Most cases of gynecomastia have no specific underlying cause. However, gynecomastia can be caused by testicular and other tumors, although this is rare. There are many drugs that can cause gynecomastia including blood pressure medications (angiotensin converting enzyme inhibitors), Valium, prostate medications, antacids such as Cimetidine, digitalis, antifungal drugs, chemotherapy agents, and marijuana, among others. Rare congenital disorders such as Klinefelter syndrome can also be responsible for gynecomastia, as can alcohol induced cirrhosis of the liver. Despite these potential contributing factors most cases of gynecomastia do not require a comprehensive work-up prior to treatment.
Most adolescents are driven to seek treatment for gynecomastia because of embarrassment in gym class or at the beach, and older men often because of self consciousness when wearing thin shirts during warm weather outdoor activities. Fortunately most cases of gynecomastia can be effectively treated and the results are permanent.
Gynecomastia is usually treated with a combination of liposuction and direct excision of breast tissue under the nipple area. The incisions are made along the lower half of the areolar circumference at the junction between the dark and light skin. These scars usually fade with time and are rarely conspicuous. Most mature men usually have some hair in this area that further contributes to obscuring the scars. Liposuction consists of injecting the breast area with a dilute anesthetic solution followed by sliding special tubes called cannulas back and forth through the breast tissue to dislodge and then extract the fat. Liposuction removes approximately 80 percent of the excess tissue but removes only the fat. There is also firm glandular breast tissue present that contributes to the condition and is not effectively removed by liposuction. Therefore after completion of the liposuction portion of the procedure the breast tissue is removed by excising it under direct vision through the incision described. The goal is to make the area flat while avoiding aggressive over-resection that could leave a dent. Extreme cases of gynecomastia with hanging breasts may require skin removal in addition to liposuction and tissue excision. The scars are much more significant when this is necessary.
Beyond adolescence beginning in the mid-twenties men will often develop prominent “love handles” around the waist in addition to gynecomastia. These areas can be conveniently treated at the same time with liposuction. The lower abdomen is another area that is commonly treated with liposuction concomitantly. While liposuction can remove bulges due to excess fat in these areas, it does not tighten loose skin. Therefore each patient must be carefully evaluated if liposuction of these other areas is being considered.
Surgery is performed in the office as an outpatient and general anesthesia is used. Any specific anesthesia concerns will be reviewed with the anesthesiologist prior to surgery. Most procedures last less than two hours. All surgery is performed entirely by Dr. Hidalgo.
Postoperative pain is typically low grade because surgery involves only the superficial tissues and not deeper structures such as muscle where there tends to be more pain fibers. Oral pain medication is sufficient to control discomfort for the first few days. The chest is wrapped with a wide ace bandage after surgery that is worn for the first week. Moderate swelling does occur but bruising tends to be mild in most cases. It is possible to return to work in a week or sometimes less. Exercise can begin after a few weeks and gradually increase in intensity.
Complications are rare. Bleeding or infection can occur with any surgery but are particularly unusual in gynecomastia surgery. Numbness of the skin in the treated area can occur and this can include the nipple itself. It is possible for numbness to be permanent.
While every effort is made to make the breast area as flat and smooth as possible, minor irregularities, asymmetry, or residual gynecomastia may become evident months later. If a touch-up procedure is indicated it is usually not performed until one year after the original surgery in order to allow complete healing and softening of the tissues to occur. Most revisions are short procedures that do not cause prolonged swelling, discoloration, or restriction of activities.
There are separate fees for surgery, anesthesia, and operating room use. Costs also include preoperative lab tests, medical grade photographs, and support garments.
If you are a good candidate anatomically a surgical date can be scheduled. Photographs and preoperative laboratory studies follow. Older men with significant medical conditions will need to obtain clearance from their internist or other specialist beforehand.
Rytid is the medical term for wrinkle, and –ectomy means remove. Rhytidectomy therefore, is a procedure that removes facial wrinkles. It is better known by the colloquial term facelift.
