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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.
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.
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.
Surgical Treatment for Gynecomastia: The Details
Treatment of Type 1 Patients: PUBERTAL GYNECOMASTIA
Patients with “Pubertal’ or ‘Pure glandular’ gynecomastia (‘puffy nipples’) generally have no fatty tissue excess and no significant skin excess. This form of gynecomastia can be treated by direct surgical excision alone. This is performed in the O.R. under IV sedation.
Surgical specimens from excision of bilateral pure glandular gynecomastia.
The glandular breast tissue enlargement is located immediately behind the nipple and areola, and the tissue is removed through an incision placed at the inferior border of the areola from about the 4 o’clock to the 8 o’clock position. 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.
A small amount of fibrous breast tissue must be left on the posterior surface of the areola to reduce the likelihood of areolar retraction or indentation as the surgical site heals. Otherwise, the areola may scar down to the pectoralis muscle and create an unnatural appearance.
In a few cases there may be a proliferation of scar tissue and/or a mild recurrence of fibrous breast tissue, which lives a slight residual fullness behind the areola once the area has completely healed. While in many cases this will resolve with time and massage, a minority of patients require a secondary procedure to reduce this slight fullness at about nine to twelve months postop. This is performed as a minor office procedure under local anesthesia.
Treatment of Type 2 Patients: MILD TO MODERATE ‘MIXED’ GYNECOMASTIA / GOOD SKIN TONE
The treatment of mixed gynecomastia (excess fibrous and fatty breast tissue) requires both liposuction to reduce the fatty tissue excess and direct excision to remove the fibrous breast tissue. The liposuction procedure is performed first, and as the excess fatty tissue is removed, the fibrous breast tissue is ‘skeletonized’, making it easier to remove through an incision at the areolar border. I perform this procedure in the O.R. under deep IV sedation or general anesthesia.
I believe that the form of liposuction that is the most efficient at fat removal, the safest for the patient, and the best able to produce smooth and natural-appearing soft tissue contours is a form of power-assisted liposuction sometimes referred to as ‘SAFE’ liposuction. This acronym describes a three-phase process of:
- Fat Equalization
The power-assisted liposuction device (MicroAire PAL System) is an electric handpiece that pistons the end of the liposuction cannula (the hollow, narrow, metal tube through which fat is aspirated) a distance of a few millimeters several hundred times per minute. This allows the cannula to pass more easily through fibrous tissue, and it enhances the efficiency of fat removal. It allows me to expend less energy and effort in mobilizing and removing excess tissue, and to focus more energy and effort on the sculptural process of body contouring.
The SAFE liposuction technique employs ‘flared’ cannula in phases 1 and 3 of the liposuction process. At the end of these cannulas where the holes are located, the walls of the cannula flare outward. This makes flared cannulas very aggressive in terms of mobilizing fibrous and fatty tissue. The flared cannulas are used with the aspirator (suction device) turned off for phase 1 (Separation). Fat and fibrous tissue is separated and mobilized for subsequent removal by aspiration.
Phase 2 (Aspiration) is fat removal which is performed with non-flared cannulas, which are less aggressive, and with the aspirator turned on. Upon completion of excess fat removal, Phase 3 (Fat Equalization) is performed with flared cannulas and with the aspirator once again turned off. The remaining fat is redistributed, ensuring that the smoothest possible soft tissue contour is produced.
Liposuction incision location is important. In patients with little or no chest-area hair, incisions made peripheral to the nipple-areola complex will in most cases leave obvious, tell-tale scars which make it obvious that surgery has been performed. If you look at lots of ‘before and after’ photos online, you will often see scars in the subpectoral fold area (the crease at the bottom on the pectoral area), and/or in the lateral chest in front of and below the underarm. These scars are in most cases completely avoidable.
I make liposuction incisions at the areolar border, where the color and consistency difference between areolar skin and chest skin completely conceals the scar in most cases. I only make incisions outside the areolar border when they can be placed in areas that have hair-bearing skin to conceal the scars. In patients with hairy chests, one can safely be more liberal with incision placement.
Once liposuction is completed, the incisions made for liposuction at the 4 and 8 o’clock positions are joined to create a continuous incision along the lower border of the areola. The fibrous breast tissue which cannot be removed by liposuction is directly excised through this incision.
In some cases a drain is left in place for a few days to evacuate fluid from the space where breast tissue has been removed. If present, the drains exit the skin through hair-bearing skin at the lower end of the underarm area, so that if the exit site leaves a small scar it is concealed by hair-bearing skin.
Treatment of Type 3 Patients: MODERATE ‘MIXED’ GYNECOMASTIA / SOME SKIN LAXITY SEVERE ‘MIXED’ GYNECOMASTIA / GOOD SKIN TONE
In treating gynecomastia patients, I do everything possible to avoid skin excision and the scars that result it. If your gynecomastia surgery leaves you with obvious scars, then you have traded one reason to never take off your shirt (your ‘man-boobs’) for another reason (the scars that show you had surgery for ‘man-boobs’).
Many patients that I treat have too much breast tissue to remove in a single operation without also removing breast skin. Complete or near-complete removal of excess fibrous and fatty breast tissue would result in a ‘deflated’ appearance which looks worse that gynecomastia – it looks like bad surgery.
However, if the breast skin is not too droopy, most of these patient can be treated in a staged fashion and achieve an aesthetically ideal or at least vastly improved chest appearance with the same set of invisible or nearly-invisible scars that result from one-stage surgery of Type 2 gynecomastia patients.
The first of the two surgeries is the same as what is described above for Type 2 patients, but the tissue removal by first liposuction and then by direct excision is limited to an amount that is not likely to create a droopy or ‘deflated’ appearance. Several months are allowed to pass, and during this time the skin of the breast area will contract in most cases as it is less distended by breast and fatty tissue excess.
