- Men's health
- Anesthesia and Pain Management
- Cosmetic Surgery
- Plastic & Reconstructive Surgery
- Gynecology Surgery
- What is Gynecomastia
- Effects of Gynecomastia
- What are the potential causes of Gynecomastia
- What are the symptoms?
- What are the risk factors of Gynecomastia?
- What complications are involved?
- What are tests for Gynecomastia?
- Coping and Support/Psychological Issues
- Treatments and DrugsGynecomastia Procedures
- Surgical Remedies
- Candidates for Gynecomastia
- Your Consultation
- Planning your procedure
- Preparation of your surgery
- The Gynecomastia procedure
- Options and alternatives
- The surgical facility
- Your Surgery
- Post Operative Experience
- What type of anesthesia will be used for this procedure?
- How long will the procedure take?
- How will I feel after the procedure?
- How long can I return to work after the surgery?
- Will the procedure leave scars?
- What is the best way to find a Plastic Surgeon?
- How can I tell if a particular Plastic Surgeon is experienced with GRS (Gynecomastia Reduction Surgery)?
- Will my insurance company pay for GRS?
- What if my insurance company denies my claim? What are my options? Do patients ever win appeals?
- What is the best way to approach my insurance company?
- How much does the surgery cost?
- What blood tests should be done before surgery?
- Who should do the testing and evaluation of blood tests?
- Does it matter what causes Gynecomastia?
- Is there a minimum age requirement for patients interested in GRS?
- Is there a maximum age limit for patients interested in GRS?
- What medical conditions would prevent me from having GRS?
- Will there be any scarring?
- What is the most common technique for GRS?
- I understand that there are two types of liposuction, tumescent and ultrasonic. Is one better than the other?
- I have large pendulous breasts. How do you remove them and how much scarring will there be?
- I am 30 pounds overweight. How will this impact my surgery?
- What do I need to do in preparation for surgery?
- What is the recovery time following GRS?
- What do I tell my employer, family and friends?
- How long will I be in the hospital? Will I have to stay overnight?
- How much pain will I be in post-surgery and for how long?
- Some doctors use drains and others do not, what is the difference?
- What kind of stitches do you use externally? How long will they be there?
- Do I need to avoid exposing my scars to the sun after my procedure? I have heard that it is recommended not to tan for a year, is this true?
- What if I don't like my results? Will I need to have more than one surgery?
- Do I need to wear a compression vest? What is it for? How long do I have to wear it?
- When can I return to work?
- Are there any post-operative complications that I should be aware of, i.e. painkillers, constipation, excessive swelling, etc.?
- Am I a candidate for male breast reduction?
- Am I too young to have gynecomastia surgery?
- How do I choose the right Plastic Surgeon?
- What results can I expect?
- How many procedures of this nature has the surgeon performed?
- What kind of scar should I expect?
- Will I have pain that will require medication?
- How much time should I take off from work or school?
- What types of anesthesia do you offer?
- Is the operating room certified?
- How should I prepare for the surgery?
- What type of dressing will I have?
- Will I have a drain?
- Should I change my own dressing?
- Will my health insurance cover this procedure?
- What can cause gynecomastia?
What is Gynecomastia?
Gynecomastia is a medical term that is rooted from Greek language, which means “women-like breasts”. This condition actually affects an estimated 40 to 60 percent of men but to different degrees. There is no distinct cause in the vast majority of Gynecomastia, although certain drugs and medical problems have been linked with male breast over-development.
Gynecomastia is a benign condition that accounts for 60% of all disorders of the male breast and 85% of male breast masses. It can occur in persons of any age, but 40% of cases occur in adolescent boys aged 14-15.5 years. As many as 65% of teenage boys have gynecomastia. In 90% of those teenage boys, gynecomastia goes away on its own in 2 to 3 years. Approximately 40% of healthy men and up to 70% of hospitalized men have palpable breast tissue. The prevalence rate increases to more than 60% in those in their seventies.
Gynecomastia is swelling of the breast tissue in boys or men, caused by an imbalance of the hormones estrogen and testosterone. Newborns, boys going through puberty and older men often develop gynecomastia as a result of normal changes in hormone levels. There are other causes as well.
Generally, gynecomastia isn't a serious problem, but it can be tough to cope with. Men and boys with gynecomastia sometimes have pain in their breasts and may feel embarrassed.
Gynecomastia may go away on its own. Gynecomastia can also be treated with medications that help balance hormone levels. In some cases, surgery to remove breast tissue also may be an option.
The condition is relatively common in adolescent boys, and 90% of the time symptoms disappear in a matter of months, or, as adolescence wanes, a few years later. But the remaining 10% are burdened with a social handicap that causes a deep and complex shame, and puts one's relationship with one's body at risk. Most commonly gynecomastia is caused by excess glandular tissue (localized fat deposits). Male breast reduction surgery can help men feel better about their appearance by creating a more masculine chest contour.
Some men and boys have fat on their chests that makes it look like they have breasts. This condition is called pseudogynecomastia (false gynecomastia). It's not the same thing as gynecomastia, they may just be overweight.
Through Gynecomastia, or Male Breast Reduction, a flatter, firmer and better-contoured chest is achieved. Breast-reduction surgery may greatly benefit men who feel self-conscious about their appearance. The procedure eliminates fat tissue from the breasts, achieving a chest that is flatter, firmer, and better-contoured.Obesity, hormonal metabolism imbalance, liver disease, or medicinal effects may be some of the causes of Gynecomastia. Before taking a surgical solution to Gynecomastia, a period of diet and exercise is required. A surgical intervention may be performed should all else fail.
