Body

Gynecomastia Surgery

Gynecomastia is the medical term for male breast enlargement. This can range from a small amount of extra tissue to a female looking breast. Gynecomastia can make it embarrassing to wear a tight shirt or to take your shirt off at the beach or in intimate situations. Since there is both breast tissue and fat, losing weight doesn’t solve the problem. The good news is that in most situations, surgery can give you a chest you can feel good about. Most of the time, gynecomastia is “idiopathic” (meaning we don’t know the cause), and surgery will remove the breast tissue and correct the problem without any need for medical treatment. About 15% of the time, though, there is a medical cause (like hormonal imbalance, a medication side effect, a genetic condition, or marijuana use) and surgery alone is not the answer. It is important to see your family doctor before coming to see me in case you are in that 15% of males who need medical treatment to remove the cause of breast enlargement.

Techniques:

In all plastic surgery, you trade getting the shape you want for putting up with scars. If you have a small chest with pretty tight skin, the incisions will be small and the recovery pretty quick. If you have large, sagging breasts, there will be more incisions and a longer recovery. At your consultation, I’ll evaluate your anatomy and expectations and come up with a personalized approach that will give you the shape you want with an amount of scarring that you’re comfortable with.

Type I – a small amount of fat
Type II – firm tissue in addition to fat
Type III – extra tissue as well as loose skin

Type I – Treated with Liposuction

If you have a small amount of fat and no firm breast tissue or sagging skin, liposuction alone may work for you. You can use twilight anesthesia (when you’re asleep but breathing on your own) or general anesthesia (with a breathing tube). I inject a fluid that numbs the chest and controls bleeding. Then, the fat is sucpioned out through small incisions, hidden in a crease in the armpit and/or at the bottom of the chest. You go home the same day wearing a garment to help prevent swelling and to prevent a fluid collection under the skin. Some pink tinged fluid will leak out of the incisions for about a day or so, and you’ll probably be sore for about a week. You will need about 2-4 days off work if you have a low physical activity job, longer if your job is more strenuous. The incisions may stay red or raised for a few months but will eventually (in 1 or 2 years) heal to an almost imperceptible line.

Type II – Treated with Excision of Tissue

If you feel firm tissue deep to your nipple and areola when you pinch your chest, then there is more breast gland tissue than fatty tissue, and liposuction alone will probably not give you the result you want. To get the best result, a small incision is made around the bottom edge of your areola (the dark circle around the nipple). The breast tissue is directly cut out, and then liposuction is used to help remove fat and feather the contour around the area that was excised. Everything in the Type I section applies, but you will also have a small drain tube in place to help remove extra fluid the body produces after surgery (this will stay from 2-10 days after surgery depending on how much is coming out). You’ll need about 3-5 days off a low physical activity job and about two weeks off strenuous activity like exercise. The scars here tend to heal well and are barely noticeable since they are in an area of natural color change on your body.

Type III – Treated with Excision of Tissue and Extra Skin

If you have sagging skin with stretch marks or if your chest is large enough that there will be excess skin after the tissue is removed, then you may need to consider skin excision. In order to remove extra skin, scars need to be placed on the front of the chest. This is often only in the area around the areola, but sometimes incisions are needed on the front of the chest in order to remove enough skin. Just like in Type II treatment, you will have drains after surgery. You’ll need about a week off work (longer if your job is more physical) and you’ll need to limit your activity for 2-4 weeks after surgery. The scars usually heal well but are not as easily hidden as in Type I or II treatment.

Risks

Unfavorable scarring
Bleeding (hematoma) - may require drainage or surgery to stop the bleeding
Fluid collection (seroma) - may require drainage in the office or operating room
Infection – you may require antibiotics, admission to the hospital, or surgery
Changes in nipple or breast sensation - may be temporary or permanent
Chest contour irregularities Potential partial or total loss of nipple and areola

Liposuction

It is quite common to have areas of your body that you have always been uncomfortable with. Exercise can be frustrating if there are certain areas of fat that just won’t disappear. Our bodies are prone to retaining fat unevenly. If you find yourself constantly focusing on problem areas and pinching the fat wishing it would just go away, call my West Palm Beach office to schedule a consultation to learn more about your options with liposuction. You can keep reading to find out the answers to the most common questions patients ask about liposuction.

