Gynecomastia, male chest reduction, gland excision, VASER liposuction

Many of my male patients have some form of male breast enlargement.  Not all decide to have that area treated as it does not bother them that much.  However, the patients that seek to have treatment for this particular area frequently ask about the other options available.  If they dont ask it is part of my consultation process to inform them of the other options available that are suitable.
In this day and age most patients opt for the non or minimally invasive procedures as they carry less risk and the down-time is less and recovery is faster.
In some cases though it is not appropriate to perform the non-invasive techniques and the surgical ones are more indicated.  It is then also imperative to inform the patients of the associated risks with the surgical options.  Although you may get a better result, you may also put yourself at more risk in terms of complications and side-effects.  It is thus important to balance the risk to benefit ratio.

We want exactly the opposite of what is depicted in this image.
If the wrong technique is used then the risk of adverse outcome is also higher.




The options are really 1. doing nothing 2. weight loss and losing some fat deposit in the area (if the bulk is glandular tissue then weight loss will not help at all) 3. traditional liposuction 4. VASER tumescent liposuction 5. Micro-cannula tumescent liposuction 6. surgical excision

Any of these can of course also be combined.  The most conservative is obviously 1. and 2. These may certainly not be an option if the situation is causing distress, clothing limitations and self consciousness.
Patients coming to us will have started doing some research on the various techniques available and generally come with some idea of what may be required.

3. is old style technique and usually performed under general anesthesia (completely asleep).  It has its limitations and works well if there is mainly fatty tissue and little breast gland.

4. targets the gland and the fat and can be performed under local anesthesia (only the treatment area is numbed)

5. targets the gland and the fat - suitable with smaller amounts of bulk.

6. suitable for large gland excision and  often skin excision in combination.  This is always performed under general anesthesia (completely asleep).  It comes with a variety of different risk factors and longer recovery period.

The important factor is that not too much of the tissue is removed and leaves fibrotic scar tissue that is visible when the chest muscle contracts.  This may leave you with an indented nipple or nipple that gets sucked in when you contract your chest muscles (see pictures below)

These are patients that have presented to me after surgical excision that have had too much removed.  The scar tissue attached to the underlying muscle now causes the nipple to get sucked in when contracting the chest muscles.
Hence I always leave some tissue behind which can be felt as a small disc of hard tissue just behind the nipple complex.

Seen on the left is a common male chest diagram with representation of enlargement of the gland component (right).  This may appear in  various degrees - some having more fat or some having more gland.  We obviously want to remove as much as possible, but also prevent the nipple retraction.





                                                         www.DrWolf.com

Top 10 tips before considering any cosmetic surgery

Top 10 tips before considering any cosmetic surgery

1. Know your practitioner
Select a qualified, reputable practitioner to perform your procedure and research that practitioner thoroughly. Find out how long they have been practicing, what qualifications they offer, which areas or procedures they specialise in, and you will slowly get an idea whether they are the right doctor for you.

2. Meet them in person
It is crucial that you meet the doctor or surgeon who will carry out your procedure before the day of your treatment. Rather surprisingly, not all practices demand that patients meet the practitioner who will deliver the procedure in advance. If you are advised that it is not possible to meet in person with the doctor ahead of treatment, you should not progress any further and choose to go elsewhere. Any reputable practitioner will demand that they meet the patient themselves beforehand. It is also important that you feel comfortable with your doctor and that you trust them.

3. Research the procedure
The internet provides a wealth of information about specific cosmetic procedures so it’s easier than ever to do your research. Watch videos of procedures being carried out, read the stories of people who have already undergone the procedure and engage in conversation on reputable forums. All of this will help you to make an informed decision about whether this is the right procedure for you.  Remember that there is wealth of information, but also that there may be conflicting information; it is important to verify this all with your potential practitioner.

4. Understand the risks
There are risks associated with every cosmetic procedure, however non-invasive they are. During the consultation stage your practitioner should be open and honest with you about the potential risks or dangers involved. Don’t be afraid to ask questions, particularly if there is something that concerns you or that you do not understand.  Any practitioner who claims there are no risks involved in the procedure is not to be trusted.


5. Don’t be influenced by price or advertising
While offers and discounts might be attractive in a supermarket, a cosmetic procedure is not something which should be offered at cut price. Remember that ‘cheaper’ does not necessarily mean ‘better’. Focus on the reputability of the practitioner and the quality of the treatment. Never be coerced into undergoing a cosmetic procedure by a clever marketing campaign or a financial offer.  Take your time in making informed decisions.

6. Ask to see their work
Ask to see examples of your doctor’s work. Seeing photographic evidence of the results that can be achieved will help you to establish realistic expectations, but it will also give you an idea of the capabilities of the doctor and how the procedure can work in practice.  But do make sure that these are not generic pictures of the manufacturer; make sure it is the work of the doctor him/herself that you are seeing.

