All human males have breast tissue. In some adolescent boys and some men, the breast tissue that always exists behind every human male nipple (but which is usually not developed enough to see or feel) may begin to grow and gradually become noticeable as a swelling behind the nipple-areola complex. In some individuals this spontaneous development of breast tissue continues to involve the entire breast/chest area. The phenomenon of male breast enlargement is called gynecomastia, and it is an extremely common medical condition that appears to be increasing in incidence.
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Gynecomastia comes in all shapes and sizes. It can occur on one side of the chest or on both, and may present as early as around the time of puberty or as late as one's retirement years. The minimal form of gynecomastia is that of a protruding nipple/areola complex, sometimes referred to as "puffy nipples" (but which would more correctly be called "puffy areolas"), which is very common in adolescent and post-adolescent young men. The condition will gradually go away in some cases, and no treatment is required. More commonly the projecting nipple/areola appearance will persist, and in some patients the breast tissue will continue to grow and may eventually produce a feminized overall breast appearance. Hence the rather callous terms 'manboobs' and 'moobs' in popular usage these days.
In some males with gynecomastia the enlarged breast appearance is primarily dense, glandular breast tissue; in others it is primarily adipose (fatty) tissue. The most common form of gynecomastia involves a combination of firm, fibrous breast tissue immediately behind the areola and excess fatty tissue in the surrounding area. Sometimes there is no significant skin excess, while in other cases redundant skin must be surgically removed.
There is currently no recommended, FDA-approved medical (i.e. non-surgical) treatment for gynecomastia. While gynecomastia may spontaneously regress in some instances, in most adolescent and adult males the breast tissue development is a permanent change that must be treated surgically. In the few cases where a definite cause can be identified, such as low testosterone levels or exposure to a particular medication, the gynecomastia almost always persists after the causative factor is corrected or eliminated. Because gynecomastia is so different from person to person, it is absolutely critical that the surgical approach to this problem is carefully individualized.
- Lifestyle and Social Concerns
- Why Do I Have Gynecomastia?
- Types of Gynecomastia
- Surgical Treatment for Gynecomastia
- Recovery and downtime
- Revisional ("Redo") Gynecomastia Surgery
- Gynecomastia and Health Insurance
Lifestyle and Social Concerns
So many gynecomastia patients have shared with me the self-consciousness, embarrassment, frustration and psychological stress that they have endured because of breast enlargement. Most never feel comfortable wearing a snug-fitting shirt, much less taking off their shirt at the beach or at the pool. Many use compression vests to try and reduce the appearance of gynecomastia in clothes. Every patient I see feels that it has adversely affected their comfort and confidence in social situations. And many describe a feeling of discomfort and embarrassment with regard to sexual intimacy. If you have experienced any or all of these issues personally, I want to assure you of two things: one, you are not alone, and two, every case of gynecomastia can either be completely corrected or at least dramatically improved.
It is important to know that patient evaluation, treatment planning and surgical management are totally discreet in this plastic surgery practice. Some gynecomastia patients have related that prior to scheduling an appointment, they were concerned about 'feeling awkward' entering and exiting a plastic surgeon's office for their consultation. Because part of this aesthetic medical practice is a medical spa offering a variety of services, including laser treatments and massage, no client in our office can ever be presumed to be a surgical patient. And while no physician office can avoid an occasional delay in the daily appointment schedule, we set our schedule so that almost every consultation and follow-up appointment is begun on time, and time spent in the waiting area is kept to a minimum. We consider your time to be as valuable as ours.
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Why Do I Have Gynecomastia?
Some enlargement of male breast tissue commonly occurs during puberty, and the incidence of noticeable, transient, pubertal breast enlargement has been reported to be as high as 60%. For most males this hormone-related breast enlargement is temporary, but for some individuals the breast tissue proliferation will persist and even increase in size.
For the majority of men with gynecomastia, no clear causative factor can be identified. It is thought that some cases of gynecomastia may relate to an imbalance between circulating levels of estrogens, which stimulate breast tissue development, and androgens including testosterone which counteract estrogen effects. Because gynecomastia may rarely be associated with endocrine (hormone) disorders, testicular tumors, and the use of some medications/drugs, it is important that you discuss the condition with your primary care physician prior to surgical treatment.