Technique of Liposuction:

Liposuction is an operation that removes pockets of fat by suctioning it out. The fat that is removed during liposuction will never come back. Where fat is on your body is determined by two factors – how many fat cells you have and how big they are. The number of fat cells in each area of your body is determined early on in life by your genetics and your weight as a child. When you gain weight as an adult, your fat cells get larger, but you don’t form any new ones. If your body has more fat cells in one particular area, that becomes a “problem area” for you. Liposuction permanently removes fat cells from selected areas. Your body can still make the few remaining fat cells larger, but it will not create new cells. This means you stay thin in those areas even if you gain weight. Of course, if you gain a lot of weight (30 or more pounds), you will notice that even those areas which were treated with liposuction become larger again. Liposuction is not a substitute for losing weight because it’s not safe to remove very large amounts of fat during a liposuction procedure. But, it’s perfect for contouring parts of the body and for removing a particular area of fat that just won’t go away.

What about SmartLipo™ and Lipodissolve?

SmartLipo™ claims to remove fat by dissolving it with a laser. Like all new things, there is a lot of media and publicity, but there aren’t any rigorous scientific studies that show that it’s better or safer than regular liposuction. Most of the physicians doing SmartLipo™ are not Plastic Surgeons but a mix of Family Physicians, Gynecologist, or Internal Medicine doctors, many of whom have received only a few days of training at a weekend course. Because I don’t believe this is any better than regular liposuction, I don’t offer it to patients. I do however offer Vaser™ which is a liposuction machine that helps dissolve tougher areas of fat with ulatrasound before it is suctioned out and can help tighten the skin in many patients.

Lipodissolve uses a chemical to dissolve fat. This process is not approved by the FDA, and it requires hundreds of injections to introduce the chemical to the area being treated since it only works on about a quarter size area. There is a good chance that the fat will dissolve unevenly or not work at all, so I don’t offer .

The liposuction procedure involves making tiny incisions (less than a half inch) in about two or three places for each area where the liposuction will be performed. Usually these are hidden by your underwear or in natural creases on the body. Then, with a small thin tube, I fill each area with IV fluid that is mixed with medications to numb the area and reduce bleeding. When more fluid is put in than the amount of fat to be taken out, this is called the “tumescent” liposuction technique. This numbs everything so that you can have the surgery while you are wide-awake and dramatically reduces the chances of bleeding or bruising during or after surgery. Next, using liposuction cannulas, the fat is removed. This is done very carefully to ensure that the fat is removed evenly and the body is contoured for the best shape.

When the liposuction procedure is complete, you will see small pieces of tape where the tiny incisions were made. You will be dressed with gauze over the incisions and a compression garment over the entire area.

Expected Recovery from liposuction:

For a day or two after surgery, there will be seepage of pink fluid from the incisions. That’s the fluid that was put in to do the liposuction combined with a small amount of blood, and it’s completely normal after surgery. Be sure to keep gauze over these areas as instructed. You may want to use extra towels or even trash bags to cover your car seats and your furniture.

Pain: Most people stay numb for 8-12 hours after surgery. The amount of pain you will experience depends on how much fat is removed and in how many areas. For example, a small amount of fat (ie: a soft drink can) removed from one areas will probably very little pain and can return to work in a few days. If you have more areas worked on or a larger amount of fat removed (ie: a two liter bottle), you will feel more pain. Soreness can last for two to three weeks. There are several other after-effects to keep in mind:

Bruising: A small amount of bruising can be expected, and the amount varies with the amount of liposuction. It lasts 7 - 10 days.

Swelling: is completely normal and is part of the healing process. You will need to wear a compression garment for about six weeks, during which the swelling will slowly improve. You will see pretty big changes in about 3 weeks, but it can take up to 6 months for the contour and appearance of skin to reflect your final result.

