Alternatively, when prior surgery has been mostly directed towards excision of the excess gland beneath the nipples, the most common problem is a “crater” deformity, in which the tissues tend to indent like a saucer. This can be apparent when the hands are down at the sides or sometimes only when the hands are elevated above the head or out to the side. Careful evaluation can then be made to ascertain if there is sufficient surrounding tissue. If there is enough surrounding tissue present, then surgery can be performed to utilize fat flaps from these adjacent areas. In Dr. Jacobs’ experience, fat flaps are the preferred method of revision treatment for this problem. However, they are limited by the availability of adequate surrounding tissue and the presence of scar tissue, which will limit movement and mobility and hence the effectiveness of any planned fat flaps.
Fat flaps are performed by separating the skin of the chest from the underlying fatty tissue. Then additional dissection separates the fat from the muscle underneath. The “tongues of fat” or fat flaps thus created will derive their blood supply from the peripheral areas. The flaps are then moved towards the area of deficient tissue and sutured to each other or even sutured over each other in an overlapping technique to build up greater thickness. The limiting factor in doing this gynecomastia revision is the availability of adequate fatty tissue and also the mobility of that tissue.
On occasion, there is insufficient available tissue with which to perform fat flaps. In these circumstances, fat grafting can be useful. This technique consists of removing fat from another part of the body (commonly the abdomen or love handles), cleansing and processing the fat, and then very carefully injecting it into the areas in which there is a deficiency of fat. There are technical considerations of fat grafting that are beyond the scope of this explanation, but it must be emphasized that there are limitations as to how much fat can be injected at one time into one location. Also, not all the injected fat will survive. Hence, multiple sessions of fat grafting may be required to achieve an optimal result.