Crater Revision

12 minute read

Getting a crater after your operation is one of the worst possible outcomes since it is extremely difficult to fix and only a few surgeons in the entire world can deliver great results. This is always caused by a technical error on the surgeons fault during the operation. No patient will receive a crater if the procedure is properly performed. This is most commonly seen if liposuction is not utilized. Most thin guys, including myself, don’t think they need liposuction for their gynecomastia operation and they are almost always wrong. I have posted below in how I resolved my crater problem with pictures.

Gynecomastia craters are an extremely common complication, so you’ll certainly have company of prior patients. Just take a simple search on realself to see the countless questions.

If you got a crater, be careful in how you proceed to fix the problem. It is my opinion that you should not allow your surgeon to perform a free revision since it is such a bad mistake that the surgeon has already clearly shown his incompetence.

Fat grafting is what most surgeons will recommend in fixing this, however fat grafting healthy tissue into a badly scarred chest will often not “take” and it will die or turn into scar tissue.

A failed revision from your first surgeon or another inexperienced gyno surgeon will leave you in an even worse situation since the accumulation of scar tissue makes it harder and harder to do it right.

Bear in mind, every subsequent operation is made more difficult by the inevitable scar tissue that results from any operation. If you have had one operation and three revisions, your chest probably has a significant amount of scar tissue present – and scar tissue does not support fat grafts too well. As for a dermal fat graft, that would require an incision to “harvest” the graft – so you will have a linear scar at the site of harvest. Dr. Jacobs

One such well-known doctor, Dr. Bermant, refused to perform the procedure since the results are usually terrible and he has yet to see an actual patient where everything looked smooth.

Fat grafts tend to die or become firm, smaller. The results often look terrible especially in motion. Watch a chest with fat grafts move, the firm tissue of gynecomastia has often been replaced by surgical scar tissue. Dr. Bermant

Here is a video that showcases one of the worst results with massive craters all over which cannot be repaired. You will notice wide areas of fat depletion even though the video quality is extremely poor.

I think he is certainly correct as there are no patients that I have conversed with nor have I seen pictures or videos of successful revision when fat grafting was performed. Unfortunately, Dr. Bermant passed away and his website is no longer available.

I have only found a single picture that shows a potential improvement after fat grafting by an extremely experienced gyno expert (Dr. Dadvand).

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It is hard to tell what the contour looks like when the muscle is tensed since this is only a still photo. The results are certainly an improvement, but an in-person examination and multiple pictures in different poses would tell the whole story.

How a crater developes

A crater is created when the surgeon takes out too much tissue. Many people believe muscle was removed, but that is much more rare and even incompetent surgeons know the difference between fatty tissue and the muscle fascia. Removing the gland requires adjacent tissue to be moved and sutured into its spot. This is basically the fat flap. Below shows an incorrect gynecomastia procedure in which this patient is left with a crater. It should have been obvious to the surgeon to fill the void with tissue, but oh well!

Some inexperienced surgeons believe the void will be filled up with scar tissue and the contour will be OK. What really happens is that yes scar tissue will develop, but the skin will adhere onto the muscle fascia below which will pull and tug with movement. No amount of post-op massage or wishful thinking will solve the problem. A revision is required to untether the bands and move healthy tissue into the void.

Adhesions

Part of the underlying problem with craters are the adhesions that form between the skin and muscle fascia. Without a fatty later, the skin will naturally scar down to the underlying tissue which is your muscle. A healthy layer must be placed in-between these two surfaces. Here is a picture of me doing a selfie with my crater side. Notice how the nipple area appears to be tethered to a single point while the rest of the tissue moves up as my arm is raised. The nipple area hence sinks while the arm is raised and gives a “cratered” appearance.

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This occurs without needing to flex. It is significantly worse when tensed. I could feel a pulling sensation when I would flex and raise my arm. It is truly miserable to get a crater due to the adhesions. These must be removed during a revision. Any doctor worthy of your money and time must mention scar release.

Failed fat grafting testimonies

Here are a few snippets of prior patients of fat grafting. I have also spoken to others in private message who have received fat grafting, but failed to see an improvement.