Testosterone deficiency (TD) is actually quite common, and it is now well understood that testosterone levels tend to decrease significantly in most men at or around the age of 50 (sometimes called 'andropause' or 'male menopause'). I have had a number of patients begin testosterone replacement therapy (TRT), under the direction of their primary care physician, either prior to or following their consultation appointment for gynecomastia surgery. While TRT can improve energy level, mood and libido in patients with TD, it unfortunately does not appear to reverse or improve gynecomastia in most cases.
Male breast enlargement can occur as a result of significant weight gain, in the absence of actual breast tissue excess. This is sometimes referred to as "pseudogynecomastia", which implies that the breast has enlarged because of the accumulation of fatty tissue only. While it is true that male breast enlargement in some cases is primarily due to excess body mass / obesity, in many cases patients who appear to have "pseudogynecomastia" turn out to have a significant amount of fibrous breast tissue as well. This is not that surprising, given the fact that it has been shown that the condition of being overweight can upset the balance of estrogens and androgens in favor of estrogens (sometimes called a "pro-estrogenic state"), which is a set-up for the development of true gynecomastia.
Male breast enlargement associated with excess body mass / obesity may improve with weight loss. In many men, however, the feminized appearance of the breast will persist, due to underlying true gynecomastia, incomplete regression of breast area fat, persistent skin excess after weight loss, or some combination of the three.
Increasingly patients are being seen for gynecomastia that develops after using 'prohormone' and/or anabolic steroid supplements as part of a bodybuilding regimen or to improve athletic performance. While the goal is to increase muscle mass, strength and performance, some of these agents and supplements can be converted by the body into estrogen-like compounds. Additionally, supplemental androgens may suppress the normal production of natural androgens by the testes. These factors can tip the balance of androgens and estrogens in favor of the estrogens, which then stimulates the development of breast tissue and results in visible breast enlargement. This form of breast enlargement generally persists after supplement use is stopped, requiring surgical treatment.
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Types of Gynecomastia
- Pubertal or 'adolescent' gynecomastia: also called (inaccurately, by the way) 'congenital' or 'hereditary' gynecomastia. This generally appears between ages 9 and 14, and may be seen transiently in as many as 30 to 50% of boys. In some cases pubertal gynecomastia recedes with age, but about a third of patients will have breast tissue that persists into their young adulthood, and surgical excision is required for improvement. Because pubertal gynecomastia can spontaneously regress, it is our practice policy to not provide surgical treatment for this group of patients until they are at least 16 years of age, or until the breast enlargement has been present for two years without any noticeable decrease in size.
- 'Pure glandular' gynecomastia (sometimes referred to as 'puffy nipples'): this is an anatomic description of the form of gynecomastia that occurs quite commonly at puberty and in adolescents (described above), although it may occur in young adults and older adults as well. The proliferation of breast tissue is limited primarily to the area immediately behind the nipple and areola, sometimes extending a short distance beyond. This creates a conical or dome-like appearance of the nipple/areola complex. There is no associated expansion of fatty tissue in the surrounding area. In most cases this can be treated by simple excision of the retro-areolar breast tissue through a limited incision at the lower border of the areola. The resulting scar is nicely concealed in most cases by the color and texture difference between areolar skin and chest skin.
Surgical specimens from excision of bilateral pure glandular gynecomastia
- Adult (mixed glandular / adipose) gynecomastia: most cases of adult onset gynecomastia, and some cases of adolescent gynecomastia, consist of a combination of enlarged breast tissue and an accumulation of fatty tissue excess. As the condition progresses, the male breast area becomes more and more feminized in appearance. The primary surgical treatment of this, the most common kind of gynecomastia, is ultrasonic liposuction (this practice uses the VASER® device from Sound Surgical Technologies). Direct excision of breast tissue through a limited incision at the border of the areola is performed when necessary, at the completion of the ultrasonic liposuction procedure. It is important to avoid skin excision procedures whenever possible, as long as the patient is open to the concept of a two-stage approach to gynecomastia correction surgery. When the surgical treatment is staged, the procedures usually take place anywhere from six to 12 months apart.
