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Gynecomastia ( Enlargement of Male Breast Tissue)

Gynecomastia is a benign enlargement or excess of male breast tissue, and male breast reduction surgery is the procedure to correct it. Gynecomastia affects 40 to 60 percent of all men to some degree. It involves developing an excess amount of glandular tissue or fatty tissue in the breast area. There are many possible causes of gynecomastia but the exact cause of gynecomastia is still unknown.

During puberty, a temporary excess amount of glandular breast tissue can develop in young boys. This is normal and generally disappears within a few months to a year. Gynecomastia is most frequently idiopathic but also can be caused by steroid abuse, obesity, excessive marijuana or alcohol consumption, tumors, genetic disorders, chromosomal abnormalities, chronic liver disease, castration, and medication side effects. There are a variety of types of medication that may cause gynecomastia in men.

In adolescents presenting with breast buds that are not significantly enlarged, gynecomastia is frequently temporary, but it can turn into permanent condition in adulthood. In Bodybuilders, gynecomastia is generally the result of anabolic steroid use or the ingestion of over-the-counter hormones. In most cases, gynecomastia in bodybuilders becomes permanent, lasting beyond the cessation of steroid use.

What is gynecomastia?

Gynecomastia is enlargement of the male breast gland tissue. During infancy, puberty, and in middle-aged to older men, gynecomastia is common. Gynecomastia must be distinguished from pseudo-gynecomastia, which refers to the presence of fatty deposits in the breast area of obese men. True gynecomastia results from over growth of the glandular, or breast tissue, which is present in very small amounts in men.

What causes gynecomastia?

Gynecomastia results from an imbalance in hormone levels of estrogen (female hormones) which are increased relative to levels of androgens (male hormones). Gynecomastia that occurs in infant and pubertal boys, that resolves on its own with time, is known as physiologic gynecomastia.

What medical conditions can result in gynecomastia?

Malnutrition has been shown to create a hormonal environment that may lead to gynecomastia. Similarly, cirrhosis of the liver alters normal hormone metabolism and may lead to gynecomastia.

Disorders of the male sex organs (testes) can result in decreased testosterone production and relatively high estrogen levels, leading to gynecomastia. These disorders may be genetic, such as Klinefelter's syndrome, or acquired due to trauma, infection, reduced blood flow, or aging. Testicular cancers may also secrete hormones that cause gynecomastia. Other conditions that are associated with an altered hormonal environment in the body and may be associated with gynecomastia are chronic renal failure and hyperthyroidism. Rarely, cancers other than testicular tumors may produce hormones that can cause gynecomastia.

Gynecomastia can also be a side effect of a number of medications. Examples of drugs that can be associated with gynecomastia are listed below:

Spironolactone (Aldactone), a diuretic that has anti-androgenic activity
Calcium channel blockers used for treatment of hypertension such as nifedipine (Procardia) and others
ACE inhibitor drugs for hypertension captopril (Capoten), enalapril (Vasotec)
Some antibiotics for example, isoniazid, ketoconazole (Nizoral, Extina, Xolegel, Kuric), and metronidazole (Flagyl)
Anti-ulcer drugs such as ranitidine (Zantac), cimetidine (Tagamet), and omeprazole (Prilosec)
Anti-androgen or estrogen therapies for prostate cancer
Methyldopa (Aldomet)
Highly active anti-retroviral therapy (HAART) for HIV disease, which may cause fat redistribution leading to Pseudogynecomastia or, in some cases, true gynecomastia;
Omega fatty acids: Causes excessive bleeding peri-operatively.
Digitoxin
Diazepam (Valium)
Drugs of abuse (for example, alcohol, marijuana, heroin)
Lavender oil and tea tree oil, when used in skin-care products, have been associated with gynecomastia.

What are the risk factors for gynecomastia?

Normal pubertal males may be at risk for gynecomastia which is part of the normal developmental process. Other risk factors include aging, due to a decrease in testosterone production, can cause gynecomastia. The risk factors for developing gynecomastia related to specific diseases and conditions (such as cirrhosis of the liver) are the same risk factors that predispose males to those conditions. Taking certain medications (see above) may increase the risk of developing gynecomastia.

What are the symptoms of gynecomastia?