7. Don’t strive to look like a celebrity
Make sure that you are doing this for the right reasons. One of the biggest criticisms of the Keogh report was the ‘trivialisation’ of certain cosmetic procedures, particularly those that are popular amongst reality TV stars. A cosmetic procedure of any kind is something to consider carefully, and is not a decision to be taken lightly. It is also unrealistic to want to try and emulate someone else’s results. Every individual is different and all cosmetic treatments should take in to account, and be sympathetic towards, the individual’s existing body shape. If someone comes in to see me clutching an image of a celebrity then alarms bells instantly ring. More often than not, they will have unrealistic expectations and if that is the case I will most likely advise that they don’t go ahead with treatment.


8. Consult a loved one
Confide in a friend or family member. Their input could be very valuable and they could raise questions that perhaps you had not considered before. Of course, a doctor must respect doctor-patient confidentiality and if you choose to undergo the procedure without consulting those around you, then this is your choice. Nonetheless, remember that this is a big decision and one which might be easier with the advice and support of loved one.


9. Understand the recovery process
Being fully informed about the recovery process is vital so that you can prepare yourself in advance. Patients often neglect to think about many important post-op factors: Is it a walk-in walk-out procedure? Will you need assistance leaving the clinic? How should you travel home? Will you be in pain? Do you need to take time off work? What does the post-operative care entail?  When are the post-operative follow up visits?  There are a number of factors to take into consideration and your doctor should discuss all of these thoroughly with you in advance.

10. Utilise and insist on a ‘cooling off’ period
After you have met for a consultation with you doctor, they should insist that you go away and think carefully about your decision. Use this ‘cooling off’ period to take your time, think through your options, do some more research and talk to your family or friends before making any decisions. If you feel like you need more information, attend a second consultation with the same practitioner or go for another consultation with a second and third practitioner. This will give you further opinions and will help you make a considered, sensible decision.

Come see our website www.DrWolf.com

Lignocaine dose

PIP implants- Fat Transfer as an alternative

The PIP scandal surfaced after regulators launched an investigation into the PIP implant manufacturing process.  This was in reaction to findings that the implants had been made from industrial grade rather than medical grade silicon.  The implants were banned in 2010.

It is feared that 300'000 women have been fitted with the implants worldwide with 40'000 in Britain and 30'000 in France.

There has been controversy in how authorities have recommended management of these cases.  France has offered and recommended removal and replacement of the implants on the national health system.  British authorities have not offered the same recourse.  At this stage the evidence does not suggest that early removal is required and the investigation is ongoing with new reports awaited early 2013.

If you have any concerns regarding your implants or are not sure whether you have the PIP implants, it is best to contact your treating surgeon or clinic and clarify what implants you have.  Alternatively your GP would be able to guide you on what steps to take.

If you have any of the following signs or symptoms, you should discuss them with your GP, who will refer you to a specialist.
Symptoms to watch for

• lumpiness of the breast

• lumpiness or swelling in the area around the breast

• change in shape of the breast

• deflation of the breast

• redness

• tenderness of the breast

• swelling of the breast

• pain or sensitivity

If you are worried

• Find out if you have PIP implants by checking your medical notes.  You can get these free from your clinic or GP. If you had a PIP implant on the NHS, you will receive a letter.

• Speak to your GP, if you had them done on the NHS, or your clinic if you had them done privately.

• Agree what’s best for you – get advice on whether or not you need a scan then discuss removal with your doctor.

• If you decide you want your implants replaced, the NHS will do it free if your original operation was done on the NHS.

• If your original operation was in a private clinic you will need to speak to the clinic to see if they will replace them free.

• If your private clinic no longer exists or refuses to remove the implants, speak to your GP. The NHS will remove your implants if your doctor agrees there is a medical need.

Alternative treatment options

In the private sector the PIP implants will mostly be removed and replaced with other implants (Mentor, Allergan etc.) giving you the desired result.  Alternative options are not to have the implants replaced at all.  This would probably be the least favourable option as the removal will result in loss of volume, emptiness and poor aesthetic result.

An alternative option becoming more popular now is fat transfer breast augmentation.  This procedure involves removing fat from one part of the body (e.g. abdomen, flanks, thighs)  and transferring it to the breast for augmentation.  The procedure is performed through tiny puncture holes so won't leave you with any further scars.

When can the procedure be performed?

Prior to having the implants removed its best to have a few consultations with surgeons that perform the fat graft procedure and get an idea of suitability.

If suitable then the implants should ideally be removed and 6-12 months of healing allowed before the fat graft is performed.  This will allow for scar tissue to settle.

