Surgical Treatment for Gynecomasia
Treatment of ‘pure glandular’ gynecomastia
‘Pure glandular’ gynecomastia (puffy nipples) can usually be treated by direct tissue excision alone. This type of treatment does not involve fatty tissue excess or significant skin excess. The glandular breast tissue proliferation 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 conceals this type of incision quite nicely for most patients.
>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. I believe that ultrasonic liposuction is without question the ideal approach to the majority of gynecomastia cases. 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. For this procedure, I use the VASER ultrasonic liposuction system produced by Sound Surgical Technologies Inc. VASER is a specialized probe developed specifically for gynecomastia.
Ultrasonic liposuction is often effective enough to eliminate the need to make an incision at the areolar border to directly remove breast tissue. This treatment method also appears to produce a degree of desirable skin retraction that is generally not seen with conventional liposuction techniques. This allows some patients who formerly would have required skin excision to be treated with a more limited and less invasive approach.
Whenever possible, I attempt to avoid skin excision due to scarring associated with this type of procedure. If the surgery leaves extensive scars, and the patient is very self-conscious about them, then the patient has merely traded one reason to never take off his shirt (‘man boobs’) for another (scars that show he had surgery for his ‘man boobs’). For that reason, I have treated a large number of patients by means of 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: much of the distending breast and adipose tissue has been removed, and the ultrasonic liposuction energy has stimulated further tissue and skin retraction.
Nine to 12 months later a second ultrasonic liposuction procedure is performed to further reduce the breasts, and in most cases a masculine chest profile is achieved without the surgical scars that result from 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 surgery quite appealing to most patients.
It is important to note 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, usually with moderate skin excess, prefer a one-stage approach, and in these cases I add a circumareolar skin excision, sometimes called a ‘donut mastopexy’ (described below) at the end of the procedure. Chest hair helps conceal surgical scars; therefore, patients with hairy chests are more likely to elect the single-stage approach, which includes circumareolar mastopexy.
Whenever possible, I avoid making 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. Many gynecomastia patients relate that prior to being treated they have been unwilling to remove their shirts in public (and some even in private), and extensive chest scarring typically does not improve the situation.
Treatment of ‘mixed glandular/adipose’ gynecomastia: moderate to severe cases
Although I prefer to avoid skin excision whenever possible, some skin removal is required in patients with significantly droopy breast/chest skin. For treatment of moderate skin excess, I strongly prefer a circumareolar skin excision pattern, which involves a ‘donut’-shaped area of skin around the areola. 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 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 the other 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 circumareolar scar revision patients experience a significant improvement in ultimate scar appearance.
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 who have a much-feminized and sometimes deflated breast appearance, which cannot be treated effectively with staged liposuction procedures or with skin excision limited to the immediate periareolar area. This procedure is also used to treat men following major weight loss, including bariatric surgery patients who have deflated breasts. The male mastectomy consists of complete surgical removal of excess breast tissue (skin, fat and glandular tissue), leaving a horizontal scar that extends the entire length of the sub-pectoral fold, which is 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 price 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 lifts, is in my opinion an inappropriate choice for male patients. The vertical scar is used with female patients because it is associated with internal reshaping techniques that help produce better breast projection, which is the least desirable outcome for a male gynecomastia patient. Additionally, the vertical scar is not concealed or camouflaged by an anatomic feature, and as a result it is the most obvious tell-tale sign that surgery has been performed.
Treatment of ‘pseudogynecomastia’
Some patients suffer from 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. For treatment of fatty tissue excess alone, I prefer ultrasonic liposuction (described above). It is important to note that in overweight patients there is often some associated skin laxity and even skin excess, which can limit the degree of a complete improvement. Also, overweight/obese patients may gradually develop some secondary breast-tissue proliferation that is related to an underlying ‘pro-estrogenic state’; therefore, careful pre-operative evaluation is required as many ‘pseudogynecomastia’ patients gradually become ‘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 appearance. For patients with an enlarged areolar diameter, I perform an areolar reduction 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. The reduced areolar diameter is critical to producing a more masculine appearance of the anterior chest. A periareolar incision is also useful for removing excess breast skin, with or without an enlarged areola, in cases where the skin excess is not severe.
Recovery and downtime
Surgery for gynecomastia is performed on an outpatient basis under general anesthesia. Patients who fly in or drive more than two hours to the surgical facility stay in the hospital overnight or at a hotel convenient to the office so that they may be evaluated on the first day following surgery.
I ask all my gynecomastia patients to 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.
Most gynecomastia surgery patients take one to three days off work, depending on the extent of their surgery. Patients who undergo the less invasive, retro-areolar gynecomastia surgery are allowed to return to vigorous physical activity about two weeks later, while patients undergoing more extensive procedures are required to wait for at least four weeks.