Gynecomastia is excess breast tissue in men. In a subset of individuals with gynecomastia, there can be redundant or excess skin. The excess skin affects the outcomes following a gynecomastia corrective surgery. It can mean a longer duration to achieve an acceptable outcome. In some cases, we may do additional surgery to take care of excess skin. 


How does skin redundancy present in gynecomastia? 
Redundant skin is usually apparent with a clinical examination. The breast tissue tends to sag in such individuals. The breasts appear deflated. There can be visible folds on the lower part, and lateral areas of the chest. The presence of ptosis or sagging gives an aged appearance to the chest. 


Who are the individuals prone to get skin redundancy associated with gynecomastia? 
The risk factors associated with excess skin in gynecomastia include:

1. Following massive weight loss: Individuals with loss of weight over 25 kg can present with skin redundancy. The weight loss can result in a relative excess of the skin when compared to the breast volume. 
2. Long duration: Gynecomastia in older individuals is associated with a deflated appearance. The ability of the skin to recoil after breast reduction is reduced as we grow older. 
3. Large breasts: These are often associated with obesity. The presence of excess skin is usually apparent after the breasts are reduced following gynecomastia surgery.
4. Smoking: Smokers tend to have reduced ability for skin recoil. The skin recoil tends to be suboptimal when compared to individuals who do not smoke. 

What are the treatment strategies that can be adopted in case of skin excess? 
hereAmong individuals with excess body weight, it is always recommended to lose weight before undergoing a surgical correction. Optimizing the body weight before surgery has certain advantages. It is easier to assess the extent of excess skin before surgery. This makes the surgical outcome more predictable. In some cases, we may opt to undertake skin reduction during the time of gynecomastia correction. With weight loss, patients can benefit from the skin recoil beforehand. 
In an individual, with excess skin, gynecomastia correction can be done in two different ways. It can be done either with skin excision or without skin excess. Both strategies lead to different outcomes. 
When the correction is carried out without a skin excision there may be a postoperative course with an increase in the deflated appearance. This usually improves with time due to the skin recoil. It may take many months before the full extent of skin recoil is appreciated. We usually advise our patients to wait as much as 8 months before deciding on an additional surgery to remove the skin excess. Many patients are usually satisfied with the skin recoil and choose not to have any skin excision procedures. This has the advantage of an initial simpler procedure with shorter scars. Skin excisional procedures are associated with longer and more visible scars. 
The second strategy would include gynecomastia correction carried out with simultaneous skin excision. The pattern of the excision can vary depending on the extent of skin excess. Patients with more excess tend to have a greater amount of skin removed. With this technique, the excess skin is addressed in a single procedure. However, it carries the disadvantage of longer scars. In our practice, this approach is less commonly used. We tend to choose individuals with severe excess for this approach. 


What are the steps that can be taken by an individual to address excess skin? 
The excess skin is usually seen to accompany increased body weight. Individuals should try to maintain their weight close to ideal. This is usually achieved with the help of dietary modifications such as diet and exercise. Weight training helps recruit the excess skin and contributes to reduced sagging over the lower part of the chest. Weight training and accompanying muscle hypertrophy also bring along aesthetic benefits. 


Excess skin is seen in some individuals presenting with gynecomastia. This is more commonly seen in those with excess body weight. The skin excess can be tackled with surgery in a staged or simultaneous way. Both strategies have their advantages and disadvantages. A treatment plan is chosen based on individual preferences and extent of excess skin. Individuals with skin excess can help improve this condition with appropriate dietary modifications and exercise. 

Learn more about gynecomastia here. 

There is an increasing demand for cosmetic procedures with minimal downtime. The advantages are shorter recovery and the ability to return to normal life. One such procedure is non-surgical rhinoplasty. 

