GYNECOMASTIA
By Robert Caridi, M.D.
Westlake Plastic Surgery
Overview
Gynecomastia refers to persistent enlargement of the male breast. In today’s vernacular, we call it “man boobs.” It is caused by the benign enlargement of the glandular tissue of the breast, as well as an accumulation of fibro-fatty tissue. Prominent nipples and “puffy” areolas are often seen with this condition, and it usually affects both breasts, sometimes asymmetrically.
Newborns may have gynecomastia as a response to their mothers female hormones. In my practice, I see two groups of patients classified by their age. The first group consists of adolescents, who developed fullness in their breasts that persisted into adulthood. The adolescent group is most at risk for the development of psychological scars from gynecomastia. Young men may suffer with serious body image problems and secondary behavior disturbances, such as withdrawing from their peers, avoiding important group social activities, and depression. The second group is found in the adult population, usually men who are older than age fifty. An interesting fact is that gynecomastia treatment is the fourth most common plastic surgery procedure performed on men (18 thousand cases in 2008).
Causes
Gynecomastia has long been considered the result of an imbalance between hormones, such as estrogen and testosterone. At least 50% of the known cases are caused either by tissue that remains after adolescent development, or the “idiopathic variety” (which means we don’t know why you have it!). Less frequent causes include: drugs (20%), liver disease or malnutrition (8%), and various other medical conditions (15%). Pseudogynecomastia refers to a condition in which excess fat accumulates at the breast, without the involvement of actual breast tissue (seen commonly in obesity).
Regardless of the cause, gynecomastia is a benign condition and has no negative impact on the individual other than cosmetic. The evaluation of gynecomastia usually entails an accurate history and physical examination. The doctor will ask questions about your use of medications, drugs and alcohol, as well as symptoms of liver dysfunction, decreased sexual desire, or impotence. If your gynecomastia is caused by an underlying medical condition, your medical doctor (General Practitioner or Internist) will treat you as needed. In cases of persistent gynecomastia, unrelated to a treatable medical condition, it is best to either live with the breast fullness, or treat it surgically. Generally, an extensive laboratory work up is unnecessary, since no abnormalities are detected in the vast majority of patients.
The issue of “puffy nipples”is more complicated than just underlying breast tissue that is poking through. There are small muscles in the skin around the areola that contract upon stimulation or to cold temperatures. When the muscle is in a relaxed state, the areola becomes more puffy. When the muscle contracts, the areola becomes smaller. There is no “surgery” that will make the areola stay in the contracted state–patients have to learn to live with this completely normal process. However, the less tissue beneath the areola, the less puffy the areolas will appear when the muscle is relaxed or non stimulated.
Treatment Options
From a treatment perspective, most patients I see fall into three groups. The first group have small amounts of dense breast tissue, in and around the areola, that is removed under local anesthesia through an incision around the areola. The second group consists of patients who have fullness around the entire breast area, as well as under the arms. This usually requires both liposuction and direct removal of tissue through an incision around the areola. The third group of patients have fullness in the breast and under the arms, as well as excess fat on the abdomen and love handles. This normally requires liposuction of the trunk and the breast, as well as removal of tissue under the areola. This comprehensive approach is necessary in order to ensure that the results are symmetrical and natural looking. Weight loss may be beneficial in some cases before surgical treatment.
Medical treatments offered for gynecomastia are not nearly as effective as surgery. Several studies have showed a small reduction in the size of gynecomastia and less pain, if present, when anti-estrogens are used like Nolvadex. Treatment must be started early in the course of the condition to be remotely effective. After a year has passed and the tissue becomes more “fibrofatty”, it is unlikely that medial treatment will result in much improvement. I have never known of a gynecomastia patient that was “cured” with medical treatments. Visible or palpable breast tissue present after medical treatments will almost guarantee dissatisfaction in my experience. Successful, satisfying outcomes usually involve surgery.The timing of surgery is important as well. When gynecomastia occurs during adolescence and does not resolve within a year or so, I highly recommend that treatment be considered. This is a critical time in the emotional and social development of young men.
Diet and exercise will not eliminate gynecomastia, unless it is mostly fatty in nature, in which case weight loss will certainly help. Exercising the chest muscles with the goal of improving the appearance of gynecomastia is unlikely to be successful, and can actually make the fullness more prominent. Although women body builders will lose breast mass, this does not occur in male body builders. You cannot exercise away gynecomastia.
It is easy to underestimate the amount of tissue present in gynecomastia. What is seen is the “tip of the iceberg.” I have before and after photos of specimens removed at the time of surgery for you to view. The surgical plan for the treatment of gynecomastia is based on the best way to remove the breast tissue, and when and how to manage excess, or loose skin.
If there is a large amount of loose and saggy skin, your surgeon may recommend its removal with a scar around the areola, or a horizontal or anchor shaped scar. Except for those who have had extreme weight loss or particularly large gynecomastia, skin removal is often unnecessary. There is an amazing capacity of the skin to retract after surgical removal of the underlying tissue. A “wait and see” approach to skin removal may be recommended. Excess breast tissue can be removed, the patient allowed to heal for several months, and then return for an evaluation for skin removal. Your surgeon will need to focus not only on your chest but your entire upper body to make sure that your results are proportional. If a patients is overweight and has fullness all over the upper body, reducing the gynecomastia without treatment of the surrounding areas may look disproportional.
Anesthesia
Anesthesia alternatives depend on the amount of tissue to be removed and the complexity of the procedure, as well as the patient’s personal wishes and comfort level. Small accumulations of breast tissue (localized tissue under your nipple and areola) can be removed under local anesthesia. Larger volumes usually require the use of IV sedation or general anesthesia, for your comfort. Adequate pain-free anesthesia is needed, so that your surgeon can appropriately and carefully contour the tissue and minimize the chance for irregularities.
