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Dr. Barry Eppley

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Archive for the ‘gynecomastia’ Category

The Uniqueness of Male Plastic Surgery – Body Procedures

Thursday, June 13th, 2013


When it comes to plastic surgery, just like many other areas in life, men are different than women. Not only are their faces and bodies not the same, but their attitudes and expectations about plastic surgery are also different. Having treated a fair number of men over the years in my Indianapolis plastic surgery practice, I have made a number of observations on these gender differences.

It is true that the number of men, particularly younger men, are making up an increasing percentage of the total plastic surgery population. While the number of men having actual surgery or in-office injectable and skin care treatments will always be substantially less than women, men are noteworthy in that their procedures are either unique or require modifications. Numerous cosmetic procedures are not only uniquely different in men, but some of them are exclusive to men.

Enhancement of the male chest is an increasingly popular male plastic surgery procedure.  Chest issues are very different from that of the female breast. While women have surgery for small, poorly shaped or asymmetric breasts, men consider surgery because their chest appearance is not masculine enough due to gynecomastia, prominent nipples or lack of pectoral muscle size and definition. Gynecomastia reduction surgery is vastly different than female breast reduction surgery. Lack of visible scarring in a man takes on primary importance and the use of liposuction tissue extraction subsequently takes on greater importance. Prominent nipples, which occurs far more frequently in men than women, can have a very negative psychological effect for some men. Having them be obscure in a tight shirt is a common goal of all ages of men and this nipple reduction procedure can be accomplished as an office procedure under local anesthesia

Male chest enlargement is done by soft solid silicone implants that have to stay within the  lower and lateral borders of the pectoralis muscle. Female breast augmentation is done with non-solid filler materials in a shell (bag) that must be often be placed beyond the lower border of the muscle to get the proper shaping effect.

When it comes to body implants, the shape objectives between men and women are different. Men undergo have body enhancements, such as the chest, arms or calfs) to create increased muscle size and definition. Women have body implants of the breasts and buttock to create more shapely soft tissue curves which are non-muscular in structure.

The distribution of fat in men is uniquely different from women. Men have liposuction exclusively in the stomach and love handle areas. While women have liposuction in the same areas they have a broader expanse of potential fat collections which leads to aspirated fat removal also being done in the extremities as well as the trunk areas of the back, hips and buttocks.

Excess and loose body skin occurs more selectively in men than women. Because of pregnancies and weight loss thereafter, women frequently require tummy tucks. Men only need such excisional body contouring surgeries after extreme amounts of weight loss. (greater than 75 to 100 lbs) Those skin removal needs are almost exclusively limited to the abdomen (tummy tucks) and chest and almost never in the extremities.

Plastic surgery for men has its own unique requirements both in the type of surgeries and the demeanor of the patients. One should not assume that every plastic surgeon or plastic surgery practice is equally adept about meeting the needs of the male patient. Just like breast reconstruction for women or body contouring after massive weight loss, the male patient presents unique challenges for a satisfying surgical outcome.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Gynecomastia Reduction by Horizontal Excision and Nipple Transposition

Friday, May 17th, 2013


Background: Gynecomastia is a common male problem that affects men of all ages. While it is most commonly recognized in teenagers after puberty, it actually affects middle-aged and older men almost as frequently…and often not less aesthetically bothersome. The older man with obvious breast tissue jiggling in their shirt is a well known phenomenon that is quite easy to find.

When gynecomastia becomes significant, the enlarged breast tissue creates a visible mound. If it is large enough or in an older man where the chest skin is more lax, an actual breast ptosis can occur. This is where the breast mound actually hangs off of the chest wall laying on or over the inframammary fold. While this is bothersome enough for a woman, it is particularly unsettling in a man. No amount of weight loss or exercise will solve this significant ‘man boob’ problem.

The most frequently used gynecomastia surgery techniques include liposuction of all types and open excisions done through an areolar incision. But this more advanced degree of gynecomastia is not going to be corrected by even a combination of areolar excision and liposuction. This is because neither can adequately treat a significant part of the gynecomastia problem…extra or loose skin.

Case Study: This is a 47 year-old male who wanted to get rid of his ‘breasts’. He was also an athletic male who used to work out a lot but had not done so over the past several years. He had gained weight, he developed breasts and his chest dropped. This was a great source of embarrassment for him.

