Oftentimes, a man will appear in the office and request surgery for only one side of his chest. For a long time, his eyes have been focused on just the larger side and he frequently will not realize that there may be some excess tissue on the other side as well.
True one-sided gynecomastia is extremely rare. Often, I find that one side is much larger than the other — but both sides frequently have excess tissue. In the past, surgeons treated only the larger side — and the patient then returned asking for treatment of the now-larger “normal” side as well. This would then require a second operation.
At present, both sides are carefully evaluated. If the two sides have varying amounts of excess tissue, then each side is treated so that it ends up as the best it can possibly be. The result is a better and more symmetric chest – but not always absolutely mirror-image identical. A physical examination is therefore needed to evaluate your chest asymmetry and to provide a realistic idea of your possible results.
OPERATING ON ONE SIDE ONLY: THE SURGEON’S PERSPECTIVE
In some cases, there may be residual, very solid breast tissue directly beneath the areola which the instrument cannot remove. In these cases, an additional incision around the edge of the areola will facilitate direct removal of the excess breast tissue. Care is specifically taken at this point to remove sufficient breast tissue but insure there is no “cratering.” If necessary, fat flaps are used to reinforce the support of the areola. The wound is then closed with dissolving sutures underneath the skin, so there are no external sutures to be removed.
It is very difficult to reduce a larger side so that it exactly matches the smaller side. During surgery, fluids are injected, tissues are removed by liposuction and/or excision, and all the remaining tissues actually continue to swell while the surgery progresses. In essence, during surgery, the breast is constantly changing – a moving target. Thus, providing an exact match with the “normal” side is very difficult to achieve.
I believe that the best course of action is to reduce each breast so that each side is as individually well contoured as possible. This may require any combination of liposuction and excision on either side. The result is usually a symmetric result.
Absolute, mirror-image symmetry, however, is sometimes elusive. Why?
LET’S LOOK AT THE ANATOMY
Human beings are basically asymmetrical. If you study your face carefully, you may note that the ears are different, the eyes are different and even both sides of your smile may be different. Indeed, if you had a photo of your face in which one side was flipped and then duplicated on the other side, you would probably not recognize yourself! In fact, the only absolutely symmetric faces are on mannequins. It is, indeed, the subtle asymmetries of our faces (and our bodies) that make us look endearingly human.
The same holds true for the chest. Are the nipples the same diameter and located absolutely level with each other? Is there more tissue, and hence more stretched skin, on one side? Does one breast hang slightly lower than the other one? Are the breast contours different and are there adjacent pockets of fat that are different? Again, the minor asymmetries of the chest are what make us look human and not like mannequins.
WHAT ARE SOME UNDERLYING CAUSES OF CHEST ASYMMETRY?
The breasts, which consist of both fat and breast tissue, rest on the foundation of the underlying muscles and skeleton. These foundation tissues may themselves be asymmetric.
Here are some causes of chest asymmetry:
There may be scoliosis (curvature) of the spine
There may be rib cage asymmetries
Your posture may be such that you naturally carry one shoulder lower than the other
One chest muscle may be larger than the other
One chest muscle may never have developed (Poland’s Syndrome)
The attachments of the chest muscle to the rib cage may differ for each side
There may be developmental abnormalities of the breast bone in which portions of it are caved in (pectus excavatum) or rarely just the opposite – jutting out (pectus carinatum)
In essence, one must determine if the foundation upon which your breast lies may be asymmetric to begin with. These conditions are not correctable during routine gynecomastia surgery. In fact, if these conditions are severe, they may require corrective surgery by a general or chest surgeon before any gynecomastia surgery can be performed.
Once the foundation is ascertained, then examination of the breasts may reveal more tissue on one side, contour differences, nipple differences in size and location, and skin excess which naturally accompanies a larger breast. If there is skin excess on one side, then the anticipated skin tightening may not occur symmetrically, leaving the former larger side with a bit more lax skin.
REALISTIC SURGICAL GOALS
Although the goal of gynecomastia surgery is a trim, contoured and symmetric chest – and this is often achieved — the surgical results may not provide absolutely perfect, mirror-image symmetry. This is due to the myriad of underlying potential sources of asymmetry as outlined above, all of which will impact on the final results. Sometimes successful surgery to remove the overlying breast tissues will then reveal the asymmetries of the foundation of the chest, which were originally masked by the excess overlying tissues.
One additional and uncontrollable factor is Mother Nature. Once appropriate surgery is performed, the patient’s body sets about to heal – and it heals by producing scar tissue. Sometimes it produces more scar tissue on one side than the other. Usually this does not require additional surgery but can be treated with injections of cortisone.
In sum, it is important for a patient to understand and accept that absolute, mirror-image chest symmetry may not be achievable in all cases. On the other hand, what is usually achievable is a normal appearing, trim, contoured masculine chest. And normal, believe it or not, is not absolutely symmetric!