Managing sunken or saucer-shaped deformities following gynecomastia correction

Some patients come to us months after their gynecomastia surgery elsewhere, worried about a new problem — the area around the nipple looks sunken in, almost like a saucer. The chest is flatter, yes, but now there is a hollow where there shouldn't be one.
This is a valid concern, and it deserves an honest answer.
To be clear, this post is not about the nipple sitting slightly high or low after surgery — that is a different issue. This is specifically about a sunken, saucer-shaped depression around the nipple-areola complex (NAC).

Why this happens? 
In our experience, this is more likely when the original surgery did not include liposuction as part of the procedure. Liposuction is not always used in gynecomastia correction, and when it's left out, a few specific problems can follow.
A few things can lead to it:

• Excising the gynecomastia tissue without adequate liposuction around it, leaving an abrupt step between the treated and untreated areas
• The nipple-areola complex getting hitched down to the underlying fascia or muscle during surgery, tethering the skin
• A hematoma in the post-operative period, which can scar down and pull the skin inward as it heals

Why it feels worse than the gynecomastia? 
This is the part patients often don't expect. A sunken NAC can feel more embarrassing than the original gynecomastia. Gynecomastia is common — most people have heard of it, and there is no real stigma attached to seeking correction. A saucer deformity is different. It isn't recognised as a usual or expected appearance, so it can carry a quiet sense of shame that the original condition never did.
It also doesn't respond to diet or exercise. No amount of chest workouts will fill in a depression that is caused by tethered skin or a step-off in tissue level. This often adds to the frustration — the usual advice simply doesn't apply here.

How do we manage it? 

If it is mild, we wait.
Most mild deformities improve significantly by around 3 months, as swelling settles and tissues soften. If we are seeing steady improvement, it is reasonable to wait longer still. As a general rule, we prefer to plan any correction only after a year has passed — by then, the treated area has usually become supple enough to work with predictably.
If correction is needed, we have three tools, usually used together.
Liposuction — Careful liposuction of the surrounding, still-full areas smooths the transition. Just as importantly, gently and discontinuously undermining the sunken area itself releases the scar tissue tethering the skin down. As a bonus, the fat removed this way can often be used as graft material.
Fat grafting — This restores volume directly to the hollow. It also does something less obvious but equally useful: it creates an intermediate layer of tissue over the fascia, which helps stop the skin from re-adhering to the deeper layer and causing the same problem again. The one caveat here is that fat graft "take" is somewhat unpredictable — some patients need more than one session before the result is where we want it.
Taping — After surgery, taping helps the undermined skin settle and adhere in a better position, rather than falling back into the old hollow. It works particularly well when combined with a pressure garment. As with most things in recovery, how well it works depends a great deal on how consistently it's worn.

The best treatment is prevention 
Honestly, the best way to deal with this deformity is to avoid it in the first place — through adequate liposuction at the time of the original surgery, and diligent use of a pressure garment afterward. Where we can, we would always rather prevent this than correct it later.

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