What Is Gynecomastia?
The term ‘gynecomastia’ comes from the Greek words gyne meaning “woman” and mastos meaning “breast”; it refers to abnormally large breasts on men. Gynecomastia is a benign enlargement of the male breast resulting from a proliferation of the glandular component of the breast. Gynecomastia is defined clinically by the presence of a rubbery or firm mass of breast tissue extending concentrically from the nipples. Male breast enlargement resulting from fat deposition without glandular proliferation is termed ‘pseudogynecomastia’.
True gynecomastia results from an imbalance between the stimulatory effect of estrogens on breast enlargement, and the inhibitory effect of androgens; there is an altered estrogen-androgen balance in favor of estrogen, or an increased breast sensitivity to a normal circulating estrogen level. Estrogen production in males is primarily from the peripheral conversion of androgens (testosterone and androstenedione), by the enzyme aromatase (in muscle, skin, and adipose tissue), to estrone and estradiol. Estrogens induce breast enlargement by ductal epithelial hyperplasia, ductal elongation and branching, proliferation of the periductal fibroblasts, and an increase in vascularity.
Other causes of gynecomastia include: obesity; side effects of several medications (eplerenone [Inspra], ACE-inhibitors, and phenytoin [Dilantin]); steroid abuse or exposure to androgens (often taken for body building); marijuana use; exposure to estrogens; chronic liver disease; kidney failure; decreased production of testosterone (castration). More rare causes include tumors, genetic defects (Klinefelter’s Syndrome, Gilbert’s Syndrome), or hyperthyroidism. Though certain drugs and medical problems have been linked with over development of the male breast, there is no known cause in the vast majority of cases.
Gynecomastia is the most common cause for male breast evaluation. It is common in infancy, adolescence, and in middle-aged to older adult males. It is estimated that 60-90% of infants have transient gynecomastia due to the high estrogen state of pregnancy.
The second most common cause of male breast enlargement is puberty. Pubertal gynecomastia usually has an onset in boys aged 10-12 years, with prevalence ranging up to 70%. The condition may occur in one or both breasts and begins as a small lump beneath the nipple, which may be tender. The breasts often enlarge unevenly. Some reports have shown a transient increase in estradiol concentration at the onset of puberty in boys who develop gynecomastia. Pubertal gynecomastia generally regresses within 18 months or as adolescence wanes, a few years later (~90% of the time); persistence in men older than 17 years is uncommon.
The third peak occurs in older men, with a prevalence of 24-65%. Gynecomastia in adults is often multifactorial. Increased aromatization of testosterone to estradiol and the gradual decrease of testosterone production in the aging testes account for most cases of gynecomastia in adult men. Older men are also more likely to take medications that may cause gynecomastia than are younger men.
For those individuals who develop gynecomastia early in life, it can be emotionally devastating. Feelings of shame, embarrassment and humiliation are common. During school years taunting from peers can lead to loss of self-esteem. Teenagers are often embarrassed to discuss this problem with their parents, and young men may be unable to seek an intimate relationship with a woman. A man or boy with gynecomastia may struggle with anxiety over such simple acts as taking off his shirt at the beach, in the locker room, or in front of family members. Affected individuals often wear several loose shirts to conceal their breast size.
Men who have develop gynecomastia later in life, from steroid abuse, obesity, medications, or some other cause, may have little to no psychological distress. However, for some in this situation, it can still be particularly distressing and leave them feeling emasculated in some matter. Men often have a very difficult time talking about their breasts to anyone, but it is the first step toward relief. Realizing that they are not alone is a powerful antidote for the shame and a beginning toward healing.
Surgery for Gynecomastia – Male Breast Reduction
Asymptomatic and pubertal gynecomastia do not require further tests and should be reevaluated in 6 months. Pubertal gynecomastia resolves spontaneously within several weeks to 3 years in approximately 90% of patients. Breasts greater than 4 cm in diameter may not completely regress. In other cases, identifying and managing an underlying primary disorder often alleviates breast enlargement.
Further medical evaluation is necessary in patients with the following: Breast size greater than 5 cm (macromastia); a lump that is tender, of recent onset, progressive, or of unknown duration; signs of malignancy (hard or fixed breast mass or positive lymph node findings).
