Gynecomastia is an enlargement of the male breast. It is a common condition. Surgical correction of gynecomastia achieves a reduction in the excess breast tissue. A reduction in the breast tissue helps improve the aesthetics of the male chest. In most cases, surgery involves liposuction and gland excision. Liposuction addresses fat, and direct removal addresses the gland. These two steps are usually adequate for most individuals with gynecomastia. However, this may be insufficient to restore the aesthetics in those with excess skin. They may require additional treatments.
The stretched-out skin usually recoils adequately after reduction in most of the individual. The problem relating to excess skin is observed commonly in two subsets of patients. They are,
How do we manage excess skin while treating gynecomastia?
The treatment approach depends on the presentation. We tend to follow a conservative wait and watch in younger individuals, and those with a less severe presentation. This is because of better skin recoil in younger individuals. Also, the removal of the gland will reduce the effect of the weight on the skin. This helps the skin to recoil better. It is common practice to wait for more than ten months to assess the full extent of skin recoil. Any secondary corrections are done after this period.
The conservative approach may not help in older individuals and those with severe forms of excess. In such cases, we may opt to add a skin removal procedure during the management of gynecomastia. Good candidates for primary correction of the skin would include nonsmokers. They must have a stable weight. Skin removal procedures in those with unstable weight may result in suboptimal outcomes.
The design of the skin excess is variable. This is based on the extent of skin excess and patient preferences. A circumareolar (around the areola) approach is preferred in milder cases. In individuals with severe excess, we prefer extensile (long) incisions with the grafting of the nipple and areola. Needless to say, individuals with longer incisions have longer scars.
What is the advantage of staging a skin removal procedure?
In other words, why wait between a gynecomastia correction and a skin excisional procedure.
Skin can recoil significantly with time. It may not be able to predict the full extent. Adequately recoiled skin results in acceptable aesthetics. The full extent of skin recoil after gynecomastia correction takes time. Avoiding a skin removal procedure means lesser scars. However, this approach may not be suitable in those with severe forms of skin excess.
Are there any approaches to prevent this issue with excess skin?
They would include the following.
Avoiding excess body weight. The excess skin problem is not common in individuals with normal or ideal body weight.
Early treatment of gynecomastia. The ability of the skin to recoil reduces with age.
Smoking is bad for skin recoil. Nonsmokers tend to have better outcomes when compared to smokers.
What is the advantage of managing the excess skin in individuals with gynecomastia?
It leads to better aesthetic outcomes.
For more information about gynecomastia please visit here.
Should one lose excess weight before a body contouring surgery? Or should it be postponed to sometime after the surgery? Many of the patients I come across seem to have this dilemma. It is common for individuals to delay losing any excess weight until after the surgery.
Does it make any difference if the excess weight is reduced before or after liposuction? It does make a difference. It is better to lose excess weight before rather than after the surgery. This is best achieved with a healthy lifestyle. Both exercise and adequate diet play an important role.
What are the reasons? A few of them would be as follows,
Hence, it is better to bring the bodyweight close to ideal before undergoing a fat reduction procedure. Liposuction or lipoplasty can then help target resistant fat.
To summarise, should one lose excess weight before a body contouring procedure? Yes. It has its benefits. Ideally, weight loss is attained using sustainable lifestyle modifications. It is associated with better outcomes and lesser complications. They continue to reap the benefits of the procedure long after the surgery.
ClicA cyst refers to a bag like swelling. Epidermoid cysts are among the most common skin swellings found in the human body. They are not life-threatening nor do they spread to another part of the body. These cysts are formed when the cells of the outer layers of the skin get trapped deep within. When this happens, the cells instead of getting shed outside the body organize themselves into a bag like swelling. Even though benign, an epidermoid cyst can be troublesome.
How does an epidermoid cyst look?
An epidermoid cyst usually presents as a skin lump. The overlying skin is usually unremarkable except for a small area of discoloration due to a punctum. Usually, a sebaceous cyst is not painful. However, once in a while they can get inflamed. And during inflammation, the cyst becomes painful to touch.
