FAQ

Gynecomastia is a term that comes from Greek words for “women-like breasts.”  It affects an estimated 40 to 60 percent of Indian men. There is no definitive reason why it’s so common in Indians.

For men who feel self-conscious about their appearance, male breast-reduction surgery helps. The procedure removes fat and glandular tissue from the breasts, and in some extreme cases removes excess skin, resulting in a chest that is flatter, firmer and better contoured. Before deciding about the surgery, the most important question you should ask yourself is: does the condition bother you both psychologically, socially and physically?  If the answer is yes; you should consider surgery and start to gather the information that will help you make an intelligent decision while consulting with a Plastic Surgeon who is experienced in this type of surgery.

Diet and exercise are to be strongly recommended – they are great for your general health. However, it is a common misconception that diligent and long term exercises reduce or even eliminate male breasts. It is routine to see an individual presenting to us with gynecomastia saying that he had worked as hard as he could, but he could not “burn the breast”. The main problem is in the understanding of male breasts- Gynecomastia.

Exercise does not burn the breast tissue. The common misconception is that the breast tissue is made of fat. It is made of BREAST GLAND. Hence it can’t be burnt, no matter the amount of exercise or workouts. What exercise however does is, it enlarges the chest muscle called the Pectoralis Major which lies beneath the breast tissue. So when the muscle increases in size and bulk it only makes the breast tissue look more prominent and hence worsens the overall appearance. Add to this the protein supplements that have small amounts of anabolic steroids or hormones. It further increases the muscle bulk and also increases the breast tissue.

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.

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.

The extent and severity of gynecomastia are graded by many methods. The commonly used method is Clark’s classification. It grades the gynecomastia based on the amount of breast tissue and the extent of loose skin over the breast. Clinically gynaecomastia is graded as follows:

Grade 1 : Small enlargement, but without excess skin over the chest

Grade 2a: Moderate enlargement, without excess skin over the chest

Grade 2b: Moderate enlargement with extra skin over the chest

Grade 3 : Marked enlargement with extra skin over the chest.

The grade of gynecomastia of a person is best assessed by a plastic surgeon as he can assess the amount of tissue and laxity of skin better.

The presence of male breast does not automatically increase the chances of having breast cancer. However if one notices signs like a hard lump, then an immediate consultation is advised with a surgeon. The most likely investigations would include biopsy and ultrasound to rule out cancer.

Its very common to have asymmetric breasts in all grades of gynecomastia. Unilateral (one-sided) gynecomastia is also a fairly common occurrence. In such occasions, the surgeon will assess the need for surgery, mode of surgery and surgical type based on the individual case. The target is to avoid the operated look and achieve symmetry as much as possible. The other issue with one-sided gynecomastia is to be very sure that it is not a tumor and hence should be checked and biopsied if neeeded.

The cause of gynecomastia is a widely researched topic. Many studies reveal multiple causes and multiple classifications. For understanding its easier to classify the causes as primary or secondary. Primary (also called idiopathic or unknown) gynecomastia is one where the cause is unknown though various genetic factors are associated with it. Secondary gynecomastia is where the cause is identifiable like hormonal issues, tumours, drug overuse or abuse.

Some estimates suggest the following causes in males seeking medical attention for gynecomastia:

Persistent pubertal (teenage) gynecomastia – 25%

No detectable abnormality – 25%

Drugs – 10-25%

Liver disorders or malnutrition – 8%

Primary hypogonadism (Underdeveloped testes) – 8%

Testicular tumors – 3%

Secondary hypogonadism – 2%

Hyperthyroidism – 1.5%

Chronic renal insufficiency – 1%

These statistics are primarily of the western population. In India primary gynecomastia is far more common and probably accounts for 90% of cases. Secondary causes account for the rest. It is however important to clinically assess the probable causes and then advise tests only if necessary.

At first consultation, all patients require a thorough history and physical exam. Particular attention should be given to medications, drug and alcohol abuse, as well as other chemical exposures. Symptoms of underlying systemic illness, such as hyperthyroidism, liver disease, or renal failure should be sought. Furthermore, the clinician will assess tutors as a possible etiology and should establish the duration and timing of breast development. Obviously, rapid and/or painful breast growth that has occurred recently is more concerning than long standing gynecomastia. Additionally, the clinician should inquire about fertility, erectile dysfunction and libido to rule out hypogonadism, either primary or secondary, as a potential cause.

No. Hormonal tests are needed in only a minority of patients who have clinical signs of hormonal abnormalities. Its unnecessary to conduct the tests in everyone.

If the hormone analysis is abnormal, then you will need a thorough evaluation by an endocrinologist. However in most cases you will still need surgery to cure the gynecomastia.

Before the surgery, you will need to get certain blood tests to assess your fitness to undergo the procedure.  Once they are normal then you can generally choose the anaesthesia you would prefer  for the surgery. The procedure can be done under local anaesthesia (with or without intravenous supplementation) or general anaesthesia.

