Liposuction is a part of the treatment of gynecomastia correction in most of our patients. It is relatively uncommon to do a gynecomastia correction without accompanying liposuction. Why so? 

Liposuction has many advantages. They include the following: 

1. Help avoid step deformity. Liposuction helps extract the fatty tissue as small parcels from a relatively large area. Since the parcels are removed in small increments and over multiple passes there is a gradual transition between the treated and untreated areas. This is smooth transition is difficult to accomplish when the breast tissue is removed without liposuction. Thus liposuction is not associated with an abrupt transition between the treated and untreated areas. This leads to better aesthetic outcomes. 
2. Better pain relief in the postoperative period. Liposuction starts with the infiltration of a solution. This infiltrate contains a mixture of various drugs including a local anesthetic agent. Because of this agent, it is also possible to perform liposuction under local anesthesia. The pain relief obtained with the infiltration continues into the postoperative period. Patients usually report less discomfort when the procedure involves liposuction. 
3. Makes gland removal easier and faster. The surgery involves liposuction followed by gland excision. The liposuction removes the fat parcels in the form of small tunnels. The gland is left behind because the gland is firmer when compared to fat. The subsequent dissection to excise the gland is facilitated by liposuction. Liposuction opens up multiple surgical planes that help make the surgery faster and more efficient. 
4. Less blood loss. The infiltration used before liposuction also contains an agent to temporarily shrink the blood vessels. This leads to very less blood loss during the removal of fat and gland. Less blood loss makes the procedure safer. 
5. Ability to contour lateral chest wall. Some individuals may present with excess fat deposits lateral (to the side) of the chest wall. This is not composed of breast tissue. Liposuction helps reduce or debulk this area effectively. This is difficult to achieve without liposuction. 
6. Ability to combine with fat grafting in secondary corrections. Some individuals may present for correction of contour abnormalities following a previous gynecomastia correction. These are often corrected in a secondary procedure with liposuction combined with fat grafting. The fat aspirated during liposuction can be injected (grafted) into areas of deficiency. 

There are instances when we may not do liposuction during gynecomastia surgery. But these are relatively uncommon. Liposuction is sometimes not done in thin individuals with less breast fat. Such individuals usually present with a gland enlargement confined to the area under the areola. They also have a very thin skin pinch. In such situations, we proceed with a gland excision through an areolar incision after local anesthetic infiltration. 


Liposuction has many benefits when done in gynecomastia treatment. It is usually done in almost all cases of gynecomastia surgery in our practice. 
To learn more about gynecomastia, please click here. 

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. 

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

Beauty is associated with proportions. A body part that is disproportionate to the rest of the body can impair appearance. An example would be women with arms that are large when compared to the torso. It is a common aesthetic concern in plastic surgery practice.

Arms are tubular structures. They consist of soft tissues around a bone. The soft tissues are made up of structures like fat, muscles, and vessels. It is surrounded by skin. Large arms usually involve a relative excess of fat and skin. The fat occupies the layer deeper to the skin. As the volume of fat increases, the overlying skin stretches to adjust to the increased volume. Hence, a reduction in the size of the arms involves a reduction in the size of the fat and skin excess. We can achieve this through surgical, and non-surgical techniques.  

Why do some individuals get big arms?
The increase in the size of the arms is associated with excess weight. This excess fat gets deposited in various areas of the body. Some of us tend to deposit this fat more in our arms. This intrinsic tendency varies from one individual to another.
Other conditions can be associated with an increased size of the arms, lymphedema, soft tissue swellings, etc.  But they are relatively less common causes of big arms. This article deals with the management of the arms as a result of excess fatty tissue.

What can be done to improve the appearance?  
A reduction in the size of arms has to address the two types of tissues involved, namely fatty tissue and skin.
First, the fat. Fat occupies the area between the muscles and skin. The amount of fatty tissue correlates with the amount that can be rolled between two fingers. Fat is amenable to dietary modifications. A reduction in body weight usually leads to a reduction in the amount of fatty tissue and a resulting in a decrease in the size of arms.
Liposuction is a surgical technique to remove the fatty tissue with the help of small tubes (cannula). It is useful for individuals with fatty tissue that is resistant to dietary modifications. A good candidate for liposuction is someone with close to ideal body weight. Liposuction does not directly address the excess skin.
Next, the skin.  The skin stretches to accommodate the excess fatty tissue. Once there is a reduction in the fatty tissue with diet or liposuction, there is a recoil of this skin. Recoil is the shrinking of the skin to a smaller area. However, this recoil of the skin takes time. It can take as much as a year for the skin to maximally recoil. In cases of massive weight loss, the recoil can be incomplete. This is seen as a persistent loose fold(s) of the skin. It is usually seen on the undersurface of the arms. Skin recoil is also reduced with advancing age and in smoking. Brachioplasty is a surgical procedure to remove excess skin. During brachioplasty, skin is removed as an ellipse from the medial surface (inside) of the arm. This is the part of the skin that abuts the torso. The decision to undertake a brachioplasty is taken after waiting for the skin to maximally recoil. Hence, it is usually not carried out during liposuction. The extent of skin removal is customized depending upon the extent of skin excess. Brachioplasty helps in improving the contour by removing the loose skin folds.  

 What are the advantages of the management of this condition?
It helps in improving the appearance of the arms in individuals with disproportionately large arms. The role of diet and exercise play a very important role in the appearance of the arms. Liposuction and brachioplasty are two surgical procedures that help to further optimize the appearance of arms.  

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, 

1. Gynecomastia when associated with significant weight loss. Obesity leads to widespread excess skin. When such an individual loses weight by dieting or surgery, there is a mismatch between the skin and underlying tissues. The skin recoil may be inadequate in such individuals. 
2. Severe, and longstanding gynecomastia. This is seen in older individuals with untreated gynecomastia. The ability of the skin to recoil reduces with age. 

It is usually possible to estimate the skin excess during a clinical examination. Individuals with excess skin usually present with ptotic (downward displacement) of the nipple and areola. A deflated appearance is also common in individuals with excess skin. 

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. 

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,  

• Safety. When done with adequate precautions liposuction is usually a safe procedure. Thin tubes called cannulas are inserted under the skin into the fatty layer during liposuction. The cannulas help in the removal of fat from the treated areas. One of the risks of liposuction comes from the injury to structures in the adjacent areas. It is easier to detect the presence of a cannula in a different surgical plane in an awake patient (local anesthesia). This is due to the absence of muscle relaxation and sensitivity to pain in areas that are not infiltrated with the anesthetic solution. As a result, the local anesthesia increases the safety margin of the procedure. 
• Recovery. The recovery from general anesthesia may be associated with postoperative nausea or vomiting. There can be variations in systemic parameters like blood pressure and heart rate. These can are avoided when liposuction is carried out in an awake individual. This leads to a more straightforward recovery. 
• Postoperative stay. Due to the faster recovery with local anesthesia alone patients can be discharged soon after the procedure. This makes liposuction under local anesthesia suitable as an outpatient procedure. 

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.