The primary symptom of gynecomastia is enlargement of the male breasts. As mentioned before, gynecomastia is the enlargement of glandular tissue rather than fatty tissue. It is typically symmetrical in location with regard to the nipple and may have a rubbery or firm feel. Gynecomastia usually occurs on both sides but it can be unilateral in some instances. The enlargement may be greater on one side even if both sides are involved. Tenderness and sensitivity may be present, although there is typically no severe pain.

The most important distinction with gynecomastia is differentiation from male breast cancer, which accounts for about 1% of overall cases of breast cancer. Cancer is usually confined to one side, is not necessarily centered around the nipple, feels hard or firm, and can be associated with dimpling of the skin, retraction of the nipple, nipple discharge, and enlargement of the underarm (axillary) lymph nodes.

How is gynecomastia diagnosed?

In most cases, gynecomastia can be diagnosed by a physical examination. A careful medical history is very important, including medication and drug use. If there is a suspicion of cancer, a mammogram is needed. Further tests may be recommended to help establish the cause of gynecomastia in certain cases. These can include blood tests to examine liver, kidney, and thyroid function. Measurement of hormone levels in the bloodstream may also be recommended in some cases.

What is the treatment for gynecomastia plastic surgery?

Gynecomastia, especially in pubertal males, often goes away on its own within about six months, so observation is preferred over specific treatment in many cases. Stopping any offending medications and treatment of underlying medical conditions that cause gynecomastia are also mainstays of treatment.

Treatments are also available to specifically address the problem of gynecomastia, but data on their effectiveness are limited, and no drugs have yet been approved by the U.S. Food and Drug Administration (FDA) for treatment of gynecomastia. Medications are more effective in reducing gynecomastia in the early stages, since scarring often occurs after about 12 months. After the tissue has become scarred, medications are not likely to be effective, and surgical removal is the only possible treatment.

Medications that have been used to treat gynecomastia include:

1. Testosterone replacement has been effective in older men with low levels of testosterone, but it is not effective for men who have normal levels of the male hormone.

2. The selective estrogen receptor modulators (SERMs) tamoxifen (Nolvadex) and raloxifene (Evista) have been shown to reduce breast volume in gynecomastia, although they are not able to entirely eliminate all the breast tissue. This type of therapy is most often used for severe or painful gynecomastia.

3. Aromatase inhibitors [such as anastrozole (Arimidex)] are a class of medication that interferes with the synthesis of estrogen. While these drugs theoretically should be able to reduce breast mass in gynecomastia, studies have failed to show a significant benefit in treating gynecomastia.

What are the complications of gynecomastia cosmetic surgery?

Although pubertal gynecomastia typically regresses on its own, in rare cases it may persist, requiring treatment. Gynecomastia that is present over the long term (12 months or more) may undergo scarring (medically termed fibrosis), making treatment with medications much more difficult if not impossible to achieve a response. Psychological consequences can occur if the breast enlargement is pronounced or is a source of embarrassment.

Treating gynecomastia through liposuction

There are lots of guys who think that treating gynecomastia through liposuction is something embarrassing to go through. This is because they feel that undergoing such procedure is not manly. However, these same guys realize that having abnormal breast is more embarrassing than submitting themselves to gynecomastia liposuction.

In the US, around fifteen percent of males prefer male liposuction. It only shows that men of today’s generation have become aware that they too can enjoy the benefit of liposuction. Gynecomastia liposuction is the most preferred procedure to cure gynecomastia. It can improve the looks of male breasts by eliminating excess fat on the breast without damaging other surrounding muscles and skin.

One of the advantages of gynecomastia liposuction is that it can prevent gynecomastia from coming back one day. Gynecomastia liposuction procedure is normally executed using general anesthesia. The process starts with general anesthesia induction and then an injection of a local anesthetic into the breasts itself to apply anesthesia into strong glandular breast tissue. Smaller cannulas are used which can penetrate easily into dense breast tissue compared to larger cannulas.

Pseudo-gynecomastia is defined as unusual growth of male breasts due to an extreme amount of fat in a normal quantity of glandular tissue. This condition is common in young oversized male adults. On the other hand, true gynecomastia is defined as abnormal growth of male breasts due to too much glandular breast tissue. In the case of pseudo gynecomastia, liposuction can be the best treatment to use. However, it is not the right treatment for true gynecomastia because in this case the condition of the breast tissue is denser and more fibrous and thus difficult to be infiltrated and removed with a usual liposuction cannula, therefore surgical excision of thick glandular tissue is recommended.

