GYNECOMASTIA (ENLARGED MALE BREASTS)
Gynecomastia is an enlargement of the male breast tissue. Because of this it causes a feminine appearance to the male chest. It is a common condition, and is often associated with a sense of shame and embarrassment in the affected individual.
Do I have gynecomastia?
Gynecomastia is a deformity. A breast that looks more prominent in the lower part is usually due to gynecomastia. Incase an individual is affected by the appearance, it is likely that the individual has gynecomastia. A clinical examination is adequate to ascertain the diagnosis. Gynecomastia can present differently. It can affect one, or both sides of the chest. One of the sides may be affected more than the other. Some individuals may present with only a prominence of the skin around the nipple.
What causes gynecomastia?
In the majority, gynecomastia occurs without an identifiable cause. These are primary or idiopathic gynecomastia. In some individuals, it can be secondary to some other rerason. For example, certain drugs, systemic diseases of liver, kidney, or chromosomal abnormalities. We usually screen individuals presenting with gynecomastia with assessment of levels of a few hormones. Normal levels of these are seen in primary gynecomastia. Any significant abnormality are evaluated with the help of an endocrinologist (specialist in treatment of diseases of hormones).
What is the treatment of gynecomastia?
Definitive treatment of gynecomastia is with surgery. There is a limited role of medications in the management of this condition. A course of Tamoxifen is sometimes advised in individuals with painful gynecomastia.
Can exercise lead to a resolution of gynecomastia?
No. However, exercise can have two positive outcomes. One is weight loss, and second is an improved definition (contour) of the chest. Weight training can lead to a hypertrophy of the chest muscles. But it can't lead to a reduction in the glandular tissue of the breasts. Hypertrophy of the pectorals cause an increase in the projection of the chest.
When is a good time to do surgery in an individual with gynecomastia?
Most of our patients presenting for correction are individuals with persistence (continuation) of puberty onset gynecomastia. We usually advise our patients to wait until 18 years of age before undertaking a surgical correction. This is because many of the instances of pubertal onset gynecomastia resolves before 18. We uncommonly operate in individuals before 18. This is done in cases with extreme enlargement, and associated with significant emotional distress. Individuals undergoing surgery before 18 also have an increased risk of recurrence.
How does a patient undergo surgical correction?
When a patient first presents for a consultation we evaluate a few things. These include, any signs of it being a secondary gynecomastia. We evaluate the presence of skin excess, Patients are screened for any risk factors that can influence the outcome of the surgical procedure. We make a surgical plan based on the clinical findings. We also advise a few laboratory tests. These include assessment of levels of hormones, and other blood parameters. In case, a patient has realistic expectations, does not have any modifiable risk factors we go ahead with the surgery on a later date.
What are the common modifiable risk factors of gynecomastia surgery?
The two most common modifiable risk factors that we come across in our practice are,
How is the surgery performed?
Most of our patients with gynecomastia get treated under local anesthesia. Less commonly, we perform the surgery under sedation or general anesthesia. This is reserved for individuals who are very anxious, or those who need skin excision. But this is relatively less common in our practice.
The surgery involves liposuction of the chest to reduce the amount of fatty tissue in the breasts. We carry out liposuction using Toomey syringes. Liposuction is performed with the help of small incisions (less than half a centimetre long) placed below the breasts. We do not place liposuction entry ports in the axilla. Liposuction is done on both the anterior (front) and the lateral (side) chest. After liposuction we make a small incision in the areola (pigmented skin around the nipple) and do a direct excision of the gland. The areolar incision is closed with the help of small sutures (stitches). The drains (small tubes that evacuate fluids) come out through the skin incisions used for liposuction. The drains are usually removed during the next day. Once the drains are removed patients are put on a pressure garment. A pressure garment is a vest that helps to minimise the swelling after surgery. It also helps reduce the incidence of contour abnormalities. The vest is worn for 4 weeks after surgery.
What is the postoperative care required after surgery?
