Gynecomastia

Dr.Alexander Aslani, Specialist Plastic surgeon and Head of Department of Plastic Surgery in Hospital Quiron Malaga, on the most important facts around male breast reduction:

Whilst it is difficult to verify exact statistics, it seems that gynecomastia (male breast reduction) is the most frequent request for cosmetic surgery among males, competing with liposuction and rhinoplasty.

There is a multitude of reasons for the condition, we have clearly identified a few drugs causing it, I personally see increasing numbers of steroid abusers.

Other common culprits causing gynecomastia are a couple of antihypertensive drugs, hormonal problems, and often, simply genetic predisposition to gynecomastia (in other words bad luck).

What is the ideal age for operating a gynecomastia?

There is none because the problem can occur at very different ages. Depending on the cause, the ideal age is when the condition becomes unbearable for patients. The most difficult question is normally what to do with young patient. Whilst cosmetic operations on miors are obsolete, gynecomastia is not strictly cosmetic and psychological distress can be unbearable.

Under these circumstances psychological distress for patients may well be unbearable and needs relief.

Does social insurance pay for gynecomastia ?

That depends. Some insurers, at least in Spain, accept grade II+ grades as medical indications. This reflects my opinion a swell, certain degress of gynecomastia are rather resonstructive by nature than cosmetic. Not all insurers share my opinion though.

In Spain the majority of cases are treated outside the social insucrance system,

Can gynecomastia be solved by liposuction alone?

In selected cases yes.In most cases resection of breast gland will be necessary.However, this depends always of the individual case. As a rule of thumb, being deliberately vague, one can say that the older you are the more fatty tisuue you will find and the more likely liposuction alone will be successful. Breast reduction can normally not be satisfactorily achieved by liposuction alone in younger pateints. In older patients with drug-induced gynecomastia it may well be possible to do lipsuction only.

What scars are involved ?

Depends. Normally a semilunar (half nipple) scar at the lower border of the nipple. I usually discuss two possible proceedings with patients: first the resection of glandular tissue (mastectomy) and , possibly later, as a second step tightening of the skin.

In the majority of cases I see sufficient skin retraction without going back to convential procedure.

If secondary skin tightening is necessary secondarily, then the scar will normally go circular around the nipple. This will only be necessary in very advanced gynecomastia cases, since in most cases skin retraction is very good.This can never be guaranteed though, but my experience is that it is preferable management of male breast reduction.

What is the biggest problem around gynecomastia ?

Recurrence. The gland behind the nipple needs to be resected in true gynecomastia cases, some part of it will usually remain and possibly lead to recurrence. Overly aggressive resection of the gland will usually lead to a dimpling nipple.

What is recovery time after a gynecomastia operation ?

Usually very short, defintely depending on the extent of resection. I like to use a compression garment of a minimum of two weeks post surgery, possibly longer.

What are the risks in gynecomastia surgery?

The main problem is insuffucient skin retraction and irregularities, mostly behind the areola. This can normally corrected by scar release and further skin resection.

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Round block breast uplift techniques

The Benelli breast uplift (concentric, or peri-areolar or doughnut lift)
This technique is considered less invasive and was designed with the scars being around the areolae. With the Benelli, a donut shaped piece of tissue around the areola border is removed and the surrounding tissue sutured to the areola. The incisions are normally closed with purse string sutures. Sometimes a little more tissue is removed above the areola (like the crescent) to compensate for a lifting effect when it is sutured. The Benelli lift results in a flatter, rounder breast shape post-operatively as opposed to a sloped breast. The flatter aspect after the uplift is, however, temporary, and given time to settle a pleasant effect does ususally occur quickly.

The Benelli breast uplift can be combined with breast augmentation in cases of moderate ptosis(saginess) of the breast and a very empty skin envelope.

Areola Reduction Surgery
Some women may be displeased with the size of their areolae which may be enlarged due to genetic predisposition, previously having had large breasts then undergoing tissue loss, stretching of the areola due to implants or other reasons. The areola reduction surgery is designed to remove the redundant areola tissue to improve the overall cosmetic appearance of enlarged areolae. The reduction may result in a slight lift and may also produce slight irregularities at the incision line if the reduction was significant.