What is a non-surgical rhinoplasty? 
It involves the injection of fillers into the nose to bring about a difference in appearance. It has more in common with a filler injection into the face than with a routine rhinoplasty. The 'rhinoplasty' in non-surgical rhinoplasty comes because the filler is being injected into the nose to alter its appearance.  Non-surgical rhinoplasty is also referred to as liquid rhinoplasty. Why 'liquid'? Because the filler that is injected is a liquid. 

What are the advantages of doing a non-surgical rhinoplasty? 
The main advantage of such a procedure would be the minimal downtime. Since fillers are injected the time taken to complete the procedure would be very short and would not need any hospital admission. 

What can be achieved with non-surgical rhinoplasty?
Compared to a surgical procedure, the benefits of a non-surgical procedure are limited. The benefits of a non-surgical rhinoplasty include, 

1. Volume enhancement. The root of the nose (radix) and the dorsum can be enhanced with filler injection. 
2. Improve a drooping tip 
3. Improve minor asymmetry and camouflage small defects 

What are the changes that can't be achieved with rhinoplasty? 
It is not possible to make a large nose smaller using injection non-surgical techniques. It is also not useful for the management of a bulbous tip. It is not possible to improve septal deviations with non-surgical rhinoplasty. Surgical rhinoplasty is the gold standard for the management of the deformities of the nose. 

How long does the effect of non-surgical rhinoplasty last?
When compared to a surgical procedure, the effects of non-surgical rhinoplasty are temporary. In most cases, hyaluronic acid fillers are injected during this procedure. Hyaluronic acid breakdown with time. The effects may last approximately one to two years. In certain individuals, the effects tend to last for a shorter period. In case of an unfavourable result, it can be removed with the help of a hyaluronidase injection. 

What are the risks associated with non-surgical rhinoplasty? 
The risks associated with a non-surgical rhinoplasty are similar to those seen with filler injections into the face. These can include tissue death and involvement of the vessels of the eyes and brain. Skin necrosis results due to impaired blood supply of the skin. Embolization of the filler into the vessels of the eyes can lead to blindness. These adverse events have been reported with filler injections, they are uncommon. 

Who is a good candidate for non-surgical rhinoplasty? 
It would include patients who want a change in the appearance of the nose without any downtime or need for aftercare associated with a conventional rhinoplasty. Patients should have realistic expectations and understand that not all deformities can be improved with a non-surgical rhinoplasty. The effects are temporary and need repeat injections for maintenance of the results. 
For more information about rhinoplasty please visit: www.amicusclinic.in/rhinoplasty

Secondary corrections refer to operations undertaken to improve the outcome after primary surgery. Secondary corrections for gynecomastia are done to improve the appearance of the operated site.

Some of the deformities that may be corrected with secondary surgery include the following: 

1. Asymmetry: Minor degrees of asymmetry can be seen in most cases of gynecomastia. They may arise as a result of the differences in the breast or the underlying muscles and skeleton. Surgery is useful in the former type. 
2. Residual gland: During gynecomastia correction, a disc of the gland is left underneath the areola. Complete removal of the gland can lead to other deformities. However, in a small number of some individuals, this may be associated with a recurrence of gland enlargement. Recurrence is more common among younger individuals. This can be corrected by secondary gland excision.   
3. Irregularities of the treated area. Some irregularities of the treated areas are common in the initial months following surgery. This is a result of scarring of the tissues following surgery. Such irregularities usually improve with time. Irregularities persisting beyond a year can be treated with the help of liposuction and fat grafting. 
4. Excess skin. Excess or redundant skin of the breasts is usually seen in two types of patients. One, in those, underwent massive weight loss. These patients may have lost more than 20 kg in a short period and have redundant ptosis or sagging of the breast during the presentation for primary correction. Two, in individuals with large breasts. This can cause a deflated appearance after liposuction and gland excision. After a gynecomastia correction, the skin recoils and adjusts to the new contours. However, this may be inadequate in some. Such patients can be treated with skin removal surgery. These corrections would involve long scars.  
5. Scar revision. The scars of a primary gynecomastia surgery usually settle without much deformity. However, the scars involving skin outside the areola may have pigmentation and texture abnormalities. In case of minor deformities, they are managed with medicines and topical applications. Some of the scars can be improved with surgical scar revisions. 

