Plastic Surgery

Our board-certified plastic surgeons assists in treating gynecomastia with a reduction

Gynecomastia refers to benign enlargement of male breast tissue. The cause of gynecomastia is unknown, but it can be associated with other more concerning conditions, such as: endocrine disorders, liver disease, and testicular tumors. It can also be associated with certain prescription medications, the use of marijuana, steroids, and some work-out supplements. Gynecomastia to some degree is common during adolescence but usually resolves within one year. Because of the association with other more concerning conditions, men with abnormal breast enlargement that is painful, asymmetric, develops after adolescence, or persists for more than one year following pubertal development should seek evaluation by a board certified physician.

Gynecomastia is graded based on the degree of excess skin and breast tissue:

• Minor enlargement, no skin excess
• Moderate enlargement, no skin excess
• Moderate enlargement, skin excess
• Marked enlargement, skin excess What are treatment options for gynecomastia?

Many men with gynecomastia seek surgical treatment from a board-certified plastic surgeon because they are self conscious about their disproportionate breast size, embarrassed to remove their shirt in public or wear tighter fighting clothing, and want to increase their social confidence.

The treatment approach to gynecomastia varies depending on the degree of excess fatty tissue, breast glandular tissue, and skin.

The most common operation involves a combination of liposuction and direct excision of excess glandular breast tissue. Frequently there is a firm area of excessive breast tissue below the nipple that will not be amenable to liposuction alone and requires direct excision via an incision placed at the border of the areola (pigmented tissue around the nipple).

In more extreme cases where skin excess is also a problem, various additional incisions that will be more visible may be necessary to achieve a satisfactory reduction in breast tissue and skin. A surgeon will review the options that are most appropriate during your consultation.

Discover how breast reduction can help improve your overall health

Breast reduction is a procedure designed to reduce the size of undesirably large breasts. Also referred to as reduction mammoplasty, the operation has a very high rate of patient satisfaction as it typically has the two-fold benefit of reducing physical symptoms associated with large breasts and improving the aesthetic appearance of the breasts. Many women with large breasts experience back pain, neck pain, shoulder pain, bra strap grooving, headaches, skin irritation, and difficulty participating in some physical activities. Frequently these women feel that their breasts look disproportionate to the rest of their body, have an excessively droopy or pendulous appearance, and have nipples that are too low or even downward pointing. Breast reduction usually results in correction or improvement of all of these issues.

What can be expected in terms of scarring?

Our surgeons have extensive training in the latest “short scar” techniques of vertical breast reduction and prefers this operation for most of his patients when they are appropriate anatomical candidates. The scar for this technique is generally limited to around the areola and down the center of the breast in a lollipop configuration. This technique has the added benefit of providing a significant reshaping of the remaining breast tissue to give a perkier and a more youthful appearance to the breast that is longer lasting than some other methods of breast reduction.

In some cases when there is a significant excess of tissue that needs to be removed or a very high degree of droopiness to the breast, the “anchor scar” pattern may be required. This more traditional technique involves a scar across the bottom fold of the breast in addition to the scar around the areola and down the center of the breast.

What is the recovery process like following breast reduction surgery?

While there is discomfort following breast reduction surgery, it is routinely very well tolerated by patients. Your breasts will feel sore but this is treated with various pain medications after surgery. Generally the worst of the pain is over within 48 hours and most patients return to work within 1 week of surgery, depending on the nature of their job. Over the ensuing weeks and months, the swelling will go down and the breasts with settle into a softer, more natural shape.

What is breast reconstruction?

Breast reconstruction offers women the opportunity to feel whole again after having treated breast cancer with a lumpectomy or mastectomy, or after injury or a birth defect.  Most techniques involve several separate procedures that can begin as early as the time of mastectomy.  Reconstruction aims to restore the shape, size, and appearance of the breast.  There are several techniques by which this can be accomplished. Reconstructive options include expanding the remaining tissues on the chest and using an implant, or by using your own tissues, often taken from the abdomen or back.  In addition to restoring the breast mound, there are also techniques to reconstruct the nipple and areola, including local skin rearrangements, skin grafts, and tattoos.  In some cases, the remaining breast will need to be lifted, augmented, or reduced in order to improve symmetry. Please note, not all patients are candidates for every technique.  Dr. Forsberg or Dr. Kelly will review the methods of reconstruction available to you during your consultation.

