Since establishing the Austin Gynecomastia Center many years ago, I have learned quite a lot about the
diagnosis and treatment of gynecomastia, a benign but very troubling male condition. Surgery for gynecomastia in Austin was presented in my formal plastic
surgical training in a confusing, somewhat subjective and arbitrary way. There were several
classifications and algorithms that attempted to determine which form of treatment was best for the many
varied presentations of gynecomastia.
Fortunately, through my experience I discovered that most forms of gynecomastia can be treated
successfully in the same way with few complications and impressive results. It is actually quite
straightforward and relatively easy! I have found that the a more challenging aspect of gynecomastia
surgery is determining which patients would benefit from skin removal and relocation of the
nipple-areola complexes to prevent loose skin after gynecomastia surgery.
To briefly review, the state-of-the-art treatment of gynecomastia consists of two small incisions, one
typically in the axillary hair (underarm) and the other at the bottom of the areola border. Through
these incisions and with the use of VASER™ ultrasonic liposuction, I’m able to effectively treat
a majority of patients regardless of size or appearance.
Illustration showing when skin excision is needed and when skin excision is not needed during
gynecomastia surgery as well as the scars associated with each case.
However, one category of patients that posed a challenge where those with very loose skin and an advanced
case of gynecomastia. In these cases, standard treatment would not result in a satisfactory result as
there was excess skin with wrinkling and folds due to poor skin elasticity (the ability of the skin to
contract or tighten). These cases required skin excision across the chest and typically under the arms,
with relocation of the nipple-areola complexes to the ideal position on the chest.
This led to the development of the concept of “open” and “closed”
gynecomastia treatment. Open gynecomastia surgery involves the removal of skin and tissue and relocation
of the nipple-areola complexes, which produces large scars across the chest and under the arms if
needed. Closed gynecomastia surgery refers to the treatment of
gynecomastia with minimal incisions and virtually no scarring.
As always, experience matters most in making this important decision. After operating on thousands of
gynecomastia patients, it has become clear who needs an open approach and, more importantly, knowing who
didn’t need the open approach! Permanent scars across the chest that could have been avoided is
the last thing any patient wants. In fact, one of the most important skills I have learned is how to
judge when a patient does not need skin removal, despite when many of my colleagues would likely suggest
an open approach. The ability of the chest skin to retract to a normal or near-normal appearance should
not be underestimated!
How a free nipple graft works, part of open / skin removal gynecomastia surgery.
Patients who are more likely to need skin removal for loose skin after gynecomastia surgery are those
with very large and saggy breasts. Often massive weight loss patients (over 100 pounds) need skin
removal because there simply is no elasticity left in the skin and it simply won’t retract and
redistribute after tissue removal. Age also affects skin elasticity, so older patients may need to have
skin excised. Some of the ancillary techniques that I use, such as quilting sutures or wide undermining,
have worked well to assist in skin redistribution after more challenging cases that help avoid the open
Hopefully your Austin gynecomastia surgeon has the experience to make a good decision regarding whether to use the open
or closed approach. If in doubt, know that it’s always possible to perform the closed
approach first and if the skin doesn’t lay out as anticipated the open approach can be used
through a secondary procedure later. Experience has shown me that most cases requiring an open
approach are obvious, but there are those “in the grey zone” cases that are more
challenging to judge how effective a closed approach would be. I will often give the patient the
benefit of the doubt in these cases and elect to perform the closed approach.
The open approach requires much more skill and experience to perform satisfactorily. The proper
placement of the final scar across the chest and the appropriate placement of the nipple-areola
complex is critical to achieving the best result. I prefer placing the scar in the native crease
under the chest area that, if necessary, extends horizontally into the underarm area towards the
back. The nipple-areola placement (usually a free nipple graft technique) is just above the chest
crease and quite lateral on the chest to avoid giving a “headlight” appearance.
Although the scars can be extensive with the open approach, the result is typically very rewarding
for the patient and satisfaction is quite high. No longer do they have to deal with the burden of
large breasts and saggy tissue with loose skin. Open gynecomastia surgery is more extensive than the
closed approach, so it does take longer to perform and has a longer recovery period. Drains are
typically used in the open approach.
To be safe, I suggest that those patients who have been told that they require an open approach to
consult with an experienced gynecomastia professional for a second opinion regarding skin removal to
prevent loose skin after gynecomastia surgery. Once the open approach is complete there is no going
With decades of experience and thousands of procedures performed, you can be confident that you will
get the best advice, care and results at the Austin Gynecomastia Center. Get my expert opinion about
your gynecomastia with a free online consultation today.
Our team at AGC is here to answer your questions, assist with scheduling your appointment, or help you with any other matters related to your treatment. Book your consultation online for specific questions regarding a personalized surgical plan.
A further detailed discussion with Dr. Caridi and his team will follow this inquiry. If you are seeking more general information or are a previous patient needing to contact medical staff, always feel free to call our office.
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