When done under local anesthesia, patients are able to move about soon after surgery. We advise our patients to take lot of rest during the initial 3 days. Patients can move about. Rest during the initial days helps minimise the chances of any reactionary haemorrhage (bleeding that happensd during the intital 2 to 3 days) at the operated site. Patients can take a shower from the second postoperative day. The wounds are covered with a small dressing, and the pressure garment is worn over it. The garment is worn continuously for the first 2 weeks and at night for the next 2 weeks. Patients can return to light work, after 2 weeks. We usually remove the areolar sutures at 2 weeks. Individuals can resume heavy exercise one month after the surgery.
What are the changes usually associated with normal healing?
Any type of surgery is associated with swelling at the operated sites. This is normal. Some of the patients tend to have more bruising thasn others. . This usually subsides without any intervention. Application of cold helps in earlier resolution of the bruising. The swelling at the operated site reduces with time. It usually takes approximately 3 months to settle on the sides of the chest. The swelling may not resolve uniformly over the operated site. This may lead to areas of intervening firmness separated by relatively softer areas temporarily. However, it settles over the course of next few weeks without any intervention.
What are the complications associated with gynecomastia correction?
Gynecomastia correction is a safe surgery. Complications are not that common. Some of the complications that can be seen include,
What are the other operative plans used during gynecomastia correction?
The previously mentioned operative approach is sometimes modified based on the clinical findings. Two common variations include,
What are differences between local or general anesthesia when used for correction of gynecomastia?
Both local and general anesthesia have relative merits and demerits. We prefer local anesthesia in our practice and reserve general anesthesia for individuals who are anxious, or need skin excision. The advantages of local anesthesia for gynecomastia correction include the following,
Is it possible to undergo secondary (repeat) surgery after a previous gynecomastia correction?
Such corrections are called secondary corrections. These are usually carried out one year after the primary surgery. The reasons for secondary surgery include, contour abnormalities, residual gland, or prominent scars. Patients who present for secondary corrections should have realistic expectations about the procedure. The operative plan for secondary surgery is similar to the primary surgery. We sometimes do fat grafting to imprve contour abnormalities. The fat harvested during liposuction in injected into deficient areas. Also improved outcomes are associated with a healthy lifestyle and near ideal body weight.
Why do we treat gynecomastia?
In case an individual is experiencing a sense of shame and embarrassment, adequate treatment of this condition leads to an improvement in the body image. Patients report improved confidence and self esteem after a gynecomastia correction.
Related topics.
Do I have gynecomastia?
Gynecomastia is a deformity. A breast that looks more prominent in the lower part is usually due to gynecomastia. Incase an individual is affected by the appearance, it is likely that the individual has gynecomastia. A clinical examination is adequate to ascertain the diagnosis. Gynecomastia can present differently. It can affect one, or both sides of the chest. One of the sides may be affected more than the other. Some individuals may present with only a prominence of the skin around the nipple.
What causes gynecomastia?
In the majority, gynecomastia occurs without an identifiable cause. These are primary or idiopathic gynecomastia. In some individuals, it can be secondary to some other rerason. For example, certain drugs, systemic diseases of liver, kidney, or chromosomal abnormalities. We usually screen individuals presenting with gynecomastia with assessment of levels of a few hormones. Normal levels of these are seen in primary gynecomastia. Any significant abnormality are evaluated with the help of an endocrinologist (specialist in treatment of diseases of hormones).
What is the treatment of gynecomastia?
Definitive treatment of gynecomastia is with surgery. There is a limited role of medications in the management of this condition. A course of Tamoxifen is sometimes advised in individuals with painful gynecomastia.
Can exercise lead to a resolution of gynecomastia?
No. However, exercise can have two positive outcomes. One is weight loss, and second is an improved definition (contour) of the chest. Weight training can lead to a hypertrophy of the chest muscles. But it can't lead to a reduction in the glandular tissue of the breasts. Hypertrophy of the pectorals cause an increase in the projection of the chest.
When is a good time to do surgery in an individual with gynecomastia?