After liposuction, you can return back to work in just a few days, but again, it depends on the amount of fat removed, the number of areas that are worked on, and if you combine liposuction with any other surgery.

Risks of Liposuction:

Bleeding: Bruising is common after liposuction, and the fluid draining out of the incisions always looks pink or red the first day or two. Very rarely, bleeding may be more serious. Contour Problems: The most common complication after liposuction is a small firm or uneven area. Most of the time, it goes away in a few months on its own or with massaging. If it doesn’t, you may need further liposuction or less commonly, fat transfer. Blood Clots: With large amounts of liposuction you are at risk of developing blood clots in the veins in your leg. These can cause swelling in the leg and can sometimes move to the lungs and where they can be fatal. This complication is rare, and I follow every precaution to ensure that the risk is as low as possible.

Do I need a tummy-tuck or liposuction?

Liposuction works if you have fairly tight skin and just want to be thinner or get rid of fat. A tummy tuck is a better option if you want to remove extra skin and stretch marks between your belly button and your groin, tighten the muscles, and shape the belly into an hour glass.  For some patients liposuction combined with a tummy tuck will give the best results. I can determine which is best for you at a consultation.

Abdominoplasty (Tummy tuck)

Weight loss, pregnancy, and aging can leave stretch marks and extra skin that don’t go away despite being at a healthy weight and exercising. Losing the definition of your waistline and the tightness of your abdominal muscles is frustrating. A tummy tuck can remove the extra skin and fat, tighten the abdominal muscles, and shape the tummy. There are a few types of tummy tucks, depending on how much extra skin and fat you have. The right procedure also depends on your medical history, how many abdominal operations you’ve had, how much weight you have gained and lost, and your current weight. I’ll start by describing the “classic” abdominoplasty, which is most often performed and then address some other related procedures.

Who should not have abdominoplasty

If you are 20 or more pounds over your goal weight, you should wait until you have lost the weight. If you plan on future pregnancies, it is best to wait until you are through having children. After previous abdominal surgeries and after some hernia repairs, it may not be safe to lift up the skin all the way to the rib cage, and a smaller procedure might be safer. Smoking increases your risk of complications, so you should not have surgery unless you stop smoking for four weeks before and after surgery.

What happens during tummy tuck surgery

• Classic Abdominoplasty
• Mini tummy tuck
• Panniculectomy
• Circumferential body lift (Belt lipectomy)

Classic Abdominoplasty

All tummy tucks start with an incision above the pubic hair that goes from hip to hip. This will be a little shorter if there is not much skin and fat to remove, and it will be longer if there is more extra tissue. The skin and soft tissue is lifted up off your abdominal muscles all the way to your ribs (the skin is cut around your belly button so it stays attached to your muscles the whole time). Stitches are used to tighten and shape the abdominal muscles to narrow the waist and make the stomach flatter. Next, the skin is stretched back down and all of the extra tissue is cut off. The final step is to make a new hole for the belly button.

Mini Tummy Tuck

If you have a very small amount of extra skin and just a small amount of muscle weakness below your belly button the tummy tuck can be performed through a shorter incision. When there is not enough skin above the belly button to stretch back down, there will either be a small vertical incision just above the pubic hair (where the belly button was cut out) or there will not be an incision around the belly button and it will just be lower down as the skin is stretched out.

Panniculectomy

If you have a large amount of tissue that hangs over your pubic area and causes problems like rashes and repeated infections, your insurance company may pay for a procedure to remove the problematic tissue. It is important to understand that although panniculectomy does improve the appearance of the abdomen, it is not a cosmetic procedure. It is done primarily for relief of symptoms and for patients who are at high risk due to previous abdominal surgery, prior hernia repairs, or obesity. All the tissue on the lower abdomen that can be pinched together is removed without lifting up the tissues, tightening the abdominal muscles, or recreating the belly button.

Circumferential Body Lift (Belt Lipectomy)

This procedure rejuvenates and reshapes the tummy, lower back, buttocks, and outer thighs. The incision goes all the way around the waist like a belt. Commonly performed after weight loss over 50 pounds, up to 15 to 25 pounds of skin and fat can be removed during a belt lipectomy.

