✍️ What Causes Gynecomastia

The Medical Definition: Gynecomastia is defined clinically as an enlargement of male breast tissue, characterized by the presence of a rubbery or firm mass extending in a diffuse and concentric fashion under the nipple and areola.

The Common Man’s Definition: Chest fat, Male Boobs, MOOBS, Male Breast, etc

It’s common in my practice to have a patient come in saying that he has a lot of chest fat and wants it sorted. Most of these people are usually quite fit and don’t even have a lot of fat anywhere in the body, to begin with. Many would have worked out endlessly only to notice that the chest bulge hasn’t reduced. If anything the ‘chest fat’ is now more prominent and protruding than it was when they were less fit. Many men who do not research or take a medical opinion to attribute this to ‘stubborn fat’. Only when a doctor examines and points out the differences in how the ‘chest fat’ feels as opposed to the fat elsewhere do they realize that it’s something else. Some people actually feel crestfallen when confronted by the diagnosis. But nonetheless, the treatment is not too different than what they would have imagined if it was indeed fat.

When a male breast is seen under a microscope it contains what we call ‘a benign proliferation of glandular male breast tissue’. It actually means that the tissue is very similar to female breast structurally, but of course, is different functionally. It means that it serves no function in males and is a vestigial and purposeless tissue. 

During puberty, changes in the breast bud occur due to the hormonal influence and lead to transient enlargement of the breasts and is a very common occurrence. It becomes an issue when this enlargement either becomes too excessive or fails to regress in time. The emotional impact that can result during these very important formative years can have long-lasting effects on the emotional and social development of the individual. 

Male breast development occurs in a similar fashion to female breast development. At puberty in the female, complex hormonal interplay occurs resulting in growth and maturation of the adult female breast.

Gynecomastia normally can occur during three phases of life. The first occurs shortly after birth in both males and females. This is caused by the high levels of predominantly feminine hormones; estradiol and progesterone produced by the mother during pregnancy, which stimulates newborn breast tissue. It can persist for several weeks after birth.

Puberty is the second situation in which gynecomastia can occur physiologically. This again is due o the imbalance of hormones. It may be due to either decreased production of androgens (male hormones)  or change in its ratio with respect to the female hormones.

The third age range in which gynecomastia is frequently seen is during older age (>60 years). Although the exact mechanisms by which this can occur have not been fully clear, it may result from reduced male hormone production associated with aging and other factors.

In early fetal (when the baby is still in the mother’s womb) life, epithelial cells (Cells on the skin surface) that are destined to become areola also form the ducts. The ducts form the supply pipelines from where the mother’s milk is produced in the alveolar structures (the milk-producing part of the breast) glands up to the nipple. As the influence of the mother’s hormones that are transferred to the baby while in the womb reduces, the breast development ceases. This process of multiplication and tissue replication restarts when the hormonal balance is altered like in puberty. But once the hormonal issues regress, the tissue also tends to reduce when it’s not large enough. But in many men, even after the hormonal influence ceases, the gland still persists and leads to all the issues at hand.

In puberty when the gland develops and gets noticeable, many complain of pain and tenderness which sometimes leads them to medical consultation. Evaluation under the guidance of a physician can be performed as needed to rule out other conditions that can result in hormonal imbalance having an effect on the breast. Although it is reasonable to simply observe patients who present with gynecomastia even until the age of 16 or 18, when social behaviors begin to become negatively affected by the condition, it is recommended to proceed with surgical correction nonetheless. 

But most patients, however, tide over the issues during puberty and come for consultation when they are independent and employed. Most Indians, come to a doctor when they are looking for alliances or during a relationship. 

The causes of gynecomastia can be broadly classified into two categories: primary and secondary. 

Primary or idiopathic or physiological is the commoner type. It is seen in up to 90% of newborns due to the transfer of hormones from the mother. Newborn gynecomastia usually resolves spontaneously within four weeks of birth. Children with symptoms that persist after their first birthday should be examined further; they may be at risk of persistent pubertal gynecomastia. It is, however, important to rule out other causes while confronted with adolescent gynecomastia.