- Pseudogynecomastia (primarily adipose tissue): this process is seen in overweight or obese individuals, where the breast enlargement is associated with a generalized increase in overall body mass and adipose tissue. While this may improve with weight loss, many men with weight gain-related breast enlargement gradually develop some element of true gynecomastia as well. The condition of being overweight or obese can increase the relative ratio of estrogens to androgens that circulate in the bloodstream, which can trigger the enlargement of actual breast tissue.
- Severe gynecomastia: when the male breast becomes significantly enlarged, it is associated with skin excess and eventually a sagging, droopy appearance. This condition requires skin removal in most cases, in addition to the removal of breast tissue and excess fat. There are a number of surgical procedures designed to treat gynecomastia with major skin excess, including circumareolar mastopexy (for moderate skin excess) to simple mastectomy with free nipple-areola grafts (for major skin excess); these procedures are described in greater detail under 'Surgical Treatment for Gynecomastia'.
More on types of gynecomastia.
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Surgical Treatment for Gynecomastia
Treatment of 'pure glandular' gynecomastia
'Pure glandular' gynecomastia ('puffy nipples') in most cases can be treated by direct tissue excision alone. There is no fatty tissue excess and no significant skin excess. The glandular breast tissue enlargement is located immediately behind the nipple and areola, and is removed through an incision placed at the inferior border of the areola. The incision can be limited, in most cases, from about the 4 o'clock to the 8 o'clock position of the areola. The color difference between areolar skin and chest skin serves to conceal this incision quite nicely for most patients. In many cases the scar is completely invisible after just a few weeks or months of healing.
Surgical specimens from excision of bilateral pure glandular gynecomastia
Treatment of 'mixed glandular / adipose' gynecomastia: mild to moderate cases
The most common form of gynecomastia ('mixed glandular / adipose') requires ultrasonic liposuction and in some cases direct breast tissue excision as well. Ultrasonic liposuction involves the use of ultrasonic energy to emulsify fat (turn it from solid to liquid) after the infiltration of tumescent solution and before the aspiration of fat. The ultrasonic energy is delivered using a solid probe that is extremely effective at breaking up the dense, fibrous breast tissue behind the nipple-areola complex. In some cases it is effective enough to eliminate the need to make an incision at the areolar border to directly remove breast tissue following ultrasonic liposuction. This practice employs the VASER® ultrasonic liposuction system developed by Sound Surgical Technologies, Inc. A specialized VASER® probe designed specifically for gynecomastia has made the device even more effective for this particular procedure.
Read DR. LAW'S PHILOSOPHY on ULTRASONIC LIPOSUCTION FOR THE TREATMENT OF GYNECOMASTIA
Whenever possible, it is preferable to avoid skin excision and the scars that result from it. If the surgery leaves obvious scars and the patient is very self-conscious about them, then the patient has merely traded one reason to never take off their shirt ("man-boobs") for another (scars that show you had surgery for your "man boobs'). In some cases this requires a staged surgical approach. In the first procedure, breast tissue is removed by ultrasonic liposuction with or without direct tissue removal - but only up to the point where a deflated or 'saggier' breast appearance is not produced. Several months are allowed to pass so that the final liposuction result can be evaluated. During this time, the skin tends to retract for two reasons: a significant portion of the distending breast and adipose tissue has been removed, and the energy produced by the ultrasonic liposuction device has stimulated further tissue and skin retraction.
Nine to 12 months later a second ultrasonic liposuction procedure is performed to further reduce breast area fullness, and an ideal masculine chest profile is achieved without the surgical scars required for skin excision. While a staged surgery may seem less convenient than a single trip to the operating room, the possibility of avoiding scars that are essentially non-concealable makes the staged surgical approach quite preferable for many patients. It is important to note here that the degree of skin retraction cannot be predicted or guaranteed, and a few patients ultimately do require some skin excision at the time of their second procedure. Other gynecomastia patients with moderate skin excess prefer a one-stage approach, and in these cases a circumareolar skin excision is performed immediately following the ultrasonic liposuction procedure which is sometimes called a 'donut mastopexy' and is described below. Chest hair helps to conceal surgical scars, and it is more often the hairy-chested patients who elect the single-stage approach that includes circumareolar mastopexy.