Risks of Abdominoplasty (Tummy Tuck) Surgery

Infection – This can vary from a small amount of redness on the skin that may require antibiotics by mouth to a pocket of infection that requires surgery and admission to the hospital for IV antibiotics.

Bleeding – A small amount of bleeding may cause bruising and swelling. Rarely, bleeding is severe enough that you need surgery to stop it.

Blood Clots – After surgery blood clots can form in the veins in the leg. They can cause swelling, and they can break off and travel to the lungs where they can be fatal. Smoking, surgery time over 4-6 hours, and inactivity after surgery increase the risk. This is a rare but serious risk of surgery, and I take every precaution to ensure your safety.

Poor wound healing – This is more common with smokers, patients with diabetes or obesity, and patients with poor protein intake which can occur with rapid weight loss or extreme dieting.

What to expect after Abdominplasty

After surgery, you will wake up with small drainage tubes placed under the skin. Your body produces fluid after surgery, and the tubes help drain the extra fluid and help the tissue stick back down. The longer your incisions, the more drains you will have (one or two for a mini tummy tuck and four or more for a belt lipetomy. The drains stay in place as long as they are draining more than 20 to 30 ml a day (about 1/8 cup). There will also be a binder to reduce swelling and to help the tissue heal smoothly. Whether your surgery is done on an outpatient or inpatient basis will depend on the extent of surgery and your health risk factors. Either way, you should arrange for someone to drive you home after your surgery and to help you out for a day or two after you leave the hospital. 
For the first few days, your abdomen will be swollen and uncomfortable, which can be controlled by prescription pain medication. These medications can cause constipation, so I recommend you use over the counter stool softners to help prevent this. Depending on the extent of the surgery, you may be released within a few hours or you may have to remain hospitalized for one or two days after surgery. You should start walking the day of surgery to prevent blood clots even though you may not be able to comfortably stand up completely straight for about a week after surgery. 

 It may take you weeks or months to feel like your old self again. If you start out in good physical condition with strong abdominal muscles, recovery from abdominoplasty will be much faster. Some people return to work after two weeks, while others take three or four weeks to rest and recuperate.

 Your scars may actually appear to worsen during the first three to six months as they heal, but this is normal. Scars which are red and raised can take nine months to a year before they flatten out and lighten in color. While they'll never disappear completely, abdominal scars will not show under most clothing, and even under bathing suits and underwear.

Thigh lift

After weight loss and due to gravity over time, the skin of the inner thighs can become loose and hang. You may be frustrated with how you look in clothing and feel self conscious wearing shorts, bathing suits, and tight pants. You may even have symptoms like infections, rashes, and difficulty exercising. Thigh lift with or without liposuction can help improve the shape of your thighs and how you feel about yourself.

Techniques of Surgery

Each surgery is individualized depending on the amount of extra skin and fat and the amount of improvement desired.

Incisions - If there is only a small amount of extra skin at the top of the thighs and no extra tissue closer to the knees, there will be an incision hidden near the groin crease. If you have extra skin all around the thighs, then you will need to have an incision shaped like the letter L that goes from just above the knee to the groin and then along the groin crease. If you want to address all the skin around the thighs, you may consider a circumferential thigh lift (incision goes all the way around the thigh) or a lower body lift (link) which also addresses the abdomen.

After the incision has been made, I will gently elevate the skin and fat off of the underlying thigh muscles. The extra skin and fat is removed, and the skin is redraped over the underlying muscles. One or more drains may be placed beneath the incision. These slender tubes assist in draining fluid that accumulates beneath the incision and delays healing.

The incisions are carefully closed with multiple layers of strong sutures to minimize your scar. All of the sutures are beneath the skin and are absorbed by your body so they will not have to be removed after surgery.

A sterile dressing is applied to the incisions, and a compression garment is placed over your thighs. This compression garment helps support your legs during healing, decreases postoperative swelling, and helps decrease bruising.