Secondary or non-physiological gynecomastia occurs due to a plethora of etiologies and requires thorough clinical and laboratory assessment

Causes of secondary gynecomastia

1. Mediation or drug abuse

   Hormones: Androgens, anabolic steroids, estrogens, estrogen agonists, and hCG

   Antiandrogens/ Bicalutamide, flutamide, nilutamide, cyproterone, and GRH  agonists       (leuprolide and goserelin)

   Antibiotics: Metronidazole, ketoconazole,b minocycline, isoniazid

   Antiulcer medications: Cimetidine,b ranitidine, and omeprazole

   Chemotherapeutic: Methotrexate, alkylating agents, and vinca agents alkaloids

   Cardiovascular drugs: Digoxin,b ACEIs (eg, captopril and enalapril), calcium channel blockers (diltiazem, nifedipine, verapamil), amiodarone, methyldopa, spironolactone, reserpine, and    minoxidil

   Psychoactive agents: Anxiolytic agents (eg, diazepam), tricyclic antidepressants,    phenothiazines, haloperidol, and atypical antipsychotic agents

   Miscellaneous 

   Antiretroviral therapy for HIV, metoclopramide, penicillamine, phenytoin, sulindac, and

   Theophylline

2. Liver disorders like Cirrhosis

3. Hormonal issues: 

 3a. Primary hypogonadism 

   5α-reductase deficiency 

   Androgen insensitivity syndrome 

   Congenital anorchia 

   Hemochromatosis 

   Klinefelter syndrome 

   Testicular torsion 

   Testicular trauma 

   Viral orchitis

3b. Hormone producing Tumors 

   Adrenal tumors 

   Gastric carcinoma producing hCG 

   Large cell lung cancer-producing hCG 

   Pituitary tumors 

   Renal cell carcinoma producing hCG 

   Testicular tumors, particularly Leydig or Sertoli cell tumors 

3c. Secondary hypogonadism 

3d. Kallmann syndrome 

4. Thyroid gland disorders like Hyperthyroidism 

5. Kidney disorders like Chronic renal insufficiency 

6. Other rare causes 

   Familial gynecomastia 

   Human immunodeficiency virus 

   Malnutrition and disorders of impaired absorption (e.g., ulcerative colitis, cystic fibrosis)

✍️ Benefits of Gynecomastia Surgery

Male breast reduction surgery in Bangalore is the leading treatment for gynecomastia and is exceptionally successful. This procedure involves removal of the breast tissue and liposuction to address the tissue as well as excess fat to achieve the desired results. Gynecomastia surgery relieves men of the embarrassment caused by having the condition and restores their chest to a pleasing masculine appearance.

Undergoing this procedure provides a broader range of benefits for a man than any other aesthetic surgical procedure would. It improves the overall masculine appearance of the chest, boosts self-esteem and confidence, makes physical activity easier, reduces back pain in cases of large gynecomastia, motivates people to stay fitter, allows men to wear tight-fitting dresses, allows one to swim bare-chested without embarrassment and improves the overall outlook of the individual.

Below are the top benefits of choosing male breast reduction surgery:

Meet Dr. Sreekar Harinatha by calling 7022543542 or 08047094167 and clear your doubts.

🎥 Gynecomastia Surgery Video

This video was made to provide you with the latest technique of gynecomastia surgery followed by Dr. Sreekar Harinatha, Plastic and Cosmetic Surgeon in Bangalore, India. This technique won an Award for the best new Technique at the IMCAS conference in Taipei, Taiwan.


Meet Dr. Sreekar Harinatha at Contura Clinic, Bangalore

Call 7022543542 or 08047094167 and clear your doubts.

Or WhatsApp your Pictures to 9902223733

✍️ Grades and Types of Gynecomastia

If there is one factor that determines the kind of surgery and the outcomes it the grade of gynecomastia. Though there are many different methods of grading gynecomastia, the most commonly followed is Simon’s grading described in 1973. He classified gynecomastia into three grades depending on the amount of breast tissue and loose skin on top of the breast.

  • Grade I: Small enlargement without skin excess
  • Grade IIa: Moderate enlargement without skin excess
  • Grade IIb: Moderate enlargement with minor skin excess
  • Grade III: Marked enlargement with a lot of excess skin, resembling a female breast
Grade 1: Mild Gynecomastia
Grade IIA: Moderate Gynecomastia without skin excess
Grade IIB: Moderate Gynecomastia with skin excess
Grade III: Large Gynecomastia with skin excess

Rohrich in 2003 proposed another classification into four grades.