Effects of Gynecomastia
For young boys, having enlarged breasts may take only a few years, and in most cases resolved at the age of 18. However, enlarged breasts on men can be awkward, not to mention socially and psychologically destructive.
In today’s demanding corporate world, looking your best is essential. This is the reason why an increasing number of men opt to have cosmetic surgery, a trend that studies have proven is associated with career development. A study showed that 84 percent of men surveyed deemed that physical appeal is vital in attaining power and success on the job.
Many patients who went through breast reduction surgery are pleased with their new, attractive shape and have boosted their self-confidence.
What are the potential causes of Gynecomastia
Gynecomastia is triggered by a decrease in the amount of the hormone testosterone compared with estrogen. The cause of this decrease can be conditions that block the effects of or reduce testosterone or by a condition that increases your estrogen level. Several things can upset the hormone balance, including:
Natural hormone changes (The testosterone-estrogen balance)
The hormones testosterone and estrogen control the development and maintenance of sex characteristics in both men and women. Testosterone controls male traits such as muscle mass and body hair; estrogen controls female traits including the growth of breasts.
Most people think of estrogen as an exclusively female hormone, but men also produce it — though normally in small quantities. Estrogen helps regulate bone density, sperm production and mood. But male estrogen levels that are too high or are out of balance with testosterone levels can cause gynecomastia.
Gynecomastia in infants
More than half of male infants are born with enlarged breasts due to the effects of their mother's estrogen. Generally the swollen breast tissue goes away within two to three weeks after birth.
Gynecomastia during puberty
Gynecomastia caused by hormone changes during puberty is common. In most cases, the swollen breast tissue will go away without treatment within six months to two or three years.
Gynecomastia in men
The prevalence of gynecomastia peaks again between the ages of 50 and 80. At least one-quarter of men are affected during this time.
- A number of medications can cause gynecomastia. These include certain:
- Anti-androgens used to treat prostate enlargement or cancer and some other conditions. Examples include cyproterone, flutamide, finasteride and spironolactone.
- AIDS medications. Gynecomastia can develop in HIV-positive men who are receiving a treatment regimen called highly active antiretroviral therapy (HAART). Efavirenz is more commonly associated with gynecomastia than are other HIV medications.
- Anti-anxiety medications, such as diazepam (Valium).
- Tricyclic antidepressants.
- Ulcer medications, such as cimetidine.
- Cancer treatment (chemotherapy).
- Heart medications, such as digitalis and calcium channel blockers.
Street drugs and alcohol
Substances that can cause gynecomastia include:
- Anabolic steroids and androgens
Certain health conditions
Several health conditions can cause gynecomastia by affecting the normal balance of hormones. These include:
- Hypogonadism. Any of the conditions that interfere with normal testosterone production, such as Klinefelter syndrome or pituitary insufficiency, can be associated with gynecomastia.
- Aging. Hormone changes that occur with normal aging can cause gynecomastia, especially in men who are overweight.
- Tumors. Some tumors, such as those involving the testes, adrenal glands or pituitary gland, can produce hormones that alter the male-female hormone balance.
- Hyperthyroidism. In this condition, the thyroid gland produces too much of the hormone thyroxine.
- Kidney failure.
- Liver failure and cirrhosis.
- Malnutrition and starvation.
- Herbal products Plant oils, such as tea tree or lavender, used in shampoos, soaps or lotions, have been associated with gynecomastia. This is probably due to their weak estrogenic activity.
In about 25 percent of cases, the cause of gynecomastia is never found.
What are the Symptoms
Signs and symptoms of gynecomastia include:
- Swollen breast gland tissue
- Breast tenderness
Gynecomastia is not physically harmful, but in some cases can be an indicator of other more serious underlying conditions. Growing glandular tissue, typically from some form of hormonal stimulation, is often tender or painful. Furthermore, it can frequently present social and psychological difficulties for the sufferer. Weight loss can alter the condition in cases where it is triggered by obesity, but losing weight will not reduce the glandular component and patients cannot target areas for weight loss.
Massive weight loss can result in sagging tissues about the chest, chest ptosis. The size and geometry of the fibro-glandular tissue present is unique to each patient. This results in a range of physically apparent aesthetic deformities, for which, classification systems have been devised
There are multiple manifestations of gynecomastia. The following types have the same basic features of gynecomastia in common, namely, hypertrophy of the male breast glandular tissue, but vary in size, shape, and the extent to which they are intermixed with adipose and fibrous tissue.
Puffy Nipples is among the most common forms of gynecomastia. This glandular tissue accumulation is concentrated under and typically confined to the areola, or can be slightly extended outside the areola forming a dome shaped appearance to the areola.
In bodybuilders this may be a result of the use of anabolic steroids. Due to their low level of body fat, bodybuilders and other athletes are sometimes afflicted with gynecomastia in its purest form. Gynecomastia in lean men is usually only a breast tissue gland with little to no adipose tissue. Proper treatment of pure gynecomastia can be done only by excision of the breast tissue, which in the case of bodybuilders is by itself sufficient to achieve a flat nipple-areola complex. Liposuction is only rarely necessary.
Congenital or Hereditary Gynecomastia is typically evident by the ages of 9 to 14 in boys. Thirty percent to sixty percent of young boys suffer from large male breasts. As many as thirty percent may live with enlarged male breasts for the rest of their lives, but in other cases the gynecomastia will recede with age. However, severe forms of adolescent gynecomastia may require an intervention, in consultation with the patient, the parents, and child development professionals.
The most common form of gynecomastia. Gynecomastia in most adults is composed of glandular tissue but may contain varying quantities of adipose and fibrous tissue.
