be no of tension and the risk of these sutures breaking will be extremely low.
However, I will recommend that you take care post-operatively for a period of 1 month not to move your arms away from your chest and not to lift weights.
Subcutaneous and intradermal sutures are made with quickly resorbable threads and you will not have threads to remove.
Before completing the intervention, I will insert a drainage tube on each side, which will have the role of removing the fluids that normally accumulate subcutaneously in the first days and at the same time being aspiration, they will help stick the skin to the muscle layer, in order to provide the best possible result. The drainage will be directed to the outside through the hole at the level of the preaxillary fold (the area between the armpit and the chest) where we went in to do the liposuction. In this way, you will not have visible scars and after these small holes have matured completely, you can say that the procedure is done without scars because they are imperceptible and some patients even forget that they once had them.
The drains will stay for a few days and will help you heal faster, and when you are discharged we will give you a special corset like a compression vest that will help you to keep everything uniform, well distributed and will help you in the process of skin contraction.
Postoperative period?
For type I, II, III and IV gynecomastia, the recovery period falls between 2 and 6 weeks to limit moderate and excessive effort. This means that I will recommend you not to drive a car or ride a bicycle for at least 2 weeks and not to go to the gym or use your arms for up to 6 weeks.
After 2 weeks, if it is absolutely necessary to go to the gym, I will recommend you to only do lower body exercises: abs, knee-flexions, calves, thighs, etc.
To keep you in shape, I will recommend you to walk either at an easy pace or even fast, something that will not cause you problems and will make you feel good. The drains will remain for 3-4 days, to help the skin stick as effectively as possible and to remove the liquid that tends to collect anyway.
After removing the drains, you will only have one sterile patch over the areola area and one over the hole in the armpit.
You will be able to take a shower immediately from the 2nd postoperative day, but it is important not to wet the scars yet and thus the water starts from the lower chest. On the area of the arms and armpits, I recommend using wet servers, specific for cleaning the skin.
We will discharge you the next day, making sure that everything is in order. You will be able to return home in the following days, depending on when the drains are removed, and all you will have to do next is to disinfect the mentioned areas with antiseptic skin solutions and protect them with sterile plasters. We will teach you everything you need to know and you will see that it is not difficult at all. All patients like you go through this.
For patients with gynecomastia type V or VI, the postoperative regime is the same, only the recovery period is longer.
The treatment of scars is recommended in all situations, regardless of their size and can be done effectively with silicone patches until the scars have matured, that is, when they become completely white along their entire length. This is especially true when the scars are long, in the case of types V or VI of gynecomastia.
I recommend the compression corset for a standard period of 4-6 weeks postoperatively or in special cases, for a period of even 6 months or more, depending on the quality of the skin.
It is possible that you need massage or lymphatic drainage sessions, but until this moment I do not remember that any patient has had them, because they were not necessary because the liposculpture was effective and the skin settled properly.
We will be able to keep in touch and I will recommend you to come for check-ups at 1, 3, 6 and 12 months postoperatively. If you are far from us, we can do the checks online and you will be able to send us pictures to see that things have evolved well.
Complications
Like any other operation or surgical procedure, gynecomastia can have some complications. First of all, we discuss the risks of anesthesia, which, being general, must be prepared and you will be evaluated by our anesthetist before the intervention. He will already be able to see your medical record and will know if there are any contraindications. Everything is evaluated and prepared in advance so that you are safe.
In the first 24-48 hours, I am interested in not bleeding excessively so that large amounts of blood do not accumulate subcutaneously, which can cause problems.
Then I am interested in having the drains removed when the amount of lymph is a maximum of 30ml/day for 2 consecutive days, in order to prevent a seroma (accumulation of excess lymph).
The infection is very rare, but must be taken very seriously. For this you will prepare with antiseptic solutions to disinfect the skin, we do the operation with maximum sterility, you will take antibiotics for at least 7 days postoperatively and you will come for check-ups to make sure that the evolution is good.
The healing will have to be done correctly by avoiding exposure to the sun and by applying silicone strips or silicone gels until the scars are completely white. That moment means that the scarring has matured and exposure to the sun is no longer a problem.
Asymmetries, under-levelling of the areola, skin imperfections, etc. are aspects related to the overall aesthetic of the procedure and what you need to know is that I know what I have to do to avoid them and I force myself to do this as best as possible, but I can’t guarantee perfection in everything. I will try to get the best possible result and I have experience in this sense that helps us a lot.
Costs
Depending on the complexity of the procedure, the costs fall between 2,500 and 7,000 euros. This includes everything from the moment you enter the door of the clinic until 1 year after the operation. This means surgery, anesthesia, corset, dressings, checks.
If you’ve made it this far, thank you for your patience and interest and I wish you success with your choice!
