Information delivered to: Version 4 October 2019 Patient’s name: ______Date:

______Signature:

This document has been created under the authority of the French Society of Plastic Reconstructive and Aesthetic surgery (Société Française de Chirurgie Plastique Reconstructrice et Esthétique - SOFCPRE) to complete the information that you received in your first consultation with your Plastic Surgeon. It aims to answer all the questions that you might ask, if you decide to undertake this surgery.

The aim of this document is to give you all the essential information you need in order to make an informed decision, with full knowledge of the facts related to this procedure. Consequently, we strongly advise you to read it carefully.

• Indications If the examination did not reveal any objective reasons for enlargement and if the patient has a large breast is a is manifested problem, then surgery may be offered to eliminate by breast enlargement in gynecomastia, provided that the patient is in good physical men with hypertrophy of the and mental shape. This operation is called "surgical mammary glands and treatment of gynecomastia". . There is unilateral and bilateral Given that this operation saves the patient from significant hyperplasia. As a rule, it is physical and mental suffering, it can be considered not just idiopathic, i.e. the cause of an aesthetic procedure, but a real therapeutic act, and in its occurrence has not been some cases covered by health insurance. identified, but in some When gynecomastia occurs excessive growth of breast cases, it may be associated tissue centred in the , often bilateral and symmetrical, with abnormal hormone production or with taking some dense consistency and sensitive to palpation. medications. To identify a possible cause, it is necessary to conduct a survey, including the production of hormones, as Gynecomastia should be distinguished from adiponectin, well as to exclude tumours of the testicles or pituitary gland. which is much more common and represent a local To analyse the density of the breast or exclude the diagnosis accumulation of fat. In adipomastia, the nipple is not of breast cancer in the elderly, especially in the case of necessarily located in the centre, its consistency is soft, it is unilateral form, the doctor may prescribe mammography or insensitive to palpation, often bilateral and symmetrical. ultrasound. If the cause is found, appropriate treatment Both diseases can coexist in one patient, then we are talking should be prescribed. Indeed, when the underlying cause of about adipo-gynecomastia. gynecomastia is found, treatment can lead to complete In adolescents, transient gynecomastia is sometimes regression of gynecomastia. observed, it is associated with a hormonal imbalance in Breast enlargement in men, especially in adolescence, can favour of oestrogen and passes within a few months. cause many psychological problems. This physical defect in Breast cancer looks different, it is a relatively rare form of adolescents, at the very moment when they create for cancer found in men, usually after 40 years, in the form of themselves their ideal of a man, can lead to closure in unilateral, hard, insensitive seals, which are often themselves, and even to a real complex. In addition, accompanied by deformation or retraction of the nipple, gynecomastia can be painful. sometimes accompanied by bloody discharge. From an anatomical and pathophysiological point of view, a • Method of operation normal man has a mammary gland, but it is underdeveloped The purpose of corrective surgery is to restore the normal and looks like a small lump. In some cases, the mammary anatomy of the patient in accordance with the following gland in men can grow, especially if it is favourable to the principles: hormonal background.

Clinique des Champs Elysées, 61 avenue Franklin D. Roosevelt, Paris-8 | www.esthetic-clinic-paris.com | +33609808955 page. 1 from 4