A second, similar procedure is performed eight to twelve months later, once maximum skin retraction and resolution of all minor residual postoperative swelling has been observed. In most patients an ideal and masculine chest appearance can be achieved without the need for skin excision and the resulting surgical scars.
Staged surgery is perhaps less convenient than a single trip to the O.R., but the opportunity to avoid scars that are essentially not concealable out of a shirt makes the staged approach quite preferable for many patients. When evaluating a gynecomastia patient, I always think to myself “What would I want if I were this patient”? I am certain that if I had the opportunity to dramatically improve my appearance without obvious surgical scars, I would without question choose that option.
It is important to make it clear that the degree of skin retraction which occurs following stage 1 and stage 2 cannot be completely predicted or guaranteed. Although it is a minority of patients treated by the staged approach, some ultimately do require skin excision at the time of their second procedure. This may be limited to an ellipse of skin at the subpectoral fold, but in rare instances it may mean total excision of skin and breast tissue excess with nipple-areola complex full-thickness skin grafting, as described for Type 4 patients below.
Some surgeons advocate a one-stage approach to these Type 3 patients, which involves a circumareolar skin excision immediately following the liposuction/direct tissue excision procedure. This is sometimes called a ‘donut mastopexy’, a technique that is also used (and which is also problematic for) female breast lift surgery. In my experience the circumareolar scar (which extends around the entire areolar border) tends to heal in a thickened and very irregular manner, and it often enlarges and distorts the shape of the normally circular areola. This creates a very obvious outward sign that gynecomastia surgery had been performed, and for that reason I think this approach should be avoided.
Treatment of Type 4 Patients: SIGNIFICANT SKIN LAXITY / DROOPY BREAST-AREA APPEARANCE
If you have very droopy breast-area skin, as often results from severe gynecomastia and which also can occur with major weight loss, then the best alternative is to completely remove the skin and breast tissue/adipose tissue excess. I refer to this as ‘total excision of gynecomastia’, and this surgery has the advantage of instantly creating an ideal chest contour – at the expense of the surgical scars that are required.
This operation removes all of the tissue excess and leaves a horizontally-oriented scar in the area of the subpectoral fold, the natural crease at the bottom of the male breast area. The nipple-areola complexes are taken off as skin grafts, of an aesthetically ideal diameter, at the beginning of the surgery. After breast excision is complete and the incision is closed, the nipple-areola complexes are placed back on the chest as full-thickness skin grafts. Location is carefully determined with the patient brought into an upright sitting position on the O.R. table (still under anesthesia).
This procedure is sometimes referred to as ‘total mastectomy’ or ‘male mastectomy’. In patients with hairy chests, the scars are relatively concealed as they are healing, and many return to shirtless activity at a pool or at the beach within a few weeks of surgery (although bear in mind that it is important to limit scar exposure to the sun during the first year after surgery).
For patients with limited chest hair or no chest hair, the scars will be much more noticeable and may take up to 24 months (or more) to fade considerably. Regardless of hair pattern, active and persistent scar treatment is critical to ensuring patients that they get the best possible long-term scar appearance. This includes the use of topical silicone gel creams and/or adhesive patches, scar massage and monthly laser treatments. In my practice we use a vascular laser called the V-beam, with treatments provided at no additional cost to the patient.
Procedures to avoid:
An operation widely used for female breast reduction is the ‘Inverted-T’ breast reduction, which creates a pattern of scars that is also used for some female breast lifts. This operation, and the resulting pattern of scars, 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 breast projection 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 is the most obvious tell-tale sign that surgery has been performed.
Treatment of ‘pseudogynecomastia’:
Some cases of gynecomastia consist primarily of fatty tissue, with little to no proliferation of excess fibrous breast tissue. This is commonly seen in stocky men and in obese patients, and can be effectively treated by liposuction alone – either in one stage or two depending of the amount of skin laxity that is present.
Some overweight patients may gradually develop a secondary proliferation of breast tissue that is related to an underlying ‘pro-estrogenic state’ as excess fat has the capacity to convert some androgens (male sex hormones) in to estrogens. A careful pre-operative evaluation is important as many patients with apparent ‘pseudogynecomastia’ actually turn out to be ‘mixed’ gynecomastia patients, with excess fibrous breast tissue in addition to excess fatty tissue. In these patients the direct excision of fibrous breast tissue is also required to restore an aesthetically ideal chest contour.
Areolar diameter reduction
A large areolar diameter creates a feminized appearance, regardless of the degree of overall breast enlargement. Removal of excess fibrous breast tissue and/or excess fatty tissue almost always results in some reduction of areolar diameter, without any removal of areolar skin. For that reason I always wait to see what degree of areolar reduction occurs in Type 1, 2, and 3 patients who are treated by direct tissue excision and/or liposuction.
It is also very common for areolas to appear darker postop, as the areolar pigmentation is now spread over a smaller surface area.
For the minority of patients who have a persistently large areolar diameter, areolar reduction can be accomplished by concentric excision of the most peripheral areolar tissue. A purse-string suture is used to ‘cinch down’ the outer margin of the circular skin excision, and to fine-tune and control the resulting postoperative areolar diameter. The resulting scar is usually very faint and sometimes close to invisible (unlike ‘circumareolar mastopexy’ scars which remove skin beyond the pigmented areola and which are closed under great tension). The color difference and skin consistency difference between areolar skin and the surrounding chest skin serves to conceal the majority of this surgical scar in most cases.
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.
Revisional (“Redo”) Gynecomastia Surgery
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