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I have been seeing more and more older male patients for ‘gynecomastia’ in the past several years. In the past, most of the males I saw with ‘chest problems’ were usually teenage boys who had the very typical adolescent form of gynecomastia. Some of these were quite small, isolated to the nipple-areola area, and others were quite large, having a B or C cup size breast equivalent to females. Surgical techniques included liposuction, open excision through the nipple, periareolar reduction methods, and rarely a more traditional form of breast reduction. These newer presentations of older gynecomastias (in reality, these are not really true gynecomastias but more accurately, pseudogynecomastias) present new challenges and require some adaptations to traditional gynecomastia approaches.

Some of these ‘newer’ gynecomastia are quite simple to treat. With the contemporary male model image of a very flat chest (I call it the Abercrombie Fitch look), some teenagers and men in their 20s and 30s want a small change in their chest contour by decreasing any projection of the nipple-areolar complex. Traditional liposuction, done aggressively under the nipple, works quite well for this small reduction.

The next gynecomasia problem is in the overweight patient who has a large chest and small pseudo breasts. Liposuction, with or without a superior crescent nipple lift, helps the chest contour but the nipple never really gets as high up on the chest wall as we would like. Similarly, the male who has lost a lot of weight usually due to bariatric surgery, poses a difficult problem due to the excess hanging skin. Proper nipple position can never really be obtained in these patients without a lot of undesired scarring.

Then there is the older male who has a combination of loose skin, low nipple position, and a ‘deflated’ chest appearance. Liposuction, nipple lifts, and occasionally pectoral implants can help rejuvenate the aged chest appearance. This is a problem of tissue volume loss and loose skin, the opposite of the younger gynecomastia patient.

Dr Barry Eppley

Indianapolis, Indiana

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