Gynecomastia, or male breast enlargement, is a well known condition that affects both teenagers and adult men. While the majority of gynecomastia occurs in teenage boys, most of which can go away on its own, those that require surgery are more common in adult men over the age of eighteen. I do far more gynecomastia reduction surgery in men than in teenage boys.
While most people assume that gynecomastia surgery involves the reduction of large amounts of breast tissue, these types of male breast enlargements do not make up the majority of cases today. Men requesting gynecomastia reduction today are just as likely to come in for a relatively small amount of breast tissue that may just be underneath the nipple (areolar gynecomastia) or limited to just around it. The enlarged nipple-areolar complex is just as aesthetically distracting for many men as is a completely enlarged breast mound. This is also reflection of contemporary body styles and cultural standards of male beauty.
One very specific type of contemporary male breast concern that I see is ‘athletic gynecomastia’. This is seen in athletes, usually body builders, and often is the result of steroids and other muscle building supplements. The specific use of steroids or testosterone has the side effect of making the female hormone estrogen which stimulates breast tissue development. This creates a very firm breast tissue nodule which is easily felt right under the nipple. It is visually evident in a normal stance but protrudes out much further when lifting or posing as the flexed pectoralis muscle pushes it forward.
In the surgical treatment of this type of gynecomastia, liposuction will not usually work well alone. The breast tissue is too firm to be broken down and removed by cannula extraction. When looking at the three zones of breast tissue, the two zones outside of the nipple (between the nipple and the sternum and between the nipple and the armpit) can be treated by liposuction as it always much softer than what lies under the nipple. Direct excision through a nipple incision is needed to remove the subareolar firm mass. The size and firmness of the areolar mass can be quite impressive and is always much bigger than the diameter of the areola.
The approach to this type of gynecomastia is always through the lower half of the areola. This places the incision in the transition zone between the areola and the skin which makes for a well concealed scar. The scar will run between the 9 and 3 o’clock position. This will allow adequate access for directly excising the breast mass by electrocautery and doing liposuction to the two outside breast tissue zones. There is no need for any additional breast incisions. The wide undermining created by the liposuction also allows the skin surrounding the areola to shrink and adapt better.
Drains are almost always used for up to a week after surgery to prevent a fluid collection which can easily turn into hard scar tissue, creating minimal improvement afterwards. The use of a chest wrap is also important for the same reason and is worn for up to several weeks after surgery.
While there are the typical risks of gynecomastia surgery, such as hematoma, seroma, prominent areolar scar and nipple and chest irregularities, these are not the ones I emphasize to these types of gynecomastia patients.
The real risk of this athletic gynecomastia reduction surgery is the need for a revisional procedure. Despite the fact that this gynecomastia is small in size compared to other gynecomastia surgeries, and thus would seem to be more easily solved, the need for revisional surgery is actually higher in my experience. This is because this type of male patient is very particular in the final cosmetic result and even the smallest amount of residual tissue or irregularity will be seen as a cosmetic distraction. When you look at the type of body on which this small gynecomastia occurs, one realizes the high aesthetic goal one has to reach for complete satisfaction.
Dr. Barry Eppley
Indianapolis, Indiana