Again the approach can be combined with  breast augmentation via implants

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Is breast augmentation combined with uplift a safe procedure ?

Breast augmentation mastopexy,which means a breast uplift combined with  breast augmentation with implants is probably, apart perhaps from rhinoplasty, the most demanding procedure in aesthetic surgery.

“There is a lot of misunderstanding around this operation,and whilst it may be extremely rewarding, patients need to understand the complexity of the operation to adequately appreciate the results “, says Dr. Alexander Aslani, who is head of department of Plastic surgery, Hospital Quiron, Malaga.
He has extensive experience with breast augmentation with mastopexy, because it is one the most frequently demanded operations within cosmetic surgery in Spain.

Indication for a breast uplift is breast ptosis (sagginess) of the breast, most commonly following weight loss and pregnancy.

This results in an empty skin envelope with no appropriate filling. The concept of the operation is to tackle the problem from two sides: firstly to tighten the skin envelope and secondly to fill it appropriately with a breast implant.
“The change can be very impressive and patient satisfaction is very high, however, depending on the degree of sagginess, a certain amount of scarring will be necessary,” says Dr.Aslani.”I normally advise patients that shape of the breast is much more important to patients than scarring in the long run, but scarring will be involved.
To what degree does very much depend on your skin type, the fairer the skin the better the result.”
There are still surgeons promoting a two-stage approach, which means doing the mastopexy in one go and then the implant placement in the next.
“The advantage of this is that the tissue reaction is more predictable” so Dr. Aslani.”On the other hand patients always need two operations. In my experience, although I completely agree that the overall revision and complication rate of combined breast implants and uplift is significantly higher than in a plain breast augmentation , it is safe and preferable to do the operation in one go.
There is a higher incidence of infection, wound healing problems, scar revision, that is true, but this is clearly outweighed by the benefit arising to the patient from a one-stage procedure.

My experience is that given that patients are aware of the complexity of such a breast augmentation and breast uplift procudure, they are usually very happy with the fairly impressive change achievable.

There is however a certain chance that both surgeon and patient agree on performing a touch-up procedure like a scar revision, often around the nipple, after about a year has passed.Whilst these are mainly minor procedures that can be done under local anesthetic, scientific literature reports incidence of such requests being as high as 15%.
Especially for UK residents coming to Spain for cosmetic surgery this has to be discussed and born in mind.
The most common misunderstanding within this procedure is the expected change of breast size.
“Uplift and implants combined do not necessarily increase cup size, but rather a preexisting cup-size is filled by proper breast volume than just by an empty skin envelope. It is about changing the shape of breast, not primarily about increasing the size. There must be a good understanding between patient and surgeon beforehand, I always say the patients with breast augmentation with uplift need to be selected very carefully.Especially patients rather wishing bigger breasts need to be advised that there is unfortunately no way to get around gravity in the long term.”
The change in breast shape is quite dramatic and patient satisfaction with the operation generally very high.
However, patient understanding regarding the procedure must be kept very clear.
Whilst scarring, implant positioning and staging were and will remain a controversial topic among Plastic surgeons for a while, the combination of breast implants with breast uplift can,on the other hand, be one of the most rewarding surgeries of all.

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www.cirumed.es

Combine botox with fillers ?

Is something that is highly advisable for different regions, for instance botox for the forehead and for restylane for the nasolabial fold. I do not recommend to combine it for the same region, as often requested for forehaed wrinkles who maybe longstanding and deep and may very well need both botox as well as a filler.

Nevertheless in the forehead it is preferable to first apply botox and secondarily treat with for instance restylane, because it is first advisable to see how the effective the botox is before “filling” the wrinkle. This avoids overdoing and gives the botox a chance to show its full effect.

It is by no means wrong to provide botox for instance with restylane, but stepping the botox treatment up can save considerable amount of substance.

