In this episode of Carpools & Cannulas, San Diego plastic surgeon Dr. Katerina Gallus of Restore SD Plastic Surgery and Dr. Jennifer Greer of Greer Plastic Surgery in Cleveland, OH, excess breast tissue in men and what gynecomastia surgery involves – from assessment to recovery time. Hear from these two board-certified plastic surgeons on all the factors that go into gynecomastia surgery.
Transcript
Dr. Gallus: Hi everybody, it’s Dr. Kat Gallus and we’re about to start the new year with another installation of Carpools and Cannulas. And tonight we’re going to talk about gynecomastia. I’ll be joined with Dr. Jennifer Greer who’s hopping on right now. And your internet is working as well as mine is so that we’re going to get on. Hey, Greer.
Dr. Greer: Happy New Year, 2023.
Dr. Gallus: Happy New Year.
Dr. Greer: Nine days into it already.
Dr. Gallus: I know. I know it’s nine days because I’m doing one of those dry January and it’s torture.
Dr. Greer: I have a dry wine. Does that count? Yeah.
Dr. Gallus: Yes, that counts. I’m drinking my concoction of ice, you know, that like flavored water and LaCroix.
Dr. Greer: Okay.
Dr. Gallus: Oh, and my dog is here just- Okay. So yeah.
Dr. Greer: Yeah.
Dr. Gallus: So, I hope you had a good holiday. And I think we took a break for the holidays, but we were going to talk about gynecomastia which surprisingly we haven’t done yet which is wild to me.
Dr. Greer: I know. I mean we do have a lot of female followers, but I still get a fair number of gynecomastia cases.
Dr. Gallus: Yeah. Yeah. I did more of them when I was in the Navy, in the military, but I sort of had a minor following and they joked because all of my patients were heavily tattooed for whatever reason. So on the occasion when somebody wanted to see before and afters and I was like I swear I operate on people who are not tattooed as well. It’s just, I mean, and I’m not talking like one tattoo, I’m talking about Travis Barker and that whole like…
Dr. Greer: I always love like when they get up to the anterior neck. And hi Amanda, I see you watching. So when you were doing it in the Navy was that covered?
Dr. Gallus: Yeah. So it was covered if they met certain criteria, pain was one of them, which is, you know, very hard to … Yeah, but yeah, they were actually even doing a study at the breast cancer center, the multi-d center, where they don’t have breast cancer. Well, we can clear that up right now, but they were treating…out of that center they were treating them with Tamoxifen which is a known treatment. So they were running a trial to see if Tamoxifen would…
Dr. Greer: I don’t know, I feel like hormone blockers versus small excision under local…
Dr. Gallus: I know. Yeah, absolutely. So I got a lot of traffic from people who were like, “You want me to take an estrogen blocker? Oh, okay.”
Dr. Greer: Although, I guess it may make sense, especially for the exogenous, yeah.
Dr. Gallus: Mm-hmm. Yeah. So, all right, well why don’t you tell everyone what gynecomastia is or what is also known as?
Dr. Greer: Right. So gynecomastia, also known as man boobs, I’ve heard them called moobs also, it’s actually glandular breast tissue because of hormone imbalances. So usually around puberty and then senescence, so like 50s, 60s when testosterone levels drop, but I think with marijuana use being legalized so many places, that can also increase the risk of gynecomastia. So can other medications. And then people also confuse the glandular tissue itself with just extra fat over the pec muscle and thinking that’s gynecomastia, but truly it’s the glandular tissue.
Dr. Gallus: Right. Right. So it’s not associated with a risk of cancer. It is associated either with a hormone imbalance or a medication or it can be our favorite medical word idiopathic. We don’t know why, but it’s common, yeah you’re right, in the teens. Now I have operated on teenagers who had gynecomastia but out of teenagers that do have it about two-thirds of male adolescent boys will develop gynecomastia but then about two-thirds of those will see it resolve spontaneously. So you certainly don’t want to operate on someone who, you know, is had it for six months is 15 years old, and is likely to not need surgery. So you just kind of have to ride that out. So then, there can be some things like liver problems some other physiological problems that can lead to it, and then medications. So it comes up all the time, do you test your patients? Do they get labs, or do they get screened by someone else first?