Most of our patients presenting for correction are individuals with persistence (continuation) of puberty onset gynecomastia. We usually advise our patients to wait until 18 years of age before undertaking a surgical correction. This is because many of the instances of pubertal onset gynecomastia resolves before 18. We uncommonly operate in individuals before 18. This is done in cases with extreme enlargement, and associated with significant emotional distress. Individuals undergoing surgery before 18 also have an increased risk of recurrence.
How does a patient undergo surgical correction?
When a patient first presents for a consultation we evaluate a few things. These include, any signs of it being a secondary gynecomastia. We evaluate the presence of skin excess, Patients are screened for any risk factors that can influence the outcome of the surgical procedure. We make a surgical plan based on the clinical findings. We also advise a few laboratory tests. These include assessment of levels of hormones, and other blood parameters. In case, a patient has realistic expectations, does not have any modifiable risk factors we go ahead with the surgery on a later date.
What are the common modifiable risk factors of gynecomastia surgery?
The two most common modifiable risk factors that we come across in our practice are,
- Smoking. Smoking is associated with increased risk of infection, hematomas and more bleeding during the surgery, and wound healing problems. It is strongly recommended to stop smoking at least one month before the surgery and during the postoperative period. Smoking is a reason for postponement of the surgery.
- Increased body weight. Better outcomes are seen in individuals close to their ideal body weight. Obesity is associated with more extensive surgery and greater risk of wound related complications. Incase an overweight individual is planning to undergo gynecomastia surgery after a few months, it is advisable to reduce their weight before surgery.
How is the surgery performed?
Most of our patients with gynecomastia get treated under local anesthesia. Less commonly, we perform the surgery under sedation or general anesthesia. This is reserved for individuals who are very anxious, or those who need skin excision. But this is relatively less common in our practice.
The surgery involves liposuction of the chest to reduce the amount of fatty tissue in the breasts. We carry out liposuction using Toomey syringes. Liposuction is performed with the help of small incisions (less than half a centimetre long) placed below the breasts. We do not place liposuction entry ports in the axilla. Liposuction is done on both the anterior (front) and the lateral (side) chest. After liposuction we make a small incision in the areola (pigmented skin around the nipple) and do a direct excision of the gland. The areolar incision is closed with the help of small sutures (stitches). The drains (small tubes that evacuate fluids) come out through the skin incisions used for liposuction. The drains are usually removed during the next day. Once the drains are removed patients are put on a pressure garment. A pressure garment is a vest that helps to minimise the swelling after surgery. It also helps reduce the incidence of contour abnormalities. The vest is worn for 4 weeks after surgery.
What is the postoperative care required after surgery?
When done under local anesthesia, patients are able to move about soon after surgery. We advise our patients to take lot of rest during the initial 3 days. Patients can move about. Rest during the initial days helps minimise the chances of any reactionary haemorrhage (bleeding that happensd during the intital 2 to 3 days) at the operated site. Patients can take a shower from the second postoperative day. The wounds are covered with a small dressing, and the pressure garment is worn over it. The garment is worn continuously for the first 2 weeks and at night for the next 2 weeks. Patients can return to light work, after 2 weeks. We usually remove the areolar sutures at 2 weeks. Individuals can resume heavy exercise one month after the surgery.
What are the changes usually associated with normal healing?
Any type of surgery is associated with swelling at the operated sites. This is normal. Some of the patients tend to have more bruising thasn others. . This usually subsides without any intervention. Application of cold helps in earlier resolution of the bruising. The swelling at the operated site reduces with time. It usually takes approximately 3 months to settle on the sides of the chest. The swelling may not resolve uniformly over the operated site. This may lead to areas of intervening firmness separated by relatively softer areas temporarily. However, it settles over the course of next few weeks without any intervention.
What are the complications associated with gynecomastia correction?
Gynecomastia correction is a safe surgery. Complications are not that common. Some of the complications that can be seen include,
- Infection. It is uncommon. In order to reduce the incidence of infection we perform the surgery under antibiotics. In case of the presence of any locus of infection like folliculitis detected before the operation, we usually postpone the surgery until the skin infection has resolved.