Reduction of breast volume by direct surgical exeresis before surgery and then before the sutures heal (usually 15 (subcutaneous mastectomy) for the glandular form of days after the procedure). The e-cigarette should be treated gynecomastia or by liposuction - for the fatty form. In cases in the same way. of mixed forms of gynecomastia both methods are used On the day of the operation, in the slightest doubt, a urine together; test for the presence of nicotine can be done, and in the case Elimination of excess skin: as a rule, after reducing the of a positive test result, the operation can be canceled by the volume of the gland, the skin itself normally shrinks. surgeon. Lipoaspirate also stimulates contraction of the skin. However, the above applies, rather, to young patients with • Type of anesthesia and hospitalization skin that has retained its density and elasticity, and on which Type of anesthesia: usually the operation is performed there are no stretch marks. Sometimes a simple massage under General anesthesia. However, in some cases, local helps the skin shrink well. anesthesia, enhanced by intravenous tranquilizers, or even simple local anesthesia may be sufficient (this issue is In some cases, when there is too much excess skin, reduction discussed in advance with the surgeon and may be required, after which scars remain. anesthesiologist). Such plastic surgery is performed either during the main operation to eliminate gynecomastia, or during a Methods of hospitalization: subsequent separate operation. This operation is most often performed on an outpatient • Before surgery basis, that is, with discharge on the same day after several We have already mentioned the need for a thorough hours of observation. However, sometimes a 24-hour or examination of the patient to identify the possible cause of even 48-hour hospitalization is desirable. The duration of gynecomastia. hospitalization depends on the surgical tactics used. Indeed, simple lipoaspiration will require a shorter hospitalization Men who are obese or overweight are prescribed diet and than a subcutaneous mastectomy. exercise, as weight loss can lead to a decrease or even disappearance of gynecomastia (adipomastia). • Operation Each surgeon has their own preferences for the operation, Considering the details of the anatomical structure of the patient, the preferences and habits of the surgeon, as well the technique may vary depending on the specific case and as the wishes of the patient, determine the operational the desired result. However, there are General basic principles. strategy. The technique of the operation and the location of future scars is chosen. In a typical operation, an incision is made along the lower edge of the areola. Through this incision, the surgeon can The doctor prescribes preoperative tests and examination. Consultation with an anesthesiologist is mandatory, it must remove the breast (make a subcutaneous mastectomy) and take place at least 48 hours before surgery. The patient excess fat. Often in addition to this, liposuction is done, should inform the doctors about all currently taken especially around the enlarged breast, so that the entire medications, as some of them may affect the course of operated area looks harmonious, lipoaspiration also contributes to a good reduction of the skin. anesthesia or cause bleeding. In the case of predominantly fatty gynecomastia, exeresis Except in special cases, no medication containing aspirin or anti-inflammatories should be taken for ten days prior to can sometimes be performed only by liposuction. The scars surgery. remain very small and can be located at some distance from the gynecomastia itself, for example, under the breast or in About the negative impact of tobacco on the result of the axillary area. surgery. When gynecomastia and excess skin are very significant, The scientific evidence that we have today, conclusively longer incisions may be required, hence more visible scars indicate that Smoking for several weeks, before and after will remain. These scars can be located around the areola, surgery is very negative. The negative impact takes a variety be horizontal and continue both sides of the areola. In of forms and can lead to serious violations of the healing extreme cases, it may be necessary to transplant the nipple- process of sutures, to unsatisfactory aesthetic result of the areolar complex. operation. There are other types of cuts (vertical, in the form of a In the case of operations with the use of skin detachment, racket...), it depends on each case. smoking can cause dangerous skin complications. Depending on the technique used and the surgeon's In addition to the risk directly associated with surgery, preferences, drainage tubes are sometimes installed to Smoking can lead to respiratory or cardiac complications remove blood and lymph residues that may accumulate in during anesthesia. the area of surgery. At the end of the operation, a In this regard, the community of plastic surgeons agrees to "modelling" bandage is applied, often with elastic bandages. request a complete cessation of Smoking at least one month The duration of the operation varies depending on the surgeon and the technique used, from a few minutes in the Clinique des Champs Elysées, 61 avenue Franklin D. Roosevelt, Paris-8 | www.esthetic-clinic-paris.com | +33609808955 Page. 2 from 4