Pseudogynecomastia is composed not of glandular tissue, but of adipose tissue. It looks much like real gynecomastia but requires different treatment. Exercise and diet may be effective in combating pseudogynecomastia. Only if this regimen is unsuccessful should surgery be considered. This is generally the only type of gynecomastia which can be improved with liposuction, but excision may be indicated in some cases. This is also known as "false Gynecomastia" and is often attributed by obesity whereby insulin interacts with an excess of sugars or certain carbohydrates, namely those of which that have been processed.
Unilateral gynecomastia occurs when only one breast is larger due to gynecomastia, the other breast is typically normal in both size and shape. Bilateral Asymmetry occurs when gynecomastia is present in both breasts, each to a different degree.
Severe gynecomastia is characterized by excess and/or saggy skin and severely enlarged breasts. This is itself determined in part by age, as older persons suffering from gynecomastia tend to have less skin elasticity and thus will have a greater abundance of excess skin related to gynecomastia. Experienced plastic surgeons will perform as much of the surgical treatment of severe gynecomastia as possible through an aereolar incision so as to avoid extensive scarring. However, some scarring may be unavoidable when treating extreme cases of gynecomastia.
What are the risk factors of Gynecomastia?
Risk factors for gynecomastia include:
- Older age
- Use of anabolic steroids or androgens to enhance athletic performance
- Certain health conditions, including liver and kidney disease, thyroid disease, hormonally active tumors, and Klinefelter syndrome
What complications are involved?
Although there are few physical complications associated with gynecomastia, having this condition can cause psychological or emotional trouble caused by appearance.
What are tests for Gynecomastia?
Your doctor will ask you questions about your medical history, what medications you're taking and what health conditions run in your family. The doctor will also do a physical examination that may include careful evaluation of your breast tissue, abdomen and genitals.
Your doctor will want to be sure your breast swelling is actually gynecomastia and not another condition. Other conditions that can cause similar symptoms include:
- Fatty breast tissue. Some men and boys have chest fat that resembles gynecomastia. This is called pseudogynecomastia or false gynecomastia, and it isn't the same as gynecomastia.
- Breast cancer. This is uncommon in men, but can occur. Enlargement of one breast or the presence of a firm nodule raises the concern for male breast cancer.
- A breast abscess (mastitis).
Initial tests to determine the cause of your gynecomastia may include:
- Blood tests
You may need further testing depending on your initial test results, including:
- Chest X-rays
- Computerized tomography (CT) scans
- Magnetic resonance imaging (MRI) scans
- Testicular ultrasounds
- Tissue biopsies
Coping and Support/Psychological Issues
Gynecomastia can be emotionally devastating. Feelings of shame, embarrassment and humiliation are common. One does not feel masculine in a society where masculinity is exalted. Self-hate threads itself through all aspects of the individual's life, creating an insidious web of powerlessness. A man or boy with gynecomastia struggles with anxiety over such simple acts as taking off his shirt at the beach.
For many men, the best solution is surgery. That accomplishes step one of the healing. Step two is psychological redress. From childhood taunting to a lifetime of hating his chest, the hurt feelings will not go away with the fact of breast reduction alone.
Men who have developed gynecomastia later in life from steroid abuse or some other cause may have little to no psychological distress. However, for some in this situation, it can leave them feeling out of control of their body or emasculated in some matter. Hopefully, corrective surgery will resolve these feelings, for some it will not and therapy will needed to relieve the distress.
It is important to recognize the scars on the inside. This is difficult work because it means coming to terms with one's body and past. Acknowledging the pain, moving into a new relationship with one';s body and changing how he thinks the world sees him is the key to healing and freedom.
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.
For a man, enlarged breasts can be stressful and embarrassing. Gynecomastia can be difficult to hide and a challenge to romantic relationships. During puberty, gynecomastia can make boys a target for teasing from peers. It can make activities like swimming or changing for gym class traumatic.
Whatever your age, you may feel like your body has betrayed you and you may feel unhappy with yourself. These feelings are normal, but there are a few things you can do to help you cope:
- Get counseling.Talk therapy can help you avoid anxiety and depression caused by gynecomastia. It can also help you communicate with your partner or family members so that they understand what you're going through.
- Reach out to your family and friends.You may feel embarrassed to talk about gynecomastia with the people you care about. But explaining your situation and asking for help will likely strengthen your relationships and reduce stress.
- Connect with others who have gynecomastia.Talking with men who have had a similar experience can help you cope. Web sites such as Gynecomastia.org provide a forum for connecting with others who have the condition.
There are a few factors you can control that may reduce the risk of gynecomastia, including:
- Don't use illicit drugs. Examples include steroids and androgens, amphetamines, heroin, and marijuana.
- Avoid alcohol. Don't drink, or drink very little.
- Review your medications. If you';re taking medication known to cause gynecomastia, ask your doctor if there are other choices.
Treatments and Drugs for Gynecomastia
Most cases of gynecomastia regress over time without treatment. However, if gynecomastia is caused by an underlying condition, such as hypogonadism, malnutrition or cirrhosis, that condition may need treatment. If you're taking medications that can cause gynecomastia, your doctor may recommend stopping them or substituting another medication.
In adolescents with no apparent cause of gynecomastia, the doctor may recommend periodic re-evaluations every three to six months to see if the condition improves on its own. Gynecomastia often goes away without treatment in less than three years. However, treatment may be necessary if gynecomastia doesn't improve on its own, or if it causes significant pain, tenderness or embarrassment.
Medications used to treat breast cancer and other conditions, such as tamoxifen and raloxifene, may be helpful for some men with gynecomastia. Although these medications are approved by the Food and Drug Administration, they have not been approved specifically for this use.
Surgery to remove excess breast tissue
If you still have significant bothersome breast enlargement despite initial treatment or observation, your doctor may advise surgery. Two types of surgery are used to treat gynecomastia:
- Liposuction. This surgery removes breast fat, but not the breast gland tissue itself.