Recovery
The discomfort during recovery is generally considered mild to moderate in intensity. I generally recommend a day or two off to recover from the procedure (mostly anesthesia related). Most patients may return to moderate exercise after seven to ten days. Mild tightness and discomfort about the chest will be present for two to four weeks. Recovery is longer and more intense in those patients who have had tissue removed surgically, compared to those who were only treated with liposuction. Compression garments are worn for several weeks to control the swelling, provide support, and facilitate skin retraction. Manual massage of the chest area expedites healing.
A plastic drainis often used after surgery to remove fluid and blood that tends to accumulate in the space formally occupied by the breast tissue. The drains are removed after three to five days, depending on the amount of daily fluid accumulation. The more tissue removed, the more likely that a seroma or fluid collection will occur. Removal of a small area of tissue below the areola is less likely to result in fluid accumulation compared to a large tissue resection similar to that of a mastectomy. This is very common and probably the greatest inconvenience in terms of healing.
It may take six months or longer for the swelling to subside completely, and for the tissues to soften or “relax” (this will not be visible however). Four to six weeks after the procedure maximal scar formation can result in areas of palpable firmness. This is normal and typical. Massage helps to soften the scar and, at times, small amounts of steroids are injected to facilitate softening of the deeper tissue. Raising your arms over your head will result in pulling sensation in the chest area where the scar is adherent to the skin. This will resolve in several weeks time.
Silicone scar strips are recommended to ensure the best scar appearance. The final position of the scar around the areola generally heals very well and won’t be visible to others (the beauty of the procedure is that no one will know that you have had treatment for it!). Dimpling of the scar is common for the first six to eight weeks after the surgery.
The pyscholocial recovery from the procedure varies considerably. Some patients adapt right away to their new “gynecomastia fee” chest while others seem somewhat shocked or perplexed by the different appearance. Many can’t believe how easy it was to have it removed and act like they expected more drama. Literally, here today, gone tomorrow. There is an adjustment period after the surgery that may last several weeks or longer until you incorporate your new body self image.
Complications
Most of the complications from surgical treatment of gynecomastia are relatively minor. The most likely complications are contour irregularities, under-correction and hematoma formation (blood collection beneath the skin). If inadequate tissue resection is performed, continued fullness may exist and be a potential source of dissatisfaction. If inexpert treatment is performed, it is not uncommon for contour irregularities to exist (fullness in one area and not another, and differences from side to side). Note, however, that it is rare for any individual to have a perfectly symmetrical chest. Sometimes the removal of breast tissue will uncover underlying muscle and rib asymmetries that will be more visible after correction of gynecomastia.
By far the most common complication that I see after this procedure is seroma formation, or fluid accumulation, beneath the breast. It’s so common we actually don’t consider it a complication—we have come to expect it. As stated earlier, the larger the volume of tissue removed, the more likely a seroma will form. This simply means that several office visits may be needed to remove this fluid with a small needle aspiration. Drinking excessive water during your recovery is not recommended as this will increase the potential for seroma formation.
Some reassuring news for men considering gynecomastia correction is that recurrence of this condition is rare. In most cases of suspected recurrance, the problem was incomplete tissue removal at the time of the surgery. Once all the swelling has resolved after six months or so patients may note continued fullness from tissue that remains. If the result of your procedure is not to your satisfaction, a secondary revisional procedure may be needed to obtain the best outcome.
One consistant observation amongst my patients is their desire to have all the breast tissue removed. Leaving behind breast tissue for any reason will often result in a patient request for additional treatment (patients want it gone!).
Psychological Considerations
“I just want to be like a normal guy”. Probably the most important issue concerning gynecomastia is the resulting psychological scars from having to live your life with excessive breast fullness. Women in our society are valued for their breasts, not men. The stigma of having prominent breasts can lead to antisocial behavior, anxiety, self-hate, poor self-esteem, poor body image, and problems with interpersonal relationships. Patients with gynecomastia often hide their chests in public, or withdraw socially, and avoid discussing their concerns with parents and peers. Feelings of shame, embarrassment, and humiliation are common. Gynecomastia patients struggle with anxiety over such simple acts as taking off a shirt at the pool. Patients have developed many “defense mechanisms” to cope with this condition. It often takes a lot of “guts” for these patients to seek medical care.
I found it interesting to learn that we don’t know much about the psychology of gynecomastia. I can not assure my patients that the treatment that I offer will provide them with a “cure,” in terms of the psychological scars. I can say, however, that my patients have been very pleased with their results overall. More study needs to be done investigating the benefits of surgical treatment. We don’t know if psychological counseling helps patients avoid surgery.
The longer the condition persists without treatment, the greater the chance for psychological damage. This is the main reason I support not delaying treatment after an appropriate diagnosis is made. I encourage all patients who suffer from gynecomastia that is unrelated to a medical condition, or to normal physiologic changes, to seek medical evaluation as soon as possible. Put simply, if a mound in your breast area causes psychological distress, I would strongly recommend that you remove the source of distress, rather than live with it. It is my experience that the risks of non-treatment are very significant, compared to the benefits of a relatively straightforward correction of gynecomastia.
Patient satisfaction with this procedure is very high. Most of my patients agree that the procedure has positively impacted their lives (in many cases, it has been revolutionary). I derive much professional and personal satisfaction treating gynecomastia patients because I have witnessed, first hand, how my patients have benefited both physically and emotionally from it.