Liposuction - If you have extra skin but no extra fat, then a one stage surgery to remove the skin will give you the results you want. If there are fat deposits as well as extra skin, then you may get better results from a two stage approach with liposuction of the inner thighs first and skin surgery at a second stage to address skin that doesn’t shrink over time. Liposuction of the outer thighs can safely be done at the same time as an inner thigh lift. Please click here to read more about liposuction and what to expect after liposuction surgery.

Risks

• Infection – This can vary from a small amount of redness on the skin that may require antibiotics by mouth to a pocket of infection that requires surgery and admission to the hospital for IV antibiotics.

• Bleeding – A small amount of bleeding may cause bruising and swelling. Rarely, bleeding is severe enough that you need additional surgery to stop it.

• Blood Clots – After surgery blood clots can form in the veins in the leg. They can cause swelling, and they can break off and travel to the lungs where they can be fatal. Smoking, surgery time over 4-6 hours, and inactivity after surgery increase the risk. This is a rare but serious risk of surgery, and I take every precaution to ensure your safety.

• Poor wound healing – This is a common complication of thigh surgery due to the length of the incisions and the moist environment near the groin. This complication is even more common with smokers, patients with diabetes or obesity, and patients with poor protein intake which can occur with rapid weight loss or extreme dieting.

• Scarring – Wound healing depends on a combination of surgical technique and how your body naturally heals based on your genetics. That being said, the scars from thigh surgery can be more prominent than for other surgeries for a few reasons. Gravity puts a lot of tension on the suture line and you use your legs a lot which can put further stress on scars. If there are small areas that don’t heal well, they can usually be improved with a small procedure under local anesthetic in the office.

• Numbness – There may be some numb areas after surgery. For most patients it improves to full sensation over several days to weeks. Rarely, there will be areas of permanent numbness or areas of increased sensitivity. It is normal for the incision to itch as it is healing as the nerves recover.

What to expect after surgery

Most thigh lift surgery can safely be done in an outpatient surgery center. You will need to be taken home by a friend or family member. You may choose to stay in the hospital overnight, or you may choose to have us arrange for a private duty nurse to care for you in the comfort and privacy of your own home. Antibiotics will be prescribed, and you should take them twice daily beginning on the evening prior to surgery. Continue this medication until it is gone. Pain medication will also be prescribed and should be taken fairly regularly, every four hours or so, during the first twenty-four hours (when you are not asleep, of course). These pain medications can cause constipation, so I recommend you use over the counter stool softners to help prevent this. The dressings will be taken off in the office a few days after surgery, and the drainage tubes will be removed when the drainage is minimal. You should plan to take it easy following your surgery. No strenuous activities, heavy lifting (over 10 pounds), aerobic exercises, swimming, contact sports, tennis, or golf should be planned for the first three weeks. You should wear the compression garment for three weeks following surgery. You will see some results instantly after surgery, but it can take 6-12 months to see the final contour and scar.

Brachioplasty (Arm lift)

After weight loss and due to gravity over time, the skin on the upper arms can become loose and hang. You may be frustrated with how you look in clothing and feel self conscious wearing t-shirts, tank tops, or shirts with tight sleeves. You may even have symptoms like infections, rashes, and difficulty exercising. An arm lift with or without liposuction can help improve the shape of your arms and how you feel about yourself.

Techniques of Surgery

Each surgery is individualized depending on the amount of extra skin and fat and the amount of improvement desired. Incisions - If there is only a small amount of extra skin improvement can be made with a small incision near the armpit. If you have a larger amount of extra skin, then you will need to have an incision shaped like the letter L that goes from just above the elbow to the armpit. The incision can even extend down the chest wall to remove extra tissue there. After the incision has been made, I will gently elevate the skin and fat off of the underlying arm muscles. The extra skin and fat is removed, and the skin is redraped over the underlying muscles. One or more drains may be placed beneath the incision. These slender tubes assist in draining fluid that accumulates beneath the incision and delays healing. The incisions are carefully closed with multiple layers of strong sutures to minimize your scar. All of the sutures are beneath the skin and are absorbed by your body so they will not have to be removed after surgery. A sterile dressing is applied to the incisions, and a compression garment is placed around your arms. This compression garment helps support your arms during healing, decreases postoperative swelling, and helps decrease bruising. Liposuction - If you have extra skin but no extra fat, then a one stage surgery to remove the skin will give you the results you want. If there are fat deposits as well as extra skin, then you may get better results from a two stage approach with liposuction first and skin surgery at a second stage to address skin that doesn’t shrink enough over time. Please click here to read more about liposuction and what to expect after liposuction surgery.