Dr. Greer: I don’t routinely but truly all the patients I’ve seen it’s been there for more than a year. It’s stable. It’s not going anywhere.
Dr. Gallus: Right. It’s actually I’ve had tougher cases where it was an older male patient who was on a medication to treat, for example, prostate cancer. He couldn’t change off of it, so the incidence of recurrence is pretty high, but what are you going to do, the alternate treatment was radiation. So it was a little…that can be hard. So yeah, so I mean usually by the time you see us you’re down the pathway for surgery, but I would I mean somebody needs to do that study and look at the incidence of gynecomastia in states who’ve legalized marijuana and what that’s done. Right?
Dr. Greer: Yeah, it’s got to be high.
Dr. Gallus: I just heard on the radio there’s a study that was just done they looked…I think Colorado is the state that’s had the longest legalization and they looked at the number of poisoning events for children like people who call the Poison Control hotline and/or show up in the ER for accidental ingestion of marijuana before it was legalized and now and you can imagine the jump is high.
Dr. Greer: Yeah, so much of it is in edible form.
Dr. Gallus: Right. And it looks like a gummy bear or something stupid.
Dr. Greer: And I mean, the packaging has to really not look like candy but it’s still a brownie is going to look like a brownie.
Dr. Gallus: Mm-hmm. I mean if people are going to eat pods, Tide Pods then, you know, I feel like a gummy bear is going to be a gummy bear.
Dr. Greer: Right. Well, actually, I think they can’t even be in a gummy bear shape. So I applied for a dispensary license the last round in Ohio, so I know a ridiculous amount about at least cannabis in Ohio. We didn’t get the license, but the gummies can’t even be shaped like a gummy bear. They have to be just round. The names have to be very not geared toward children or sound anything like candy which is interesting.
Dr. Gallus: Yeah. Well, that’s smart, and like the tobacco company. But so, I wonder if somebody who’s looked at…somebody should do a study, Jeff Janis, just throwing out a name, just kidding, somebody who’s always doing research, be perfect for him, to look at states that have legalized marijuana and then see if the incidence of gynecomastia has increased. It would be easier to figure out. So, anyhoo, once you’ve seen us you usually have some problem that’s not going to get solved unless you embark on surgery, right? And what’s your usual technique? What do you usually do?
Dr. Greer: So it’s interesting because most of the people who come in with gynecomastia have a combination of excess fatty tissue and the actual glandular tissue. And for those of you who don’t know what that glandular tissue feels like it’s like a little firm ball right behind the nipple and it can be tender or not, it can be one, or both sides. So that’s the true gynecomastia part. It’s generally a combination of liposuction and then direct excision of that fibrous part because that stuff doesn’t come out with lipo.
Dr. Gallus: Right, and yeah. And so as per usual, we’re on the same page. So, I do a combination of liposuction…
Dr. Greer: It’s so funny how we trained in totally different places and times and we do everything the same.
Dr. Gallus: Yes, it is weird. Yeah, so a combination because there are more than one way to do it. I’ve even reviewed papers for the journal where someone is presented their unique technique of gynecomastia excision or whatever and then the paper gets rejected because you’re like just doing liposuction and direct excision and then open the space underneath.
Dr. Greer: [cat appears onscreen] He always shows up for this!
Dr. Gallus: Oh, your cat is joining us.
Dr. Greer: He’s excited about the gynecomastia because he’s got the little fluffy belly. He’s hoping this will apply to him. Yep.
Dr. Gallus: Yeah. So of techniques, you can do liposuction only. I find that that ends up being a fail because that little butt of a tissue doesn’t go away and even if it’s just a small amount it ends up leading to a puffy nipple even if the rest of the chest looks…
Dr. Greer: And I’ve seen people too present with just a puffy nipple, the rest of the pec is well defined. There’s no extra fatty tissue. It just makes the nipple look puffy. So if you have that, you may not realize that’s gynecomastia and it’s very easy to treat. I mean, I do these cases under a local if the patient wants it. Sometimes they would prefer to have general, but you can definitely do them under local and keep people comfortable.