For many men who are self-conscious about their appearance the best solution is surgery. Surgery for gynecomastia is considered for patients with long-standing gynecomastia, in those in whom medical therapy has failed, for cosmetic reasons, and for accompanying psychosocial reasons. Surgery may be discouraged for men who are overweight or obese, and have not first attempted to correct the problem with exercise and weight loss. In these cases, weight loss can reduce gynecomastia, but for many it will not eliminate it. Individuals who drink excessive amounts of alcohol, smoke marijuana, or use anabolic steroids are not usually considered good candidates for surgery, since these drugs may cause gynecomastia. These patients are first instructed to stop the use of these drugs to see if the breast fullness will diminish before surgery is considered an option. For all other causes, surgery is the only known physical remedy.
Your plastic surgeon may, in extreme cases, also recommend a mammogram, or breast x-ray. This will not only rule out the very small possibility of breast cancer, but will reveal the breast’s composition. Once your surgeon knows how much fat and glandular tissue is contained within the breasts, he or she can choose a surgical approach to best suit your needs.
Male breast reduction is usually a cosmetic procedure. According to The American Society for Aesthetic Plastic Surgery National Data Bank Statistics, surgery for gynecomastia was the fourth most common surgical procedure (24,234 procedures) among men in 2014; this was over a 7% increase from the previous year. Male breast reduction surgery may involve direct excision of breast tissue, liposuction of excess fat, or a combination of both depending upon the consistency of the breast.
The best candidates for surgery have firm, elastic skin that will reshape to the body’s new contours. If excess glandular tissue is the primary cause of the breast enlargement, an incision is made in at the edge of the areola and the breast tissue is excised. The excision may be performed alone or in conjunction with liposuction. If liposuction is used to remove excess fat, the cannula may be inserted through the existing incisions. Major reductions that involve the removal of a significant amount of tissue and skin may require larger incisions that result in more conspicuous scars. Liposuction is used to remove gynecomastia caused primarily by excessive fatty tissue. A small incision is made around the edge of the areola or elsewhere on the chest. A cannula which is attached to a vacuum pump is used to break up the fat and suction it out. Sometimes, a small drain is inserted to prevent fluid accumulation. A post-operative compression garment is frequently used to keep the skin firmly in place and reduce swelling. More extensive plastic surgery involving removal of excess skin may be required in patients with marked gynecomastia, in those who have developed excessive sagging of the breast tissue, or following weight loss. We will discuss treatment options during your consultation.
Male Breast Reduction Before & After Photos
If you would like to schedule a consult to discuss whether gynecomastia breast reduction is right for you please call our office at 414-443-0033.
Post Operative Instructions and Information for Male Breast Reduction:
- Wear your elastic compression garment at all times, except when bathing. This garment helps minimize post-operative swelling, bruising, and fluid collections.
- It is not uncommon to experience some drainage from your incisions for the initial 24 – 48 hours; you may change them as needed.
- If you have drains, empty the drainage bulbs two times per day, and as needed. Measure and record the amount of fluid emptied from each drainage bulb separately. Bring this drain record sheet with you to your next office visit.
- Do not shower when the drain tubes are in place. Wait 24 hours after all the drains have been removed before showering; you may then shower as usual but do not soak the incisions. If you do not have drain tubes, you may begin showering the day after surgery, but do not soak the incisions.
- If steri-strips have been placed over your incisions, leave them in place. You may wash over the strips gently with mild soap and water; then blot dry with a clean towel.
- Do not take Aspirin, Ibuprofen, Advil®, Motrin®, Naprosyn®, Aleve®, etc. for the next 5 days.
- Take any prescription medication as directed. Take any prescribed antibiotics until gone.
- Avoid high-salt foods and alcohol.
- Do not participate in any strenuous activity or heavy lifting for at least 2 weeks following your surgery. Your doctor will instruct you when you may begin a gradual return to activities. Patients generally return to an unrestricted activity level by 4-6 weeks after surgery.
- Following liposuction it is not uncommon for post-operative swelling and bruising to develop in an area remote to the surgical site. This will usually resolve within 2 weeks. Numbness at the surgical site may remain for 2-6 months.
- Observe the incision line for signs of increasing redness, tenderness, swelling, pus or foul smelling drainage, and please notify our office if any of these signs are present. Be aware that for the first 2 weeks after surgery your breasts will normally be swollen and tender. Swelling will subside over 6 – 8 weeks.
- If you develop a fever greater than 101° F, please notify our office.
- Direct exposure to full sunlight should be avoided for at least 8 weeks. The surgical site should be protected with clothing and a sunscreen (SPF 30) that blocks both ultraviolet A and B rays. Avoid exposing the incisions to the sunlight or other ultraviolet light for 6 months after surgery.