case of isolated liposuction to two hours for complex forms the breast (adiposity) and this is the more common forms of of gynecomastia requiring significant reduction. gynecomastia fatty component. In some cases, the cost of surgery may be compensated by • Possible errors of the result the health insurance system. − Residual volume asymmetry: this may be because less • After operation tissue has been extracted on one side than on the other, In the first days after surgery, the patient may experience but this is more common in cases where the volume pain, so painkillers are prescribed, depending on the asymmetry already existed before surgery. In some cases, intensity of pain. In the case of isolated lipoaspiration, the the asymmetry may be associated with a large patient may experience pain localized in the liposuction zone postoperative swelling on the one hand: in this case, and resembling muscle aches after intense exercise. wearing compression underwear and massage can correct the defect. If the asymmetry persists for about one year In the first postoperative days there is swelling, bruising and after surgery, and if it bothers the patient, then surgical discomfort when lifting the hand. correction may be offered. The first bandage is removed after a few days. Then it is − Areola and nipple height asymmetry: in most cases, this replaced with a lightweight bandage. Often, the original asymmetry was already present in the patient before the bandage, which provides a strong compression of the operation, however, he did not pay attention to it or simply operation zone, is soon replaced by a special compression did not notice it. After the operation, even if the surgeon underwear, which should be worn day and night for some tried to correct it, the asymmetry can persist and time. Compression improves the contraction of the skin and sometimes even appear stronger, that is, become more promotes even healing. noticeable. − In other cases, asymmetry may be associated with healing The period of sick leave after surgery can be from five to of the tissues under the skin. Daily massage and hydration twenty-one days. It is recommended to wait one to two will help to correct the problem. months before resuming sports activities. − Cup-shaped areola: this may be because the gland is more • Scars removed in the centre, behind the areola, and the After gynecomastia surgery, scars remain. The goal of the transition to the periphery of the gland is uneven, too surgeon is to make these scars as inconspicuous and sharp. If this bothers the patient, it will be possible to make aesthetic as possible. a small surgical correction. − Excess (stretched) skin: after surgical correction of The scar is formed within one to two years after surgery. It gynecomastia, excess skin is not uncommon and skin is first white and thin in the first month, and then turns pink contraction may take several months. How the skin shrinks or red and a little hard until the fourth month. After that, the depends on its condition. Sometimes surgical correction scar gradually fades. may be required. Scars should be protected from the sun for the first year − Dips or small nodules under the skin: these are associated after surgery. Their length and location depend on the with lipoaspiration, which in some cases can enhance the operating technique, and the final appearance-not only on "cellulite skin" aspect. This phenomenon is considered the technique of surgery, but also on factors directly related normal: daily massage in combination with hydration will to the patient, such as age, skin quality, Smoking, and others. break these fibrous nodules and avoid adhesions, manifested in the form of a characteristic cellulite "orange It is necessary to monitor the condition of scars throughout the period of their formation. peel". − As for the healing process of scars, we have already written • Result about it above. In most cases, the improvement is noticeable immediately − The sensitivity of the is usually not impaired, or the after surgery. However, a period of two to three months is sensitivity disorders are temporary, and it gradually required to assess the result. This is the time it takes for the recovers after a few months. postoperative swelling to subside and the stretched skin to − Loss of nipple sensitivity is extremely rare. On the other contract. During this period, the tissues will gradually regain hand, if you must transplant the nipple-areolar complex, their elasticity. Reducing breast size brings physical comfort, then in this case it can lose sensitivity, and there may also especially during the dressing process. And of course, a great be a violation of pigmentation in this area (dyschromia). importance has a positive result on the morale of the patient, because the female breast does not give the male • Possible complication body masculinity. Surgical treatment of gynecomastia, although carried out mainly from aesthetic motives, nevertheless, remains a real As for the stability of the result, there are options. For the surgical operation, with all its inherent risks, no matter how purely glandular form of gynecomastia, exeresis of the insignificant they may be. breast usually excludes recurrence. However, significant weight gain may lead to further increase in the volume of

Clinique des Champs Elysées, 61 avenue Franklin D. Roosevelt, Paris-8 | www.esthetic-clinic-paris.com | +33609808955 Page. 3 from 4