Dr. Gallus: Just the local…just excision only or excision and liposuction under local?
Dr. Greer: Excision and lipo but you just tumesce slowly.
Dr. Gallus: Okay. Not all men are great with pain. I mean some of them are, some of them aren’t.
Dr. Greer: Yeah. I mean some guys, but you know women. Yeah, I think more of my male patients prefer to be under general anesthesia. Although one of the funnest cases I ever did on a wake patient was a gynecomastia case and the patient was hilarious. I was like, “You’re not going to remember any of this tomorrow.” He’s like, “I’ll remember your cell phone code. You just gave it to your nurse.” He came in for his follow-up appointment, he’s like, “1998.” I’m like, “Oh, that’s not it, obviously because that’s only four digits.”
Oh, we have a question, breastfeeding. Ooh, good question. Six months generally is minimum because it takes a while for that milk to dry up, especially if there’s any intermittent nursing in there and even if you haven’t nursed or pumped or anything for six months there will still be some milk in there when we do your reduction.
Dr. Gallus: Yeah, and that’s not the end of the world but your breasts are still maybe changing size, so you don’t want to hit a moving target and over-resect or under-resect. So it’s nice if the breast is stable.
Dr. Greer: And you don’t want to get any healing problems too. You don’t want a galactocele or a fistula, yeah.
Dr. Gallus: Yeah. A large abscess on the left one. Oh, that’s a drag.
Dr. Greer: Yeah. I’m sorry. I’ve had patients where this happened. Usually, the drain should be coming out soon unless it’s still putting out. Oh, thank you. I mean, I’ve had that happen too sometimes that just does happen.
Dr. Greer: [to commenter] I look forward to meeting you. And congrats on your baby.
Dr. Gallus: Yeah. Yes, that is always, I don’t want to miss on that. I usually demand that those patients bring their babies in.
Dr. Greer: We are so baby-friendly in my office. We’re like, “You have to bring your baby in for your Botox? We’ll hold it. Okay. Yeah. We’ll totally hold your baby while we talk.”
Dr. Gallus: Well so, okay, so excision and liposuction, some kind of combination, right? Almost always need excision, almost always. Sometimes you don’t need liposuction and that’s like on a super, super skinny two percent fat person who just has that little glandular bud, but there are other techniques or things that have been explored to see. I’ve seen it done a couple of different ways. Where do you put your incision? Is it around the nipple-areola complex?
Dr. Greer: So, this is one of the things that I fiddled with because for the lipo I feel like having the incision laterally is much easier than trying to do it in the nipple and then I used to do an incision right on the edge of the areola to excise but then I forget who somebody pointed out that like straight across the areola actually blends in better and heals better. So I’ve done that too. How about you?
Dr. Gallus: Yeah, I like going around the areola complex. I know that the problem can be that that can dent in a little bit and I’ve seen cases that’s happened for, you know, I think if you’re super careful on how you close and honestly the premise of that paper that got rejected was making sure that the tissue underneath is stable so you don’t end up with that and I think like, I mean, common sense but I feel it can look a little weird if it goes right across the nipple-areola complex. And honestly, as per usual, depends on the patient, right, depends on what their areola looks like. If this teeny tiny thing might be hard to go all the way around. I don’t mind the little incision in the axilla if I need to for liposuction. I try to do it all through one incision but again it depends on the patient and what we’re accomplishing. I worked with a guy at Kaiser who would make a random incision on the chest which I thought was wild but then he said, “Oh well, then it’s not stigmata of having gynecomastia.
Dr. Greer: Yeah. I’ve seen that.
Dr. Gallus: Yeah. So he put one scar here and one scar somewhere else on the chest. I’m like, I guess so, as long as you clear that with the patient.
Dr. Greer: I mean once they fade, they’re pretty hard to define.