  • Grade I: Minimal hypertrophy (< 250 g) without ptosis
  • Grade II: Moderate hypertrophy (250–500 g) without ptosis
  • Grade III: Severe hypertrophy (> 500 g) with grade I ptosis
  • Grade IV: Severe hypertrophy with grade II or grade III ptosis

Though these two are used worldwide, Simon’s grading is simple and used more widely. One addition I would like to suggest to these gradings is the addition of skin tone factor. To put it simply, while skin excess is the loose skin on top of the breast tissue, skin tone is the inherent capacity of the skin to shrink and contract after the surgery. While skin excess has a linear progression from grades 1 to 3, skin tone can be independent of it. 

The revised grading by Dr. Sreekar Harinatha is as below:

  • Grade IT: Small enlargement, No skin excess, Normal skin tone
  • Grade 1L: Small enlargement, No skin excess, Poor skin tone
  • Grade IIAT: Moderate enlargement, No skin excess, Normal skin tone
  • Grade IIAL: Moderate enlargement, No skin excess, Poor skin tone
  • Grade IIBT: Moderate enlargement, Minimal Skin excess, Normal skin tone
  • Grade IIBL: Moderate enlargement, Minimal Skin excess, Poor skin tone
  • Grade IIIT: Marked enlargement, Lot of excess skin, Normal skin tone
  • Grade IIIL: Marked enlargement, Lot of excess skin, Poor skin tone

The ‘L’ here would indicate laxity, meaning poor skin tone. This revised grading would also predict the eventual surgical results in terms of skin reshaping in a more accurate way. And once documented into history, it would serve as a reminder about the patient’s original skin tone before the surgery and during follow-up.

Dr. Sreekar Harinatha’s revised grading is now widely accepted and also published in the prestigious Brazilian Journal of Plastic Surgery. Read the article here…

This is very important and is very often understated for reasons I cannot fathom. When two patients with grade IIA come for surgery and get operated by the same technique under the same surgeon, the results may be different. The reason being the difference in skin tone between the two. This should not come as a surprise as such a difference in results follows other surgeries like liposuction too. The lack of skin tone makes a visible difference in the results after any procedure. And patient with loose skin even after seemingly lack of loose skin may need other non-non-surgical procedures or very rarely surgery to tighten the loose skin. This can happen even in Grade IIA gynecomastia.

Meet the experienced gynecomastia surgeon in Bengaluru, Dr Sreekar Harinatha to get your male breast sorted.

✍️ When should you undergo Gynecomastia surgery?

Traditionally it was viewed that one should undergo Gynecomastia surgery only after puberty and around 16-18 years. Unfortunately, many teenagers spend their entire teenage years waiting for the surgery and are subject to ridicule and embarrassment during this critical time in their lives. Many people even think that Gynecomastia resolves on its own after puberty which is a very rare occurrence. It’s important to notice the state of the breast gland for a period of two years. If it has increased or is the same, then it’s prudent to plan the procedure. The decision to operate is based not only on the diagnosis of gynecomastia but also on the physical and mental maturity of the person and his capability of understanding the surgery as well as the ability to cope with the post-op pain and to follow the post-op care regimen. Surgery has been successfully performed on hundreds of young men from ages 12 through 18. Obviously, this decision is made is on an individual basis. 

One parent in 2014 met me with their son who was studying in 11th. They were worried about the sudden drop in his grades and his low self-esteem. They had taken him to a psychiatrist too. The boy was on medication as he did not fully disclose the issue to the psychiatrist. Only later did he reveal gynecomastia to his father who in turn got him to meet me. The boy had in the last four years been under severe psychological impact apparently as his friends poked fun at him for his breasts. He started wearing loose-fitting shirts on top of a male bra. Yes, you read that right; a male bra.

