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Check out our latest Gynecomastia Surgery Video!
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When someone talks about a breast, the common mental picture one comes up with is a feminine figure, voluptuous and in all its angelic beauty. Surely, that’s regarded as the most intricate and mystifying creation. But that same divinity probably despised this partiality amongst the two sexes and endowed many men with a similar bosom. And this is the divine oversight that leads many men to explore the possible treatment for the illegitimate part of a male body.
Jokes apart, Gynecomastia or male breast as it is commonly referred to, is a serious issue. Gynecomastia is generally defined clinically as an enlargement of male breast tissue. It is characterized by the presence of a rubbery or firm mass extending diffusely and concentrically under the nipple and areola.
Most men with gynecomastia feel the presence of a firm to hard mass under their nipples during the puberty. Most notice it under their school uniforms. Many of them are subjected to jokes or ridicule and some even suffer various psycho-social issues. Many students start wearing loose-fitting shirts in this period hoping the gynecomastia gets noticed less. Many others try working out. I have noticed many students in their high schools or early college working out endlessly in the gyms trying to burn the ‘fat’ under the nipples. They sometimes overwork enough to get disproportionately bulky chest muscles as compared to the rest of the body. Some extreme cases of steroid injections and unhealthy dietary supplement intake are not uncommon.
It’s a common complaint from such a student’s parent during the period that their son’s self-confidence and outlook have drastically dimmed as he entered high school or college. Many attribute it to the academic stress or mental changes at puberty. It is further complicated by the fact that many such boys don’t talk openly about the male breast with their parents which leaves parents guessing what suddenly went wrong with the kid. This can interfere with very important group social activities, including swimming, playing sports, and participating in the gym.
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 a compression vest that is used following surgical correction for a few weeks so that the surgical swelling reduces faster. 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 hope that wearing it long enough would make the gland disappear. Some others try bandaging, wherein they roll a tight and lengthy bandage or a cloth 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. The skin damage is due to tightness and subsequent skin irritation. 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 straightforward 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 the 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. 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 breasts. There are many more detailed and meticulous trials and studies that second this conclusion.
Many studies have shown that the incidence of gynecomastia is highest during puberty. The percentages vary from 20-60%. Though this seems like a very high number, it does however give us an insight into the wide prevalence of male breasts. It’s not as rare as you think. There is also a wide difference in its occurrence among various races. Asians and Indians are perched right at the top of the pile, while Caucasians experience far lesser incidence of gynecomastia.
Now, it does seem strange that an issue that affects such a large populous is discussed so less among mainstream media and has so few books written on them. There is a visible lacuna and knowledge gap among the common men. They book endeavours to fill that gap as much as it can. As I go through, I would be discussing the various aspects of gynecomastia with special focus on the treatment. It goes without saying, if you have a gynecomastia, the least you can do is know what it is.
Summary of Gynecomastia Surgery in Bangalore
Get Gynecomastia treated by leading gynecomastia surgeon Dr. Sreekar Harinatha.
Procedure time: 60 mins
Admission: Daycare basis (9 am to 6 pm)
Stitch Removal: No (Absorbable stitches)
Leave from Work: A total of three days including the day of surgery, Follow-up consultation after two days of surgery. Gym, swimming, and workouts can be resumed after three weeks
Cost: Rs.55,000 plus 18% GST 9,900= 64.900 plus cost of the compression garment (around 2-3000): Total: Approximately 67-68,000
Appointments: Call 7022543542 or book at www.conturacosmetic.com
Gynecomastia is the most common condition affecting the male breast. It affects 32%–65% of all men. Gynecomastia can be physically and psychologically harmful to the patient and hence surgical correction is needed in many circumstances. Many grading classification systems and surgical approaches exist including the one by Dr. Sreekar Harinatha that was published in the Brazilian Journal of Plastic Surgery
Methods of surgical treatment of grade I gynecomastia vary and include gland removal only, gland removal in combination with liposuction, etc. Most authors agree that skin resection is not indicated for patients with grade I gynecomastia.
Gland removal can be done using various techniques, including a traditional, larger, 2-cm infra-areolar incision for direct excision, or a small 6–8 mm infra-areolar or inferolateral quadrant incision for “pull through” or “orange peel” techniques for direct excision. Both techniques include grasping of the breast tissue through a small incision with removal of the breast tissue from surrounding structures under direct visualization.
A large variety of surgical approaches was also noted for the treatment of grade II gynecomastia like in Grade I.
