Good Morning everyone, so after a fun weekend at the beach. I’m back at work and have some great cases today. We are starting with a case of gynecomastia. Gynecomastia is the development of male breast tissue, and this patient is a young man who is very, very fit but he still has this. So…
Let’s take a look at some of his photos. I’ll talk about what we’re going to do and we’ll go in there and get it done.
Alright, so this is the patient just at rest, and you can see it’s actually great. The guy is in incredible shape. Overall looks good. But, let’s take a look at something. Take a look at what happens to his chest and breasts when he flexes his pectoral muscles. You see, here it just looks off. There’s this extra tissue there that doesn’t- also look at his nipple, this is at rest. And you know he really is bothered by this puffy protuberant appearance of that nipple. We’re going to fix it. And to really show you how significant this is, look at what happens when he flexes his pec here. It just does not look right. So, let’s fix it.
HOW TO SCRUB YOUR HANDS BEFORE SURGERY
So, I have a French medical student who asked me how I scrub my hands in preparation for the case. We’re going to show you. I’m going to start this way (tilts body to the right) and we will end (tilts body to the left). So, first thing, take off jewelry and stuff like that. Gotta bling it up apparently in Beverly Hills, right? First thing- this guy is to clean your nails. So, it goes in under there, do this for the first scrub of the day. Alright, then you get your arms and the scrub wet. First just get the soap everywhere. Okay, then you start washing each finger in four zones and you get your whole hand. Finally, rinse your hands so that the water drains from the top down. And that’s it. We actually made a video about washing your hands. Check yourself out in the mirror and make sure you look okay.
Okay, so you can see this is blanching that I always talking about. The skin is white and that’s from the local anesthetic. It’s also a little more full than what he really is. Alright, guys so made a little incision down here. I’m just sort of mid-way through the process. So, I’ve dissected some tissue free down here. You can see this is actually that breast tissue that I’m going to continue dissecting out, around in this area. Okay, so this is the breast tissue, as you can see very firm.
So, you can see this is, it’s very nice because these are natural planes that are basically just saying ‘get me out!’. Okay, so all the tissue is out. This is nice and flat now. As is this. It’s much more homogenous to the rest of the chest. This is a perfect example. This is his pectoralis major muscle you can actually see it as I’m— it flexes in, that is the muscle. Beautiful.
So, really important aspect of this operation is the closure because it’s really important you don’t want this incision to sort of invert down. So, you take a lot of steps. Okay, so remember this is how it was at the beginning, all this extra breast tissue- took it out. Let’s take a look. Nice and flat now. Much smoother. Much better looking. He’s going to be very happy.
And here are the specimens left and right, you can see the left is much bigger than the right. Here is my hand for comparison. Not very huge, but very important.
ABOUT TUMMY TUCKS
Hi again, so that was a fun case. Our next one is a very interested tummy tuck. This is a patient who I’ve known for some time. I’ve done a ton of liposuction on her. Okay so this was her back in November and you know she had a lot of extra fat, which we have done a tremendous amount of work with. And this is her now. Where you see, she’s lost a huge amount of that girth. But she’s got a ton, lots of loose skin and lots of just not smooth contours. We’re going to fix that. Also from having had children, she’s got loose abdominal wall muscles and we’re going to fix that with a tummy tuck.
TUMMY TUCK PROCEDURE
Okay, so I actually just did a bunch of facial procedures. She didn’t want me to show her face. So, we’re finally getting started with the tummy tuck. We actually just freed up the- so steps of the tummy tuck were going to make an incision here, dissect up under the skin & fat over the muscle all the way up here. Then we tighten the muscles to give a nice flat abdomen. We’ll flex her, pull this down, pull the skin down and cut out the extra. So, we’ll pull everything down, close the skin. It’s going to be awesome.
DR. GABBAY PHILOSOPHIES
Okay guys, really as expected this was a very difficult dissection so far because of all of her liposuction. She had a huge amount. Huge liposuction and as a result, a ton of scar. So, we went through very carefully. We’re up, we actually freed the belly button, here it is and now we’re going to cut. So, we’re going to cut the flab here with this blade to give us better access and better exposure. So, we were just talking about this, one of the philosophies I’ve talked about before as you’re doing a challenging case is: is ‘do what’s easy first, and then what’s hard becomes easy’ and that is certainly true here. That is certainly the case here. So, you know you can see here the muscles on the side here, and here are pretty well exposed but there’s a lot of scar here. So, I’m using this stuff. So, because it’s easy to get here it allows me to move in towards the middle with more clarity and it’s really scared here.
