Managing excess skin in gynecomastia

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. 

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