Timing of secondary corrections of gynecomastia. 
We usually wait for a year before undertaking secondary corrections. This has some advantages. They include the following,

1. Remodeling of the scar. In addition to the visible scar over the skin, gynecomastia surgery leads to scarring in the deeper tissue planes. These scars change with time. This phenomenon is known as remodeling. The operated areas can feel firm and nodular in the first few months following surgery. They soften with time and do need any particular treatment in most cases. 
2. Skin recoil. Skin recoil takes time. We tend to stage skin removal in those presenting with skin excess for two reasons. One, they may not be warranted since the skin recoil may be adequate at the end of a year. Two, removal of skin leads to lengthy scars. These may be easily noticeable. 

 Various procedures are undertaken during secondary gynecomastia corrections. These may be carried out in isolation or as a combination. They include, 

1. Liposuction. This can help treat any step deformity and persistent irregularities of the chest. 
2. Fat grafting. Fat grafting is useful to treat contour defects. The fat may be harvested from the adjacent regions or distant parts of the body. Fat grafting is usually not combined with open gland excisions. 
3. Gland excision. This is sometimes carried out when there is a residual gland or during a recurrence. The gland is usually removed by an areolar incision. 
4. Skin removal surgery. This is carried out when there is the persistence of skin excess beyond a year. The pattern of skin removal is determined by the severity of excess skin. The different patterns of the skin include those of a doughnut shape and ellipse. The resulting scar may be at the junction of the areola and surrounding skin or may extend downwards. 

A surgical plan is based on the appearance of the deformity and concerns of the patient. In other words, such plans are customized. Two patients with a similar-looking deformity may undergo different types of surgical correction. A realistic expectation is important since it is usually only possible to make some improvements in the appearance. Also, secondary corrections are usually taken after a year following the primary surgery. During this period patients can help optimize their appearance by the following activities. 

1. Healthy diet. Having a stable weight close to the ideal body weight helps in skin recoil. 
2. Avoid smoking. Smoking impairs skin recoil. 
3. Exercise. Weight training improves muscle volume and this additional volume can recruit excess skin. This lessens the sagging of the chest skin. 

Secondary corrections of gynecomastia can help improve the appearance of selected individuals. 

For more information about gynecomastia please visit: https://www.amicusclinic.in/gynecomastia

I could also have gone for a title called ‘why am I fond of syringe liposuction?’. Liposuction is a technique in cosmetic surgery for removing fat cells from certain parts of the body. The fat cells amenable to liposuction are between the skin and muscles. We do not perform liposuction on fat deeper than the muscles. Liposuction may be part of another procedure like abdominoplasty or gynecomastia correction. 


Liposuction involves the creation of a vacuum. This vacuum helps remove fat cells with small cannulas. Such cannulas are called liposuction cannulas. Cannulas vary depending on their diameter, length, and shape of openings near the end. We use different types of cannulas based on the area treated.  


During liposuction, a vacuum is obtained by a machine or a syringe. Syringe liposuction employs a syringe for generating liposuction. A cannula is attached to one end of the syringe. After insertion of the cannula inside the body, the surgeon pulls back the piston and locks it in place. The vacuum created inside the syringe helps move the fat cells into the syringe during to and fro movement. Once the syringe gets filled, the cannula is disconnected and the fat is emptied. The same process gets repeated till the desired endpoint is reached. This constitutes syringe liposuction. 