There are several popular misconceptions about facelifts. First, it does not treat the entire face. It is designed to eliminate jowls and tighten the loose neck (Figure 1). It does not by itself improve the appearance of the eyes (even the lower eyes) or the forehead. Most importantly, it does not change the appearance of the central face, meaning the corners of the mouth are not distorted when the procedure is properly performed. The folds that extend from the crease in the nose to the corner of the mouth (laugh lines or nasolabial folds) do not disappear when a facelift is performed. However, the lower portion of the nasolabial folds are softened considerably, and the downward extension of the nasolabial folds seen in some individuals that reach almost to the jawline (marionette lines) are usually eliminated (Figure 2).
A facelift is intended to make a person look fresher, not fundamentally different. When properly performed it reverses aging changes without leaving telltale signs. It is an effective way to “turn back the clock” and the beneficial effects will last for about ten years.
Most women become candidates for a facelift sometime after forty-five and men about ten years later. Jowl formation and loose neck skin are the most common indications for surgery. The decision to operate depends not only on the severity of the problem but the individual’s reaction to it. Early aging signs may be insignificant to some but enough for others to consider surgery. Facelifts are not performed on a preventive basis however. There must be enough aging changes present to warrant the procedure. That said, results are generally better in younger patients with good skin quality.
Everyone wants the least amount of surgery needed to achieve the best result. However, it is not logical to expect that either a simple “tuck”, liposuction of the neck, or nonsurgical treatment with radiofrequency waves (Thermage®) will reverse decades of progressive aging. This is rarely possible and the results of “doing less” are usually disappointing. Objection to needing a facelift is unrealistic when aging changes are significant.
Some individuals, though few, do benefit from a neck lift only. They are usually young and have very minimal conditions. The amount of tightening possible with a neck lift is limited by restricted incision access behind the ears (Figure 3, left). Moreover, the skin has to be pulled hard to adequately tighten the neck with this method. High skin tension resulting from this predisposes to thick or wide scars. Rotation of the lower cheeks and neck together in a facelift tightens the neck more effectively. Overall scar quality is far better because skin tension is distributed over a broader area.
Restylane® and Juvéderm® are examples of fillers used to treat problems of volume loss, grooves, and static wrinkles (wrinkles observed with the face in repose). BOTOX® and Dysport® are temporary paralyzing agents used to treat wrinkles from hyperactive muscles, like the frown lines between the eyebrows. Neither treats tissue laxity, the main indication for facelift surgery. Overuse of fillers in an attempt to compensate for tissue laxity frequently results in an unnatural appearance without addressing the underlying problem. Using the wrong solution in order to avoid surgery is also incrementally expensive.
Thermage is a nonsurgical technique. It uses radiofrequency waves to heat skin collagen, supposedly causing skin contraction and tightening. This method is ineffectual in those with true skin laxity. It is not a substitute for a facelift nor is it proving to be an effective temporizing measure to delay having a facelift.
Stem cell facelifts are not facelifts at all. This method isolates fat stem cells that are claimed to have rejuvenating properties on the skin. The fat is injected into the face to enhance shape in areas that exhibit hollowing. It can be used as an adjunctive measure but is not a substitute for surgery.
The Lifestyle lift is a surgical procedure. Barbed sutures that resemble miniature fish hooks are passed into the cheeks through scalp incisions. The sutures “catch” the tissue when they are pulled upward, elevating the cheeks as they are tied under tension. The results are often imperceptible, and not long lasting. Problems with suture breakage, slipping, and skin dimpling can occur.
The incision typically starts in the scalp just above the ear, courses downward following the curve of the ear, disappears behind the small protruding cartilage in front of the ear, emerges to course around the earlobe, and runs in the crease behind the ear (Figure 3, center). It will either stop there in those with little neck laxity, or continue backward into the hair behind the ear in those who are older and have looser neck skin (Figure 3, right).
A separate scar is often necessary under the chin in order to eliminate the muscle cords in the front of the neck. All facelift scars are permanent but fade with time, most being inconspicuous after one year (Figure 4). It is not necessary to cut the hair at the time of surgery.
Facelifts consist of more than just skin tightening. There is an important layer under the skin called the SMAS, which is short for Superficial Musculo-Aponeurotic System. The SMAS is made of strong fibrous tissue and fat. Tightening the SMAS layer eliminates the jowls, restores cheek contour, and softens the nasolabial folds. It also reduces the amount of pull necessary on the skin, thereby greatly aiding in achieving a natural appearance and good quality scars.