The size of a sebaceous cyst can vary.
Why do we remove an epidermoid cyst?
It is usually removed for the following reasons:
How are epidermoid cysts removed?
An epidermoid cyst is usually removed under local anesthesia as an outpatient procedure. It does not require an inpatient stay.
The swelling is removed with a small ellipse of the skin that contains the punctum. The wound is closed with the help of a few sutures. A modified approach involves the avulsion of the cyst wall through a small incision. This may be suitable for some individuals. In most cases, individuals have an uneventful recovery.
Liposuction is among the more popular procedures done by a plastic surgeon. Liposuction is carried out as a single procedure or in combination with other surgical procedures. Some individuals refer to it as the 'keyhole' surgery for gynecomastia.
Liposuction has certain advantages over open or conventional surgery. These include small incisions, faster recovery, and less postoperative discomfort. Liposuction can be carried out both under general or local anesthesia. Doing liposuction under local anesthesia has certain benefits.
So, what are these benefits?
The important ones include,
Are there any differences in technique with liposuction under local anesthesia?
There are a few differences.
Firstly, the patient is awake, and the monitoring of the patient is simple. When done in an awake patient, it takes longer to complete the procedure. There are a few reasons for this. The initial infiltration of the anesthetic solution in the treatment areas is done in multiple steps and takes longer to complete. Also, we prefer the use of smaller cannulas for infiltration and fat aspiration (suction). We usually use cannulas of sizes 3 mm or below in an awake individual. Due to the smaller cannulas, the aspiration of fat takes more time to complete. Liposuction in the awake individual is more gentle.
Who is the right candidate for liposuction under local anesthesia?
Almost all candidates for the procedure under general anesthesia are also good candidates for the procedure to be carried out under local anesthesia. However, if the patient is very anxious or has a fear of needles they may not be a good candidate for local anesthesia alone. Such individuals would be better suited for general anesthesia.
To summarize liposuction, in awake patients has a better safety profile. It has the added benefits of a faster recovery, and this also makes it suitable as an outpatient procedure.
For more information about liposuction click here.
Pressure sores tend to occur in bedridden individuals. It is more common among the elderly, though persons of any age can get affected. Pressure sores could be as a result of spinal injury or any prolonged debilitating illness. It is a cause of increased stress in the affected individual and caregivers. It results in increased medical expenses.
Proper care can help us reduce the incidence (prevent) and achieve early healing of pressure sores. The following three aspects form an important part of care among individuals at risk of developing a pressure sore:
The onset of a skin breakdown must be viewed seriously. It may not be possible to eliminate all of the risk factors that can lead to a pressure sore. However, with adequate care, it is possible to prevent this condition.
You can learn more about pressure sores here.
Removal of small skin swellings is common in our practice. Patients usually get them removed for the following two reasons,
In most cases, removal of the swelling is a simple and straightforward procedure. It is usually carried out under local anesthesia in adults. Patients usually go home after the procedure and follow up as an outpatient for inspection of the wound and suture removal. In case a biopsy was done, the case is reviewed once again after the biopsy report.
One of the reasons why patients come to a plastic surgeon is due to the concerns relating to the postoperative scars. In other situations, the referrals are due to the relative difficulty in obtaining closure in regions such as folds near the eyes, mouth, or nose. In the majority of cases, we remove the swelling with a small margin of skin. This can vary based on the type of swelling. Some of them mandate a narrow margin while others require a wider margin. This is based on clinical presentation. Additional pre-operative investigations may be ordered in some cases.
The removal of swellings consists of two parts. First is the removal, resulting in a wound. And the second is the closure wherein the tissues are approximated to achieve optimal healing. In most cases, the second part is done with a straight line closure. However, this may not be possible in certain situations. This may be due to wide separation between the wound edges, or proximity to regions such as eyes, nose, or mouth. In such situations, we resort to techniques such as skin grafts or flaps. We make intelligent use of neighboring or distant tissues to effect good closure. Some of the swellings may not arise from the skin. They may originate from other structures like fat. Removal of such swellings gives us some liberty concerning the placement of the surgical wounds. Some orientation of the surgical scars may be associated with a better outcome compared to others. Knowledge about the orientation of optimal incision lines helps us give a better looking postoperative scar.