- Mastectomy. This type of surgery removes the breast gland tissue. The surgery is done on an endoscopic basis, meaning only small incisions are used. This less invasive type of surgery involves less recovery time.
In cases of obesity, weight loss can alter the gynecomastic condition, but for many it will not eliminate it. For all other causes, surgery is the only known physical remedy. Once the physical encumbrance is lifted, psychological scars still need to be addressed. One must come to terms with one's body, accept it, and heal the wounds from the past.
Treating the underlying cause of the gynecomastia may lead to improvement in the condition. Patients should talk with their doctor about revising any medications, such as risperdal, that are found to be causing gynecomastia; often, an alternative medication can be found that avoids gynecomastia side-effects, while still treating the primary condition for which the original medication was found not to be suitable due to causing gynecomastia side-effects (e.g., in place of taking spironolactone the alternative eplerenone can be used). Selective estrogen receptor modulator medications, such as tamoxifen and clomiphene, or androgens (typically testosterone) or aromatase inhibitors such as Letrozole are medical treatment options, although they are not universally approved for the treatment of gynecomastia.
Endocrinological attention may help during the first 2–3 years. After that window, however, the breast tissue tends to remain and harden, leaving surgery (either liposuction, gland excision, skin sculpture, reduction mammoplasty, or a combination of these surgical techniques) the only treatment option.
Many American insurance companies deny coverage for surgery for gynecomastia treatment on the grounds that it is a cosmetic procedure. Radiation therapy is sometimes used to prevent gynecomastia in patients with prostate cancer prior to estrogen therapy. Compression garments can camouflage chest deformity and stabilize bouncing tissue bringing emotional relief to some. There are also those who choose to live with the condition.
The following procedures should be discussed with an experienced Board Certified Plastic Surgeon who will help you choose the technique best suited for each individual.
- For pseudogynecomastia: Men Liposuction or lipo sculpture of the of the pseudogynecomastia is used to remove the fatty tissue by suction using a negative pressure source (pump or syringe). Usually performed with tumescent method to decrease bleeding.
- For true Gynecomastia: Excision of the male breast tissue. This real gynecomastia tissue cannot be suctioned and has to be removed by surgical excision - male breast reduction. Usually performed through the lower part of the aerola (between the pigmented part and the skin). When done properly, this usually leaves inconspicuous scars (athletes and body builders cannot afford prominent scars).
- For a combined pseudogynecomastia (fatty tissue) and true gynecomastia (breast tissue) The treatment of choice is a combination of surgical excision and liposuction for men (for better breast contour).
- For treatment of severe Gynecomastia. For easy understanding, we will compare the male breast size to the female breast size (A, B, C, D, DD, etc.) and as such, there are a few modalities of treatment available:
- Periaureolar (incision around the nipple aureola complex) male breast reduction: this procedure is meant for mild to moderate reductions. This can be compared to size A and B in women.
- Classical breast reduction with superior or inferior flaps: this is for larger breasts (C, D) and leaves an inverted xTx incision and periaurieolar incision. It is used very rarely.
- Vertical incision breast reduction that results in a vertical subareolar scar (not horizontal scar) in large breasts: this is new and exciting alternative.
Candidates for Gynecomastia
Gynecomastia surgery is best recommended for healthy men who have overly developed breasts. Overweight or obese men who have not sought exercise or weight loss as preliminary solutions are discouraged from undergoing surgery. Gynecomastia is also not recommended for individuals who drink too much alcoholic beverages or smoke marijuana. These drugs, combined with anabolic steroids, may cause Gynecomastia. Patients are advised first to stop the use of these drugs to know if the breast fullness will be reduced before resorting to surgery.
BHMG’s Certified Surgeon will discuss with you your goals and expectations of the surgery. The doctor will evaluate the nature of your breasts and the elasticity of your skin to determine the cause of your breast enlargement, which can be brought about by fatty tissue and/or glandular tissue.
Your doctor may present you several pre- and post-surgery photographs of patients having similar breasts. The procedure will then be explained to you as well as the possible outcome.
Planning your procedure
The initial consultation with your surgeon will require your complete medical history, so you will want to be prepared to provide the necessary information. Your surgeon will examine your breasts and discuss lifestyle issues which may be causing your condition. You must be completely open and honest with your surgeon. If there is impaired liver function or another medical problem, you will be referred to a specialist.
A mammogram or breast x-ray may be recommended to determine how much fat and glandular tissue is contained in the breasts. The very small possibility of breast cancer can also be ruled out. With all of this information, your surgeon can plan the best procedure for your needs.
This consultation is also the time to ask all of your questions about the treatment and costs. If you have health insurance, treatment of Gynecomastia may be covered. Call your carrier, and if you are covered, obtain written pre-authorization for the treatment. Your surgeon's office staff will assist you with this.
Preparation of your surgery
You will be given specific instructions, including diet, taking certain vitamins and medications, and stopping cigarette or other smoking for at least one to two weeks prior to your procedure, and during your recovery. You must follow your surgeons instructions carefully. Smoking decreases circulation and impedes healing.
The Gynecomastia Procedure
Male Breast Reduction is done on an outpatient basis with the use of a general anesthesia. The procedure takes from 1 to 3 hours depending on the extent of correction.
Before surgery you will have a complete medical checkup to rule out any curable medical cause of your enlarged breasts. Obesity, impaired liver function, excessive use of alcohol or marijuana, estrogen containing medications and anabolic steroids can all contribute to gynecomastia. If any of these conditions are detected, they must be corrected before surgery can be performed. Overweight men are encouraged to diet and exercise prior to their surgery.