Although reconstructive surgery has improved with modern implants and techniques, a reconstructed breast will never have the exact same look and sensation as the breast it replaced.  In addition to being prepared for the emotional adjustment involved in breast reconstruction, patients must have realistic expectations about outcomes.

Before and after breast reconstruction procedures

When and where is breast reconstruction performed?

Breast reconstruction procedures can be performed in an inpatient or outpatient setting.  In most cases, a general anesthetic or a deep sedative, along with local anesthetics, are employed to ensure your comfort and safety.  The initial procedures for breast reconstruction may be performed at the same time as your mastectomy, or in a delayed fashion.  Immediate reconstruction offers the psychological and aesthetic advantage of waking from the mastectomy procedure with a less traumatized breast region. 

What are the different types of breast reconstruction?

The two broad categories of breast reconstruction are implant-based reconstruction and autologous reconstruction – where your own tissues are used to reconstruct the breast mound.  Most often, implant reconstruction begins with the placement of a tissue expander to enlarge the tissues on the chest wall slowly over a period of a few months until a permanent saline or silicone implant can be inserted in a secondary procedure.  In some cases, it is possible to place a small permanent implant in the first procedure. 

Fluid is placed into a tissue expander during an office follow-up procedure

During implant-based reconstruction, the Acellular Dermal Matrix, which is derived from human or animal tissue, may be used.  Use of this product facilitates the placement of a permanent implant at the time of mastectomy.  It can also be used with a tissue expander to speed the expansion process and improve the aesthetic outcome of the reconstruction.  Some studies indicate these potential advantages may come at the cost of a slightly higher complication rate.  You should tell your surgeon if you are opposed to the use of this product.

Autologous tissue – called a flap – from another part of your body is used to reconstruct the breast mound when a breast implant is not used.  The tissue is most often taken from the abdomen or the back.  Other donor options include the buttocks or thighs.  Flaps can be kept attached to their dominant blood supply and tunneled into position in the chest or they can be disconnected from their native blood supply and attached to other vessels in the chest.  The latter involves more operative time and a higher risk of total loss of the flap, but it can afford more versatility in the donor location or configuration of the flap.  When the flap is taken from the abdomen, it will often require repair of the abdominal wall with a synthetic, mesh-like material.  In general, autologous reconstructions tend to produce a more natural looking breast mound that ages with the patient and may not require as many secondary operations as implant reconstructions.  It does, however, involve more operative time, longer recovery, and subjects other areas of the body to surgery.

Breast reconstruction using prosthetic implants or flaps of tissue from the patient’s own body

How is the nipple reconstructed during breast reconstruction?

Nipple sparing mastectomy, where the nipple and areola are left intact while the remainder of the breast glandular tissue is removed, is becoming more widely used in some patients who are appropriate candidates.  In this case, the patient’s own nipple and areola remain, and no reconstruction is necessary.

In cases where the nipple and areola are removed during mastectomy, they can be reconstructed after the breast mound is made using combinations of small tissue flaps to create an elevated nipple mound and a tatoo to create the coloration of the areola.

Is there anything else I should know?

The manufacturers of breast implants expect them to last a long time, but everything man-made does break or wear down eventually. The life span of all types of implants can be shortened by trauma or mechanical failures. A rupture, for example, may be clinically undetectable to you or your surgeon if you have silicone gel implants, but it could be picked up during mammography or other specialized tests. The rupture of the older gel implants often led to gel migration or the formation of lumps within the breast as a result of scar tissue developing around the free silicone, necessitating future breast biopsies and implant replacement.  However, today’s gel-filled implants are made of a cohesive gel that stays intact even in the event of a shell rupture.  They are also less likely to migrate and are easier to remove.  The rupture of a saline-filled implant, on the other hand, will be obvious because the breast will return to its previous size and shape over a short period of time. Unfortunately, no one can predict in advance when an individual implant will fail. Replacing an implant will become necessary if a leak is detected. It is strongly recommended that you see your plastic surgeon at least once a year for a breast examination.

What is a breast lift (mastopexy) with augmentation?

