Gynecomastia is an enlargement of the male breast tissue. This enlargement can be of one or both sides.  In cases of bilateral involvement, one side can be affected more than the other, leading to an asymmetrical appearance.

Mild cases of asymmetry are common. But in certain cases, the difference between the two sides can be readily noticeable. The asymmetry can be as a result of two causes, namely, a difference in the amount of breast tissue or changes as a result of the underlying chest wall and muscles. The treatment strategies for managing the asymmetry depends on the underlying cause. Usually, the reason is apparent during a clinical examination.

In the case of asymmetry arising due to the difference in the size of the breast tissue, the treatment involves liposuction and direct glandular excision. We take care to leave behind equal amounts of subcutaneous tissue at the end of the procedure. A more enlarged gland will require a longer time for adequate skin recoil. Such a gland may also have a longer duration of postoperative firmness. In most cases, adequate symmetry is achieved with the passage of time.

In cases of asymmetry due to underlying chest muscles, unfortunately, nothing much can be done to correct the difference at the time of surgery. We bring this to the notice of the patient during the consultation. Usually, such differences in chest muscles arise from altered posture and position during strength training exercises. It is recommended that individuals seek help and guidance from an expert physical trainer for the correction of the posture and technique.

Gynecomastia surgery is essentially a cosmetic procedure and the goal of undertaking a correction is to minimize the effect of the deformity. Wide variations occur in the presentation of this condition. Asymmetry is a commonly seen variant, even though severe asymmetry is uncommon. In cases of asymmetry, it is important that individuals understand the reason and the role of different treatment strategies to tackle the same.

For more information about gynecomastia and related topics, click here.

An individual with asymmetry due to difference in the size of the gland. The right side is bigger compared to the left.

Asymmetry due to the difference in the size of the underlying muscles. The left pectoralis major is more developed when compared to the right.

Macromastia is a condition with disproportionately enlarged breasts in women. This can be a cause for significant emotional and physical distress in those affected by this condition. Reduction mammaplasty is a surgical condition to reduce the size of the breasts by making it more proportionate to the rest of the body.

The cause of macromastia is usually undetermined. It can be as a result of a change in levels of hormones and sensitivity of the tissues to hormones. There can be an enlargement of the gland, fat and excess skin in this condition. Medicines do not have a significant role in the treatment of macromastia. Surgery is the mainstay of treatment of this condition.

Macromastia can result in physical symptoms such as neck and backache, skin grooving and skin rashes over the folds below the breasts. Patients may find it difficult to perform strenuous exercise and other physical activity. Individuals with this condition also find it difficult to get appropriately sized clothing. Macromastia can result in emotional distress and a feeling of embarrassment and social inhibition.

Surgical correction is achieved by reduction mammaplasty. This is aimed at reduction of the size the breasts, and reshaping it to give a more pleasing appearance. The areola (pigmented skin around the nipple) is also reduced in diameter in case they are enlarged. The scars associated with this procedure are confined to the skin at the junction between the areola and breast and a vertical limb towards the undersurface of the breast. In most individuals, the scars settle well.

Reduction mammaplasty is carried out in the hospital setting under general anesthesia. Patients are admitted overnight after the procedure and discharged home the next day. Discomfort is controlled with the help of pain medications. Patients are not confined to bed and are able to carry out daily activities like showering from the next day. Most patients resume work in a week. Strenuous activities can be started after a month.

Benefits of reduction mammaplasty are physical, emotional and social. After reduction mammaplasty, individuals report the absence of back and skin symptoms. Patients find it easier to perform strenuous activities.  Patients have increased levels of self-confidence and are no longer embarrassed by this condition.

For more information, visit us at:
 https://www.amicusclinic.in/breast-reduction

Gynecomastia correction is a commonly carried out procedure among men.

The aim of the surgery is an improved contour of the chest. This is accomplished with the help of minimal incisions such that patients do not have an operated look. Most of the patients undergoing correction have liposuction for removal of the fat surrounding the gland and in the lower part of the axilla (armpits). The incision is placed in the areola (pigmented skin around the nipple) for removal of the gland. The areolar incision usually settles very well and has a high patient satisfaction. We sometimes place small tubes (drains) to remove any fluids from the operated site. This is usually removed on the next day. Many of our patients do not have a drain.