- Collections. This refers to accumulation of fluids at the operated site. This is less common when we perform the surgery under local anesthesia. Reducing physical activity during the initial days and placement of a drain help reduce the incidence of collections. In case of presence of a collection, or hematoma we manage it in three different ways. This depends upon the appearance. Small collections are treated without any intervention. They settle by themselves. In the presence of significant collections of about 10 ml or more we do a needle and syringe evacuation after 2 weeks. In case an individual has a large hematoma, we evacuate by taking the individual back to the operation theatre. These events are not that common.
- Prominent scars. The scars associated with gynecomastia surgery are usually well tolerated. They may be associated with pigment (color) abnormalities and small unevenness during the initial days after surgery. These settle well in a few months. Some individuals tend to have an intrinsic prominent scarring tendency. They would require additional care in the postoperative period with the help of silicone sheets. We do not consider hypertrophic scarring tendency as a contraindication for gynecomastia surgery.
- Contour abnormalities. These are usually uncommon in individuals with adequate skin recoil. Incase there is a persistence of contour abnormalities after a year, it may require additional surgery for correction.
- Recurrence of gynecomastia. This is usually seen in individuals who get operated before 18 years. Otherwise, it is not common.
What are the other operative plans used during gynecomastia correction?
The previously mentioned operative approach is sometimes modified based on the clinical findings. Two common variations include,
- Gland excision without liposuction. This is done in thin individuals with very less fatty tissue in the breasts. These individuals usually present as a puffy areola without any breast under the non-pigmented skin. These are carried out under local anesthesia.
- Gynecomastia with excess (redundant) skin. These individuals present with sagging breasts. It is usually seen in individuals following massive weight loss. Weight loss in excess of 25 kg is leads to such presentations. After a liposuction and gland excision the skin may not recoil (flatten out) adequately. In case such an outcome is anticipated, we approach the condition in two different ways. One, proceed with reduction of the breast tissue and wait for skin recoil to take effect. There is an improvement of skin recoil with time. The presence of excess skin after a year is treated with a skin excision procedure. Second, involves removal of the excess skin during the first surgery (gynecomastia correction). The skin removal pattern depends on the severity and extent of the excess skin. It may be removed as a doughnut with a vertical extension, or a vertical with lateral extension. The removal of skin is associated with longer scars. The treatment plan is undertaken on a case to case basis. The skin excisional (removal) procedure is usually done under general anaesthesia.
What are differences between local or general anesthesia when used for correction of gynecomastia?
Both local and general anesthesia have relative merits and demerits. We prefer local anesthesia in our practice and reserve general anesthesia for individuals who are anxious, or need skin excision. The advantages of local anesthesia for gynecomastia correction include the following,
- Patients can avoid fasting both before and after the procedure.
- Faster recovery. Patients can ambulate soon after the procedure when it is done under local anesthesia.
- Absence of postoperative nausea and vomiting. Some individuals may experience nausea and vomiting with general anesthesia. This is not seen with local anesthesia. Other complications associated with general anesthesia are also avoided when the procedure is carried out under general anaesthesia.
- Reduced incidence of collections. We find a reduced incidence of seromas with local anesthesia in our pracrtice.
- Better pain relief during the postoperative period. Under local anesthesia a higher dose of agents are used during infiltration. The benefits of ensuring a complete pain relief during the surgery continues after the procedure.
- Lesser cost. Use of general anesthesia requires more expertise and consumables. Surgical correction under local anesthesia is cheaper when compared to surgery general anesthesia.
- It takes longer to perform the procedure under local anesthesia. The achievement of adequate analgesia before the surgery takes longer when compared to general anaesthesia.
- Doing the procedure under local anesthesia may not be suitable for anxious individuals.
Is it possible to undergo secondary (repeat) surgery after a previous gynecomastia correction?
Such corrections are called secondary corrections. These are usually carried out one year after the primary surgery. The reasons for secondary surgery include, contour abnormalities, residual gland, or prominent scars. Patients who present for secondary corrections should have realistic expectations about the procedure. The operative plan for secondary surgery is similar to the primary surgery. We sometimes do fat grafting to imprve contour abnormalities. The fat harvested during liposuction in injected into deficient areas. Also improved outcomes are associated with a healthy lifestyle and near ideal body weight.
