Dr. Blau’s Tips

THE PROCEDURE: “The Natural Blend Technique” Pioneered by Dr. Mordcai Blau

Over the course of performing thousands of gynecomastia surgeries, I’ve developed my own technique, which I call the Natural Blend Technique. The most important aspect of my method is to remove breast and fat tissue in specific locations to make sure the patient’s chest is well-balanced in proportion to the rest of his body.

During surgery, I typically start by making an inch-long incision along the underside of the patient’s areola. That’s a good site for the incision because it allows enough room to completely remove the gland and perform liposuction if necessary, while the incision’s size and location lend themselves to minimal scarring, especially since I make the cut where the skin tone changes from chest to areola. The incision is usually inconspicuous because of its location, and because the actual size of the incision may shrink over time after the surgery. In more serious cases of gynecomastia, I may need to make a slightly larger incision in order to remove all the glandular tissue, but in recovery, I find that the scar can still go unnoticed most of the time, as long as it’s placed correctly. Some physicians cut into their patients’ armpits or along the crease of the breast, but I’ve found that those are more visible and less effective locations.

Once I’ve made the incision, I remove excess gland, fat, and fibrous tissue. If I need to perform liposuction, I can insert the liposuction tool—called a cannula—into the same incision. I use it to maneuver between the layers under the skin, breaking up excess fat and suctioning it out of the chest. With IV sedation, the patient doesn’t remember or feel a thing.

The key is to make the chest appear natural and smooth. If, for example, I removed the glandular tissue from an average patient without removing surrounding fat, his chest could be concave where I took out the gland. That would be akin to taking a bowl of ice cream and scooping a spoonful from the top—there’s going to be a crater unless you smooth out the remainder. In a bodybuilder, on the other hand, I generally don’t need to remove any fat because he has almost none in the first place. On some rare occasions, if I find that removing the glandular tissue and fat doesn’t produce the proportional structure I’d hoped for, I use a “fat flap” to blend the tissue and create a smooth contour. Often, this means detaching a small region of fat on the chest almost completely but leaving one part of the flap attached at the base, kind of like a peninsula. I can then maneuver the “peninsula” of fat in certain ways to smooth over any contours or unevenness.

After I’ve done this initial work, I always pause to examine the chest as a whole. After all, of what help is it to the patient if each breast looks good on its own, but the two don’t appear good together? No one is totally symmetrical, of course, but we want to achieve the best aesthetic result possible. As always, the patient has to be realistic in his expectations.

After the surgery, I send all breast tissue to a pathology laboratory for testing, which ensures that the tissue was, in fact, glandular and that the patient doesn’t have breast cancer.

Recovery Process

The most frequent question I receive is what to expect in the days, weeks, and months following gynecomastia surgery. It’s perfectly normal to feel some discomfort for a few days after surgery. It’s also common to experience some swelling and bruising. One of the first things a patient wants to know is, how did my surgery go? Right off the bat, patients can usually see a reduction in breast size, and the results will only become more noticeable as the swelling and bruising subside.

It generally takes months or even a year to see the final result of gynecomastia surgery because the swelling takes time to disappear. I’ve found that if there’s zero improvements soon after surgery, waiting a year likely won’t change that very much. Most of my patients see an improvement of about 50 to 90 percent in the first few weeks after surgery; if a patient tends to retain fluids or experiences serious swelling, he may see an immediate improvement of only 30 to 40 percent. All the same, there should be some visible improvement almost right away. If not, the amount of gland excised may not have been sufficient.

Bruising can last up to a few weeks so I ask patients to stay out of the sun during this time because they risk permanent skin discoloration if the bruises experience too much sun exposure. Bruises that start black and blue tend to become yellow after about five to seven days and disappear in three or four weeks. Swelling can vary depending on the patient and the severity of the case. Sometimes it’s localized, just around the area where the procedure took place. Other times, it spreads throughout the chest and abdomen. Generally speaking, swelling starts to occur on the first day, gets worse around the second day, and starts to recede toward the end of the first week. It’s much better by the second week and continues to disappear after that. During the first three days following surgery, patients may use a cold compress to reduce the swelling; after that, I recommend a warm compress. If you have severe swelling or extreme pain, make sure to contact the office immediately because it could be an indication of a large hematoma. Large hematomas are extremely rare in our practice, about 1 to 2 percent (seromas are more common). Either way, neither seroma nor hematoma will affect the long-term results of your surgery, and both can be treated. Although much of the initial swelling and bruising will disappear within a few weeks, it can take as long as three to twelve months for all of the swellings to entirely dissipate. It can take even longer in secondary cases.

Skin Healing

It’s normal for there to be some crusting along the incision lines, which can be treated with an antibiotic ointment. Itching and occasional small shooting electrical sensations within the skin are common as the minor nerve endings heal, too. To help, you can use ice, skin moisturizer and massage.

Pain After the Surgery

Everyone has a different tolerance for pain. My patients usually find that surgery is much less painful than anticipated. If you undergo extensive liposuction, the pain might feel like being sore after a strenuous chest workout. More often than not, my patients don’t need anything stronger than Extra Strength Tylenol, but if the pain is really bad, your surgeon can prescribe stronger medication. Severe pain is abnormal and may indicate a large hematoma that should be evacuated. If you are experiencing a great deal of pain after your procedure, inform your surgeon. Although it’s uncommon, I have had experience with patients who are addicted to pain meds like Vicodin and claim that they’re in more pain than they are in order to score prescriptions. Doctors must always take their patients’ discomfort seriously but should also be wary of patients who seem only to be seeking prescriptions.