An even wider variety of surgical techniques exists for grade III gynecomastia, including gland isolation with central subdermal plexus pedicle, with posteroinferior subdermal plexus pedicle, liposuction + gland removal, breast amputation through inframammary fold (IMF) approach with free nipple graft, etc. Several of these surgical approaches have been previously detailed in this report for the treatment of grades I and II gynecomastia.
No definitive, universally accepted algorithm exists regarding the ideal surgical approach for the treatment of gynecomastia based on severity. Each patient must be considered individually, and the treatment decided upon should be tailored as such. Given the wide variety of acceptable surgical techniques available regardless of patient severity, several factors should be considered. These include patient scarring/tendency for poor scarring, patient comfort with the possibility of revision, patient comfort with the presence of skin redundancy, and other specific circumstances such as the presence of tuberous breast deformity, size of the nipple, and large nipple-to-IMF (Infra-mammary fold) distances, as seen in massive weight loss patients.
Based on the published literature and personal experience, Dr. Sreekar Harinatha provides the following surgical algorithm based on the Simon grading system to assist the plastic surgeon in determining the most appropriate surgical approach for each individual patient.
The first step in the determination of appropriate surgical treatment should be the grading of the patient’s gynecomastia based on Simon’s grade. For patients with grade I gynecomastia, the patient’s previous scars should be examined. If the patient is known to form hypertrophic scars or keloids, excision of glandular tissue should be avoided as an unsightly periareolar scar may cause distress to the patient. In this case, liposuction alone should be chosen as the modality treatment of choice. Conversely, if that patient does not scar poorly, liposuction in addition to SSPM may be chosen.
For patients with grade II gynecomastia, the question regarding the presence of excess skin should be considered. If that patient does not have excess skin but does have an enlarged NAC, gland removal ± liposuction may be utilized. If the patient does not have excess skin and NAC is not enlarged, we advocate for the use of gland removal+ liposuction. If significant excess skin exists regardless of NAC size, we advocate for the use of secondary skin tightening.
Finally, for patients with grade III gynecomastia, the primary question we consider pertains to the nipple-to-IMF distance. If that distance is >10 cm, we advocate for the use of simple mastectomy via the IMF approach with free nipple grafting, as the amount of resection necessary to achieve an acceptable contour would likely revascularize the NAC. If the nipple-to-IMF distance is <10 cm, we advocate for the use of gland removal ± liposuction.
Though the clinical diagnosis of gynecomastia is straightforward, there is some issues that may make this seemingly simple issue a little tricky. These diagnoses that mimic a certain other disorder are called differential diagnoses.
One such common differential diagnosis is pseudo gynecomastia. As the name suggests it refers to ‘false male breast’ meaning fat that masquerades as breast tissue. It is especially common in men who are overweight or obese. However in my opinion the term pseudo gynecomastia is overused and over-diagnosed. There have been instances in mine and my colleagues’ practices where a patient is referred to us as pseudo gynecomastia and the patient is expecting liposuction as the sole treatment.
Some surgeons have even gone ahead and done liposuction to this apparently pseudo gynecomastia only to them realize that there is in fact a large amount of breast tissue left. Now, this complicates the issue manifold. One, the patient has not been told that he requires a gland excisions and a bigger skin cut to do the same. Now, either the surgeon has to explain to the patient’s friends or relatives who have accompanied the patient that the surgical plan has changed as he has now noticed breast tissue or he has to end the procedure there and plan breast tissue removal later on. In either of these scenarios, the surgeon does not come off with flying colors. More importantly, the patient is put through a procedure that he is ill-prepared for.
If the surgeon takes the relatives into confidence and goes ahead and operates and removes the breast tissue, it is left to him to explain it to the patient when he comes out of anesthesia. The matter is easier said than done as it depends entirely on how the patient takes the news. If the surgeon chooses the second option and ends the surgery without removing the gland, he needs to explain that to the patient who may not be happy hearing that he needs another procedure to sort out his chest. I have seen patients who underwent only liposuction for ‘pseudo gynecomastia’ and coming to me complaining that their surgeon has left a lot of hard fat under the nipple. I have had to explain such patients that only fat was removed and the gland was left behind and indeed the diagnosis may be wrong. Now imagine the patient’s conundrum at this phase. An issue that could have been easily sorted in the first procedure has now dragged on not only needing another procedure but also making the patient invest a disproportionate amount of time to sort out the one issue at hand.
This is especially true if the patient following liposuction gets fitter and loses more weight only to notice his breast tissue getting more prominent. Before the surgery and his weight loss, the overall smooth contour due to fat might have camouflaged the breast tissue better than when he gets the liposuction or loses weight. All these issues are readily avoided if one is carefully diagnosing pseudogynecomastia. If the diagnosis is correct then liposuction should suffice.