Under general anesthesia, overall liposuction of the chest was initially performed removing about 250cc of aspirate per side. A horizontal elliptical excision of skin was then removed along his inframammary folds but staying below the nipple-areolar complex. Incisions were then made around the areolas and the upper chest skin flap undermined. This allowed the remaining breast mound carrying the nipple-areolar complexes to be pushed upward as the chest skin flap was brought down and closed along the inframammary fold. The skin overlying the buried nipple-areolar complexes was removed and the complexes brought out and sewn to the skin in a more elevated position.

His postoperative course included the use of a drain in each chest for five days. All incision lines had been taped and they were removed a week later. He wore a compression wrap for several weeks after surgery. He went on to heal uneventfully with a dramatic change in the appearance of his chest, being flatter, absent of a breast mound and the nipples back in an elevated and more aesthetically pleasing location.

Gynecomastia surgery that includes wide horizontal excision and nipple-areolar transposition is one of the most extensive treatment methods. But when a large and hanging breast mound exists, this is the only effective approach. While it involves bigger incisions, the recovery time is not much longer than most other gynecomastia surgeries.

Case Highlights:

1) Large gynecomastias that involve breast mounds that hang off of the chest wall with a low nipple position will not respond to traditional gynecomastia treatment methods.

2) Breast tissue and skin must be removed but traditional breast reduction methods in men introduce unacceptable amounts of chest scarring.

3) A horizontal excision of breast tissue and skin with superior nipple transposition can effectively lift and flatten the chest with an acceptable scar location and a preserved nipple in large male gynecomastias.

Dr. Barry Eppley

Indianapolis, Indiana

Adolescent Gynecomastia and Its Negative Psychological Effects

Monday, April 8th, 2013


The number of gynecomastia surgeries has been steadily increasing over the past few years for a number of reasons. One of these is that more teens and older men are aware that there is a surgery for it and are not afraid to ask for it. Another reason is that smaller types of gynecomastia are being treated as the aesthetic desire for a completely flat chest, including the nipple, has become more prevalent.

The psychological embarrassment of having gynecomastia at any age is well known and begins as early as the teenage years. This is borne out by a recent published study in the April issue of the journal Plastic and Reconstructive Surgery. In this article, the researchers gave psychological tests to nearly 50 teenage boys with gynecomastia who averaged 16 years of age and compared them to teens without gynecomastia. Nearly two-thirds of them had mild to moderate gynecomastia and were also overweight. The study results showed that boys with gynecomastia had lower scores on a quality of life assessment. Even after adjustment for weight, their scores were lower for general health, mental heath and social functioning.

There are no surprises in this psychological study as I know full well how much breast enlargement of any size in a male is tremendously bothersome. And the concerns about having enlarged breasts is not just related to being overweight as many of the non-gynecomastia study patients with higher test scores were overweight as well.

Because teenage gynecomastia will often resolve as they mature, a wait and see approach is usually justified. But there is a point where its psychological impact exceeds the patience to justify waiting it out. I don’t have a magic age at which gynecomastia surgery should be done if it is particularly bothersome. Early puberty at age 12 or 13 would be too young but age 15 or 16 seems very justified in treating unremitting or only partial resolution of a problematic gynecomastia.

An aggressive approach to treating adolecent gynecomastia is warranted given its documented psychological impact. In many cases, liposuction alone or combined with some limited open excision through the areola can produce a very satisfying flattening of the chest and nipple. Given the relatively quick recovery from gynecomastia reduction and a low risk of any serious complications, the benefits of the surgery can be obtainjed fairly quickly.

Despite the psychological evidence that gynecomastia is adolescent boys has a very negative psychological effect, parents should not expect insurance to pay for the surgery to reduce it. Insuracne companies are focused on the physical or functional alterations that occur from a medical problem and gynecomastia has none. They place little to no significant that the medical condition is psychologically bothersome and thus label gynecomastia surgery as a cosmetic procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Postoperative Instructions for Gynecomastia Reduction

Sunday, January 27th, 2013


Gynecomastia reduction surgery is done to create a flatter male chest and near zero nipple-areolar projection. It can be done with liposuction alone, by breast tissue excision through an areolar incision or both procedures combined. In some larger gynecomastias, skin may need to be removed from around the entire areola as well.

The following postoperative instructions for excisional lip enhancement surgery are as follows:

1.  Gynecomnastia reduction surgery has a minimal to moderate amount of postoperative discomfort. Pain medications are prescribed and you should take them as directed on the label, usually 2 tablets every 3 to 4 hour as needed.

2.  There will be a circumferential chest binder applied at the end of the procedure. This is to be worn fairly continuously for the first week after surgery. You may take it off the next day to shower and then put it back on thereafter.

