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Gynecomastia, or male breast enlargement, is an increasingly common reason that male patients schedule consultation in our practice. Gynecomastia may occur on one or both sides of the chest, may be localized primarily behind the nipple and areola or involve the entire pectoral area, and may arise in the teen years or in retirement years. As the manifestations of gynecomastia vary significantly from patient to patient, the surgical treatment must be carefully individualized.
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 a few individuals the breast tissue proliferation will persist and in some cases even continue.
For the majority of patients with gynecomastia, no clear causative factor can be identified. However, because this phenomenon may be associated with endocrine (hormone) disorders, testicular tumors, and the use of some medications/drugs, a careful medical evaluation is an absolute necessity prior to surgical treatment.
Over the past two to three years I have evaluated and treated a number of male patients who developed gynecomastia after using 'prohormone' and steroid supplements as part of a bodybuilding regimen. These agents are known to increase estrogen activity in some individuals, which may stimulate the proliferation of breast tissue and result in visible breast enlargement. The breast enlargement generally persists after the cessation of supplement use, requiring surgical treatment.
Patient evaluation, treatment planning and surgical management are carried out with complete discretion in this practice. Some gynecomastia breast surgery patients have related that prior to scheduling an appointment, they were concerned about 'feeling awkward' while sitting in a plastic surgeon's waiting room before their consultation. Because we are 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.
The Surgical Options
Gynecomastia may be treated surgically by direct excision (removal) of breast tissue, liposuction, and in some cases by removal of breast skin, when indicated. The majority of patients have at least some degree of glandular tissue proliferation immediately behind the nipple and areola, which is usually removed through an incision placed at the inferior border of the areola. The incision can be limited, in many 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 nicely for most patients.
Some patients have proliferation of primarily fatty breast tissue over the pectoralis major muscle, which can be effectively reduced by liposuction. In many of these cases there is actually little glandular breast tissue present, and this situation is sometimes referred to as "pseudogynecomastia". For the majority of liposuction procedures, whether involving the chest/breast area or other sites, I perform power-assisted liposuction. The surgical device involves an electrically-driven handpiece that pistons a modified liposuction cannula several thousand times per minute, enhancing the efficiency of fat removal.
The power-assist handpiece turns an 'elbow grease' operation into a sculpting and finesse operation. For patients with densely fibrous breast tissue, and for planned 'second stage' liposuction procedures for gynecomastia, I generally prefer to use an ultrasonic liposuction device. Ultrasonic liposuction uses heat energy to emulsify (liquefy) fat, allowing removal of fatty tissue that may not be extractable by suction alone, and is also highly effective in assisting the passage of the cannula through densely fibrous areas.
Areolar reduction and breast reduction
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, 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, and the reduced areolar diameter is critical to producing a more masculine appearance of the anterior chest. A peri-areolar incision is also useful for removing excess breast skin, with or without an enlarged areola, in cases where the skin excess is not severe.
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 for male patients. Many gynecomastia breast surgery patients relate that prior to being treated they have been unwilling to remove their shirts in public (and some in private as well), and extensive chest area scarring typically does not improve that situation.
With the goal of limiting the need for surgical scars in mind, I not infrequently will stage gynecomastia breast surgery, with the initial procedure designed to remove as much breast tissue as possible, primarily by liposuction, without 'deflating' the breasts. The second procedure, performed several months later, is designed to remove additional tissue, usually by means of ultrasonic liposuction, after the breast/chest skin has had time to contract. While a staged surgery may seem less convenient than a single trip to the O.R., the possibility of avoiding scars that are essentially non-concealable makes the staged surgery preferable in many of these cases.
A few gynecomastia patients have a degree of breast enlargement that requires what is essentially a 'male breast reduction', using the standard 'inverted-T' pattern of breast reduction incisions/scars. This surgery is reserved for patients that have very feminized appearing breasts including significant skin excess, who can not be treated effectively with staged liposuction procedures, or with skin excision limited to the immediate peri-areolar area.
Recovery and downtime
Breast 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 postoperative day.
I have 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.
Most gynecomastia breast 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 weeks.
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