In this operation, possible complications are associated occur. Necrosis is treated with appropriate care and primarily with the reaction of living tissues to surgical special dressings. Everything will heal, but with some intervention, which can never be fully predicted in advance. delay. − The postoperative period after gynecomastia is usually Pneumothorax: a very rare complication requiring specific simple. However, the possibility of complications is not treatment. excluded. Some of them, the most common, can occur after − Abnormal scars: the surgeon does his best to make any surgical operation, others-are characteristic of beautiful stitches; however, the healing of incisions is gynecomastia surgery. subject to random laws, and sometimes the scars are not as inconspicuous as one would like. In the same person, in It is necessary to distinguish between complications different parts of the body, healing can occur in different associated with the surgical act and complications ways. Sometimes the process of scar formation deviates associated with anesthesia. from normal, and scars can become hypertrophic or even As for anesthesia, about it, including possible complications, keloid, which, of course, adversely affects the aesthetic you will be told in detail by the anesthesiologist during the result. This complication requires specific local treatment, consultation. It is necessary to know that anesthesia causes often long-term. specific reactions in the body, sometimes unforeseen, but − Skin sensitivity disorders: changes in skin sensitivity are which are easy to manage. Trusting a competent observed in the first months, but gradually the sensitivity anesthesiologist with experience in the operating unit, you returns to normal. Occasionally there is excessive can be sure that statistically the risk of complications is sensitivity, these special cases require specific treatment. extremely small. Indeed, over the past 30 years we have As we mentioned above, if the surgeon must transplant seen tremendous medical progress in the field of methods the nipple-areolar complex, this area can permanently lose and drugs for anesthesia, as well as protocols for patient sensitivity. observation, which provides optimal safety, especially given In general, one should not overestimate the danger, but that aesthetic surgery is usually performed on generally simply realize that the operation, even seemingly simple, healthy patients. always carries a certain amount of risk. When the operation As for surgery as such, choosing a qualified and experienced is performed by a qualified plastic surgeon-it is a guarantee plastic surgeon who has received special training and has a that, with enough experience, knowledge and skills, he hand in conducting operations of a certain type, you knows how to avoid complications or respond correctly in minimize the surgical risk, which, however, cannot be case of their occurrence. completely excluded. Fortunately, real complications are rare after surgical treatment of gynecomastia performed in accordance with These are the facts which we wish to bring to your attention, to the rules. In practice, most operations occur without any complement what you were told during the consultation. problems, and patients are completely satisfied with the Our advice is for you to keep this document and to read it and result. think it over carefully after your consultation.

However, even though complications are very rare, the Once you have done this you will perhaps have further queries or patient should be objectively informed about the presence require additional information. of possible complications: We are at your disposal should you wish to ask questions during − Postoperative bleeding and hematoma: the risk of your next consultation, or by telephone, or even on the day of the bleeding persists for several hours after surgery. If the operation, when we will meet in any case, before the anesthesia. bleeding is profuse, it leads to swelling and painful tension (hematoma), in which case its evacuation is required. PERSONNAL OBSERVATIONS: − Phlebitis and pulmonary embolism: early walking after surgery minimizes this risk. − Serous effusion, lymphocele, seroma: sometimes there is an accumulation of lymphatic fluid in the mastectomy area. Evacuation may require one or more punctures. − Postoperative infectious complication: the risk of its occurrence persists for several days after surgery and is manifested by a high temperature, sometimes above 39°C. the area of surgery swells, reddens and becomes painful. Antibiotic treatment may be enough, but surgical drainage is often necessary. − Necrosis of the skin: Skin needs a good blood supply (oxygen) to live. With insufficient or poor-quality vascularization, for example, due to excessive skin tension, hematoma, infection, Smoking, etc., skin necrosis may Clinique des Champs Elysées, 61 avenue Franklin D. Roosevelt, Paris-8 | www.esthetic-clinic-paris.com | +33609808955 Page. 4 from 4