Dr. Gallus: You can’t see it, yeah. And then also, I will sometimes add Renuvion. I know I use that radio frequency device. If somebody is a little bit fluffier and has some lax skin because then in addition to lipo, it will tighten everything up. I do it because you don’t want to have to put a bunch of incisions on someone’s chest because then instead of being insecure about having man boobs you’re now insecure about these wild incisions. I did work with a guy who came and was like a reservist in the Navy came out and he was in practice on the east coast and instead of excising the glandular tissue and I’ve heard of these other places they use like a cartilage burr to like burr it down and then suction it out. I just never found it really satisfying.
Dr. Greer: You know I’ve done cases with like trying to do the Dermabrader and it just sounds slippery and difficult. Yeah, I don’t know. I know where I trained in residency one of our attendings was really, really big on having the patient build-up pec muscles beforehand so that they would see a better result. He’s like, “You got to build the foundation.” So I mean we weren’t, you know, we were mostly trauma, so we did very few gynecomastia cases, but he’d be like, “Go do some bench presses, do your push-ups, and then we’ll talk.”
Dr. Gallus: That’s funny. Did he have a regimen like start with 10 push-ups a day? That’s so wild.
Dr. Greer: He might’ve. I don’t even know. But then, I remember seeing a video of Simeon Wall who does back grafting into the pec muscle to build it up.
Dr. Gallus: Mm-hmm. I know. So I have seen that too. I was going to say the high-def guys who do liposuction and then turn around and do fat injections in areas where muscles should be, I feel like that’s cheating.
Dr. Greer: I feel like you have to be actually stronger, you can’t actually just do pushups.
Dr. Gallus: Yeah, you don’t have the muscle, now you just have weird fat where your muscles should be.
Dr. Greer: Squishy.
Dr. Gallus: Like what does that feel like? The delts and every…it looks crazy. I do try to make it consistent with the rest of their torso right, so you don’t want to do a chiseled chest if someone overall, you know, some super cut model.
Dr. Greer: Is a little fluffy.
Dr. Gallus: Yeah. That’s fine. You want to get it so that the contour is consistent with the rest of them which I think is a nice approach. Do you use drains? I don’t put drains in.
Dr. Greer: I don’t, no. I have started doing Topi foam vest and then I wrap it with an ace wrap for two days. I love that ace wrap.
Dr. Gallus: Okay. Yeah. I do a vest for sure. I don’t ace them on top of that, but that’s not a bad idea.
Dr. Greer: I started ace-ing all my breast reductions because I got a seroma or two early on when I stopped using drains. Now I just…everybody who gets chest surgery gets wrapped pretty much.
Dr. Gallus: I just put them in a bra or a vest.
Dr. Greer: Oh I wrap twice around.
Dr. Gallus: Yeah, so I like the…
Dr. Greer: Two layers, yep, keep it on.
Dr. Gallus: You’re like, “Nope. We’re still going to like [mimes pulling a wrap tight].” Yeah, I just put him in a vest, but I like the ace wrap for people that you might be a little worried about. I don’t like putting drains in. Everybody hates drains as the person who commented earlier. So if you don’t need them I try not to use them. With men, the reason that sometimes people consider doing drains is just because they have a little bit higher rate of post-operative bleeding just based on their blood pressure, but I feel like that as long as you’re careful. Do you do any top surgery, speaking of…
Dr. Greer: Not commonly. I’ve done some like very aggressive breast reductions for non-binary. I’ve done some male-to-female with implants but not a ton, yeah.
Dr. Gallus: Oh, yeah. Yeah. For everybody listening, top surgery is when you go from female chest to male, and it involves I mean it’s basically a very aggressive gynecomastia procedure. It can involve two incisions what they call a double incision or just if they’re not very big-breasted to start with just going through that peri-areolar incision or it can be much more dramatic. The only reason I brought it up is because a lot of those patients are on testosterone so they’re on hormones for transitioning and so that puts them…
I’ve worked with surgeons…I don’t really do top surgery but when I was working for Kaiser as a per diem we would do some and some surgeons chose to take them off of testosterone for weeks before surgery because it increases the risk of bleeding. I think people tend not to do that anymore because it made people…everyone miserable.
