Grade IV or skin excess gynecomastia

When I evaluate a patient for Gynecomastia, I evaluate the:

Gland size
Fat distribution and content
Nipple position and areola size
Amount of excess skin.

It is the nipple position and amount of excess skin is the main determinant of the complexity of the case.

When there’s little skin excess, such as is found with grades I/II and some grade III’s, we remove the gland and rely on the skin’s natural ability to retract , without directly removing any skin. The ability of skin to retract, especially in younger patients with good dermal tone, is sometimes fairly amazing.

As we age, or in cases of extreme weight loss or weight fluctuations, that same skin loses its ability to retract. I will make an evaluation based on my experience, and when I don’t think the skin will retract much, then I will sometimes propose cutting out the skin.

There are two ways that I remove excess skin:

1. The circumareolar approach:

With mild skin excess,. I will tackle the excess skin via a circumareolar “pinch to the center” type skin removal, along with an areola reduction. This is a good operation that will handle mild skin laxity without too visible of a scar, as the scar will heal in a circular fashion around the areola. This also allows me to reduce the overall size of the areola when needed.

Example of circumareolar approach:

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after

2. The double incision technique:

This operation is suited for cases of extreme skin excess, or in cases where the patient desires the tightest possible scar. With grade IV or advanced skin excess, the operation changes drastically from a simple gland removal operation to a wedge resection of tissue that contains the skin, the gland , and the nipple.

The nipple then has to be reconstructed as a nipple graft. On occasion, with only short distances of nipple droop preoperatively, we can do a nipple flap instead. You may see an example of a double incision/nipple flap surgery on the video
below

The main downside to the double incision technique is the scarring involved. The scar is across the chest. Sometimes it can fade nicely, however I always tell patients that if the scar is very visible, they may want to cover the scar with a nice and masculine chest tattoo like the example below

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after

Real Patient Results

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Conclusion

Skin excess on the chest presents its own challenges, in addition to those presented by the gland itself. Often a more drastic approach will yield final results that are still very pleasing. I will consult with you and let you know my opinion on what would work best for your particular case.