The male bra is actually a compression vest that is actually used post-surgical correction for a few weeks for the surgical swelling to reduce. Many misguided boys wear it under their shirts to compress the breasts hoping that it would not show up on top of clothes and also that wearing it long enough would make the gland disappear. Some others try bandaging, where they roll a tight length of a bandage or a cloth in order to compress the glands against their chest to hide it better. Some boys end up getting their skin damaged and even sustain rashes that have to be treated independently. They occur due to the tightness and the subsequent skin damage and irritation.

Examples of skin damage and pigmentation due to overuse of Male Bra (Chest compression garments)

The extent to which some men go to for correction of the breast is quite baffling; especially in these days where a simple google search reveals that surgery is the straight forward option.

In August 2018, a very important and systematic meta-analysis was published on the psychological impact of gynecomastia and surgery. Meta-analysis is like an analysis of many research projects under one umbrella. In such studies, various other research patterns and results are analyzed to give us a better and clearer understanding of the issue being researched on. This study was published in the Gland Surgery journal by Martin Sollie from Denmark. They analyzed over 500 research papers on the topic. They too noted that gynecomastia impacts the general health, functional capacity, social aspects, vitality and mental health of the individuals. And all these were significantly and objectively improved once it was corrected by surgery. This is a seminal piece of information on the often neglected psychological aspects of the male breast. There are many more detailed and meticulous trials and studies that second this conclusion. 

Men older than 45 years suffering from gynecomastia are also candidates for surgery but must understand that the skin may not totally tighten after the surgery is performed since they may have lost some elasticity in their skin through the natural process of aging. Such candidates also require more blood tests and other investigations before surgery.

🎥 Male Breast Reduction Surgery on YouTube

  • The Procedure: Bilateral Gynecomastia Gland Removal Surgery
  • Goal: To remove the Gynecomastia Glands, Shape the surrounding Fat to give a Sculpted Masculine Look
  • Results: Immediate and Perfect RESULTS
  • How it works: A small incision under the nipple, breast tissue is removed and fat removed and contoured
  • Note: Individual results and downtime may vary
  • Duration: Around 90 mins

✍️ What can I expect on the day of Gynecomastia Surgery?

On the day of surgery, you will need to come down by 9 am. You will also need to be on empty stomach from 12 midnight. Once you come to the clinic, your medical history will be taken and you need to read, understand and sign on the consent forms.

Then Dr. Sreekar Harinatha will mark the extent of breast tissue and the areas of fat that need to be treated. You can again clear all your doubts before the procedure is started. He may point out any asymmetries and the scar location during the markings. Then you will be started on a few injections through an intravenous cannula. Then your chest and armpit hair are shaved (if not already done). The anesthetist will also check on you and talk to you before you are shifted to the OR.

In the OR you will be anesthetized. It will feel like going to sleep. You will be given certain injections along with oxygen for inhalation through a mask. The male breast reduction procedure typically lasts for around 90 minutes. The procedure is performed under general anesthesia by our experienced anesthetist and surgeon. Dr. Sreekar Harinatha will create a well-hidden incision either around the areola. He will then remove the excess fat, skin and glandular tissue from the chest area depending on the requirement.

Once the procedure is completed, a compression dressing will be done on the chest. Then your anesthesia will be reversed and you will be shifted back to your room. Here, you will recover for a few hours during which the staff will monitor you and check on you frequently. Once you are feeling better, you will be given liquids to drink and then made to walk. Once you are walking comfortably and fit our discharge criteria, you will be sent home with a discharge summary and detailed instructions. Before you leave, Dr. Sreekar will check on you and let you know about the follow-up protocol. You will normally be advised to come for a check-up after two days.

✍️ Gynecomastia Myths- Busted

Gynecomastia is as common as it is misunderstood. Let me clear a few now!

Gynecomastia is fat and you can just workout and burn it

This is probably the most common misconception going around about gynecomastia. Gynecomastia, the word itself means ‘Male Breasts’, so there is no question of fat causing it. hence any treatments or remedies that focus on only reducing the fat will never work to treat gynecomastia as it is primarily breast tissue and NOT FAT!

Gynecomastia is caused by Hormone imbalance

While hormone imbalance is definitely one of the causes of gynecomastia, it is not the only one. There are over 50 factors that can contribute to gynecomastia including chromosomal anomalies, genetic disorders, excessive smoking, alcoholism, liver disorders, tumors etc. In most of the cases it is just idiopathic- Meaning there is no definite cause!