Apart from fat, there may be other swellings on the chest that simulate a gynecomastia. These swellings may arise from any of the structures over the chest. In most of cases they are unilateral, meaning they are usually only on one side. Nonetheless, it is paramount to diagnoses the swelling before proceeding with the treatment plan.
Skin swellings are quite common on the chest too. The commonest of them is the lipoma. It is an accumulation of immature, abnormal fat cells under the skin. They are more mobile under the skin than the breast tissue and are softer. The treatment for these lipomas is excision (removal) through a small cut in the skin. A big enough lipoma can mimic a breast. Many other such swellings can occur on the chest skin like a sebaceous cyst, dermoid cysts, fat necrosis after injury ( a situation where the fat cells die in a particular area following a high impact injury and clumps up) etc.
Most of them are quite straight forward for the doctor to rule them out. But another sometimes serious and under-diagnosed issue is mastitis. It is basically an infection of the breast tissue. It is way more commoner in females but does occasionally affect men with breasts. The breast glands can get infected by various paths. It can get infected through external sources across the skin like an injury to the skin, nipple piercings, or just a skin infection that spreads inwards. The other mode is infection via blood. Any infection in a part of the body can theoretically spread to another tissue like the breast. When one has mastitis they would complain of severe pain, redness over the chest skin, sometimes pus discharge from the nipple, enlarged lymph nodes in the armpits ( axilla), and fever. The treatment is a course of antibiotics and occasionally removal of the pus and if necessary, the gland.
The word ‘Tumor’ incites various feelings in people. They vary from formidable, dread, distressing, and downright scary. But, not all tutors are not cancers and not all cancers are untreatable. Most of the tumors are benign, meaning, non-cancerous. They are treated like any swellings and usually require removal. In the breast tissue, some men do develop breast cysts and fibroadenomas.
Breast cysts are fluid-filled swelling that has a thin capsule. These cyst again are commoner in females and show up a lump on examination. In most cases, ultrasound is required to correctly diagnose. Sometimes your doctor will insert a thin needle into the breast lump and attempts to withdraw (aspirate) fluid. This may be done under ultrasound guidance or by feeling the lump itself. If the fluid comes out and the breast lump goes away, your doctor can make a breast cyst diagnosis immediately. If the fluid is not bloody and the breast lump disappears, you need no further testing or treatment unless it comes back. If the fluid appears bloody or the breast lump doesn’t disappear, your doctor may send a sample of the fluid for lab testing and refer you to a radiologist for the scans. If no fluid is withdrawn, your doctor will likely recommend a scan such as a diagnostic mammogram and or ultrasound. Lack of fluid or a breast lump that doesn’t disappear after aspiration suggests that the breast lump or at least a portion of it is solid, and a sample of these cells may be collected to check for cancer (fine-needle aspiration biopsy). The treatment of breast cysts is rarely by surgery. It is operated upon only if the diagnosis is unclear even with the scans or if it is troublesome to the patient.
Other breast swellings that may occur in a male breast are duct ectasia, fibroadenoma, and breast cancers. While duct ectasia and fibroadenomas are benign, cancer is another matter altogether. In duct ectasia, the patient may have a scary sign of bloody nipple discharge. One fine day he wakes up to find a bloodstain on his nipple. Many men freak out and rush to the doctor fearing cancer. It usually is a duct ectasia which is nothing but an alteration in the ductal structure. It sometimes needs treatment but always needs assessment. Cancer should be ruled out when there is nipple discharge.
Fibroadenomas are the commonest swellings in a female breast. Some do occur in a man. They feel like a firm lump that is unnaturally mobile. It was often referred to as the ‘mouse in the breast’. While that scenario is far fetched for a male breast, nonetheless it depicts how mobile a fibroadenoma can be. The treatment is removal if the size is more than 3cms in diameter. Occasionally men do wait for them to get very big assuming it’s just a skin lump. While it’s not necessarily dangerous, it’s better to wait to know what it is than without.
Gretchen Dickson in 2012 published a widely referenced article in the journal, American Family Physician that outlined an algorithm to diagnose gynecomastia.
When one talks about tests for a gynecomastia patient, it has two facets to it
- Tests to check for causes of gynecomastia
- Test mandatory to check if the patient is fit for surgery
Once the doctor suspects its gynecomastia, then the next step is to check if there is indeed a hormonal issue or its idiopathic in nature. The word idiopathic itself means that the cause is unknown. It accounts for over 70-90% of all cases of gynceomastia. However, before diagnosing someone as ‘Idiopathic gynecomastia’ the doctor needs to rule out a few things. The other category of patients belongs to ‘Secondary gynecomastia’ wherein there is a proven cause for gynecomastia as was enlisted above.