Your surgeon will make an incision under your breasts or around the areola (the dark skin around the nipple). Liposuction is usually the treatment of choice to remove these excess localized fat deposits. Persistent excess glandular tissue, fat and skin can be surgically removed from around the areola and from the bottom and sides of the breasts to create a new smaller breast contour if liposuction is not indicated.
Swelling and bruising are normal and will subside over the next few weeks. You will need to wear an elastic bandage or pressure garment as your breasts heal. Scarring is usually minimal and will fade with time. You should avoid direct sun exposure for six months.
Options and Alternatives
Liposuction is preferred if your Gynecomastia shows fatty tissues as the primary cause. Liposuction surgery is the process used to actually take out unwanted loaclized deposits of fat cells from the body. A straw-like cannula is inserted through a tiny incision placed in an inconspicuous location on the skin. With the use of a vacuum system attached to the cannula, excess fat cells are sucked out. The result is the transformation of bulging breasts into more attractive contours.
Traditional Surgical Excision
Should your Gynecomastia prove to be a result of a glandular disorder, liposuction alone may not likely be beneficial. Traditional surgical excision may be the best way to go.
The excision may be done alone or in combination with liposuction. The incision is typically placed on the edge of the areola (colored area of the nipple) or in the underarm area. What your surgeon will do is he will work through these incisions to eliminate the excess glandular tissue, fat, and skin from the breast. If your reduction necessitates the removal of significant amounts of tissue, larger incisions may be required.
In extreme cases where there are large amounts of fat and/or glandular tissue that have to be removed, excess skin may also have to be excised.
Silicone implants for men are called "Pec" implants. These are used to enhance the pectoral muscles of a man’s chest. Pec implants can be inserted simultaneously with your breast reduction surgery and may add an hour to the process.
The surgical facility
Your breast reduction surgery will most likely be an outpatient procedure, performed at your surgeon's office surgical suite, ambulatory surgical center, or hospital. If there are medical conditions of concern, an overnight hospital stay may be recommended. The procedure typically takes an hour and a half to complete, although individual factors may increase the length of the surgery.
Your surgeon will choose either general anesthesia or local anesthesia with sedation. Your surgeon will discuss this with you during the surgery planning and will explain the basis for the option recommended.
In a typical procedure, an incision is made in an inconspicuous location - either on the edge of the dark skin around the nipple, or in the underarm area. Through the incision, the surgeon cuts away the excess glandular tissue, fat and skin from around the areola and from the sides and bottom of the breast. If your surgeon has determined that liposuction will be used in conjunction with excision to remove excess fat, the cannula can be inserted through the incisions. In a reduction involving greater amounts of excess tissue, larger incisions may be necessary and can result in more noticeable scars.
If your surgeon has determined that your Gynecomastia consists primarily of excessive fatty tissue, liposuction would be an appropriate surgical technique for removal of this tissue. At the edge of the areola, the dark skin that surrounds the nipple, a very small incision, less than a half inch in length is made. Depending on individual factors and preferences, the incision may be made in the underarm area. A cannula, which is a slim, hollow tube attached to a vacuum pump, is inserted into the incision. Your surgeon moves the cannula through the layers beneath the skin, breaking up the fat and suctioning it out.
In cases where large amounts of tissue have been removed, it may be necessary for excess skin to be removed so that the remaining skin will adjust to fit the new breast contour.
Occasionally, a small drain will be inserted through a separate incision to relieve excess fluids. Upon completion, the incisions are usually covered with a dressing and the chest may be wrapped with an elastic bandage to hold the skin firmly in place.
Post Operative Experience
It is normal to feel some discomfort for a few days after your procedure. This can be controlled with medication prescribed by your surgeon. You should arrange to be driven home after your surgery and have someone to help you manage for a day or two if necessary.
Bruising and swelling may make it appear that there's been no improvement in your condition initially. You will most likely be told to wear an elastic pressure garment around the clock for a week or two, and for several weeks longer at night. The extreme swelling will resolve in the first few weeks but it may be three months or longer before your true result is visible.
While you are waiting for this, it is important to begin to resume normal activity. You should walk around on the day of surgery, and return to work within a day or two, as soon as you feel well enough. If you have stitches, they will be removed one to two weeks after the surgery.
You should avoid sexual activity for a week or two, and heavy exercise for about three weeks. You must avoid any activity or job that risks a blow to the chest area for at least a month. Avoid exposing scars to the sun for at least six months. Sunlight can cause the scar to darken permanently. If sun exposure is unavoidable, use a strong sunblock.
Bed rest is advised for the first day. You will experience some pain for a couple of days. For the first few days after your surgery, you will have to wear surgical dressings which will be substituted for a special compression garment. This will have to be worn for a period of two weeks. Your surgeon may prescribe oral medication for the control of discomfort related with breast surgery. Antibiotics may also be prescribed.
A majority of men who undergo the procedure experience some degree of swelling, bruising, and tenderness. These symptoms should mellow down in a short time. Within about two weeks, all sutures are cleared away. Your surgeon will discuss with you the appropriate time of returning to your normal activities. Most patients are back to work within the first week.
As with any other surgery, the risks with a procedure like this involves bleeding, infection, numbness, poor healing or a reaction to anesthesia. The specific risks of Male Breast Reduction surgery can be discussed thoroughly in your personal consultation with our doctors.
You can minimize the risk of bleeding by terminating Aspirin products a few weeks before your surgery, as well as two weeks after your surgery. Patients can diminish the risk of poor blood supply or dead tissue by not smoking before or after the surgery.
Certain specific risks of male breast reduction surgery:
- When male breast reduction is performed by an experienced plastic surgeon, complications are infrequent.
