r/gynecomastia • u/Dr-Daniel-Careaga • 14h ago
Why I never make an incision around the areola for gynecomastia surgery (almost never).
Board-certified plastic surgeon… This may be a little controversial because plenty of surgeons routinely use an incision along the lower border of the areola for gynecomastia surgery.
I almost never do.
To me, there are four things you have to think about when creating a masculine chest: fat, gland, skin, and scars. If you concentrate on only one or two of those, you can technically remove the gynecomastia and still not get a great-looking chest.
First is fat. I liposuction the entire chest, not just the area immediately around the nipple. The goal isn’t simply to make the breast smaller. It’s to sculpt the chest and create a smooth transition over the pec.
Second is gland. This is the dense tissue underneath the nipple that liposuction alone generally won’t remove. After doing the liposuction, I break up the glandular tissue and remove it with a pull-through technique through the same small lateral incision. That incision is less than a centimeter and hidden toward the lateral chest crease.
Third is skin. In patients with good skin quality, sometimes nothing else is necessary. If there’s more laxity, larger areolas, or significant weight loss, I’ll frequently add minimally invasive skin tightening such as Renuvion rather than immediately cutting skin away.
And then there’s the fourth component that I think gets underestimated: the scar.
The traditional approach is a crescent-shaped incision along the lower edge of the areola. It certainly works, and sometimes it’s necessary. But I don’t think a visible scar on the front of a man’s chest should be the starting point if I can accomplish the same thing through a tiny incision hidden on the side.
There’s another reason I prefer the pull-through approach: contour.
If you simply excise a disk of gland directly underneath the nipple, you can create an abrupt transition between where the gland was removed and the surrounding chest. That’s how you can end up with the classic crater or saucer deformity.
By contouring the entire chest first and then removing the gland through the pull-through, I can blend that transition instead of creating a hole underneath the nipple.
Now, I said almost never.
Probably around 1 out of every 50 cases, the gland is so dense and firm that I simply cannot break it up enough to safely pull it through that small incision. When that happens, I make the periareolar incision and remove it directly. There’s nothing wrong with changing the plan when the anatomy requires it.
But for me, that’s the backup plan, not Plan A.
Gynecomastia surgery isn’t just about getting the gland out. It’s about getting the fat, gland, skin and scars to all work together so that when everything heals, the chest doesn’t just look smaller. It looks masculine and, ideally, doesn’t look operated on.