What size can I expect?

Realistically 1-2 cup sizes, depending on how much fat is harvested and how much of the graft survives.  If large (200ml+) implants were removed then you may not regain the size that you were before.  There is a possibility of performing serial injection over a period of a few months.  This may then enhance the shape a little more.  This all depends on the amount of fat that can be extracted.

What will the breast feel like?

As it is your own fat that is transferred into the breast the tissue will feel soft and natural and take on a very natural shape too.

How much fat do I need to have?

Ideally you need to have a BMI of more than 22-23.  If you are in doubt whether you have enough fat then its best to go for a consultation with a surgeon for an assessment.

Other benefits.....

The procedure is performed through tiny puncture holes which leave you with almost no scar.  The downtime is very short with patients returning to normal routine in a few days.  You get a bit of body sculpting where the fat is harvested from.

Often the original implant scars will fill out and the skin may take on a rejuvenated appearance due to the stem cells in the fat.  If there is some contracture in the original scar this may improve too.

I use the PureGraft system as it is gentle on the tissue, filters out any unwanted constituents (blood, local anaesthetic, serum) and leaves me with pure fat.  It gives me a slightly drier graft which allows for a much more accurate assessment of breast size.

Come see our website www.DrWolf.com 

VASER Breast reduction - non surgical

The female breast reduction procedure is generally a surgical procedure to reduce the weight and size of the breasts.  During the surgical version of the procedure fat, gland and skin are removed to resize the breasts and in most cases the nipple needs to be repositioned.

Breast size varies in women and often there is an asymmetry between the left and the right side.   A variety of factors determine the size and shape - genes, hormones, body frame, weight and lifestyle.
In later life the breasts often lose volume and may become droopy, especially in some that have breast fed and have had children.

Breast reduction can assist in lifting the breasts and changing the size, weight and shape.

Physical problems may also include:

• backache 
• neck pain
• skin irritation
• poor posture
• excessive sweating, rashes and skin
• infections under the breasts
• weals or grooves on the shoulders from bra straps
• an inability to exercise or take part in sports

Common psychological problem also include:

unwanted attention or harassment

self-consciousness

depression

Traditional breast reduction involves a general anaesthetic and fairly extensive scars that take on an "anchor shape".  Many women find this option unattractive due to the risk factors.


An alternative to this is VASER Breast Reduction. 
The procedure is performed under sedation and local anaesthetic.  The access points are very small (5-6mm) and heal to leave almost no scar.  The postoperative care includes MLD sessions which remove unwanted fluid and swelling.  The breasts will be relatively firm and swollen for about 1-3 months, although this various between individuals.  MLD sessions help alleviate the swelling.
As the VASER helps contract the skin it also creates a bit of a lift of the breast.


The main benefits of VASER breast reduction are:

• volume reduction
• weight reduction the breasts
• reduce backache and neck pain
• marginal lift
• local anaesthetic
• minimal scarring
• day case procedure

Dr Wolf recommends a mammogram before and about 6-12 months after the procedure.

VASER treatment areas in male and female patients

Alternative, non-invasive liposuction techniques have been developed to treat smaller areas of adipose deposit.  The collection of anatomical areas has remained fairly consistent over the last few years in both male and female patients.
Our figures confirm this - for males the most popular treatment area is still the abdomen and chest (gynecomastia) and flanks.  Males tend to limit themselves to these areas as they have only really become aware of the cosmetic industry in the last few years.  As treatments become more available and less invasive our male patients will undoubtedly look at other treatment areas.

For females the most popular treatment areas remain the abdomen, flanks, outer thighs (saddle bags) and gluteal fold.  For women the most troublesome areas are the midriff and the outer thighs.  These respond well to VASER with most patients achieving very good results.

Audit Figures of VASER Gender distribution 2011

I've looked at all the VASER cases I performed last year and audited the figures.  Interesting stats to say the least.  On the whole female patients still form the bulk of my clientele.   Male patients have certainly become more aware of their aesthetic requests and demands.  Industry figures correlate with these stats nationwide.  I think males are becoming less critical and less averse to cosmetic procedures and are realising that there is nothing wrong with looking after one-self.

Skin Laxity after VASER

Many patients, in fact all patients, will during some stage of a consultation ask about skin laxity.  Most will mean they are concerned about skin wrinkling or having rolls of skin hanging from their torso.
In my experience it is fairly easy to assess whether a patient will react well to the VASER treatment and suffer from lax skin or not.  If there is any doubt that there is going to be wrinkly skin then the patient is not a candidate and I decline to treat them.
The term "Loose skin" applies to the mobility of the skin.  This occurs when the interface between the muscle and skin becomes less elastic and allows the skin to move freely over the muscle and connective tissue.  As we become older our elastic tissue becomes a little lax and thus allows for the skin to be a little more mobile.
This becomes especially noticeable when someone has lost a few stones.  Compare this to a ballon that deflates - the membrane becomes flaccid as the volume depletes.   Similarly the skin becomes a little "wobbly" over the muscle.  VASER does help a little with skin tightening, but there is a limit as to how much will take place.

