Medical Term: Gynecomastia

There are many causes of gynecomastia. In the majority of cases, it is a benign condition with no etiologic factor. Natural hormone changes during puberty and as an adult may cause increased amounts of breast tissue, especially in men who are overweight. Massive weight loss patients, or patients who have had major weight fluctuations may present with excess breast tissue and excess skin of the breasts. A number of medications can cause gynecomastia. These include: steroids, prostate medication, certain antidepressants, Valium, certain antibiotics, ulcer medication, and heart medication. Drugs and alcohol can also cause gynecomastia. Other causes are related to health conditions that affect the normal balance of hormones. Whatever the cause, breast tissue fullness in men can be undesirable, as it interferes with the fit of shirts and causes distress in social situations. Patients wear loose clothing and often avoid exposure in showers and swimming pools. Certain individuals are reticent to participate in any athletic activity that may directly or inadvertently require removal of one's shirt, exposing the chest. Poor posture may result from slouching in an attempt to hide the condition.

Ideally, cessation of any possible etiologic factor should be performed followed by a complete medical evaluation and breast exam, especially if the condition is more recent or sudden in onset. The majority of patients that present with gynecomastia to Desert Hills Plastic Surgery have long-standing breast fullness since puberty, with mild size changes associated with weight fluctuation. Often, patients report a genetic factor, where other male family members have a similar physique.

There are different types of gynecomastia. It is usually fairly symmetric and the tissue itself may have a fatty component or dense breast tissue component. The skin can be firm and tight, or loose, redundant, and saggy. The treatment recommended depends on individual’s characteristics. Ideally in men who have a mostly fatty tissue component to their breasts with normal overlying skin tone, a liposuction procedure is advised. With this approach, visible scars are avoided, and the fatty breast tissue is extracted. In men with good overlying skin tone, skin retraction occurs so that excision of skin is unnecessary. Dr. Brown prefers a technique called Ultrasonic Assisted Liposuction in order extract the breast tissue effectively and aggressively. During this process, naturally dense male breast tissue is liquefied, so that it can be extracted easily. In patients with more of a dense breast tissue component, which may be well localized behind the nipple/areola, a surgical excision may be performed through an incision around the areola to remove this firm mass of breast tissue. In men with a redundant skin envelope, varying degrees of skin tightening and resection may be required, however scars are the trade-off from this maneuver. Dr. Brown advises liposuction as a first line of treatment, avoiding visible scars on a man’s chest. Natural skin retraction after ultrasonic liposuction can sometimes be remarkable. Secondary skin tightening can always be performed as a secondary procedure if necessary, if loose or redundant breast skin remains an issue.

Who is a Candidate?

• Healthy men with fullness of the breasts or chest area, which can be a result of genetic disposition, history of obesity, or from certain medications
• Men who have experienced fat accumulation in this area which is resistant to diet and exercise, or individuals who have experienced major weight fluctuations over the years which subsequently increased breast fullness
• Men who have had breast fullness since puberty
• Men who have experienced gynecomastia from the normal aging process

Goal of Surgery:

• To decrease the size of the breast, create flatter and more masculine contours

Procedure Description:

• Ultrasonic liposuction works well to reduce the fatty component of the breast. Two small (1/4 inch) incisions are made for access along natural creases, and the scars fade to be generally inconspicuous. The best candidates for this preferred approach have good skin tone, a soft consistency to the breast tissue and minimal skin redundancy
• For patients with firm and well-localized breast tissue under the nipple-areola, a direct excision approach may be required, with a small incision that hides well around the areola
• General anesthesia is used, and men often add liposuction of the abdomen and flanks at the same time to improve the contour of the entire trunk with no additional recovery time

Postoperative Course:

• Bruising and swelling is to be expected and takes weeks to resolve
• A compression garment is worn underneath your clothes for 6 weeks to keep swelling to a minimum
• 80 % of the swelling is resolved by 6 weeks; the remaining 20 % may take 4-6 months to resolve
• Expect temporary sensation changes and firmness of the treated area from residual swelling and scar tissue. It takes roughly 4-6 months for scar tissue to resolve and to appreciate maximal effect of skin retraction
• Sutures come out in a week
• No exercise for 3 weeks, then gradual resumption of fitness activities as tolerated
• Most patients take 1 week off of work
• Discomfort is well controlled with oral pain medication
• Appearance changes can occur over time from weight gain, aging, or continued usage of medications that can contribute to gynecomastia.

Results of liposuction for gynecomastia can be variable, based on many individual characteristics, but are always appreciated. Reasons for the variability in surgical results include: the ease of extraction of the breast tissue at the time of the procedure, the relative amount of fatty tissue to denser breast tissue in the gland, overlying skin tone and subsequent skin retraction, prominence of the areola, and definition of underlying pectoralis major muscles. Men with well-developed and large pectoralis chest muscles may have persistent breast/chest fullness based on underlying musculoskeletal anatomy. Some men will be completely flat after the procedure; others may have mild persistent fullness. Dr. Brown ensures that your liposuction procedure is done in a safe manner and as aggressively as possible while preserving a uniformly smooth subcutaneous layer under the skin to avoid contour irregularities.

For patients with severe skin excess and breast sagging, a skin tightening procedure may be required. For mild cases, skin can be removed and tightened by the excision of a “donut” of skin from around the outer border of the areola. A permanent scar around the areola would result. For moderate cases, the addition of a vertical or horizontally oriented skin excision is performed with additional scarring down the lower half of the breast or horizontally coursing toward the lateral trunk. In cases of severe skin excess, as typically seen in massive weight loss patients, skin tightening is required in all dimensions, and permanent scars would result in the configuration of an anchor: around the nipple, down the lower half of the breast and along the inferior breast fold toward the lateral trunk and back.

Patients consult with Dr. Brown to request treatment for gynecomastia to enhance psychological and physical wellbeing. These patients seek treatment because they find that the condition, which is readily apparent in everyday life, adversely impacts day-to-day activities under various circumstances. The confidence a patient gains after surgery becomes a life-changing event.