- Scarring can be minimized when the incision is done correctly and in the proper location. In my experience, noticeable scarring is minimal. Should adjustment be necessary, this can be done using several treatment modalities including Kenalog injection, laser and revision.
- Hypoesthesia (reduced areola sensation). This condition usually improves within six months post surgery. Based on my experience, this has not been a major issue.
- Areola or breast depression:
- Static - Can be seen when the pectoral muscle is relaxed. This is the most severe form and sometimes requires correction.
- Dynamic - Can be seen only when the patient lifts his arm or flexes the pectoral muscle. This is usually less bothersome to the patient.
- Correction for these conditions:
- Fat transfer
- Fat and dermis transfer
- Injection of Radiance, etc
- Recurrence of the breast tissue occurs, according to recent literature on the subject, 10% after excision and 35% after male liposuction only. The best solution is prevention which requires a plastic surgeon who is experienced in this type of surgery. In my practice, this has occurred in less than 1% of my patients (intake of steroid after the surgery might increase recurrence rate).
- Patient who have large areolas prior to surgery: This can be addressed during surgery in several ways:
- Adequate thinning of the areola. In many cases this is enough to reduce the size. (should be done by a plastic surgeon who is experienced with this technique).
- Pursestring sutures of the areola and nipple complex.
- Surgical excision of the areola, which I rarely perform.
- Hematoma and Seroma: this accumulation of blood and blood products may cause excessive swelling of the breast after the Gynecomastia treatment surgery which sometimes requires intervention. This occurs more often in the following circumstances:
- People who suffer from high blood pressure.
- People who take aspirin or blood thinners prior to surgery.
- People who take certain food supplements.
- People who take anabolic steroids prior to surgery.
- People who do not follow postoperative instructions.
The Final Result
Gynecomastia surgery can greatly improve your appearance and boost your self confidence, but individual results are unpredictable. Before undergoing any plastic surgery procedure, discuss your expectations candidly with your surgeon. The results of the procedure are significant and if you have realistic expectations, you will be extremely satisfied with your improved physique.
Frequently Asked Questions
What type of anesthesia will be used for this procedure?
General or local anesthesia with sedation is often utilized in Gynecomastia surgery procedures.
How long will the procedure take?
The Gynecomastia surgery usually takes between 1 to 3 hours.
How will I feel after the procedure?
The healing process of each patient varies. Some may experience temporary pain, swelling, some bruising, soreness, numbness, a burning sensation, or fatigue.
How long can I return to work after the surgery?
Recovery periods may vary, but patients who have undergone Gynecomastia surgery are oftentimes able to go back to work within 5 days to one week following the surgery. It should be noted though that exercise and any strenuous activities should wait until after 3 to 6 weeks after the surgery.
Will the procedure leave scars?
It will take a period of time for the small incisions around the areola to fade and flatten. Topical scars can be improved with topical gel.
What is the best way to find a Plastic Surgeon?
Do your research. It's always a good idea to check your potential surgeon's credentials with your medical board, as well as your local medical society and hospitals in your area.
How can I tell if a particular Plastic Surgeon is experienced with GRS (Gynecomastia Reduction Surgery)?
Your potential surgeon should display confidence during the initial consultation. Ask to see before and after photos of previous Gynecomastia patients. The surgeon may be able to put you in contact with previous GRS patients. Most importantly, ask the surgeon how frequently he/she performs GRS each year. As the old saying goes... practice makes perfect!
Will my insurance company pay for GRS?
Unfortunately in most cases they will not cover this procedure. I have had only one insurance company agree to cover a case.
What if my insurance company denies my claim? What are my options? Do patients ever win appeals?
If your insurance company denies your initial request for coverage, you can always file an appeal. Most appeals are not won, however there have been a few cases that have prevailed.
What is the best way to approach my insurance company?
When requesting coverage for GRS, it is most important to inform them that you have a congenital condition and that you experience breast tenderness if this is the case for you. If you are overweight, it would be a good idea to get as close to your ideal weight prior to making a claim, as this can have an affect on their decision.
How much does the surgery cost?
In the USA, the average total cost of GRS is around $6000 to $7,500, broken down as follows:
- Surgeon's fee: $3,000 to $5,000
- Certified Operating Facility fee: $1,500 to $1,800
- Anesthesia fee: $275/hr. (Board Certified Anesthesiologist)
- Miscellaneous costs: Compression vest, lab tests, pathology and prescriptions
What blood tests should be done before surgery?
A "CBC," or complete blood count, is required of all our surgical patients. For GRS patients, a "PT/PTT" may possibly be requested if you have been using any type of aspirin-containing medications or certain types of vitamins/supplements. This test measures your "clotting mechanism".
Who should do the testing and evaluation of blood tests?
You can have the testing done at any lab convenient for you. The results should be faxed to your surgeon and anesthesiologist for evaluation before surgery.
Does it matter what causes Gynecomastia?
Yes. Gynecomastia can be drug induced (i.e. steroids, excessive marijuana or alcohol use). Medications such as Propecia (prescribed for hair loss) can also cause Gynecomastia. It is highly advisable to discontinue the use of these substances prior to surgery.
Is there a minimum age requirement for patients interested in GRS?
There is not a minimum age requirement for GRS, however many surgeons prefer to wait until the sufferer has completely finished puberty (18-20 years old). The reason for this being that for many teens who are still in their pubescent period, the Gynecomastia they're experiencing can, and usually will, go away on its own. The surgeon will use his clinical judgment if the case is severe and causing severe social/psychological issues. This may encourage surgery at a younger age.
Is there a maximum age limit for patients interested in GRS?
There is not an age limit for GRS, however if you have any medical conditions that could compromise your health during surgery, your surgeon may be hesitant to proceed or decline to perform the surgery altogether.