I hope this explains and reassures you a little with regards to skin laxity.

Come see our website www.DrWolf.com 

VASER Hi Def - before and after

I saw another VASER Hi Def patient yesterday.  The procedure was performed in June last year.
One of the important aspects of having this treatment is being willing and able to maintain the result.  Its not a quick fix at all.  Ideally prospective candidates should be relatively fit and already have a fair amount of contour.  The procedure is aimed at pronouncing the contour and definition.
I see many patients that see themselves as very fit, but are not suited for the procedure.  This can be due to a variety of reasons:
lax skin, too many stretch marks, musculofacial laxity (when the skin is very mobile), too much visceral fat (fat around the organs), clear inability or lack of motivation of not being able to maintain the result.


Understandably many patients are disappointed if I tell them that they are not suitable for the VASER Hi Def procedure.  It all boils down to being honest and realistic.  There is no point in trying to attempt to perform the procedure on a patient that is not suitable.  Firstly its unethical from a medical standpoint, secondly the patient will not be satisfied, and thirdly, one will be trying to correct what one cannot achieve.

There are many before and after pictures available on the net that are good examples of patients that were not suitable for the VASER Hi Def procedure.

The procedure needs to be tailored to the individual patient.  Thats where the 3D "vision" comes in.  Visualising the anatomical landmarks and underlying muscles is of paramount importance.  Hence its easier to treat patients that have a fair amount of muscular definition already.  It is although not impossible to visualise these under a thinnish fat layer.  Also important is input and feedback from the patient prior to the procedure. Some patients don't want specific types of the definition and its important to specify this at the marking stage.  I always get my patients to look at their marking and make sure they are in agreement with the style of definition.  Before pictures of the markings will then also confirm this.
Below is a picture of another content patient who has managed to maintain his result.......

Come see our website www.DrWolf.com

Click here to see a video on VASER, its indications, how it works and what it can achieve.
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MLD after VASER lipo

I thought I would you some insight into what is required in the post-operative period of VASER.
Besides wearing the compression garments it is also important to have manual lymphatic massage.
The duration that you will wear the garment depends on the practitioner.  Each will have their own preference.  My patients wear the first line garment for 2 weeks 24/7 (taking it off for washing etc), then for another 3-4 weeks about 10 hours a day.  Best is to wear it during the day as at night most of the oedema (swelling) will settle so its not as effective.
MLD has only really been introduced in the post-operative period in the past 2-3 years.  Many traditional, old school plastic surgeons still don't see the benefit in the treatment.
I have noticed a tremendous improvement in the speed of recovery, minimising swelling, softening of tissue, minimising bruising and general improvement in comfort.
The number of sessions that are required is variable.  My feel is that one cannot have enough MLD.  Obviously finances are a limiting factor.
Here is a rough guide as to the average number of session:
arms - 3
abdomen - 5-10
flanks - 5-10
outer + inner thighs - 3-5
chin/face - 3-5
In Hi Def patients this may rise to 15-20 sessions (remember that these are just guidelines and your Dr may recommend more or less)
As I said it is variable from patient to patient and also depends on your level of activity.  Most patients getting back into gym and exercise usually require less sessions.

MLD therapists can be found on the www.MLDUK.ORG.UK website.  Make sure they are registered or otherwise they may be using traditional massage techniques which are not appropriate.  The treatment is very gentle, almost like stroking.  It should not be uncomfortable - if it is then its being done incorrectly.
Try and see the therapist that the Dr recommends as they generally have a good relationship and give each other feedback on how the patients are doing.  Thereby concerns are flagged up early and can be dealt with immediately.  Many therapists have gotten to know me now due to the many referrals and anticipate the treatment regime I recommend. Some have even come to seek VASER treatment themselves after seeing the dramatic results and the snappy recovery of their patients.
The procedure kickstarts the lymphatic system back into action.  With all the fluid that is infiltrated for the local anaesthetic the tissue becomes a bit overwhelmed with the tissue load and struggles in reducing this.  Once the sustain is complete majority of the fluid has been aspirated out.  However, tissue swelling soon starts and results in a little swelling.  Occasionally some lumps and bumps appear too.  These again respond very well to MLD.

Hope that gives you a little more insight into MLD and VASER treatments.

Have a look at this video for more clarification......

Come see our website www.DrWolf.com 

Bye for now.
Dr Dennis Wolf