Removal of these swellings is associated with a good outcome in most individuals. A small subset of individuals tends to have problem scars. It is usually possible to predict the scarring tendency of an individual by observing previous scars on the body. Two possible adverse outcomes related to the tendency for stretched out scars and hypertrophic scars. Though scar hypertrophy can be treated, patients need to be aware of such a possibility.
Removal of skin swellings is a minor and safe surgical procedure with very little downtime. With good technique, it is possible to get good outcomes in most individuals.
For more information on skin procedures, click here.
Patients with gynecomastia have increased gland in addition to the fat. Fat is found both within the glandular tissue and immediately underneath the skin. Fat in both these places contributes to the deformity. In an overweight individual, the proportion of fat is more than that of a person with ideal body weight. During the surgical correction, fat is removed with the help of liposuction. Small cannulas are introduced under the skin and fat is removed with the help of suction combined with repeated movements of the cannula. Removal of fat leads to an improvement in the contour.
Prolonged and severe gynecomastia is also associated with excess skin. In most individuals removal of the breast tissue leads to the recoil of the skin during the months following surgery. However, in certain individuals, this recoil may not be complete. We may have to perform additional skin excisional procedures to improve the contour in such cases.
Individuals with excess weight should try to reduce weight by non-surgical methods. This involves dietary and lifestyle modifications. There are many advantages to doing so. It leads to better postoperative outcomes with more pleasing results. This is in addition to the other health and psychological benefits. Operating in a near-ideal bodyweight individual also means a simpler and shorter surgery. There is a lesser chance of wound-related adverse events such as infection and prolonged healing. BMI or body mass index is commonly used to assess the weight in comparison to the height of the individual. We usually discourage operations on individuals with a BMI greater than 30.
Being overweight increases the deformity associated with gynecomastia. However, it is possible to give a good outcome with surgical correction in conjunction with the appropriate lifestyle and dietary changes.
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These are uncertain times. There is a lot of uncertainty regarding health and finances. Each one of us is affected as a result of Covid19.
Though Covid19 is a recent disease and the first case was reported in December 2019, we have come to know a lot about this illness in this short period. However, there is a lot we are yet to know. An improved understanding would help us better deal with this at the level of an individual and that of the community. Though it leads to a mild illness in those affected, a small percentage can have a severe outcome. Because of this, and that the virus can spread rapidly, a lot of individuals can become simultaneously be affected by it. This leads to the possibility of our existing health care becoming overwhelmed. Hence, we take multiple steps to prevent the rapid spread of this virus. Some of the steps are easy and some are difficult.
One of the recommendations during this pandemic is to defer elective surgeries. Especially those in which the outcome may not significantly change if they are done at a later date. An example would be aesthetic or cosmetic surgery. Now, why should we postpone such types of surgeries? There are multiple reasons. One is that hospitals tend to be more exposed to individuals affected by Covid19. It is also known that many of the people with Covid19 can be mildly symptomatic and yet have the ability to transmit the infection. Another reason is that many individuals may come in close contact with a patient during the procedure and in the postoperative period. Many of the interventions may generate aerosols which can lead to a greater chance of transmission. We would also like to conserve our resources so that all our protective equipment and manpower can be used in case there is an escalation during a community spread.
All elective surgeries are not similar. In certain cases, it would be important to treat certain illnesses early since early intervention leads to better outcomes. An example would be cancer surgeries. It is also important for individuals with chronic illnesses to continue with medical care. An example would be dialysis in those with chronic kidney disease.
Cosmetic procedures are meant for improving appearance. Postponing such surgery is unlikely to influence the outcome.
Even during these times, there are a lot of things we can do to improve our health and appearance. We should exercise. Even if going out is not an option we would be able to exercise inside our homes and yards. Eating right is important. Eat only when we are hungry. Eating should not be a remedy for boredom.