As much as possible, it is best to avoid incisions outside the areola (except for the very small, strategically-placed incisions used for liposuction) as such incisions are generally not well-concealed and can be a continued source of self-consciousness for male patients. Many gynecomastia patients relate that prior to being treated they have been unwilling to remove their shirts in public (and sometimes in private as well), and extensive chest area scarring typically does not improve that situation.
Treatment of 'mixed glandular / adipose' gynecomastia: moderate to severe cases
Although it is best to avoid skin excision when possible, some skin removal is absolutely required in patients with significantly droopy breast/chest skin. For treatment of moderate skin excess, one option is a circumareolar skin excision pattern which amounts to a 'donut'-shaped area of skin around the areola. This is frequently done for patients with excessively large areolas that need to be reduced in diameter. This procedure produces a circumareolar scar, meaning the scar encompasses the entire circumference of the areola. A 'purse-string' suture is used to narrow the diameter of the outer border of the skin excision site, and thus the outer edge of the surgical closure is pleated/gathered for several weeks to months postoperatively. In about half of cases the circumareolar scar is minimally noticeable and quite acceptable once the scar has fully matured (12-24 months), while about half of patients eventually return for partial or total revision of the surgical scar. Because there is much less tension on the healing scar when it is revised, the vast majority of patients undergoing circumareolar scar revision experience a significant improvement in the ultimate scar appearance.
While circumareolar skin excision allows significant gynecomastia to be treated in a single stage, it is still my personal preference to take a staged approach to treatment of these patients when it appears likely to allow that patient to avoid the scars associated with skin excision. Our pricing for the staged approach is structured so that it is not impractical compared to single stage surgical treatment. It is certainly the option I would select if I were the patient being treated. It is less convenient in the short run, certainly, and maybe slightly more expensive, but the long-term outcome provides a patient with the most natural-appearing result.
Some gynecomastia patients have a degree of breast enlargement and associated skin droopiness that requires what is essentially a 'male mastectomy'. This surgery is reserved for patients that have a very feminized and sometimes deflated breast appearance, which cannot be treated effectively with staged liposuction procedures or with skin excision limited to the immediate circumareolar area. This procedure is also used to treat men with major weight loss, including bariatric surgery patients, who have deflated-appearing breasts. The male mastectomy consists of complete surgical removal of excess breast tissue (skin, fat and glandular breast tissue), leaving a horizontal scar that extends the entire length of the sub-pectoral fold (the horizontal crease that normally exists at the bottom of the pectoral area). The tissue that is removed includes the nipple-areola complex, so the nipple-areola is removed at the beginning of the procedure and is re-applied at the end as a full-thickness skin graft. This procedure produces a masculine-appearing chest profile in a single stage, at the expense of the associated scars. Fortunately, the scars are limited to anatomic 'border zones' and thus are partially concealed by the local anatomic features: the border of the areola and the sub-pectoral crease.
'Inverted-T' breast reduction, which is the pattern used for many female breast reductions and breast lift surgeries, is not a good choice for male patients. The vertical scar between the areola and inframammary fold is acceptable for female patients as it is associated with external and internal reshaping techniques that help a surgeon to produce better breast projection - but that is certainly not what one wants to provide for a male gynecomastia patient. Additionally, the vertical scar has no anatomic feature that conceals or camouflages it, and as a result it can be the most obvious tell-tale sign that surgery has been performed.
Treatment of 'pseudogynecomastia':
Some patients have proliferation of primarily fatty breast tissue over the pectoralis major muscle, which can be effectively reduced by liposuction alone. This is commonly seen in patients who are overweight or obese. For treatment of fatty tissue excess the ideal treatment is ultrasonic liposuction, which is described above. It is important to note that in overweight or obese patients there is often some associated skin laxity and even skin excess, which can limit the degree of improvement that is possible with ultrasonic liposuction alone. Also, overweight/obese patients may gradually develop some secondary breast-tissue proliferation that is related to an underlying 'pro-estrogenic state', and therefore careful pre-operative evaluation is required as many 'pseudogynecomastia' patients actually turn out to be 'mixed adipose/glandular' gynecomastia patients and must be treated accordingly.