There is a thin sheet of muscle in the neck called the platysma. It blends into the SMAS in the lower cheek. This muscle is tightened together with the SMAS to improve neck contour and help reduce neck skin laxity (Figure 5).
A deep plane lift is a variation on SMAS technique where the skin and SMAS layers are lifted together and not separately. It is quicker but has the disadvantage of not allowing the skin and SMAS layers to be tightened in the slightly different directions necessary to achieve optimal results. It also places the underlying facial nerve branches at greater risk for injury. This method is not commonly used today. Interestingly, it has even been abandoned by its original developer.
Facial aging changes commonly include the development of prominent neck cords under the chin. These cords, or bands, form two vertical folds that consist of loose platysma muscle edges underneath (Figure 6, left). These bands also contribute to poor neck contour from the side (Figure 6, right). Minimal bands do not require specific treatment other than pulling the platysma from the side as part of SMAS cheek tightening (see above). However, most patients benefit from sewing the loose muscle edges together in the middle through a separate incision under the chin (Figure 8). This eliminates the visible cords and also improves neck contour on the side view (Figure 7). Removing excess fat under the chin through this same incision further improves neck shape.
Aging changes of the forehead and eyes are commonly addressed at the same time as a facelift so that balanced facial rejuvenation is achieved. Hooded upper eyelids and lower eyelid fat pouches can be effectively treated with eyelid surgery. The incisions are hidden in natural creases. Sagging eyebrows associated with deep furrows between them can be treated with a browlift, although the need for this is infrequent. Surgery to improve the forehead and eyelids at the same time as a facelift does not affect recovery time.
A facelift does not eliminate fine wrinkles and textural problems of the skin although these conditions are often partially improved. Chemical peels and dermabrasion are adjunctive procedures that can treat fine lines around the eyes and mouth. These procedures are quick, simple, and rarely prolong recovery time (Figure 9).
The cartilages of the nasal tip continue to enlarge through life and may result in a prominent tip that droops. Making the tip smaller and raising it enhances overall appearance. This is a both simple and subtle procedure that is focused on the tip without changing the rest of the nose.
Thinning of the upper lip often occurs with aging and is difficult to treat effectively with any method. A lip lift is an ancillary procedure that is not widely applicable but in the right patient can make an improvement.
A chin implant is helpful for those who have weak chin projection. This can enhance the profile without changing the frontal view significantly (Figure 10). The implant is inserted through an incision under the chin and is permanent. There is little awareness of its presence once healed.
Fat grafts can be injected to add volume to selected parts of the face such as the nasolabial folds, the jaw line on either side of the chin, and other areas. However, the longevity of fat grafts is unpredictable. Several injections may be necessary over time to achieve permanent fat build-up.
Facelift surgery is performed in the office as an outpatient procedure. Operating time correlates with the severity of the aging changes. A facelift alone usually requires about 3 hours. Upper and lower eyelid surgery adds another hour and a half. Dermabrasion, chemical peels, and other ancillary procedures do not add much time. All surgery is performed entirely by Dr. Hidalgo.
Surgery is usually performed with deep intravenous sedation combined with local anesthesia. There is no awareness. A board certified anesthesiologist is present for the entire procedure and uses state-of-the-art monitoring equipment.
The most common complication is a hematoma, occurring in about one percent. A hematoma is an accumulation of blood that forms a lump under the skin. It usually requires removal in the operating room but does not adversely affect either short-term recovery or the long-term result. Other problems such as infection, eye irritation, delayed healing, or excessive scarring can occur but are unusual. Facial nerve injury with weakness of a part of the face can occur on a transient or permanent basis. This is extremely rare. The vast majority of patients do not have any complications.
Smoking severely reduces blood supply to the skin and also delays healing. Facial skin loss around the ears can occur in those that smoke. Disfiguring scars can result that may require revisional surgery. It is therefore essential to stop smoking completely for at least three weeks before surgery. Simply cutting back is not enough. Nicotine containing patches and gum are equally harmful.
Private duty nurses are required for 24 to 48 hours after surgery. They are arranged by our staff. These nurses are specially trained to take care of facelift patients. They monitor vital signs and the surgical site, provide dressing and drain care, administer medications, and assist with feeding and ambulation. They prevent unnecessary activities in order to minimize the possibility of hematoma formation. They meet our patients at the office following surgery and escort them either home or to a hotel to continue postoperative care.