Gynecomastia can be operated by any surgeon

Gynecomastia surgery is one of those where the specialist’s skill is conbined with the science and art behind achieveing an aesthetic chest. This requires expereince, a keen understanding of the anatomy and the aesthetics. This is best achieved by a board certified, professionally trained and specialised plastic and cosmetic surgeon.

If you still have gynecomastia, it means you dont workout enough

The truth cant be farther from this statement. As obvious, gynecomastia is breast tissue and hence cant be expected to resolve with exercises. In fact excess chest exercises only make the gland stand out as the fat around it gets reduced. This is in fact called “bodybuilder’s gynecomastia”.

Hormone tablets can reduce gynecomastia

Once the breast tissue grows in puberty, any number of hormone pills cannot reverse the tissue growth. only way that can be sorted is by surgery. Morever unsolicited use of hormone pills can have various advers effects on the indivisual including loss of bone density, hair loss, sterility etc.

✍️ Teenage Gynecomastia

Gynecomastia is a cause of considerable psychosocial discomfort, stress, and worsening of self-image in adolescent boys. It is important to understand these concerns in order to provide proper management. Many parents casually neglect the issues raised by the boys only to later realize the psychological effects of a poor body image.

Many parents attribute adolescent gynecomastia to fat. A rapid increase in obesity among children and adolescents results in a higher number of patients presenting with breast enlargement and disproportionate diagnoses of ‘pseudo gynecomastia’. Despite the fact that obesity causes pseudo gynecomastia, which is a proliferation of fat rather than breast glandular tissue, true gynecomastia is also associated with higher body weight. Many studies like ones by Rivera et al. indicated that there is a correlation between pubertal gynecomastia and higher BMI (Basal Metabolic Index) percentiles (Reference). Kulshreshtha et al also reported that most of the patients (64%) with breast enlargement were obese as per scientific Coles criteria (Reference).

It is common to notice higher BMI values than the general population according to the Centers for Disease Control (CDC) growth charts in gynecomastia patients. However, there is no relationship between BMI and breast size. Despite the fact that many overweight children (57.1%) succeed in losing some weight, breast size was not reduced in any of them and weight changes did not affect sex hormone levels (Reference). This observation, that weight loss alone will not correct true glandular breast enlargement is consistent with that reported by many other authors (Reference 1, Reference 2).

It should be also underlined that in the majority of our patients the breasts do not show a drastic increase in size with age. Adolescents with gynecomastia should be encouraged to lose weight, but it does not treat the underlying breast tissue.

Surgical management of pubertal gynecomastia may be considered in obese or non-obese male adolescents who present with persistent breast enlargement after a period of observation of at least 12 months, breast pain or tenderness, and/or significant psychosocial distress. Obesity is not a contraindication to the surgical approach. Liposuction techniques are helpful in those patients with considerable fat deposition in the breast during the removal of the glandular component. The aim of surgical treatment is to achieve a normal appearance of the masculine thorax with the smallest possible scar. The surgical treatment of gynecomastia requires an individualized approach.

In conclusion, teenage boys who have persistent gynecomastia after the end of pubertal development and adolescents who have concerns about the cosmetic correction can undergo gynecomastia surgery. Therefore, the decision to perform surgery depends on the degree to which this condition has affected the quality of life, psychology and on their desire for cosmetic correction

✍️ Who is a good candidate for Gynecomastia Surgery?

Though gynecomastia is very common, it is fairly obvious that not everyone is the right candidate for under gynecomastia surgery. There have been instances where we had to reject a few healthy patients when they did not meet a few criteria.

Here is a list of pointers that make one a good candidate to undergo gynecomastia surgery:

  • Men with realistic expectations
  • Men who do not have a medical condition or life-threatening illnesses that can delay healing
  • Nonsmokers and non-drug users
  • Men with a positive outlook
  • Men with specific goals in mind for improving the symptoms of gynecomastia
  • Men who are physically healthy and have a stable weight
  • Men whose breast development has stabilized
  • Men who are bothered by the feeling that their breasts are too large
  • Men without major skin disorders involving the chest area