Breast lift with augmentation refers to the combination of two very common breast procedures.  The first, breast augmentation, is a procedure where breast size is increased using silicone or saline breast implants.  It is also referred to as augmentation mammoplasty, breast enhancement surgery, or breast enlargement surgery.  Breast augmentation is the most common cosmetic surgical procedure performed in the United States and has a very high rate of patient satisfaction. 

Causes of breast sagging

Breast lift, also called mastopexy, is a procedure where the breast is reshaped to provide a more youthful appearance.  A breast lift improves droopy or saggy breasts in 4 primary ways:

• The excess loose skin of the breast is reduced
• The breast tissue itself is reshaped, becoming firmer and more youthful
• The nipple is elevated to the center of the breast mound
• The size of the areola (pigmented skin around the nipple) is also reduced

Typical appearance before and after breast lift surgery

Breast augmentation and mastopexy are frequently performed together in a combined operation, although they can also be performed in separate, staged operations.  During your consultation, Dr. Kelly or Dr. Forsberg will go over which procedures you are the best candidate for as well as the advantages and disadvantages of doing the procedures combined or separately. 

For more detailed information about each procedure, click here:

Breast Augmentation (link to respective pages)

Breast Lift

Above is a patient of Dr. Forsberg’s who experienced deflation and drooping of the breasts following significant weight loss.  She underwent simultaneous breast lift and breast augmentation using 400cc subpectoral silicone implants.

Will breast implants alone provide a lift without formal mastopexy?

While increasing the volume of the breast with an implant can fill out loose skin and improve the appearance of a slightly droopy breast, it will not elevate the nipple position.  If there is significant skin excess, or a significant elevation of nipple position is desired, a breast lift will most likely be needed in addition to the implant to provide the best result.  During your consultation, Dr. Kelly or Dr. Forsberg will perform a detailed physical exam after discussing your goals and expectations to help determine which operation is best for you.  A good rule of thumb, however, is that if the nipple lies below the level of the lower breast fold, a breast lift will be needed to provide optimal results.

Where will I have scars after the breast lift (mastopexy)?

There are three primary patterns of scar location for a breast lift.  The most common type of mastopexy performed is called a vertical mastopexy, with a scar resulting in a “lollipop” configuration around the areola and down the center of the breast. 

Vertical mastopexy done with a “lollipop” scar

In some cases of mild drooping, a scar limited to the areola (periareolar scar) can accomplish the necessary lift and tightening. 

Periareolar mastopexy

In other cases of severe ptosis or sagging, scars in an anchor configuration, around the nipple, down the center of the breast, and across the base of the breast may be needed to provide optimal shape. 

Anchor scar mastopexy

Why would I consider getting breast implants in addition to a breast lift alone?

While a breast lift will result in a breast that appears more perky and youthful, it does not increase the overall volume of the breast.  Additionally, while the breast can appear more full, the increase is primarily in the lower portion of the breast.  Women who desire an increase in breast size or who are particularly concerned about improving the fullness in the upper portion or cleavage area of the breast, should also consider augmentation.  

Pictured above is a 56yo patient old patient of Dr. Forsberg’s who wanted to improve the sagging of her breasts that occurred with age and after having several children.  She did not want a large increase in size, and she wanted to enhance her cleavage and improve the fullness in the upper portion of her breasts.  She chose to undergo a breast lift with augmentation using 213cc moderate profile silicone subpectoral implants. 

See what patients of Dr. Forsberg have had to say about breast surgery. 

Breast augmentation is a procedure in which breast size is increased using silicone or saline breast implants. It is also referred to as augmentation mammoplasty, breast enhancement surgery, or breast enlargement surgery. Breast augmentation is the most common cosmetic surgical procedure performed in the United States and has a very high rate of patient satisfaction.

See what Dr. Forsberg’s breast implant patients have to say about breast surgery

What are the most common reasons to have breast augmentation?

Many women choose to undergo breast augmentation because they feel their breasts are not proportionate to their overall body shape. For some this is genetic, but for others, breast volume is lost after pregnancy, menopause, or weight loss. If you find that the clothes that fit your hips well are loose up top, if you feel self-conscious in swimwear or low-cut tops, or if there is a noticeable size discrepancy between your breasts, you may be a good candidate for breast implant surgery.

Pictured above is a 38-year-old female patient of Dr. Forsberg’s who chose to undergo breast augmentation with 350cc silicone implants after becoming dissatisfied with the small, deflated appearance of her breasts after nursing several children.