Most of the cases of gynecomastia correction are performed under general anesthesia. We reserve treatment under local anesthesia for cases with minimal gynecomastia in slim individuals.

Patients are retained overnight after the procedure. Dressings are removed and operated area is inspected on the day after the surgery. Patients are instructed to wear pressure garment continuously for a month following the surgery. They are usually discharged home after an overnight stay. Due to liposuction and accompanying infiltration of the operated sites with local anesthetic most patients are comfortable on oral pain medications.

At home, patients can move about and carry light activities. We review our patients back in the clinic 2 to 3 days after the procedure. The dressings are removed and skin adhesive tapes are used to secure the suture line. Patients can shower with the skin adhesive tapes.

We review the patients after one week for removal of sutures after one week. Skin adhesive tapes are reapplied for 2 more weeks. Most patients usually return to work within a week. Heavy exertion such as weight lifting is restricted until one month following the procedure.

A normal recovery can involve the following,

1. Swelling. Postoperative swelling accompanies any surgical procedure. The swelling gradually resolves over the next few weeks. Most of the swelling is gone by one month. However, some residual swelling occurs till three to four months. In some individuals, it can last longer.
   
2. Seroma is not unusual following liposuction. In most cases, it subsides without any intervention. Uncommonly we may aspirate the collection under image guidance.
   
3.  Puffiness of the areola. This can be due to the swelling associated with the scar tissue under the areola. It may sometimes take a few months to soften. Puffiness of the areola can also be due to shortening of the areolar scar. The scar initially shortens over the first few months before it lengthens to its original dimensions. We reassure our patients to wait it out. Gentle massage along the scar helps in softening of the scar.  
   
4. Deflated appearance.  In longstanding gynecomastia, the skin over the chest becomes lax and saggy after removal of the underlying fat and gland.  This similar to the abdominal skin being lax after pregnancy. The skin adapts to the new shape of the chest over the next few months. An exception to this would be in individuals with significant obesity. However, we ask our patients to wait for at least 6 to 8 months before deciding on secondary procedures to address the laxity of the skin.
   

 
In most patients, gynecomastia correction is associated with a boost in self-confidence.

Learn more about gynecomastia here.

An axillary breast is a common condition that affects women. It presents as a swelling over the axilla (armpits). The severity may vary from a mild bulge to a loose baggy fold. Those affected by this condition often view this as unsightly and avoid wearing clothes which reveal this condition.

This axillary swelling is usually an extension of the breast tissue from the outer and upper quadrant. This tissue is also prone to the same changes which occur in the rest of the breast. There may be accompanying pain and discomfort in certain phases of the menstrual cycle.

The axillary breast is usually removed as a daycare procedure. Patients are usually discharged home after a brief period of rest following the procedure. Liposuction and open removal (axilla-plasty) are two techniques that are combined to treat this condition. Liposuction is used to remove fat from the edges of the wound. It helps in the removal of the fat with short incisions.  Open removal of the breast tissue has the advantages in allowing better preservation of the nerves which travel through this space. It also helps get rid of the relatively non-retractile axillary skin. The removal of the excess skin gives a better contour to the axilla (armpit).  

Wounds are approximated with sutures and dressings are applied. Drains are sometimes placed to avoid any collection from occurring at the operated site. Patients are followed up as outpatients and sutures are removed at one week. The postoperative swelling usually resolves over the next few weeks. Patients are usually able to resume work after a few days. There are no restrictions on any activity after a month following the procedure.

Treatment of the axillary breast gives a better contour to the axilla (armpit). Liposuction and open removal when combined help women achieve better contours with short incisions. After the procedure patients usually feel more confident about their appearance.

You can learn more about female breast reduction here.

Have you ever bothered about the size of your arms and had wished that they were thinner? If so, you may benefit with an arm lift surgery. 

What is an arm lift? 
It is a surgical procedure to improve contours of the arms. The lax tissues of arms are manipulated such that they result in tighter looking arms. The extent of surgical modification depends on the extent of laxity of arms and torso. 