What medical conditions would prevent me from having GRS?
It is very rare for a patient to be turned down for surgery, however there are some serious medical conditions that can cause concern. Severe heart disease, malignant hyperthermia or severe bleeding disorders would be reasons for a surgeon to deny service.
Will there be any scarring?
If the surgeon removes glandular tissue, he/she will make a small peri-areolar incision, a half-circle incision around the lower half of the areola. In most cases the surgeon will also perform liposuction to sculpt the chest into the best contour/shape possible. Whichever technique your surgeon uses, there will be scarring afterward. However within 6 months to a year most scars fade to the point where you cannot distinguish them from your normal skin.
What is the most common technique for GRS?
The most common technique for GRS is where the surgeon makes a peri-areolar incision to remove glandular tissue and then performs liposuction of the area for definition. Some surgeons only use liposuction, but in most cases I think this is a mistake unless it is pseudo-gynecomastia (all fat content). Twenty percent of my practice is re-do surgery from unhappy patients. This is most often due to the technique of liposuction only. This leaves the glandular tissue behind.
I understand that there are two types of liposuction, tumescent and ultrasonic. Is one better than the other?
The tumescent technique is the gold standard for liposuction. Basically, the surgeon enlarges the area to be suctioned with a large amount of sterile fluid combined with a vaso-constrictive agent such as epinephrine to reduce bleeding. The fat and the fluid are then suctioned out. Ultrasonic liposuction uses sound waves to break up fat which is then suctioned out. In my opinion, there is no advantage to this technique and I do prefer tumescent. In some surgeons' hands it works very well.
I have large pendulous breasts. How do you remove them and how much scarring will there be?
This is a very different and often more complicated problem. The skin has a tremendous ability to contract, especially if a patient is young. I usually do an aggressive sub-cutaneous mastectomy (breast removal) with liposuction. At the end of the procedure, I usually place drains in the area to allow fluids to drain for a few days following the surgery. Foam padding and a compression garment are also used as part of the post-op care. I have only had to perform a full breast reduction on one patient in the past that had a very extreme case of gynecomastia. I try to avoid these extensive scars at all costs.
I am 30 pounds overweight. How will this impact my surgery?
Gynecomastia does not react to either weight loss or gain. The breast is composed of breast glands and fatty tissue. The change in body weight can affect the fat content of the chest. The breast gland will increase in size due to hormones or other drugs, like steroids.
What do I need to do in preparation for surgery?
It is absolutely necessary to quit smoking starting at least 2 weeks prior and continuing until four weeks after your surgery. Do not take any aspirin-containing products, such as Advil/ibuprofen or any other drugs that promote excessive bleeding. Herbal remedies such as St. John's Wort, Ginkgo Biloba, Fish Oil, Flax Seed Oil and excessive amounts of Vitamin E can cause excessive bleeding. Bottom line is it is best to avoid all medications/vitamins/supplements such as these for two weeks prior and two weeks after your procedure. In my practice we supply the patient with a comprehensive booklet of pre-operative instructions before the surgery, clearly outlining these recommendations.
What is the recovery time following GRS?
The initial recovery period is the 7 to 10 days right after your procedure. If drains are used, they will typically remain in for about three days after which they will be removed at your first post-op appointment. Total recovery time can vary from patient to patient. Most patients can expect to be fully healed by 3-6 months. At this point most or all of the bruising and swelling should have dissipated and the scars should have begun to shrink and fade. Sometimes, it may take as long as a year to completely heal to the point where the scars are no longer visible.
For the first 4 to 6 weeks after surgery, it is necessary to avoid all strenuous activities, especially those involving the upper body such as lifting weights or intense workouts at the gym. In addition I advise my patients to wear a compression garment for 6 weeks post-operatively.
You as a patient have invested a lot of time and money into this procedure, and as such you owe it to yourself to also invest the time and patience needed for healing in order to achieve optimum results.
What do I tell my employer, family and friends?
All medical conditions and patient records are confidential. At my practice, we gladly provide any letters/paperwork necessary to excuse you from work. We can provide such medical excuses without giving any details to your employer by simply stating it is for a medical condition. Your employer does not have the right to know what your surgery is for. Your medical information is between YOU and your DOCTOR and nobody else!
As for family and friends, you can tell them exactly what your surgery is for or you could tell them that you are having 'benign lumps' removed from your chest. Saying that you are having benign lumps removed is not lying and more than likely they will not pressure you into divulging anymore information than that.
Gynecomastia is a very common procedure, and yet, we have many patients that don't want to tell anyone that they are having GRS. It is completely normal to not want to share the details of your surgery with anyone, and it is at your discretion to do so if and when you feel the time is appropriate.
How long will I be in the hospital? Will I have to stay overnight?
This is a same-day outpatient surgical procedure. The actual surgery takes about 2½ to 3 hours. After your surgery, you will be taken into recovery for at least one to one and a half hours to be observed and attended to by a nurse. Once your surgeon feels you are in a stable enough condition, you are released to return home. It is necessary to have a family member or close friend escort you home and stay with you for at least the first 24 hours.
How much pain will I be in post-surgery and for how long?
A long-acting local anesthesia will last at the surgical site for about 24 hours. When this wears off, you may begin to experience moderate discomfort for about another 24 hours. After that, most patients only experience minimum discomfort and most never complain of any severe pain, only soreness of the area. Regardless of you pain level after surgery, I always prescribe pain medication for you to have on hand should you need it.
Some doctors use drains and others do not, what is the difference?
I use drains in most of my cases. Drains help reduce swelling and promote better skin condition following your procedure. Remember, the function of a drain is simple. It allows the fluid underneath the skin to drain into a small bulb/bottle, where it can easily be emptied by the patient. This prevents such fluid from collecting inside the body and needing to be drained by other means.
