If we could ask prospective gynecomastia surgery patients to read just one post on gynecomastia.org, it would be this one. And it’s not due to the praise for our work, though we thank our Arizona patient for the positive review.
We’d like every guy with man boobs to read this patient’s story because he experienced one of the worst outcomes possible with an inexperienced surgeon: a crater deformity. It is also unfortunately common and difficult to fix.
We perform dozens of gynecomastia revisions in New York every year, and we have learned the subtleties of using fat to improve poor surgical results. Let us share with you some of the ins and outs of fat and fat flaps in gynecomastia revision.

Fat Grafting

In the gynecomastia.org post, our Arizona patient details the tremendous amount of research he did, including nine consultations. He reported that most cosmetic surgeons recommended fat grafting to fill the crater or additional liposuction to reduce the surrounding areas. Due to the knowledge he gained, the patient concluded that fat grafting would probably not work, and lipo would actually take away tissue needed to do a proper revision with fat flaps.
We could not have advised him better.
Here’s the problem with fat grafting. When you transfer fat cells harvested from a nearby area, you use them to fill a tricky area between the skin over the crater and the underlying pec muscle. There isn’t much blood supply there to keep the fat graft alive. If the cells die, more scar tissue forms. When fat transfer is successful at all it’s usually done with small amounts in multiple stages to gradually build up the area.

Fat Flaps

Using fat flaps to fill craters solves the problem of vascularization—or blood supply—because small tongues of fat are rotated in to fill a crater, remaining partially attached to preserve blood flow. This is our favored approach when there is enough fat tissue nearby to do the job. It’s more effective than fat grafting, and it’s a “one and done” procedure.
We explain to patients that the inevitable scar tissue we’ll find presents a challenge. First, the small flaps themselves will likely be less pliable than before the first surgery. In addition, scar tissue throughout the chest generally makes results less predictable.
You might be surprised to learn how often we use fat flaps, in primary surgery as well as for our New York gynecomastia revision patients. For the vast majority of primary surgeries, we perform light, gentle liposuction first, to contour the breast and loosen the skin for re-draping. The actual gland is usually concentrated mainly under the nipple/areola complex—this is where we perform excision as a second step. It’s not unusual to have a bit of an indentation after aggressive excision, but we recognize it immediately and move soft, flexible surrounding fat flaps into the indentation. Smooth contours (with little remaining gland) are the result.

Understanding the Makeup of Man Boobs

Crater deformities are common complications following male breast reduction because most cosmetic surgeons—even board certified plastic surgeons with very successful practices—do not have enough experience treating gynecomastia to understand how male breast tissue behaves. When removing the gland, many doctors don’t recognize that a crater has developed. If they do, they very well may not know how to treat it. They simply suture the wound and hope it gets better or fills with scar tissue. This doesn’t often happen.
We have learned so much in our three decades of man boob surgery and gynecomastia revision in New York. Occasionally we have to break the news to a patient that we don’t believe his results can be improved, it’s true. But we do take on challenging revision cases—when the patient has the expectation that we can improve his appearance, not deliver a miracle.
We recently worked with a patient with a very large crater, for instance. Our approach was to use fat flaps to fill as much of the crater as possible, then perform grafting on top of the flaps. As this guy heals, we believe he will be satisfied with the outcome.

Lessons Learned

There’s a reason we post articles like this and spend so much time interacting with guys on gynecomastia.org. We want to help as many patients as possible avoid poor results. It’s always better to get it right the first time, steering clear of disappointment, scar tissue, more money, and another recovery.
As our Arizona patient said:
I am extremely jealous of people who go to expert gyno surgeons for their first procedure and have an excellent result and go on with their lives. They have no idea what they dodged…
If it’s too late and you’re already considering a do-over, please choose your plastic surgeon extra carefully. You can consult us about gynecomastia revision in New York; we would be happy to start a conversation. There are also a few other highly qualified man boob specialists available, but not as many as you might think. Check out the surgeons on gynecomastia.org first, and do your research.

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