What is the role of liposuction of the arms? 
Liposuction of arms is recommended for those with fatty deposits and good skin tone. This may be a good option in those under thirty. In individuals with laxity of the skin, liposuction does not address the laxity of skin. 

Who can benefit with an arm lift?
Individuals bothered about the contours of their arms can benefit with this procedure. This includes those with laxity of arms following significant weight loss as a result of weight loss surgery, diet or exercise.

When is it a right time to undergo arm lift among those with massive weight loss? 
Individuals who have undergone massive weight loss should wait until the weight loss has stabilized. In those following weight loss surgery, an opinion from the bariatric surgeon is recommended prior to the arm lift.

Who is a good candidate for an arm lift? 
This would include:
1. Those with laxity of the arms and desire an improvement of shape of their arms.
2. Are in good health.
3. Non-smokers.
4. Those with realistic expectations about the procedure.

What are the different types of arm lift?
The type of arm lift recommended to a patient depends on the extent of laxity of the arm and torso. The variations of an arm lift include:

1. Classic arm lift: Here the incision extends along the inside of arm from the armpit (axilla) to the elbow. This results in improvement of laxity of the arms.  
2. Mini arm lift: The incision is transverse and stays at the junction of the arm and the armpit. This improves the laxity of the upper arms. An advantage of this incision is that it remains hidden with most clothing.
3. Extended arm lift: This is performed in individuals with excessive laxity of the arm and torso. The incision extends from inside of the arm to the lateral aspect of the torso. It helps tighten skin on the lateral aspect of the torso as well as the arm.

How does one get an arm lift?
The first step would be a consultation when a physician evaluates you for the arm lift. Various treatment options will be discussed depending on the physical findings and individual expectations with the procedure. An arm lift is usually performed as a short stay procedure. Patients can return either the same day or the next. Sutures are removed during the follow-up visits. 

What is the anesthesia for an arm lift?
It is usually carried out under general anesthesia. The mini-arm lift can be carried out under local anesthesia with sedation. 

What is the recovery following an arm lift? 
Patients can go home the same day or the next. Small tubes (drains) may be placed which are usually removed the next day. They help prevent a collection of any tissue fluid at the operated site. Compression garments are advised for six weeks. Sutures are removed during the follow-up visits. Patients can return to light activities after one week. Heavy activities including exercise can be started after a month.

What are the risks associated with arm lift?
The risks associated with arm lift include:
1. Infection: It is an uncommon complication,  as arm lift is a clean procedure. 
2. Prominent scarring: Scars of an arm lift are confined to the inside of the arms. In some cases, they extend to the side of the torso. In some individuals surgery can result in prominent scars, which are treated with massage, application of silicone sheets and pressure garments. 
3. Seroma: This refers to the collection of fluids. The incidence of seromas is reduced with the help of drains. 
4. Swelling: It is mostly temporary and subsides without any active intervention.

What are the benefits of an arm lift? 
It helps an individual to get arms which are more proportionate to the torso. This leads to a younger and healthier appearance. The positive results of the procedure are associated with improved confidence and better options in clothing. 

Are the results of the arm lift long lasting? 
When combined with lifestyle changes and appropriate diet, the results of the arm lift last a very long time. 

As in all injuries, burns end up as scars. The deeper burns usually give rise to problem scars. These scars can be a cause of disability and impair quality of life of the affected individual. It can lead to problems relating to self-esteem. However, it is possible to improve these scars with the help of restorative surgery. This forms one of the most rewarding specialties of plastic surgery. Restoration means an improvement of both the form and function of the affected part. 

How do burn scars lead to impairment of function?

Scars differ from the native tissue it replaces. They are less elastic and tend to contract with time. Due to this intrinsic property of contraction, scars reduce the movement of structures  associated with it. For example, scars stretching across the front (anterior surface) of the elbow can reduce the ability to straighten out the elbow. This leads to a reduction in function of the affected upper limb. In a manual laborer, this can mean the loss of ability to earn his/her livelihood.  
Scars also look and feel different compared to the unaffected (native) skin. This causes disfigurement. Deformity due to scars can make an individual shun social encounters. 

What are the indications for surgery for burn scars? 

They mainly done for two reasons: 

1. Functional: When the scar impairs the function of the affected part. Burns affecting the hand may prevent the individual from using the part. With surgical treatment, it is possible to regain useful function of the hand.