In local anesthesia, the aesthetic injections are injected into the chest. In general anaesthesia you will be completely unaware of the process. Most surgeons and patients prefer general anaesthesia as it is much smoother in terms of recovery and pain.

If you are a smoker, you will be asked to stop smoking well in advance of surgery. Aspirin and certain anti-inflammatory drugs can cause increased bleeding, so you should avoid taking these medications for a period of time before surgery. Your surgeon will provide you with additional preoperative instructions. Gynecomastia surgery is usually performed on an outpatient basis. If this is the case, be sure to arrange for someone to drive you home after surgery and to stay with you for at least the next day or two.

On the day of procedure, you will have to read, understand and sign on a consent for the procedure. The surgeon will do some markings on the chest skin delineating the breast tissue along with the fat deposits to be tackled. 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 arm pit hair is shaved (if not already done). In the operation theatre you will be given certain injections along with oxygen for inhalation through a gas mask.Then you will fall asleep and wake up only after the procedure is complete. When you wake up you will notice a dressing over your chest which will be tight.

The most common technique for gynecomastia correction is Lipo-Excision. It is a combination of liposuction(removal of fat) and gland excision(removal of breast gland). The liposuction is better done through the same site where the incision of excision is going to be. Some surgeons may use a small liposuction incision on the chest and may leave an additional scar there.

Once the liposuction is done for the whole of the chest, excision is started. It is where the surgeon makes a half peri-areolar incision to remove the excess glandular tissue. During the removal of the gland some surgeons leave about 10-20% of the gland behind so that the shape of the chest is much smoother as opposed to complete removal where the chest may look sunken. Some surgeons only use liposuction, but in most cases this is a mistake unless it is pseudo-gynecomastia (all fat content). Many unhappy patients come for re-do surgery following only liposuction or only excision.

Like liposuction surgery, even in lipo-excision, the choice of the method depends on various factors like, the area and quantity of fat to be removed, the associated side effects and recovery time, surgeon’s preference, cost etc. Before surgery, its important to decide on the method of liposuction after detailed discussion on the pros and cons of each method. Check the chapter on liposuction for more details on the types of liposuction.

The breast tissue does not grow after puberty. It can however increase slightly in size after the surgery in rare chromosomal anomalies and severe hormonal disturbances.

The pain factor depends primarily on the type of anaesthesia(Local or general anaesthesia) and the extent of surgery. Most patients report minimal discomfort under local anesthesia. Lipo-excision under general anaesthesia is painless as the individual is totally anesthetised.

This is a different and often more complicated problem. The skin has a tremendous ability to contract, especially if a patient is young. In grade IIB and III gynecomastia this can sometimes happen. In such situations, the patient is reassessed after three months and the need for a further skin tightening is discussed. It is however rare in most patients

The initial recovery period is the 3 to 7 days after your procedure. Total recovery time can vary from patient to patient. Most patients can expect to be fully healed by 3-6 weeks. The final results will however be obvious after three 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 3 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 patients are advised to wear a compression garment for 6 weeks post-operatively.

After the surgery you will need to do massage of the operated area twice daily for three weeks. This helps the swelling to reduce faster and the skin to even out better. Also the pressure garment is mandatory for proper reshaping of the chest. The following diagram depicts the general post surgery protocol:

Some surgeons use drains. Drains help reduce swelling and promote better skin condition following your procedure. However with newer and meticulous techniques drains are not always mandatory.

Most surgeons use dissolving kind of stitches that fall off in two weeks, while other may prefer stitches that need to be removed after 7-10 days.

Many studies and findings suggest that young men suffer emotional distress concerning gynecomastia. They feel socially isolated as they are unable to go out barechested during swimming or other activities. They feel they cannot wear tight-fitting garments due to the chest bulge. They suffer from depression and emotional distress which is very often overlooked. Studies have assessed the physical and psychosocial aspects of the condition and how it changes after the gynecomastia is corrected. It is an accepted fact that gynecomastia surgery significantly improves the psycho-social outlook of such patients.

The potential risks or complications associated with male breast reduction may include bleeding, infection, hematoma, and delayed wound healing. The collection(seroma/hematoma) if less in quantity will be absorbed by the body even without any intervention. If however the collection is large in quantity, an aspiration and compression will be needed. Delayed wound healing is especially seen in chronic smokers and hence they need to be advised to quit as early as possible.

The incisions are normally made around the areola masking the appearance of scars especially because its at the junction of darker areolar skin and the surrounding normal skin of the chest.  With the appropriate post-operative scar management, your male breast reduction scarring should be minimal.

Liposuction which is a part of gynecomastia treatment is a procedure by where the fat cells are permanently removed. Any major weight gain will generally be distributed proportionately over other parts of your body. However one must still maintain a healthy diet and sensible eating thereafter. With excessive weight gain after surgery, one may realize that their treated areas (chest) may look aesthetically pleasing, but weight gain to the stomach has affected the natural shape of the body in general. But once removed, breast tissue cannot grow back. So it’s a permanent solution.