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Reconstructive rhinoplasty after trauma

If patients approach a nose correction after having had an accident, the procedure can be a lot more complicated. Depending on the nature of nasal trauma, in case of multifragmented fractures the osteotomies (which is the correction of the position of the bones) may be less stable than in a primary rhinoplasty. Also, posttraumatic rhinoplastiy esfrequently involve work on the nasal septum as well because septal deviation frequently follows nasal trauma.

This results in a slightly higher risk of secondary dislocation of bones and possibly patients undergoing such a reconstruction may look at waering the nasal splint, which normally needs to be worn for 7 days, for about three days longer. Some  irregularities irregularities may be camouflaged without a full rhinoplasty operation, but with fillers. I prefer to first apply a permanent filler and secondarily a permanent one.

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Will aesthetic medicine rise average facelift age?

Possibly yes, however, aesthetic medicine is a widespread field where different treatments are applied for different symptoms. Aesthetic medicine can definitely not replace facelift surgey on a wider range , but we do observe the average “entrance” facelift age for  being slightly on the rise.

Certain aesthetic medical measures, such as dermal fillers, facial resurfacing and mesotherapy, have a preventetive effect that can withhold the effects of dermal aging but it can not withold the effects of gravity on your face.  I personally feel that in cases of moderate soft tissue sagginess of the face and increasing wrinkling effects effective aesthetic medical measures can herald significant results and enhance appearence, therefore not replacing a facelift, but prolonging the period till such is desired. In patients requiring a facelift, I think the easiest way to describe the difference is to make them aware of the difference between  gravity related changes and changes in the skin structure by aging effects. A facelift tackles the gravity effect, but not the skin structure.

Additionally , the result of a facelift can be considerably enhanced by additional aesthetic measures, so combination of the two can make a lot of sense.

For more information visit our Homepage:

www.cirumed.es

Breast enlargement-what implant to take ?

“There is no easy answer to this question, because not every breast is the same”, says Dr.Alexander Aslani, who is head Consultant Plastic Surgeon of the Cirumed Clinic Marbella and Consultant Plastic Surgeon in London´s Highgate Hospital.

“It depends very much on the breast and , more importantly, on patients preference. Different patients prefer different looks, and this has to be taken into account when planning the procedure.
Generally, The question is where fullness is required….if it is on the upper pole, a round implant may be the better option, especially if the implant is positioned behind the breast muscle, choice of breast implant,but this depends very much on the case.I prefer to show patients pictures with relevant examples, and then we make a choice together .Breast surgery is not just a “boob job” but a very individual and every breast is different and therefore requires different solutions,” says Dr Aslani.

Round implants or anatomical ? Again this this depends, says Dr.Aslani. People perceive that breast enlargement with anatomical implants as more natural.

“Anaomical implants behind the muscle can occasionally look a bit flat on top, if the breast is fairly flat on top in the first place and the muscle rather strong,” so Dr.Alexander.Aslani.

Generally breast augmentation is one of the operations with he highest degree of patient satisfaction, which tends to give patients an enormous boost in self confidence.

Materials used are, without exception, cohesive silicone-gel filled implants.

Breast augmentation/breast enlargment in Cirumed Clinic Marbella continues to be one of the most popular procedures for patients from abroad seeking cosmetic surgery in Spain, the backbone of medical tourism in Marbella.

There is a couple of other procedures breast enlargement can safely be combined with, says Aslani, depending on the nature of the request.

A frequently asked question is….can Breast enlargement be done as a day case ? Yes, it can says Dr.Aslani, but he suggest for patients not to enter without a “plan B” to possibly stay overnight.

How long do breast implants last ?

“At present, we don’t know”, says Dr.Alexander Aslani.”We presume that patients can enjoy the effects of a breast enlargement for as long as there are no problems. Should problems occur, action might naturally have to be taken and the breast implants exchanged”.

Dr.Alexander Aslani, Cirumed Clinic Marbella, Marbella, Malaga, Spain, www.cirumed.es, www.alexanderaslani.com