I went back to the Doctor that did my original gyn surgery once more, and he did fat injections straight from my abdomen into the concave nipple on my right side, but that changed nothing. I have since moved and wouldn’t go back to the first Doctor since I feel so discouraged and am visibly deformed now. CIder Mills

I’m 2 weeks post-op from the fat transfer and am a bit concerned. It feels as though most of the fat has died, and has left a firm lump in that area. It’s basically an area that has a lump south of my nipple. Jgunzz

This poor fellow had 4 surgeries, 3 of which were fat grafting to correct the crater from his first procedure. All of the surgeons were board certified in plastic surgery too.

Please nobody mention fat transfer! For me at least, it doesn’t work. DannyH

Most surgeons recommend fat grafting

Talking to multiple gynecomastia doctors is a good idea, however there are only a handful of gyno experts when it comes to revisions. Gynecomastia surgery is rare making a revision expert even rarer. Do not think that fat grafting is the best course of action only because most doctors have recommended it.

It is a fallacy to accept what most surgeons tell you what to do for your revision of fat grafting since most are not a gynecomastia revision expert!

Fat grafting alone is not a great idea since the scar tethering also needs to be taken care of. At a minimum, scar release must be performed.

Here is a board certified plastic surgeon that is claiming fat flaps won’t work because they require a scar and incorrectly infers that fat flaps would create another divot.

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And one that hasn’t even heard of this treatment

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Another surgeon that claim fat flaps are not a solution because they are difficult for him.

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Ask for proof of successful fat grafting

You should always ask your potential doctor for pictures of their before/after of successful fat grafting for craters. You will soon realize how reluctant most doctors suddenly get when asked for this. This is because most are not experts and most have not performed gynecomastia revision cases, let alone any successful ones. I inquired with one local plastic surgeon who claims he is an expert, board certified plastic surgeon. So I just asked about this procedure and if they have any photos. The doctor’s name is Dr. Carlos Mata in Scottsdale, Arizona USA.

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Wow! Sounds great. Surely there are some before/after pictures of a few patients, right?

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How can they claim “Your case like many we’ve done”, yet have absolutely no pictures or video? Perhaps all of those patients were from out of town and decided not to fly back. Surely they would have before pictures to at least prove they have done these procedures in the past?

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I received no response back at this time. I did go in for the consultation anyways and was shown a patient who had a severe crater at rest. They showed me only the immediate post-op of him standing straight with the crater gone, however the huge caveat here is that swelling is at its peak following surgery and so the result shown is never what it settles to. Craters are complicated and deceiving. Even my massive crater looked fantastic immediately following my first surgery. I contacted their office 2 times since then asking for any followup pictures and they have yet to call back. As the saying goes,

Extraordinary claims require extraordinary evidence

Who does have crater pictures then? Dr. Jacobs has an extensive page on crater repair, but they are all with fat flaps.

Fat flaps to the rescue

Fat flaps have a much better change of survival and they are a “one and done” procedure unlike fat grafting. Fat flap means moving some of the local fat over to the defect. That can be done provided you have enough fat to move without creating another crater. Here is my before/after shot of my massive crater on my left side after undergoing the fat flap procedure with Dr. Jacobs in his Manhattan office.

I actually had craters on both sides, but the one on the right was much worse. It distorted the maximum when the arm was raised or tensed. There still is a lack of tissue following the surgery on my right side, but it is much improved and no one would notice it even in all positions.

Here is a picture that clearly shows the craters and them being filled by rotating fat into them.

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Dr. Jacobs also claims to have improved an even worse crater with fat flaps in conjunction with fat grafting. The fat flaps provides the healthy tissue on-top of which the grafted fat can live from.

Our approach was to use fat flaps to fill as much of the crater as possible, then perform grafting on top of the flaps. As this guy heals, we believe he will be satisfied with the outcome

Summary

In short, try to see a gynecomastia expert who can first attempt a fat flap procedure before going the fat grafting route. Fat grafting is fraught with horror stories. It is the most commonly advised treatment, yet the most common that has no pictures of any success. Dr. Elliot Jacobs, Dr. Delgado, Dr. Dadvand, and Dr. Parson (AZ) are all candidates that I have found to perform the flap procedure. It is also important to realize that the fat flap won’t 100% correct the defect, but it may improve it by 80-90% as in my case.

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