Apart from the drug induced gynecomastia that may be easier to diagnoses, the doctor should bear in mind other hormone disorders. Laboratory evaluation is indicated only if the clinical assessment suggests a secondary underlying cause. It is not needed for boys at puberty for enlargement due to fat (pseudogynecomastia) and for men taking drugs known to cause gynecomastia.
In cases of secondary gynecomastia without a clear cause, laboratory tests should be advised and must include, liver, kidney, and thyroid function tests (to exclude the respective causative medical conditions), as well as hormonal tests. The hormonal analysis is always in a series of tests as a part of the evaluation. They include:
- Estrogen level
- Total and free testosterone
- Luteinizing Hormone
- Follicle-stimulating hormone
- And occasionally hCG, DHEASO4 or 17 ketosteroids, SHBG and αFetoprotein
- If the patient’s testes are small, the patient’s karyotype (chromosomal analysis) should be done to exclude Klinefelter’s Syndrome.
If all tests are negative, the patient should be diagnosed with idiopathic gynecomastia. Sometimes it is indeed advisable to have an endocrinologist look at such patients, as there may be other important than just gynecomastia. It is especially more prudent to meet one if these tests reveal significant variations. Early stages of secondary gynecomastia can be medically treated through the gland does not always regress and may end up needing procedure to sort the gland.
Ultrasonography and mammography can occasionally be used to differentiate fat from breast tissue or if there are abnormal masses especially in terms of consistency. Scans are definitely when the patient has one of the signs suggestive of a cancer lump. Other than these, scans may be necessary also to ascertain breast tissue that feels abnormal or feels irregular in places. Mammography is about 90% sensitive and 90% specific for cancers compared with benign masses in men.
However, a biopsy is the only way to make a definitive diagnosis. Patients with a hard, irregular, or asymmetrical mass, nipple discharge (bloody or non-bloody), enlarged armpit lymph nodes, or a mass fixed to skin or the chest wall must have a biopsy. Usually, a core biopsy is recommended over a fine needle or excisional biopsy. In core biopsy, a small amount of tissue is taken via a small hole under local anesthesia. It is more accurate over the commonly done fine needle biopsy. In a fine needle biopsy, an injection is given and the feels obtained through it are examined under a microscope. Since the amount of cell sone gets from such biopsy is very small, the chances of error are consequently high. An excision biopsy is one where the lump is removed in its entirety and sent for testing. While this is the most accurate, it is reserved for specific cases where the diagnosis with routine biopsies are not confirmatory.
Rarely done tests include:
Ultrasound of testes: If there is any abnormality in the testes on examination, or if there is a raised beta-hCG or alpha-fetoprotein.
Abdominal Scans: If a tumor of the adrenal glands or the testes is thought to be responsible for the gynecomastia after hormonal analysis.
Chest X-ray: If a lung tumor is suspected as a cause for gynecomastia. Sometimes tutors in other tissues may be hormonally active, meaning they may produce hormones which in turn may lead to gynecomastia. Though these are rare, one does come across such cases and a quite often a diagnostic dilemma.
Once these diagnostic tests are done as necessary, the next set of tests are for those planning to undergo the corrective procedures. Since the procedures can be theoretically done under local or general anesthesia, the test also varies depending on the anaesthesia planned. For a gynecomastia surgery under local anesthesia, no additional tests are needed, if the patient is clinically fit and has a clear unremarkable history. When the procedure is planned under general anesthesia a set of tests are mandatory.
- Complete blood counts
- Blood sugar levels
- Coagulation parameters: PT, INR and aPTT
- Kidney function tests: Serum Creatinine and Urea levels
- Other tests that are often done are: HIV screening, HBsAg to check for hepatitis B, HCV etc
- Apart from these routine tests, a few more may be advised depending on the patient’s age, medical history and the factors. These include Echocardiography, Chest X-rays, ECG, Liver function tests, Sickle cell tests etc. Cardiac (heart) evaluation becomes necessary when an older patient comes for corrective surgery. Occasionally a consultation with a cardiologist or the relevant physician is needed before surgery.
This post is an excerpt from Dr Sreekar Harinatha’s highly acclaimed book on gynecomastia titled ‘The Male Breast: What You Should Know about Gynecomastia’. It’s available on Amazon on the link here.
To Book Appointments with Dr. Sreekar Harinatha, call 7022543542…