Today, doctors can use a government website to monitor prior prescriptions a patient has received and make an informed decision to avoid overprescribing. One complaint I’ve heard, particularly through online forums, revolves around “nerve damage.” Despite some patients’ claims, I have never seen medical proof of such a condition or direct evidence of nerve damage from gynecomastia surgery in my entire time practicing medicine. This is a puzzling, and troubling, claim because there are no major nerves above the pectoralis muscle the way there are in the hands and the face, which could paralyze you if you cut them. There are superficial nerves in the chest that do get cut while operating, but this is true of every single surgery in any part of the body, like a hernia surgery or appendix removal.

Aside from discomfort and, rarely, minor pain during the healing process, these superficial nerves in or under the skin are truly nonessential to the way we perceive sensations, unlike major nerves elsewhere in the body. It is perfectly normal for some patients to experience temporary numbness or loss of sensation around the areola-nipple complex as their bodies heal, especially if theirs was a particularly severe case of gynecomastia that required liposuction. In most cases, the sensation returns in a year or less and isn’t indicative of a more dire medical problem. Although these patients may feel emotions that they are experiencing something akin to nerve damage, I don’t see any evidence for the claim. Simply put, there aren’t any major nerves above the pectoralis muscle to be damaged. A superficial neuroma is an extremely rare condition that can develop after any skin laceration or surgery; it’s an abnormal healing of the nerves and may manifest as a tiny area sensitive to the touch. It can occur in any part of the body.

Bathing and Hygiene

You can shower or bathe twenty-four hours after surgery, even if your doctor inserted drains to evacuate the fluid that accumulates after surgery (this is very uncommon in my practice). That said, if the doctor wrapped a bandage around the incision, don’t remove it without permission. In my practice, patients must leave on their compression dressings until I remove them, usually three to five days, and they cannot shower in that time. They can, however, clean themselves with a sponge bath.

Exercise

The first three days are crucial for recovery after gynecomastia surgery. Light activity like watching TV and walking around is fine, but anything involving prolonged walking is off-limits, as is any activity that requires moving the shoulder joint. It’s fine to move your elbow, but rotating your shoulder or moving your arms overhead can negatively impact the healing process, like pulling a stitch or leading to a hematoma. I also recommend against driving until you feel able, at least three to five days. You need your reflexes at full capacity, so if the pain will inhibit them, don’t drive. Lots of motion, even from driving, can encourage fluid collection and bleeding. One unfortunate note: I don’t recommend sexual intercourse until about ten days after surgery. After the first two weeks, patients can reintroduce exercises like walking, jogging, and leg exercises. After three to five weeks, you can reintroduce chest, shoulder, back, and arm exercises, including weight lifting, and these exercises can progress in difficulty over the next couple of weeks.

Going Back to Work

If you work at an office job that doesn’t require physical exertion, it’s fine to return to work within a few days of surgery. If your job requires physical activity, like police or construction work, I recommend waiting at least two weeks before returning. Talk to your surgeon for instructions particular to you.

Sun Exposure

Patients should remain out of the sun for about four weeks after surgery to reduce the likelihood of the scar becoming permanently discolored. When going out in the sun, I highly recommend wearing sunscreen of at least SPF 30 for the first few months.

Scarring

Mederma, Scar Guard, and other scar reduction creams can be used according to your plastic surgeon’s directions. These are only useful when the scar is raised, so they won’t help if the scar is wide and flat. Injectable Kenalog is the best option for treating your scar, but it’s only available through a surgeon. All the same, if the incision is done under the areola, there’s less of a need for these scar-reducing treatments. Some male breast reduction patients develop post-op inner scars underneath the areola, which feel like a hard doughnut surrounding the nipple. This is normal. It can be tough to distinguish between scar tissue and glandular tissue, but an inner scar doesn’t mean the surgeon left behind gland tissue he shouldn’t have. These inner scars typically diminish within a few months to a year—more in secondary cases—and in my practice, it’s not common that I need to excise internal scar tissue.

Nipple-Areola Sensation and Gynecomastia Surgery

Most gynecomastia patients experience temporary numbness around the nipple-areola complex, especially those with more severe gynecomastia requiring liposuction. This temporary numbness is not harmful in itself and is not indicative of a larger problem; in no way does it indicate nerve damage. For most patients, this temporary loss of sensation returns within a year or less.

Post-Surgery Massage

If scar tissue builds up in your chest, you can lightly massage the area with your fingers to help break up the scar tissue. That said, don’t do this during the first week following surgery because it might interfere with the healing process. This post-surgery massage is usually not needed, and it will only work on real scar tissue. If your surgeon hasn’t removed enough glandular tissue, this won’t remedy your problem.

Is Gynecomastia Surgery Right for You?

Though some medical conditions may impact your ability to have a successful surgery, the most important question is whether you feel that gynecomastia surgery will have a significant positive impact on your life. Over time, I have devised a list of questions to help men decide whether surgery is the best option for them:

• Do you avoid social outings at the beach, pool, or any other place where you may expose your chest?
• Are you bothered by other people’s comments about the appearance of your chest?
• Does your chest limit your confidence in intimate situations?
• Does your chest detract from your overall confidence?
• Are you experiencing depression due to your gynecomastia?
• Does your chest bother you to the point where you feel that no other option but surgery will fix the problem?