Dr. Greer: Right. That’s like when you take people off birth control for blood clots. I mean, yes, blood clots are bad but so is pregnancy if you don’t want it.
Dr. Gallus: One of those long-term implications if you get pregnant.
Dr. Greer: I mean that right there increases the risk of blood clots, pregnancy.
Dr. Gallus: Right, yes, true. Yeah. So anyway because of the higher testosterone, a male patient versus a female patient is why some people I know choose to use drains. But like I said I think if you’re not sticking a cartilage shaver in there and praying for the best you can get away without using them.
Dr. Greer: Yeah. Especially if your tumescing some epi and get good hemostasis.
Dr. Gallus: Yeah. Yeah. So I find that the hardest thing about gynecomastia surgery similar to tummy tucks but in that patient population is the post-op not pain it’s just the recovery because I did when I was in the Navy I did a fair amount on like Seals and Marines and these like superpower guys so not a lot of body fat not too much liposuction but a direct excision and what you don’t want them to do is like a week out they’ll bust out some pull-ups, right. And so I think that… Yeah. So what’s your like…what do you tell these guys for the real, you know, gym rats.
Dr. Greer: Four weeks. I tell them four weeks and they sometimes hate me.
Dr. Gallus: Mm-hmm. I know it’s really hard to not work out. The whole reason you’re there is because you like the way your chest looks except for this, and you really spend all this time and energy working out and doing those push-ups or whatever and then you’re like four weeks, but it really is a short time in the grand scheme of things to have nice stable results for sure.
Dr. Greer: And if you cause a problem, if you cause a hematoma and then you have to go back to the OR, and then that restarts the clock, and it just takes longer for everything to go down.
Dr. Gallus: Right, yeah. I think it can be a little daunting for people to take but if you can find that time and commit to the recovery process then, yeah, then it’s easy breezy. And I get it, I got my eyebrows done and I didn’t want to take seven days off of not sweating. It was like seven days?
Dr. Greer: I can definitely take seven days off of working out without… I mean like without any trouble.
Dr. Gallus: I know, I love those people who are like what is that?
Dr. Greer: Not a problem. Well, and the other thing that drives people nuts too like we’re not talking four weeks of no push-ups or bench press we’re talking four weeks of no anything because what happens is your blood pressure increases when you’re working out and then you can spring a bleed. I had a breast aug patient who started working out week three and that week four got a big hematoma. We had to go back to the operating room. And I didn’t know if she had started working out. I go to talk to her partner afterward and he’s like, “She was running.” I’m like, …
Dr. Gallus: Ooh. Yeah. No box jumps. I know you’re not using your chest, but yeah.
Dr. Greer: No squats. Don’t even get the 5-pound dumbbells, just don’t do it.
Dr. Gallus: Yeah. I get that, “Can I Peloton?” “No, you can’t Peloton. Please, just take it easy. You can walk. And by walk I mean just walk. Do not go hiking.”
Dr. Greer: I literally tell them like, “Two miles, heart rate under 100.” Because I had somebody go for a 10-mile hike the week after an eye lift. Their incisions dehisced a bit!
Dr. Gallus: Oh, I get it. Like once you’re told you can’t do something like I don’t know during the month of January then you really want it.
Dr. Greer: It is.
Dr. Gallus: It’s just human nature. One of my favorite patients, was post-mommy makeover, we had talked about how she’s planning a trip to Hawaii like six to eight weeks after. I was like it should be fine. I mean you should heal and be healed but you’re…I am in San Diego but, you know, you’re just going to be hanging out at the pool like you can show off your body but like, you know, no zip lining.
Dr. Greer: Don’t go into the ocean if you have any open areas at all, yeah.
Dr. Gallus: Right. So I see her right before she’s supposed to leave for Hawaii and she’s like, “Can I scuba dive?”
Dr. Greer: No, maybe, I mean six weeks. I don’t know.