3. In some cases of gynecomastia reduction surgery, drains will be used for a few days after surgery. These are small tubes that come out of the side of the chest and are connected to a small bulb which collects any fluids. Empty the bulb as directed and there is NO need to measure the amount of fluid that comes out. You only need to apply antibiotic ointment where the drain comes out of the skin. No dressings are needed, You may shower and get the drain wet.

4. The areolar incisions at the nipples will be covered with glued-on tapes that you do not need to remove. They will be removed in the office at your first postoperative visit. You may get them wet when showering.

5. All sutures at the areola are under the skin and covered by the tapes. They will not need to be removed. Incisions at the side of the chest for liposuction will have one small stitch that will need to be removed at your first postoperative visit.

6. Your chest will be sore for several weeks after surgery. This is not the time to be working out or returning to any chest exercises or lifting weights. That should not be done for three to four weeks after surgery.

6. You may eat and drink whatever you like right after surgery.  Focus on liquids and soft foods for the first few days after surgery.

7. After sutures are removed and the incision lines healed (several weeks), massaging the lips and stretching them gently will help make them feel softer sooner and regain their normal suppleness again.

8.   You may return to work and any non-strenuous physical activity as soon as you would like based on your comfort level.

9.   You may drive when you feel comfortable and can react normally and are off pain medication.

10. If any chest or incisional redness, tenderness, or drainage develops after the first week of surgery, call Dr. Eppley and have your pharmacy number ready.

Consent for Plastic Surgery: Gynecomastia Reduction

Sunday, January 27th, 2013


Every plastic surgery procedure has numerous issues that every patient who is undergoing a procedure should know. These explanations are always on a consent form that you should read in detail before surgery. This consent form, while many perceive as strictly a legal protection for the doctor, is actually more intended to improve the understanding of the various lip enhancement procedures. The following is what Dr. Eppley discusses with his patients for these procedures. This list includes many, but not all,of the different outcomes from surgery. It should generate both a better understanding of the procedure and should answer any remaining questions that one would have.


There are no effective alternatives to surgical gynecomastia reduction. There are no exercises, drugs or weight loss strategies that will work. In very young male teenagers, further physical development may cause some lessening of the size of the breasts in some individuals.


The goal of gynecomastia reduction surgery is to decrease the size of the breast tissue to make the chest as flat as possible. This includes the overall shape of the chest as well as the projection of the nipple-areolar complex.


The limits to the amount of gynecomastia reduction is how much chest skin exists and the size of the nipple-areolar complex. The shape of the chest will ultimately be determined by how well the overlying skin shrinks down and adapts to the reduced breast tissue. Excess chest skin, chest skin with stretch marks and a large nipple-areolar complex may fail to produce a completely flat chest based on his elasticity and the amount of skin retraction.


Expected outcomes include the following: temporary bruising and swelling of the chest, temporary chest skin numbness, temporary vs permanent nipple numbness, permanent scars around the areola and at the side of the chest (if liposuction is used), undercorrection (residual gynecomastia), overcorrection (indentation of the nipple-areolar complex, chest skin irregularities and asymmetry if bilateral gynecomastia reduction is done. Healing of the scars and settling of any chest irregularities is a process that may take months (6 to 12) to see the very final result in many cases.


Significant complications from gynecomastia reduction surgery are very rare but could include infection and bleeding. (hematoma) More likely complications could include aesthetic deformities such as asymmetry and irregularities of the chest skin, scar deformities of the areola and chest wall, too little breast tissue removed, too much breast tissue removed and nipple-areolar deformities.Any of these risks may require revisional surgery for improvement.


Should additional surgery be required to adjust chest symmetry, remove further breast tissue, correct a nipple-areolar deformity or for scar revision will generate additional costs.

Case Study: Large Tumor Gynecomastia Reduction in Young Male

Sunday, December 23rd, 2012


Background: Gynecomastia is a well known condition of breast tissue enlargement that most commonly occurs in teenage and young males. Its incidence appears to be increasing in numbers based on surgeries performed for its correction although this may reflect increased awareness of surgical treatment and a fashion trend amongst young men with little tolerance for any areolar protrusion. While historically gynecomastia reduction was more frequently done for one-sided breast enlargement, it is more common today to do bilateral gynecomastia surgery. (perhaps due to the change in young male awareness of a pleasing chest appearance)

Gynecomastia reduction can be done using either liposuction removal or an open excisional approach. In some cases, both techniques are combined for optimal reduction. Which technique is needed can usually be determined before surgery by physical examination. Soft non-nodular gynecomastias can be removed by liposuction, firm masses which are almost right under the nipple-areolar complex which need to be cut out through an areolar incision. The patient’s description of their concerns is also helpful, it is just around the nipple or does it extend over a larger chest area?