How can it be normal for men to develop breasts?

The male chest has muscle, fat, and even little buds of breast tissue. In fact, if one were to squeeze a newborn baby’s nipples (even a boy), a couple of drops of milk can come out due to stimulation of the tissue by his mother’s hormones. Some amount of breast tissue is normally found in all males and females. The difference is that the estrogen surge during female puberty causes it to grow into a full-fledged breast.

Even the raging levels of testosterone during puberty are always accompanied by an increase in the level of estrogen in every male. That is because testosterone production is not a perfect process; when the body makes a large amount of testosterone, some estrogen is also made. Likewise, even the most feminine women produce some testosterone.

Testosterone is also converted into estrogen by fatty tissues, thereby increasing the growth of the breast buds on top of the additional chest fat seen in overweight young men.

Adolescent boys in particular are embarrassed by it, as they perceive the development of male breasts as some kind of sign that they are somehow “less male.” But the contrary is true! The fact that weightlifters taking testosterone often develop gynecomastia is proof that this is related to maleness, not the lack thereof.

It is said that 90% of boys develop some degree of male chest enlargement during puberty. That means that it is actually more normal to get it than not to get it. Usually it subsides as men enter their twenties, but for at least a quarter of them, some degree of breast enlargement persists. It can persist in any man, even the thin, healthy, and fit, but it is more common in boys and men who are or who have been overweight. Anabolic steroid use in weightlifters can also increase gynecomastia, as can heavy marijuana use. There is also a long list of prescription drugs that can cause chest enlargement in males.

That being said, the majority of male chest enlargement patients have no identifiable cause. The bottom line is that it is so common that it is really a variation of normal and should not be considered abnormal. I emphasize this point because gynecomastia patients tend to be very private and embarrassed about their condition; one of my goals, beyond just treating my own gynecomastia patients, is to try to change men’s perception of this condition in general so that we create a climate in which men suffer less embarrassment.

Psychology of gynecomastia in plastic surgery

Like starting to shave, the lowering of one’s voice, or developing an Adam’s Apple, a flat and strong looking chest is seen as a sign of masculinity. It is humiliating to have a chest that looks even the slightest feminine. Many women seek breast augmentation because they say, “I look like a boy and just want to feel feminine” though men never make the opposite statement – probably because the words are too hard to say – it is probably in the back of their minds. As shy as some flat-chested women are about men seeing their chest naked, they tend not to have the same level of shame or humiliation, as do men with gynecomastia. It is very common that even men with the mildest forms of male chest enlargement never want to take their shirt off, wear loose clothes over a tight undershirt, and spend time in front of a mirror pushing their chest back to make it look flatter.

Men are also much more hesitant than women to undergo plastic surgery in general, and male breast reduction surgery in particular. Perhaps they still believe in stereotypes that have long since been abandoned about plastic surgery not really being for men. Or they remain in some degree of denial about their gynecomastia, privately hiding their embarrassment, but not wanting to look the problem squarely in the eye.

What are the types of gynecomastia surgery:

Many gynecomastia patients are men who never lost the extra bit of puffiness they had on their chest during puberty. They may be fit or work out, but no matter what they do, they cannot see the outline of their Pecs. Others may have taken steroids for weight lifting, and these steroids can cause a rapid growth of the breast tissue. In the case of weight lifting, usually there is a very firm marble or walnut that they can feel. Many others suffer from gynecomastia as a side effect of prescription medications or recreational drugs.

What are the surgical options for gynecomastia plastic surgery?

There are two methods for treating male chest enlargement: liposuction and excision. In the pre-liposuction era, the only thing to do was to cut out the tissue (excision), usually using a small incision around about half the diameter of the areola. This worked great when there was a small and well-demarcated and circumscribed gynecomastia mass under the areola, but it didn’t work well when there was fat spread throughout the chest. Liposuction is ideal for the reduction of fat because fat is soft and is easily removed through the liposuction instrument (much like a straw). However, firm and glandular gynecomastia tissue cannot be removed by liposuction; it needs to be excised.

How will I know what needs to be done?

The preoperative physical exam is often very helpful in revealing what will need to be done to reduce a man’s chest so that it looks the way that he wishes it to look. On one extreme, imagine a very thin man, who has just a little puffiness deep to his nipple; other than that the chest is flat. When feeling the chest, a very firm and well-delineated mass can be felt beneath the nipple. Therefore with no excess fat distributed throughout the chest, and a firm, well-circumscribed mass that is too firm to be removed by suction, excision through an incision around the areola would be the method for reducing his chest.