As mentioned before these are uncertain times. But it is also certain that this uncertainty can't be permanent. Till then it is important to stay safe and wear masks (cloth would do) when we step outside.
Pushback otoplasty is done for improvement in the appearance of prominent ears. It is usually carried out under general anesthesia in children and local anesthesia in adults. During this procedure, ear cartilage is removed and reshaped so that it lies closer to the head. It is carried out either as a short stay or outpatient procedure. Pain is controlled with the help of oral medications.
After the procedure, a dressing is given in the form of a head wrap with a bandage. The ears are inspected on the first postoperative day for the presence of any collection. The bandages are retained for a week.
At the end of the week, the dressings are removed. Patients can shower once the dressings are out. For two weeks following the procedure, a headband is advised to be worn constantly. After this period, a headband should be worn during the night.
It is common to have swelling of ears following surgery. This gradually subsides over time. Most of the swelling disappears by the end of a month. Pushback otoplasty is a cosmetic procedure. It does not alter the hearing. It helps individuals with prominent ears to obtain a better body image.
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Hair transplant is a surgical procedure for redistribution of hair from areas of relative abundance to those with deficiency. It is most often carried out for male pattern baldness (MPB). In MPB, the hair of the posterior (back) of the scalp is relatively spared when compared to the hair in front of the scalp. The word, 'relatively' is important since the hair in the posterior part of the scalp is not completely unaffected by the changes in MPB. However, this property of relative sparing of the posterior scalp hair in MPB continues even after grafting (transplant).
Hair shafts occur as small groups called follicular units. During a hair transplant, a follicular unit is removed from the donor area (usually the posterior scalp) and implanted at the recipient area (usually the front of the scalp). A follicular unit may contain one, two or three hair shafts. The number of follicular units transplanted in a procedure depends upon the donor and recipient areas. Male pattern baldness usually requires the transfer of a large number of grafts. This is in contrast to the small numbers required for hair loss associated with small scars.
As mentioned previously, the posterior (back) part of the scalp is usually used as a donor area for hair transplants. Less preferred donor areas include beard and body hair. In certain individuals, the posterior scalp hair may be inadequate as a source for donor grafts. This can be due to the progress of MPB. This is observed as reduced density (hair follicles per square cm) and thinning (miniaturization) of hair follicles. It can also be as a result of a previous harvest of hair follicles during a hair transplant. An individual with a poor donor area also tends to have an advanced stage of MPB.
In spite of these challenges, it is possible to improve upon the appearance of those with a poor donor area. In such a situation we try to achieve improvement with the help of fewer grafts. Frontal forelock occupies the portion behind the central part of the forehead. Many individuals with advanced male pattern baldness tend to retain hair in this region. A relatively full forelock does not give an unnatural look in an individual with advanced hair loss. The forelock helps frame the face when an individual is observed from the front. It would be the part of the scalp that would be visible as a person steps out of an elevator. Increasing the density in the forelock region would require lesser grafts when compared to the rest of the scalp.
In patients without donor deficiency, other areas that are addressed include the hairline and mid-scalp. These occupy the area adjoining the forelock. The crown is given lesser importance when compared to the previously mentioned areas because of the lesser aesthetic significance and the requirement of a large number of grafts.
Salvaging the remaining hair follicles is also important in a person with MPB. MPB is usually a progressive condition and left untreated many can progress to more advanced stages of baldness. This is especially true in the case of younger individuals in whom the hair loss has not stabilized. Preservation of remaining hair follicles is achieved by means of medications. These medications include nutritional therapy, topical Minoxidil, and Finasteride. It is important for individuals to make an informed decision about the use of these medications. They should be taken for long periods for adequate results.
Male pattern baldness with poor donor areas offers some challenges for hair restoration. But often it is possible to improve upon the appearance with the help of medications and a limited hair transplant.
For more information on hair transplant please visit, https://www.amicusclinic.in/hair-transplant
I like to keep it simple.