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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A + B = C. So C - B = A. This may apply to simple arithmetic, but things get a bit complex when we are dealing with weight gain and weight loss.

We store our excess energy in the form of fat. Excess calories we may have acquired from our diet. This excess of fat gets stored in our body as fat deposits in different locations. Fat immediately under the skin can be pinched. This layer of fat is found between the skin and muscles. This is also the layer that can be removed with liposuction. Fat also gets stored deep inside our body, close to our internal organs. This is visceral fat. We can neither pinch this fat nor get it removed with plastic surgery.

A proper diet can help us get back to our ideal body weight. In some situations, bariatric surgery achieves the same end. However, a prolonged period of increased fat has effects beyond the fatty tissue. It stretches out the overlying skin. Visceral fat also stretches out the fascial layer. This layer is closely associated with the abdominal muscle layer. When we lose fat, the size of the fatty layer reduces. This may be dramatic in cases of severe weight reduction as with weight loss (bariatric) surgery.

The stretched out skin and fascia may not get back to the dimensions before the weight gain. As a result, individuals end up with loose folds of skin. To improve this appearance, we have to surgically remove the excess folds of skin. These surgeries are together clubbed under body contouring procedures. We usually wait for a year or more for the weight to stabilize and allowing the skin to recoil by itself before attempting any skin correction. The same approach is used for different body parts, arms (brachioplasty), abdomen (abdominoplasty), thighs (thighplasty) and torso (body-lift).

The presence of stretched out skin and fascia is the reason why liposuction may not be the right procedure for abdominal fat. Liposuction can't do much to tackle the laxity of skin and underlying abdominal fascia. With liposuction alone, we may worsen the skin laxity of the abdomen resulting in an increase in loose folds of skin after the procedure. The same line of reasoning is applied to individuals who present for a reduction in the size of arms. We undertake it in two stages, with the first being deflation with diet or liposuction and a second stage with the removal of loose folds of skin.

To conclude, we have to tackle the laxity of skin and deeper fascia in cases of weight loss following periods of excess weight gain. These may have undergone irreversible changes. Treatment of such deformities often requires the management of tissues like skin and fascia with the help of body contouring procedures. Such an approach helps us to optimize aesthetic outcomes.

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1. Liposuction
2. Brachioplasty
3. Abdominoplasty

In this age, it is almost essential to look lean and fit. Lean is associated with health and vitality. It is common knowledge that a large waistline is contributed by excess fat deposits. And because of this many individuals turn to plastic surgery for liposuction as a solution to this problem. However, all cases of the protuberant belly cannot be tackled by plastic surgery.

 Excess deposits of fat can be found in many places within the abdomen. They are found in the layer between the skin and the muscles of the abdominal wall. This is the layer that can be pinched between the fingers as a roll. Fat is also deposited deep inside the muscle layer. This fat is referred to as visceral fat and is found in association with our gut and the area behind it.

Other than fat deposits, laxity of the abdominal wall can contribute to protuberance. Laxity of the abdomen can be seen as a result of changes due to aging and pregnancy. A separation of the abdominal muscles in the midline, known as divarication is often seen in such individuals. Some of the above-mentioned deformities can be tackled with the help of plastic surgery. The modalities used for correction include procedures such as liposuction and abdominoplasty.

Liposuction involves suction of fat with the help of small cannulas inserted through the skin. Fat is aspirated with the help of a vacuum producing device. Advantages of this procedure include the treatment of relatively large areas with the help of tiny incisions. Patients usually recover fast and are ambulant as soon as they are awake from the effects of anesthesia. It does not involve a prolonged stay in hospital. Liposuction targets only fat that is superficial to the abdominal muscles. We are not able to access the deep or visceral fat with liposuction. Another limitation of liposuction is that it does not address the laxity of the abdominal wall or skin.

Abdominoplasty translates into reshaping the abdomen. During an abdominoplasty, we tighten the layer of the muscles. This helps tackle the laxity of the muscle layer. Liposuction is often carried out as a part of abdominoplasty. Liposuction is used to reduce the fat deposits on the flanks and in the upper abdomen. This improves the appearance and increases the safety of the procedure by limiting the areas of surgical dissection. We also reduce the excess skin as an ellipse from the lower abdomen. The rest of the skin is draped to result in a tighter-looking abdomen. As with liposuction, abdominoplasty can't address the visceral fat.

A clinical examination helps reveal the cause of the deformity and arrive at a treatment plan. Ideal candidates for both the procedures include patients close to their ideal body weight. They should be non-smokers and have reasonable expectations about the procedure. It is also important to be aware of what can be achieved using plastic surgery. We can achieve a reduction in the fat deposits that are external to the muscles and obtain a tightening of the muscle-fascia layer and skin. Plastic surgery does not address the visceral fat. And because of this, patients need to adopt a dietary and exercise regimen to maintain appropriate levels of visceral fat.

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.

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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.

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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.

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