On the other extreme would be an overweight man who has diffuse fat throughout his whole body, but with disproportionately more in the chest area. His whole chest feels evenly smooth and spongy, with no discernible discrete mass beneath his areola. Since fat is best removed with liposuction, and he has no firm tissue that needs to be excised, he would best be treated with liposuction alone.

Most men are somewhere in the middle: they have some fat, but they also have some firm glandular tissue that can only be removed with excision. Oftentimes in the operating room, once the fat is removed, the mass of glandular tissue can be more easily felt. It is kind of like a chocolate bar with almonds in it; once the chocolate is melted away, the almonds become more visible.

So we usually have a discussion before surgery. Some men want to be “as flat as possible,” and so we go into surgery knowing that we will do both suction and excision. Others want to have the excision only if I determine during surgery that it will make a noticeable difference. In these cases, we start with the suction, and if I can feel or see bulge after I am done with the suction, then I proceed to do the excision.

What type of anesthesia is used?

There are three choices for anesthesia: local, IV sedation, and general. Most of the time patients prefer having this done under general anesthesia. With new developments in anesthesia, patients wake up quickly and are almost never nauseated. Men’s chests are frequently very sensitive to pain, so it appears that a more thorough and complete improvement can be done when men are asleep. However if there is just a little “nubbin” of breast tissue beneath the nipple, then that can usually be removed very comfortably under local anesthesia. Dr. Movagharnia has experience using all three types of anesthesia for gynecomastia, and he will give you all the options that he thinks are appropriate for your condition.

What is the recovery for gynecomastia surgery?

The pain after treatment of gynecomastia is usually fairly mild. It feels like you had heavy work out or had been punched in the chest. Patients describe it as more sore than painful per se. and we give you strong pain medicine; if it hurts, the pill will work to take it away.

Right after surgery, you will have a special foam pad over your chest and a vest over that. That original dressing is left in place for two to three days. On the second day after surgery, you will remove the vest, throw away the foam, wash the vest, and put the vest back on. The longer you wear the compression, the faster the swelling and bruising will go away. In general, I like men to wear some compression day and night for the first month, or at least for two weeks during the day only if they are not too active. You need not always wear the surgical vest we give you; most men will buy a tight nylon/spandex undershirt that fits slimly under their clothing.

Some men barely bruise; most will have some diffuse bruising and discoloration over their chest. This usually resolves between 10 and 14 days after surgery. If you have an excision, you will have a scar around the lower half of your areola. The sutures are all dissolvable and hidden beneath the skin. If there is any hair at all, this is usually well concealed. For liposuction, we usually use a ¼” incision at the edge of the areola, plus another one in the outer part of the crease under the chest or near the shoulder, just in front of the armpit. These can look pink for the first year, but usually fade after that.

What are the risks and complications of gynecomastia plastic surgery?

Male chest reduction is an operation that is very frequently performed by Dr. Movagharnia. The incidence and severity of complications is very low – but it is never zero. All surgery carries a risk of infection and bleeding, seroma (12%, but the rate is higher in revision or secondary procedures) . While treatment of gynecomastia is usually permanent, there have been cases in which the gynecomastia returns. Scarring usually fades, but sometimes the scars remain visible. There is always a chance of asymmetry between the two breasts. There is a possibility of contour irregularity, meaning that there is some waviness or irregularity to the skin over the area treated. For instance, if there is a large, firm gynecomastia mass beneath the nipple, there are times when there is a little depression where it was removed. If there is extensive liposuction, especially going out to the sides of the chest, there can be irregularities in the contour of the skin.

What other procedures can I do at the same time?

About 50% of Dr. Movagharnia’s patients receiving surgery for male breast reduction have other procedures done at the same time. The most common of these procedures is liposuction of the abdomen, liposuction of the love handles, and other cosmetic procedures. All of these can be safely done at the same time as male chest reduction. Dr. Movagharnia will not mention these to you and embarrass you, but if you are bothered by these areas, and have any questions about what can be done or whether they can be treated at the same time as your gynecomastia, you may ask him at your consultation.

For more information about gynecomastia, please call CCRS at 770 951 7595