Syringe liposuction is a simple technique with a lot of benefits. This makes it popular among many practitioners. Some of the benefits include the following, 

1. Precision. Syringe liposuction enables the exact measurement of the aspirated fat. This helps correlate fat aspirated from both sides of the body. In the case of pre-existing asymmetry, the aspirate can be adjusted to improve the symmetry. This is more difficult to achieve with conventional liposuction in which the fat is collected in a large canister. 
2. Combination with fat grafting. Fat grafting is done to correct deformities of liposuction or pre-existing asymmetries. Since the aspirated fat is collected in syringes, it does not require any complex processing for it to be injected back into the body.  
3. Lower cost. The disposables used in syringe liposuction are not expensive. It does not involve any costly equipment. This helps reduce the cost of the procedure. 
4. No sound or smoke. The absence of any electrical moving parts makes this a very quiet and smoke-free procedure.

Syringe liposuction was introduced by Toledo in 1989. The advantages of this technique make it very endearing to some practitioners of liposuction. One of them includes me.  

For more information about liposuction, please click here.

For more information about gynecomastia, please click here. 

​Do I have gynecomastia?

'I don't know if I have gynecomastia. Maybe it is fat. So, I came.' 

I hear this often in my practice. Gynecomastia is male breast enlargement. It can be diagnosed easily because of its appearance. But sometimes, the presentation can be a bit confusing. 

The breast tissue is seen under the nipple and areola. The areola is the pigmented skin immediately surrounding the nipple. Depending on the severity of enlargement, gynecomastia can present as puffiness of the nipple and areola, or it can extend towards the sides of the chest. It can affect one side or both sides. Both sides can look different.  In other words, there can be asymmetry. 

The word, ‘gynecomastia’ comes from ‘gyneco’ and 'mastia'. 'Gyneco' means female, and ‘mastia’ means breast. Thus gynecomastia translates into the female-looking breast. This occurs due to an enlargement of the breast tissue. Compared to female breasts, male breasts are positioned more laterally (meaning to the side of the chest). Hence, the deformity of gynecomastia is also especially pronounced when viewed from the side. 

Hypertrophy of the underlying muscle (pectoralis major) looks different from that of the breast. The muscle animates (moves) in certain maneuvers. This means the muscle contracts during certain activities like flexing the arm against resistance. Also, the lower border of the muscle usually stops at the level of the nipple. Any enlargement that significantly extends below the level of the areola is usually due to breast tissue. The lower border of the muscle is straight or flat. This is easily made out in men who perform weight training. The presence of breast tissue tends to make the inferior border curved. The curved lower part of the breast gives it a feminine appearance. 

It is also possible to pinch the breast tissue separately from the underlying tissues. We usually carry this out during a clinical examination of an individual presenting with gynecomastia. Puffiness of the nipple and areola is also associated with enlargement of the breast tissue. It is not associated with hypertrophy of the underlying muscle. 

There is an entity called pseudogynecomastia. ‘Pseudo’ means false. This is due to increased fat deposits in the chest. There is no glandular enlargement in pseudogynecomastia. It is usually seen in the setting of obesity with fat deposits that mimic the appearance of male breast enlargement. Losing weight will lead to an improvement in the deformity associated with pseudogynecomastia. 

It is usually simple to diagnose a case of gynecomastia during a clinical examination. We sometimes request additional investigations to look for any underlying cause for gynecomastia. Imaging can help us to confirm the condition. Most cases of gynecomastia are benign and are self-limiting. Surgery is undertaken when gynecomastia results in significant distress in the affected individual. 

To learn more about gynecomastia, please visit, ​https://www.amicusclinic.in/gynecomastia

Recently I was asked about home remedies for scars. I usually don't suggest any. Some of my patients describe the benefits of certain types of oils. I do not promote or recommend the use of any particular type of medication on settled scars. Also, I do not caution them against the use of any particular oil. 

But there is a definitive role of certain conservative measures that can help improve scars. They are not advised in all cases. The effect of these measures should be understood by those using these. They should be carried out as per the guidance of the treating doctor. Some of the commonly advised measures for scars include the following,

1. Application of silicone sheet. Continuous application of silicone sheets is useful in individuals prone to develop prominent scars. Prominent scars include hypertrophic scars and keloids. It is common for patients to be advised to apply a silicone sheet for up to 3 months. For individuals who can't use silicone sheets, silicone can be applied as a topical gel. 
   