2. Cosmetic: Scars can result in deformities. It is usually possible to surgically modify them and improve their appearance. 

Who are good candidates for burn scar surgery? 

Good candidates include those who are in good health and have reasonable expectations about the corrective surgery. 

When does one undergo surgical correction of burn scars? 

Scars are living tissues which undergo change in a appearance and texture with time. This is sometimes referred to as maturation of a scar. This can around eighteen months and surgery for scars are undertaken once the scars mature. However, in certain instances when the scars are associated with severe functional problems they are corrected earlier. For example, the involvement of the eyelids with scars can result in an absence of eyelid closure. This can lead to ulceration of cornea and blindness. In such a situation scars are treated without waiting for the scars to mature.

What are the techniques used in scar surgery? 

Generally, the scars are cut and the resulting defect (gap) is covered either with neighboring tissues (local flaps) or skin grafts. The exact technique chosen depends on the deformity, treatment options and aesthetic and reconstructive goals of the patient. It is often possible to treat a deformity by more than one technique. Some of the procedures include:

Skin grafts: These involve the transfer of the outer layers of the skin to cover a wound elsewhere. The area from where the grafts are obtained heal by itself. Grafts are an attractive option since they are abundantly available. Skin grafts tend to undergo contraction in the postoperative period. Because of this use of splints and pressure garments are important during the postoperative period. 

Flaps:  They are tissues with the associated blood vessels transferred for coverage of a defect. They provide thicker tissues compared to skin grafts. Flaps closely mimic the native tissue in appearance and texture. Thus, they are  usually aesthetically superior when compared to skin grafts. Flaps do not contract like skin grafts and once the wounds heal they are easier to manage and do not require rigorous use of splints. 

Tissue expanders: These are devices which are placed surgically underneath the skin adjacent to a scarred area. During the follow-up visits, they are progressively filled with saline. The inflation of the expanders causes the overlying tissues including skin to get stretched. Once a critical volume is achieved the expanders are removed and the extra skin is used to cover the scarred area. The advantage of such a procedure is that they provide tissues which bear a close resemblance to the native (original) tissue. They are frequently used to treat scars of the scalp. The use of adjacent scalp tissue enables the scar the be replaced with hair-bearing skin.  

Serial excision: Due to the size of a scar it may not be possible to close the wound edges after removal of the scar. During serial excision, this process is done in stages when a part of the scar is removed during each step. This takes advantage of the increased laxity of the tissues as they respond to the increased tension at the operated site. The advantage of serial excision is that they help narrow a broad scar without the use of additional grafts or flaps. 


What type of anesthesia is used for burn surgery? 
Surgery for burn scars is done under local or general anesthesia. General anesthesia is used in children and in adults when the area being treated is extensive. Local anesthesia is used in adults when the area affected is small. 

What is the recovery following a burn scar surgery?
Burn scar surgery is usually performed as a short stay procedure. Patients can return home the next day. They need to come for follow-up visits for the change of dressings and suture removal. Splints are continued after the surgery till the scars mature. Pressure garments are worn once the wounds have settled. They help in reducing the swelling and discomfort at the operated site. Patients can usually return to light work one week after the procedure. 

What are the measures taken during follow-up of burn scar surgery?

In addition to the follow-up visits, patients are advised to use splints and pressure garments. Physical therapy is important for maintaining adequate range of motion and to keep the treated areas supple. 

Why are splints used? 

They help in resisting the contractile forces of a scar. During the early postoperative period, they are worn constantly. Later on, they are used during the night. 

What are the benefits of burn scar surgery? 

They help the person regain useful function of the affected part. This can mean the ability to earn and look after oneself. Burn scar surgery also improves the appearance of the affected part. They are associated with improvement in self-esteem and confidence. 

For more information on scars, visit here.

Fat grafting is a technique wherein living fat cells are transferred from one part of the body to another. The transferred cells obtain blood supply from its new location. Since they become integrated with the body they tend to be last long. This is in contrast to the injectable fillers which produce temporary results and need to be repeated at intervals for volume enhancement.  

What are the benefits of fat grafting? 