Dr. Forsberg discuss who is a candidate for breast augmentation.

What can I expect in terms of scarring?

In general, there are three options to consider for the location of the incision used to create the pocket for the breast implant. The final scar can hide within the lower fold of the breast (inframammary incision), along the outside border of the areola, which is the pigmented skin surrounding the nipple (periareolar incision), or within the armpit (axillary incision). While there are advantages and disadvantages to each technique the inframammary incision frequently provides the least visibility and best long-term result. Usually this incision fades away into the crease between the lower portion of the breast and the chest wall. It affords the surgeon the most direct accessibility to the pocket being created for the implant which results in the shortest incisions and most symmetric and accurate implant placement. Unlike the periareolar incision, the inframammary incision avoids dissection through the breast tissue, which can result in contamination of the breast implant with bacteria normally found within the breast ducts.

Incisions for breast augmentation are generally placed on the areola, in the arm pit, or in the bottom fold of the breast

Should the breast implants be placed over or under the muscle?

In general, most patients will be better candidates for placement of the breast implants underneath the pectoralis major muscle in the chest in what is referred to as a dual plane. There are two major advantages for placing the implants under the muscle. The first advantage is that implants under the muscle have a lower rate of excessive scar tissue forming around the implant, called a capsular contracture. The second advantage is that it provides an added layer of tissue over the implant and helps to conceal the shape and outline of the implant, particularly in the cleavage area. This second advantage is more relevant to thin women with less breast tissue.

Breast implants placed “under the muscle” sit partially under the pectoralis major muscle

Left: subglandular placement of implant; Right: submuscular placement of implant

Implants placed in the submuscular plane are generally only partial covered by chest muscles, referred to by plastic surgeons as a “dual plane.”

There are women who are better candidates for an implant positioned above the muscle, or a subglandular position. These include women with adequate breast tissue to camouflage the presence of the implant, women who have a slight droop to the breast but want to avoid the scars associated with a breast lift, or women such as body builders who participate in strenuous upper body exercise. Dr. Kelly and Dr. Forsberg also perform a procedure called “subfascial breast augmentation” where the implant is placed above the muscle fibers but below the dense layer of muscle fascia. Is some cases, this technique gives patients the best of both worlds!

Implants placed in the subglandular plane are above the chest muscles but below the breast glandular tissue.

What is the difference between saline, silicone, and “gummy bear” (form stable) breast implants?

Both saline and silicone breast implants are made of a silicone elastomer shell on the outside. The difference between them lies in the substance filling the implants. In saline implants, the filler material is salt water, while silicone gel is the filler material for silicone implants. Modern silicone gel implants have thick outer shells and the gel inside is more cohesive. This means that if a modern silicone gel implant ruptures, the gel inside is very unlikely to move far from the site of the rupture.

Round saline breast implant

Saline breast implants being filled during surgery

Many patients are still concerned about the safety of silicone gel implants as a result of their temporary removal from the marketplace in the 1990s. During this time, the safety of silicone breast implants was studied extensively. Researchers found no increased risk of autoimmune diseases, breast cancer, chronic fatigue syndrome, or depression in women who had silicone breast implants (even ruptured silicone breast implants) than in women who had never had breast implants. For this reason, silicone is one of the most commonly used materials in medically implanted devices today.

See Dr. Forsberg discuss the difference between saline and silicone breast implants

Form stable breast implants, sometimes called “gummy bear” implants, are the newest type of breast implants to be released on the market. The gummy bear breast implants are filled with a highly cohesive silicone gel, which is thicker and stiffer than a traditional modern silicone gel implant. These implants are made in an anatomic, tear drop shape. Because of the stiffness of the gel inside, they maintain this shape in all positions. This means the form stable implant will maintain its teardrop shape whether the woman is standing upright or lying down.

There are several potential advantages of form stable breast implants. For small breasted women who want a conservative increase in size, the gummy bear breast implant provides a more natural shape. Additionally, the cohesive gel inside the implant is less likely to migrate outside of the shell if the implant cracks or ruptures. The rupture rates and capsular contracture rates of these implants are the lowest of any breast implant ever developed. Potential disadvantages of these anatomically shapes implants are rotation within the pocket and a slightly firmer feel.