The one thing that has become apparent in gynecomastia surgeries in my experience is that open excision is needed more times than not. Even in cases where the breast tissue appears soft there almost always is some nodular tissue right under the nipple. Failure to get this tissue will leave am areolar protrusion afterward that may result in the patient’s desire for revisional surgery for complete flattening. When the enlargement of the breast is mainly nodular, liposuction is not going to be effective at all.

Case Study: This 20 year-old college student had a unilateral left breast enlargement since he was an early teenager. Contrary to earlier medical opinions, it never resolved on its own. While the breast development was significant (a true B-cup), he never underwent surgery in high school due to his active participation in sports year round. While it always bothered him tremendously, he lived with it and covered it up as much as possible. Now that he was in college, he no longer did any organized athletic activities,m so he had the time to finally treat his gynecomastia.

Physical examination before surgery showed a remarkably-sized breast mound for a male that felt fairly firm but without any palpable nodules. Under general anesthesia, his gynecomastia was initially treated by liposuction with minimal fat extracted. It became apparent that much of the breast mound was a large fibrotic mass through which the liposuction cannula would not penetrate. Then through a lower areolar incision, the entire mass was excised using a facelift scissor technique. The large mass was able to be delivered in one large piece through this small 2 cm incision. This produced a complete and immediate resolution to his entire breast mound enlargement.

After surgery, a drain was kept in place for three days and then removed. When seen at three weeks after surgery, no fluid accumulation had occurred and the chest was completely flat and matched the opposite side. No areolar inversion was seen. Pathology of the removed specimen showed benign breast tissue.

This case represents an uncommon form of gynecomastia in which the entire breast mound was one large fibrous tumor. Removal of it produced a dramatic one-stage cure without fluid accumulation and good skin retraction back down onto the chest wall.

Case Highlights:

1)      Large unilateral breast development in young males may represent a single solid tumor rather than simple breast tissue hypertrophy that makes up most gynecomastias.

2)      Firm nodular gynecomastias will not respond to liposuction extraction and must be excised by an open technique

3)      Excision of even very large solid gynecomastias can be done through a small areolar incision without the need for visible scars on the chest skin.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery’s Did You Know? King Tut and Gynecomastia

Sunday, September 16th, 2012


The most well known or at least the most publicized ancient pharaohs of Egypt, King Tut, ruled and died early. The demise of the young pharoah has always been a mystery and much speculation has centered around his cause of death from murder to accidents. But a recent theory based on medical evidence suggests that he died from a genetic condition of temporal lobe epilepsy. Based on art and figurines of how he was depicted, King Tut is consistently shown with highly feminine features, including enlarged breasts. His enlarged breasts indicates that he suffered from gynecomastia. What is the connection between the temporal lobe of the brain and gynecomastia and other feminized features? The temporal lobe is connected to parts of the brain that are involved in the release of hormones. Epileptic seizures are known to alter the level of hormones involved in sexual development. This might well explain the development of the pharoah’s large breasts. Scans of his body showed that he died from a fracture of his leg at the time of death. People with epilepsy have a much higher incidence of dying from accidents and falls and are more likely to die young. The art of the time also depicted him with a walking stick, also suggestive of leg injuries or impairment. Further clues is that King Tut’s predecessors and relatives also had early deaths as well as similar body features, including gynecomastia.

Plastic Surgery’s Did You Know? Gynecomastia and Marijuana Use

Saturday, August 4th, 2012


The development of breast tissue in young men (gynecomastia) goes by a lot of unflattering names such as man boobs and bitch tits. For the overwhelming majority of men affected, there is no identifiable cause. Clearly there is some hormonal influence but the exact trigger is not clear for most patients. Some of the young men that I treat for gynecomastia often sheepily say that they smoke marijuana and that is why they probably developed it. That belief is well known and frequently stated as fact but is it really true? The unequivocal answer is…maybe. The main active ingredient in marijuana is THC which has been shown to affect testosterone production. Presumably this could cause a man’s estrogen levels to increase causing a stimulatory effect on breast tissue. But what levels of THC are needed and how long does it take to cause this adverse effect? No one knows for sure and how a man may be affected is undoubtably different. There also other compounding factors such as being overweight, taking steroid or muscle building supplements and using Propecia for hair loss, all of which can also decrease testosterone levels. Gynecomastia is a multifactoral problem as many men smoke marijuana and never develop gynecomastia while a few do. It is a risk factor but its inhalation does not assure that gynecomastia will develop.    