Dr. Gallus: I was like do you… Hi Neighbor. I was like, “Do you scuba dive?” Like this is news to me. Usually, I get to know my patients a little bit and if they’re an avid scuba diver I feel like I would know that. She’s like, “Oh no, I’ve never scuba-dived.” I’m like, “So let’s just be clear you want to start this Hawaii trip six weeks after surgery?” She’s like, “Yeah. I heard …” I go, “Are you even qualified?” She’s like, “No, but you can do that like the crash course…” “No, no, no.”
Dr. Greer: Yeah, how about not? How about the next trip?
Dr. Gallus: Right! You can hold a margarita or whatever, your Mai Tai, at the pool like we discussed. Please do not start scuba diving but that is just because, you know, you’re supposed to lay low. So that’s when you’re like, “Wow, I think it’s a good time to, you know, take up fencing or something random,” things you’ve never thought of and then you’re like, “This would be great.”
Dr. Greer: Maybe I’ll get horseback riding lessons or parasailing or…
Dr. Gallus: Yeah! Yes, parasailing, I know. I should just make this long list of things not to try just let’s cross these off for the first six weeks. Anyway, well we should figure out what we’re going to talk about next and then yeah I think we’ll wrap up because…
Dr. Greer: Yeah, talk about next week.
Dr. Gallus: I got to go interview a… virtual call here!
Dr. Greer: Yeah.
Dr. Gallus: Yeah, oh I don’t know, we can chat about it unless anybody has a suggestion or put it in here.
Dr. Greer: I’m trying to think of something we have not talked about in a while.
Dr. Gallus: Maybe we could talk about breastfeeding, yeah, or something we haven’t covered. Let’s see. I’m trying to wave to people. Okay. Do you want to talk about breastfeeding and breast surgery and just discuss with that?
Dr. Greer: We can, and we can talk about all the fun commonly held ideas like whether you should wear a bra all the time or whether you should not wear a bra according to some article about French people.
Dr. Gallus: Yeah, that sounds good yes because I do have patients that say, “I want this surgery, so I never have to wear a bra again.” Which I get because same here.
Dr. Greer: If we’re doing reduction to an A cup, done. You will not have to, but yeah. Okay. We can talk about that. That’ll be good.
Dr. Gallus: Okay. All right. Well, it was super good to see you. Are you going to be in Charleston, right?
Dr. Greer: Yeah, I’ll be there. I’m bringing my boyfriend. It’ll be fun, yeah.
Dr. Gallus: Nice.
Dr. Greer: Yeah, I’m pulling the meet-the-group. I’m like, “She brought her boyfriend. I’m bringing my boyfriend.”
Dr. Gallus: Okay. As long as he can take the overwhelming estrogen I think he’ll be fine.
Dr. Greer: Yeah, I think he’ll be totally fine. And he’s in the Navy. He’s in the reserves now. So you guys can chat over that yeah.
Dr. Gallus: Oh yeah. Yeah. We can discuss that. Awesome sauce.
Dr. Greer: In two weeks I’m here and then I’ll see you in person in Charleston.
Dr. Gallus: Sounds good.
Dr. Greer: Bye. You too.
Dr. Gallus: Bye. Have a good night.
About Restore SD & Dr. Katerina Gallus
As the Director of Restore SD Plastic Surgery, board certified female San Diego plastic surgeon Dr. Katerina Gallus has over 15 years of experience helping patients enjoy head to toe rejuvenation with face, breast and body procedures. After a successful career as a Navy plastic surgeon, Dr. Gallus founded her San Diego plastic surgery center Restore SD Plastic Surgery with the intention of creating a welcoming space for anyone seeking cosmetic enhancement.
Restore SD Plastic Surgery offers popular facial rejuvenation procedures like facelift & neck lift, facial fat grafting, and eyelid lift; breast augmentation with implants, breast lifts or breast reduction; body contouring procedures such as tummy tuck, liposuction, mommy makeover, and Brazilian butt lift (BBL), as well as aesthetician services, BOTOX, injectable fillers, and laser treatments.
Dr. Gallus and her highly-experienced aesthetics team are here to help you look and feel your best! To schedule a personal consultation, please contact us online or call our San Diego office at (858) 224-2281 today.
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