What kind of stitches do you use externally? How long will they be there?
I use very thin 6-0 nylon sutures that are removed 7 to 10 days after surgery.
Do I need to avoid exposing my scars to the sun after my procedure? I have heard that it is recommended not to tan for a year, is this true?
Early sun exposure to your incisions after surgery is not advisable. To avoid scar pigmentation, you should use sunblock on your scars for 3 to 6 months following surgery. I also recommend silicone sheeting to be placed directly on the incisions for 2 months after surgery. I find the silicone gel sheeting improves the appearance of the scars by flattening them and decreasing the pigment.
What if I don't like my results? Will I need to have more than one surgery?
Within the first year, a redo or touch-up procedure is covered by the patient's initial surgical fee. However, it is important to remember that one must have realistic expectations for the outcome of any type of cosmetic surgery. That being said, I do want all my patients to be happy and I will always do what I can to achieve that.
Do I need to wear a compression vest? What is it for? How long do I have to wear it?
It is necessary to wear a compression vest for about four to six weeks following the procedure. After the gland is excised and liposuction is performed, a large open space exists. The compression garment helps the tissue come together and close properly. The placement of the drains helps as well. Another function of the garment is to help reduce the initial swelling and contract the skin over the surgical site.
When can I return to work?
Usually patients are able to return to work 5 to 7 days after surgery, depending on what type of work they do. If they work in an office environment that does not require much physical activity then it is easy to return shortly after the procedure. If you do physical labor then it is recommended to wait at least 10 to 14 days or whenever you feel you are ready. Listen to your body! It will tell you when it is ready to return to your normal activities.
Are there any post-operative complications that I should be aware of, i.e. painkillers, constipation, excessive swelling, etc.?
Excessive fluid can accumulate underneath the skin. If a drain is not used, the fluid would have to be aspirated with a needle. Also, if you have extreme pain after 24-48 hours which is not helped with your pain medication, this could indicate a problem. One potential complication is a hematoma. A hematoma is a collection of blood underneath the skin, made noticeable by excessive bruising, swelling and pain, typically of only one side of the chest. If this happens it is imperative to contact your surgeon immediately.
Am I a candidate for male breast reduction?
The most important question you should ask yourself is: does the condition bother you both psychologically and physically? Should the answer be positive, you should consider surgery and start to gather information that will help you make an intelligent decision while consulting with a Board Certified Plastic Surgeon who is experienced in this type of surgery, obtaining information from web sites and referrals.
Am I too young to have gynecomastia surgery?
In general, we recommend you wait until the age of 18 years. There are some circumstances where a person should consider it earlier. For this you will have to consult a Plastic Surgeon.
How do I choose the right Plastic Surgeon?
As a rule, he/she should be a Board Certified Plastic Surgeon. Most importantly, the surgeon should have experience with this specific procedure. In today's world, the Internet is an invaluable tool that can help you to make your decision by reading specific content and viewing photo galleries.
Communication with your surgeon's office staff and the physician are of paramount importance. Once you decide to have the surgery, you should interview a few surgeons and expect to receive complete and satisfactory answers to all of your questions. Good rapport with the office staff and surgeon prior to surgery is essential for a successful end result.
What results can I expect?
You should discuss this with your surgeon prior to surgery, and make sure you fully understand everything that is involved while keeping your expectations realistic. Your experienced surgeon can help you with this.
How many procedures of this nature has the surgeon performed?
If he has significant experience, it should be substantiated with good quality pre and post-operative photos as well as references.
What kind of scar should I expect?
Usually periareolar (about 1 inch scar in the lower part of the areola) that is generally inconspicuous. Sometimes, tiny scars remain in the armpit or chest after liposuction. Some people need more extensive procedures, and this should be discussed with your surgeon in detail prior to surgery.
Will I have pain that will require medication?
Usually pain is minimal, but since we want to make sure you will be comfortable, we do provide you with a prescription for pain medication.
How much time should I take off from work or school?
This depends on the type of work you do and the extent of the surgical procedure. Usually it's between 3 and 10 days, but healing time varies for each individual and should be discussed with your surgeon
What types of anesthesia do you offer?
Local anesthesia is determined based on the type of surgical procedure and the patient's tolerance. Sedation is not a general anesthesia, but the patient is asleep. This is the preferred method in my office because it is safe when done by an experienced Board Certified Anesthesiologist. General anesthesia is rarely needed in my office
Is the operating room certified?
Make sure that the facility is credentialed locally by the Department of Health.
How should I prepare for the surgery?
Prior to surgery you should get detailed instructions from your surgeon's office. Pre-operative testing is mandatory. You should stop medications such as blood thinner, aspirin, Advil, Vitamin E and herbal remedies such as St. John's Wort and Ginkgo Biloba. Do not eat or drink eight (8) hours prior to surgery. Arrive on the day of surgery in comfortable clothing that is not tight or confining. Have a responsible person accompany you to and from the doctor's office
What type of dressing will I have?
My personal preference is an elastic (ACE bandage) or surgical vest. Sometimes gauze dressing is all that is necessary.
Will I have a drain?
Usually not, but in cases of excessive bleeding, a drain will be necessary. This will be removed in a few days post-operative.
Should I change my own dressing?
This depends on the amount of bleeding or discharge, and should be discussed with your surgeon. It is always wise to have sterile gauze and surgical tape at home.
Will my health insurance cover this procedure?
In most cases, they do not cover this procedure
What can cause gynecomastia?
Gynecomastia can be caused by drugs, steroids or marijuana as well as other factors. These should be discontinued prior to surgery to minimize recurrence.