Fat grafting provides an increase in soft tissue volume. This helps in obtaining a more youthful proportion. Aging changes of face and body are associated with laxity (loose) of skin with loss of the volume of the underlying tissues. These changes are partially reversed with fat grafting. 

What are the areas which can be treated with fat grafting? 

Fat grafting techniques are used for improvement of 

1. Face: Cheeks, Forehead
2. Breasts
3. Buttocks (Brazilian butt lift)
4. Scars ( Depressed scars)

Where is the fat harvested from? 

Abdomen and thighs are the sites commonly used as donor areas for fat harvesting. This has the added benefit of improving the contours of these areas.

Who is a right candidate for fat grafting? 

This would include individuals who need volume enhancement but want to avoid the use of any artificial substances. The volume enhancement in the case of breast augmentation with fat transfer would be lesser when compared to the conventional silicone implants. 
Individuals for fat grafting should have good health and not have any serious comorbid illness. It is also important to have realistic expectations about the outcomes which can be achieved with the procedure. 

How is fat transfer performed? 

It begins with a consultation when a surgeon evaluates you to find out if you are a right candidate for the procedure. A treatment plan is made which depends on the physical features as well as the treatment expectations of the individual. Fat grafting to face may involve multiple sessions wherein small quantities are transferred to avoid over correction.

Anesthesia for the procedure is either with local or general anesthesia. This depends on the extent  and areas being treated. Fat grafting to areas in the face is done under local anesthesia. Breast and buttocks are treated under general anesthesia. Fat is harvested from the thighs and abdomen with thin cannulas. The harvested tissues are processed to increase the fraction of viable cells which would then be transferred back into the body. The processed tissue is injected back into the recipient sites with thin cannulas. 

Patients can soon return home after correction of smaller areas. More extensive grafting though performed as a short stay or day care procedure and individuals can return to work in a week. 

Recovery from fat grafting will include swelling at the treated site. This is more prominent at highly vascular sites like face. This gradually subsides with time and usually does not need any specific treatment. 

What are the possible complications of the procedure? 

The complications specific to fat grafting will include: 

1. Fat did not last long enough: This can be lessened with refinements of harvesting and processing the fat. Fat transfer does suffer from a lack of precise predictability of the take. It tends to take up better in highly vascular areas like the face. It tends to be lost more in highly mobile areas like lips. 

2. Over grafted look: This can be avoided by carrying out the procedure in small sessions and trying to avoid over correction. This complication probably results from the treating doctor trying to compensate for the possible loss of the fat cells with time. 

3. Irregular and lumpy appearance: This is seen in areas where the overlying skin is very thin. This can be minimized with grafting at deeper planes. 

What are the benefits of volume augmentation with fat grafting? 

Since we are using part of the body for volume enhancement, it tends to
 
1. Last a long time when integrated by the body (this is in contrast to the temporary fillers). 

2. Do not suffer from extrusion as can happen with foreign implants. 

Scars are common and vary from mild to severe. They are the natural result of healing of injury which can be as a result of infection, trauma, burns or other causes. When scars are severe it can lead to cosmetic and functional problems. These, in turn, can cause psychological impairment of the affected individual. Even though it is impossible to completely eliminate scars, it is possible to improve them.

The various procedures for improvement of scars range from less invasive techniques to surgical correction. Each of these procedure has certain advantages and disadvantages compared to others. So a technique that may be effective in a certain type of scar may not have a similar benefit in another. It is seldom one approach suits all. Less invasive techniques include dermabrasion, peels, and LASERS.  These are useful for mostly superficial scars. Superficial scars do not involve all the layers of skin. 

Type of scars amenable to surgical procedures
Such type of scars would include the following
1. Deep scars  
2. Contractures (scars with distortion of surrounding structures)

Deep scars involve most of the layers of skin. In some cases,  scars can draw attention due to their orientation across the natural skin creases (lines). 
Contractures occur due to the progressive contraction of scar tissue. Across mobile areas like joints, these contractures can limit the movement. For example, a burn contracture across the fingers can reduce the function of the hand. During surgical correction, these contractures are first removed and the resulting wound is covered with a graft or flap such that free movement is possible across the joints. 