Male Nipple Disorders and Their Surgical Correction

Monday, July 16th, 2012

The size and shape of a man’s chest can be a source of pride or embarrassment. Much emphasis on the aesthetics of a masculine chest is based on the pectoralis muscular anatomy. While this muscle provides support for the overlying skin, and clearly its size and border outlines are important, the lone remaining aesthetic feature is that of the nipple. While a man’s nipple is usually much smaller than a woman’s, it can have numerous aesthetic deformities which are both bothersome and embarrassing.

The male nipple has the same anatomic features as that of a female, a centrally elevated nipple and a surrounding areola. Men typically have much less nipple projection, even when stimulated, and a thin width to the surrounding areolar circle. This is no surprise given that it has no lactation function and has no purpose in being any larger. But despite its small size, it can have a series of aesthetic problems that men would like improved.

Nipple protrusion, or the overly projecting nipple, is a frequent source of male embarrassment. For some men, the nipple sticks out all the time. For other affected men, the protrusion is only bothersome as it occurs with stimulation, particularly when one is cold. Sticking out through shirts is the common complaint which brings men in for a nipple reduction procedure. Men want a completely flat nipple that does not become erect at all. A nipple reduction is a simple procedure that is performed in the office under local anesthesia. To be more accurate, it should be called a nipple amputation or nipplectomy. While a nub of nipple can be retained, most men want it completely gone and flat. Removing the nipple through a wedge excision to include the ducts and bringing the areolar edges together is the surgical technique.

A different form of nipple protrusion is that of the puffy nipple. The puffy nipple is not protrusion of the nipple but that of the entire nipple-areolar complex. This is caused by breast tissue pushing out from behind. This is known as areolar gynecomastia, a small form of breast tissue enlargement that causes visible projection of the overlying nipple. This is commonly seen in young men who desire a completely flat chest profile. This is treated by an open excisional approach through a lower areolar incision. The breast tissue is directly excised and feathered into the remaining breast tissues beyond the areolar margins. This is the smallest form of gynecomastia that is treated. Care must be taken during the procedure to not over-resect the breast tissue, causing a nipple inversion problem later.

The sagging or ptotic nipple is a problem of older males. As the chest tissues lose volume and sag, the nipple sits much lower on the chest wall. This is caused not by the nipple sagging per se, but by the entire chest skin on which it sists falling off of the muscle and ribs so to speak. This can be improved through a nipple lift procedure. By removing a crescent of skin above the nipple, the nipple is lifted upwards into a higher position. There is a limit to how much movement can be done, often being no more than 10 to 15mms upward. While greater upward nipple movement is possible trough different patterns of skin excision, this results in scars that extend downward from the nipple. This is usually not an acceptable trade-off for most men.

Nipple asymmetry can also occur due to either congenital deformities or some more natural amounts of chest asymmetry. Nipple asymmetries can occur in either horizontal or vertical dimensions. Most commonly, it is the difference in their horizontal positions that is disturbing. It can involve just one nipple or both. Based on the movements needed to move the nipples to more symmetric positions determines where on the nipple circle the crescent skin excision is oriented. Often moving both nipples, splitting the difference in the asymmetry, is the best way to get the most symmetric result.

Male nipple deformities can be easily treated and improved, many of which can be treated  under local anesthesia with virtually no recovery.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery’s Did You Know? Contemporary Gynecomastia Reduction Surgery

Sunday, July 8th, 2012


Male breast enlargement or gynecomastia (Greek derivation, gyne = female and mastos = breast) is a common male chest condition. According to the American Society of Plastic Surgeons, gynecomastia accounts for more than 65% of all male breast disorders. While occurring most commonly in teens, it can affect all men throughout their life due to hormonal fluctuations and certain medications. Once not talked about and treated with an old-style approach that left large scars, gynecomastia reduction today has evolved into a highly successful surgery that can be quickly done with minimal scarring. Using a combination of liposuction and gland removal through a peri-areolar incision, most gynecomastia conditions can be resolved without recurrence. Whether it is just a puffy nipple or a more visible breast mound, there is no reason teenage boys or adult men have to forever worry about taking off their shirts or having their nipples or breast mounds show through their shirts.

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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