2. Pressure garment or band. This is also useful in individuals prone to develop prominent scars. They should be applied continuously for maximum benefit. Pressure garments may be advised for periods up to 18 months in certain situations.
   
3. Massage. Indications of massage vary. In certain situations, they can be useful. In others, we advise them not to massage the scars. Gentle massage is advised after injuries to limbs. When carried out properly they can help improve the pliability of tissues and range of motion. We usually advise against massage in the face. Facial scars can get stretched out after massage in certain situations.  
   
4. Sunscreen and sun protection. Most of us tend to tan easily when exposed to the sun. The scars can also become dark when exposed to sunlight. This can be prevented to some extent by the use of sunscreen and avoiding direct contact with sunlight. The use of goggles, caps, or protective clothing is recommended. 
   
5. Taping. Surgical tapes are sometimes used to reinforce a wound closure. They are commonly used in highly mobile areas. Scars associated with lower eyelids are often taped during the postoperative period. This helps avoid scar stretching and reduces secondary deformities. Tapes also have a role in reducing swelling. Tapes can be easily applied by patients.
   

Certain other non-surgical measures are carried out to help improve a scar. Examples would include laser and intralesional injections. But these are carried out by a doctor. Even though home remedies may not have many roles for optimizing scars, certain conservative measures are frequently advised. Most of them help in scar remodeling. 

​

Rhinoplasty is a commonly known plastic surgery procedure to improve the appearance and function of the nose. The function of the nose relates to breathing. As in all surgical procedures, complications can happen. The goal of preoperative evaluation is also to seek out any potential problem. But despite the best efforts, complications can occur. 


The incidence of the complications varies. It can vary depending on the type of procedure, and patient factors. It is more common to have a greater incidence of complications in difficult (challenging) cases. Some of the complications are uncommon when compared to others. The complications can be seen under those that are nonspecific to rhinoplasty and those specific to rhinoplasty. 


The nonspecific complications can occur in any surgical procedure. It need not be in rhinoplasty alone. These include, 

• Infection: These are uncommon in rhinoplasty. But when they happen, they tend to be serious and can impair a surgical outcome. 
• Prominent scars: These are uncommon. However, more common would be a scarred appearance of a nose that has undergone multiple rhinoplasties. 
• Delayed healing

The specific complications of rhinoplasty are those related to aesthetic (appearance) and functional (breathing).


The aesthetic complications include, 

• Asymmetry: This could be a worsening of a pre-existing asymmetry. 
• Dissatisfaction with the appearance. This could be due to the appearance of the tip, dorsum, projection, width, base, and various other parts of the nose. It is a reason for revisionary or secondary corrections. 

Swelling is usual after rhinoplasty. The various layers of the nose are swollen. This includes the outer skin, lining mucosa, and the structures in between these two layers. Swelling subsides with time. Even though most of the swelling settles by a month, the residual swelling lasts longer. This can take about a year or longer to subside. Hence, any decision to undertake revisions is taken after this period.  


Functional problems associated with rhinoplasty include, 

• Difficulty with breathing. It is common to have difficulty in breathing during the initial weeks due to swelling of the inner lining of the nose. There would be an improvement in the breathing as the swelling subsides. So any evaluation for persistent difficulty in breathing is carried out after this period. 
• Septal perforations. The septum is the midline structure that separates the two sides. This can undergo perforations. This is more common in previously operated noses. Septal perforations of the posterior (back) and those that are asymptomatic are usually left alone. The symptomatic perforations can need revisionary procedures. 

Some of the complications are more serious when compared to others. Also, the difficulty level in performing a rhinoplasty can vary depending on the presentation. It is also more so in previously operated noses. It is not possible to eliminate the possibility of complications. However, it is usually possible to reduce their incidence with careful planning and attention to detail. 

For more details about rhinoplasty, visit here.