Why do we treat gynecomastia?
In case an individual is experiencing a sense of shame and embarrassment, adequate treatment of this condition leads to an improvement in the body image. Patients report improved confidence and self esteem after a gynecomastia correction.
Related topics.
- Gynecomastia correction under local anesthesia
- Recovering from gynecomastia corrective procedure
- Scars associated with gynecomastia correction
- Late changes following gynecomastia correction
- Asymmetry (difference between the left and right) and its management.
- When not to do gynecomastia surgery?
- Nipple-areola appearance and gynecomastia
- Being overweight with gynecomastia
- Liposuction under local anesthesia
- Shedding weight before liposuction
- Managing excess skin in gynecomastia
- Do I have gynecomastia?
- Secondary corrections for gynecomastia
- Treatment options in individuals with excess skin in gynecomastia
- Why do liposuction in gynecomastia treatment?
To visit our web page on gynecomastia in Malayalam, please visit: https://www.plasticsurgerymalayalam.com/gynecomastia
Well settled areolar scar three months following surgery
Patient journey: The following images describe a patient journey during gynecomastia correction. Patient underwent liposuction and gland removal with an areolar incision under general anesthesia in a hospital setting. Recovery was uneventful.
1. Preoperative appearance of gynecomastia.
2. Preoperative markings to highlight the muscle, fat and gland
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3. Liposuction
4. Gland removal
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5. After gland removal with an areolar incision
6. Appearance as well as dressing after 3 days
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7. Pressure garment
8. Appearance two weeks following procedure. Residual swelling gradually resolves over the next few months.
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Gynecomastia with excess glandular and fatty tissues with lax skin
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Gynecomastia treated with liposuction, direct excision of gland and dough-nut excision of skin
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Gynecomastia treated in a muscular individual with direct excision of the gland through an areolar incision. Liposuction was not performed.
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Gynecomastia with excess fatty and glandular tissues.
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Gynecomastia treated with liposuction and direct excision through intra-areolar incision under general anesthesia.
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Before: Fatty and glandular excess with good recoil of skin
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After: Liposuction and glandular excision done with an intra-areolar incision
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Before: Gynecomastia in an individual with asymmetry of the underlying muscles (left pec major is bulkier compared to the right).
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After: 6 weeks post-operative image following liposuction and gland removal using areolar incision.
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Before: Marked asymmetry with gynecomastia on right greater than left
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Intra-operative: With the excised gland near kept near the wounds
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After: Improvement in the symmetry with gland removal
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Before: Gynecomastia in a muscular individual without lipodystrophy
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Preoperative markings
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After: 10 weeks postoperative appearance
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Before: Gynecomastia in a middle aged male with pendulous abdomen
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Before: Lateral view
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After: 2 weeks postoperative appearance. No abdominal procedures were performed
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After: 2 weeks postoperative appearance
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Before: Gynecomastia with mild lipodystrophy
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Preoperative markings
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After: Early postoperative appearance at 11 days with swelling (temporary) and sutures in situ
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Before: Gynecomastia in an individual with massive weight loss and excess skin
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Before: Lateral view
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After: 5 months postoperative appearance. Skin excision (removal) was not performed
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After: Lateral view. Skin recoil continues to more than a year
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Before: Glandular asymmetry of the breasts
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Preoperative markings
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After: Early postoperative appearance at 3 weeks. Swelling is visible over the lateral aspect of the chest
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Before: Gynecomastia in an individual with mild lipodystrophy
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Preoperative markings
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After: 1 month postoperative appearance
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Before: Gynecomastia in an individual with a low IMF (inframammary fold)
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Preoperative markings
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After: 3 month postoperative appearance
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Before: Gynecomastia with moderate lipodystrophy
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Before: Lateral view
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Before: 1 month postoperative view. Swelling of the treated regions is visible
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After: Lateral view
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Before: Gynecomastia with preoperative asymmetry, ptosis, and a keloidal scarring tendency
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Preoperative marking
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After: 5 month postoperative appearance
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