Each of the various implants has advantages and disadvantages. For this reason, it is important to have a detailed consultation with a board certified plastic surgeon with whom you feel comfortable prior to deciding which implant is best for you.

See Dr. Forsberg discuss the differences between round and anatomic breast implants

What is a “high profile” breast implant?

For a traditional round breast implant, there are three important measurements to consider: the width or diameter of the breast implant, the volume of the breast implant (measured in cubic centimeters or ccs), and the profile of the implant. When looking at an implant from the side, the profile refers to how much the implant will protrude from the chest wall. The diagram above shows 3 breast implants of equal volume. The implant on the right is a high profile implant. As you can see, it is narrower and will protrude a greater distance from the chest wall. The lower profile implant on the left has a wider base for the same total volume. In general, a higher profile implant will result in a more projecting or more “busty” look. In addition to preference, skin type is important for the surgeon to consider when helping you decide which profile breast implant will be best. Relatively loose, stretchy breast skin will more easily and naturally accommodate a high profile breast implant, whereas breast skin that is very inelastic and tight may not accommodate a high profile implant as well.

How do I pick the size of my breast implant?

A common misconception among patients preparing for breast augmentation surgery is that a certain implant size equates to a certain bra cup size, or that they can look at pictures or see a friend’s augmented breasts and choose their implant size based on what they see in other people.
Every patient has a different breast width, height, and a different amount of their own breast tissue that contributes to the final size and shape of an augmented breast. When the goal is to provide an appropriately shaped, natural result, the reality is that the volume of the breast implant is the least important when selecting the breast implant measurements. A qualified, board certified plastic surgeon will measure the width of your breast and select a breast implant with a base diameter that fits your chest appropriately. The projection of the implant is determined by your preferences for final breast shape, the amount of natural breast tissue you have before surgery, and the elasticity of your breast skin. After the ideal implant width and projection are determined, the volume of the implant is essentially defined.

The reality, however, is that it is much easier for patients to think and experiment with different sizes of breast implants. We encourage our patients to experiment with different breast sizing systems at home and in the office.

How do I know if I need a breast lift (mastopexy) or breast implants?

In general, breast augmentation increases the volume of the breast while a breast lift elevates the nipple and areola to a more youthful position on the breast and tightens loose skin. While a breast implant will help fill loose and deflated skin on the breast, it will not correct a breast with significant droopiness on its own. A good rule of thumb is that if the nipple lies below the level of the lower breast fold, a breast lift will be needed – with or without implants – to provide an optimal result.

Breast lift is generally needed if the nipple lies below the position of the lower breast fold.

Are complications possible with breast implants?

As with any surgical procedure, there are complications associated with breast augmentation. While rare, complications such as bleeding, infection, and capsular contracture (formation of thick scar tissue around the breast implant) do occur. It is also important that patients realize breast implants are not permanent. Overall, breast implant revisions are done on average about every 10 years, whether it’s done for a ruptured implant, capsular contracture, or an augmented breast that later needs a lift or other adjustment. Patients desiring excessively large breast implants should know that larger implants result in more thinning and stretching of tissues, have more frequent complications, and tend to require more frequent revision operations.

Watch Dr. Forsberg discuss how long breast implants last…

What should I expect during the healing process from breast augmentation?
While there is discomfort following breast augmentation surgery, it is routinely very well tolerated by patients. Your chest will feel sore and tight, but this can be treated with various pain medications. Generally, the worst of the pain is over within 48 hours, and most patients return to work 3-7 days after surgery, depending on the nature of their job. It is important to avoid quick movements or heavy lifting with the upper extremities after surgery for 4 to 6 weeks. You may have bruising and some swelling after surgery. Most swelling will be gone within 1 month. The breasts may appear too high and tight right after surgery, but during the first 1-3 months, the breast skin will stretch and the implants will soften and settle down to their final position.

Breast implants will soften and settle over the first few months following surgery.

Breast surgery can address a wide variety of problems with the size, shape, and overall appearance of your breasts.

People have many different reasons for seeking out different breast surgery procedures. Although some women are simply looking to increase the size of their breasts, others may actually want them smaller to avoid back and neck pain, or even to fix sagging breasts that have lost their volume (termed “breast ptosis”).