Treatment options for surgical correction of scars 
The goal of plastic surgery would be an improvement in appearance and function. This is brought about by redistribution of tissues. The most commonly applied techniques include, 

Scar revision: During scar revision the scar is removed and neighboring tissues are brought together. Stretched out scars can be narrowed down with an approximation of dermis. A straight line scar can be broken down for a more pleasing outcome. In mild contractures, Z-plasty and Y-V plasty can be used for scar lengthening and functional relief. Most of these cases are carried out as outpatient procedures and patients can return home soon afterward. 

Serial excision: Sometimes it may not be possible to remove an entire scar and close the wound by approximation of the neighboring tissues. In such situations, it may be possible to remove the scar in stages. This is commonly adopted for removal of burn scars and naevi. 

Split thickness skin grafts: This is indicated when large areas need to be covered after a release of extensive contractures. Skin grafts are obtained from the top layers of skin and transferred for coverage of wounds. An advantage is the ability to cover large wounds in a single stage. The release of burn contractures and coverage with split thickness skin grafts result in a dramatic improvement of function. Skin grafts are usually obtained from lower extremity. The donor site heals by itself. 

Full thickness skin grafts: The full thickness of skin is used to cover the wounds following removal of the scar. These are cosmetically superior compared to split thickness skin grafts. Full-thickness grafts are limited by the limited availability.  The donor site can usually be managed with straight line closure. 

Flaps: Flap surgery involves recruitment of neighboring or distant tissue with its blood supply for coverage of the wounds. They have the advantage of mobilization of tissues with similar texture and appearance. 

Tissue expanders: These are inflatable devices placed under the skin and adjacent to a scar. Once the operated site heals, these expanders are gradually inflated with saline. Over a period of time, this leads to stretching of the overlying skin. Once an adequate expansion is achieved the expanders are removed and the redundant skin is used to cover the wound after removal of the scar. Tissue expanders are useful in coverage of large areas with tissues similar to the native tissue. 

Timing to undergo plastic surgery for scar improvement
It is advisable to undertake surgery once the scar has matured. This can take more than a year. During this time, the scar tends to become soft and supple. An exception to this would be cases with contractures causing significant impairment of function. For example, a scar of the neck which prevents the patient from carrying out daily activities needs early release and coverage. Patients should be in good health at the time of any elective surgery. 

Recovery following scar revision 
Most of the procedures are outpatient or short stay procedures. Depending upon the location and extent of the procedure, anesthesia can be local or general anesthesia. Patients need to follow up regularly after surgery. Use of silicone sheet, splints, and pressure garments form a part of the post-operative management. 

Benefits of undergoing surgical scar revision 
These would include, 
1. Improvement in appearance and function.
2. Improved confidence and self-esteem. 

​To learn more about scars, click here. 

 
Gynecomastia is enlargement of male breasts. It can be a cause of significant anxiety and embarrassment in those affected by this condition. Surgical correction results in a long-term improvement in appearance. The different options available for a surgical cure include:

1. Liposuction: This involves removal of fat cells with thin tubes attached to a suction device. The suction can be produced with a machine or a syringe. The fat cells are permanently removed from the treated site resulting in a flattened contour. Liposuction is especially useful when gynaecomastia is mostly due to fatty tissue. 

2. Gland excision: The glandular tissue also contributes to a varying extent in gynecomastia. This is more amenable to direct excision. The placement of incision can be at, 

a) Intraareolar: The areola is the pigmented skin surrounding the nipple. The incision and the resulting scar lies within the areola. This usually results in a scar which is not easily made out.
 
b) Periareolar: Here the incision lies at the junction of pigmented and non-pigmented skin. It heals with a light-colored scar. 

3. Skin excision: In certain cases of long standing gynecomastia there may be an excess of skin with a reduced ability to recoil. In such situations, a disc of skin is removed for treatment of the excess skin. The removal of skin can also be done at a later stage to allow for the natural recoil of the skin. 

All these modalities can be combined in one procedure depending on the severity of gynecomastia. Postoperatively dressings are removed during the next day. Drainage tubes are sometimes placed to evacuate fluids from the operated site. They are usually removed during the first few days. Sutures are  removed after seven days. Patients can return to work after one week. Workouts and heavy exertion can be resumed after six weeks.