Risks

• Infection – This can vary from a small amount of redness on the skin that may require antibiotics by mouth to a pocket of infection that requires surgery and admission to the hospital for IV antibiotics.

• Bleeding – A small amount of bleeding may cause bruising and swelling. Rarely, bleeding is severe enough that you need additional surgery to stop it.

• Blood Clots – After surgery blood clots can form in the veins in the leg. They can cause swelling, and they can break off and travel to the lungs where they can be fatal. Smoking, surgery time over 4-6 hours, and inactivity after surgery increase the risk. This is a rare but serious risk of surgery, and I take every precaution to ensure your safety.

• Poor wound healing – This is a common complication of thigh surgery due to the length of the incisions and the moist environment near the groin. This complication is even more common with smokers, patients with diabetes or obesity, and patients with poor protein intake which can occur with rapid weight loss or extreme dieting.

• Scarring – Wound healing depends on a combination of surgical technique and how your body naturally heals based on your genetics. That being said, the scars from thigh surgery can be more prominent than for other surgeries for a few reasons. Gravity puts a lot of tension on the suture line and you use your legs a lot which can put further stress on scars. If there are small areas that don’t heal well, they can usually be improved with a small procedure under local anesthetic in the office.

• Numbness – There may be some numb areas after surgery. For most patients it improves to full sensation over several days to weeks. Rarely, there will be areas of permanent numbness or areas of increased sensitivity. It is normal for the incision to itch as it is healing as the nerves recover.

What to expect after surgery

Arm lift surgery can safely be done in an outpatient surgery center. You will need to be taken home by a friend or family member. You may choose to have us arrange for a private duty nurse to care for you in the comfort and privacy of your own home for the first few days after surgery. Antibiotics will be prescribed, and you should take them twice daily beginning on the evening prior to surgery. Continue this medication until it is gone. Pain medication will also be prescribed and should be taken fairly regularly, every four hours or so, during the first twenty-four hours (when you are not asleep, of course). These pain medications can cause constipation, so I recommend you use over the counter stool softners to help prevent this. The dressings will be taken off in the office a few days after surgery, and the drainage tubes will be removed when the drainage is minimal. You should plan to take it easy following your surgery. No strenuous activities, heavy lifting (over 10 pounds), aerobic exercises, swimming, contact sports, tennis, or golf should be planned for the first three weeks. You should wear the compression garment for three weeks following surgery. You will see some results instantly after surgery, but it can take 6-12 months to see the final contour and scar.

Labiaplasty

Many women feel self conscious about the appearance of their genitalia. Some even have symptoms that make it difficult to wear tight pants, exercise, ride on a motorcycle or bicycle, or enjoy intercourse without pain. Luckily, there is a simple surgery to improve both the appearance and symptoms related to an over-sized or asymmetrical labia. The procedure is usually done under local anesthesia in the office after you have taken oral medication for pain and anxiety. Alternatively, some patients choose to use a surgery center where IV anesthesia is used. There will be discomfort and swelling for 1-2 weeks, which is controlled with prescription pain medication. Depending on your job you may be able to go back to work in as few as two of three days. Stitches dissolve on their own within a few weeks after surgery. You should refrain from resuming all normal activities for 4-6 weeks after surgery.

Risks

Any surgery carries with it a risk of infection or bleeding. Serious infection and bleeding are extremely rare with labiaplasty. Additional risks with include asymmetry, delayed wound healing, and excessive scarring.