Even with minimal breast tissue enlargement, an enlarged areolar diameter tends to produce a feminized breast/chest appearance. For patients with an enlarged areolar diameter, an areolar reduction can be performed in addition to direct excision of breast tissue and liposuction. This requires an incision, and thus a scar, that encompasses the entire circumference of the areola. However, the scar is usually obscured fairly well by the color difference between areolar skin and the adjacent chest skin, and the reduced areolar diameter can be critical to producing a more masculine appearance of the anterior chest.
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Recovery and downtime
Surgery for pure glandular (mild) gynecomastia, usually consisting of direct excision of breast tissue directly behind the areola, is performed on an outpatient basis in the office procedure room under local anesthesia and oral sedation.
Treatment of moderate to severe gynecomastia is performed in an operating room under deep IV sedation or general anesthesia. Patients who fly in or drive more than two hours to the surgical facility stay at the surgery center overnight (if indicated for patients having multiple procedures) or at a hotel convenient to the office so that they may be evaluated in the office on the first postoperative day.
Patients wear a postoperative compression vest around-the-clock (except for bathing and garment washing) for the first two weeks following surgery, and for half the day (either daytime or nighttime) for an additional two weeks. Many patients find the garment to be quite comfortable and wear it for longer than the prescribed amount of time, as it helps to control edema (swelling) and enhances outward appearance in a snug-fitting shirt.
In some cases a surgical drain is left in place to remove fluid that may accumulate in the space where breast tissue is removed. The suction bulb that collects fluid can be concealed under clothing. The drain usually is removed within the first few days following surgery.
Most gynecomastia surgery patients take one to three days off from work, depending on the extent of their surgery. Patients with minimal, retro-areolar gynecomastia are allowed to return to vigorous physical activity about two weeks postoperatively, while patients undergoing more extensive procedures are required to wait about four to six weeks.
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Revisional ("Redo") Gynecomastia Surgery
This surgical practice has treated a number of patients who have previously undergone gynecomastia surgery and felt that their results were not ideal, and who came to this practice seeking an improvement of their chest area appearance. The most frequently encountered problems are the following:
- Liposuction only was performed, leaving behind a mass of breast tissue behind the areola.
- Over-resection of breast tissue behind the areola resulting in nipple retraction, areolar indentation/depression, or chest area surface irregularities.
- A deflated appearance from excessive tissue removal.
- Unfavorable scarring from skin excision procedures.
It is obviously a very difficult and frustrating experience for a man to seek surgical improvement of a problem area that keeps them from being comfortable without a shirt on, and to end up with a post-surgical problem that leaves them with the same situation. The good news is that essentially all unfavorable results from prior gynecomastia surgery can be improved with careful preoperative evaluation and re-operative treatment planning.
The improvement of unfavorable results may require any number of surgical techniques including additional adipose and/or breast tissue removal, replacement of tissue using structural fat grafting and/or dermal-fat grafts, revision of scars, and removal of excess skin. While in some cases there are inherent limitations to the degree of improvement that is possible, most problems can be improved dramatically and some can be completely corrected.
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Gynecomastia and Health Insurance
The unfortunate reality is that most health insurers view gynecomastia as a cosmetic issue, and therefore do not provide benefits for its treatment. Ideally, this would be a covered service in most health insurance plans. It is a medical condition that is essentially the same kind of physiologic process as a benign tumor, and the removal of benign tumors in other parts of the body are usually covered services under most health plans. A reasonable person would, it seems, see the abnormal proliferation of male breast tissue as a medical problem deserving of treatment. Unfortunately, health insurers don't use the 'reasonable person' standard in their decision-making about insurance policy benefits.
This practice does not participate with any health insurance plans, so the surgical treatment of gynecomastia is paid for by the patient. In some cases it may be possible for your gynecomastia surgery expenses to count against your annual deductible. Contact your insurer if you are interested in determining whether or not your health insurance policy covers the treatment of gynecomastia. If you are one of the fortunate few, the cost of your treatment in this practice may be partially covered - but only if you have out-of network benefits, as this practice is not a participating provider for any health insurance plans. If you have in-network benefits only, you should ask your insurer for a list of participating providers in your area.
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Content updated 01.10.11