So, that’s also in line with another philosophy that is, ‘go from known to unknown’. That always is a safe way to get you where you want to be. Okay guys so we’ve done our dissection all the way up here, so you can see. Lifted it all up, all the way to the rib cage to the sternum there. Okay, so let’s talk about it.
Okay so you can see how loose her abdomen is and part of that is you can actually see the muscles are totally separated. We’re going to fix that by pulling. So, in addition to totally flattening the stomach here. It’s actually going to pull in the waist to give a nice cinched in waist. Which is going to be beautiful for her. So, you can see this is where the belly button is. Where things were originally just by freeing it up, look how far down this can go. We’re actually going to bring it even farther down. Okay, guys so you can see, this what we call the diastasis. Her six pack muscles have spread out where this is, their inner edge. So, what we’re going to do is sow along these lines and bring this in together to tighten everything up. We’re going to do that in two layers. Alright, guys so mid-way. You can see I started my first row of what we call plication, I tightened this up. This part still needs to be done, look how loose it is. So, we’re just- Alright guys you can see I have tightened the tummy up as well as I possibly could. It’s beautiful, but here’s an interesting thing, you see this bulge over here? It’s still big. It’s missing over here. And that’s because I also tightened this portion here. There’s a row of sutures here, which I’m going to do that, it’s going to make it even tighter.
So, I finished the with the plication, now I’m actually bringing the pubis up, the pubic area so it stays nice and rejuvenated. What we’re doing here is putting in what we call our quilting sutures. This will allow me to so this tummy tuck without the need for a drain. So, this is all closed we are going to do out belly button right now. We’re almost done. It looks spectacular. I am very very happy. Alright everyone, so take a look this was her before. Okay and let’s see some side views, here we go. So big, big bulge here, and just very loose, loose skin. Okay, let’s look at her now. Nice and smooth, very flat. Check that out, she is going to absolutely love it. I want to point something out. Take a look at this little pimple. Okay, I took this picture today. Look how high his pimple is, let’s see where it went. And of course, here are the little pieces of skin that we took out, she’s not going to need those anymore.
PLASTIC SURGERY QUESTIONS ANSWERED BY DR. GABBAY
Okay, long, long day. Let’s get out of here. I will answer some questions on my way to the car. The first question, I was asked a lot today was why I did not do any liposuction for the guy who had the gynecomastia? It’s a good question. So, traditionally liposuction was not a part of gynecomastia surgery, it was actually a complete just excision of the gland. With more modern liposuction techniques a lot of people are now adding liposuction because, in addition to just having breast tissue, many patients have an excess of fat. So, that brings up another question that I was asked: ‘Is there a difference between breast tissue and fat?’ And absolutely there is a distinct difference. Breast tissue is much denser and firm. And fat, of course, is soft and very distinct from breast tissue. So, some people have both, some more of one than the other. Again, this guy today had almost no extra fat, he was very very fit, so he just had breast tissue.
Next question, ‘what is the deal with these progressive tension sutures for a drain less tummy tuck?’ That is a very important question. What these sutures do, is they close the dead space under the skin and fat flap of the tummy tuck and they prevent fluid. Without that accumulation of fluid, you don’t need drains to be put in there. Also, some people say that the drains themselves actually cause fluid to accumulate. So, it is interesting, but there are a lot of other very big advantages to these sutures. An important one is it can actually take tension off of the wound. So, it can potentially allow for a scar that heals much much better than a traditional tummy tuck. Now, you know this is another tool that we have. And it’s very important to choose the right tool, the right technique, for the right patient and that was certainly the case in this patient today. So, those were just a few of the very good questions I had today. Please let me know if you have any other questions you want me to answer, I’m happy to do so. Today was a really good day, a lot of really good teaching points and other fun stuff. Hope you enjoyed it, have a great night everyone. Again, let me know if you want to talk about anything.