Gynecomastia is defined succinctly as male breast enlargement. While this description is accurate, it is overly simplistic. Gynecomastia is a wide spectrum of male breast problems caused by the growth of excess male breast tissue. This can range from the smaller areolar gynecomastias (puffy nipple), up to a size that resembles a large droopy female breast (giant gynecomastia), to a deflated sac of skin and sagging nipple. (elder gynecomastia) The quest for younger males is a completely flat chest with no nipple protrusion.
One of the unique types of gynecomastia that is rarely discussed is that seen in the younger male which may be small but is very firm. Generally seen in men between late teens and mid-thirties, it presents as a discrete swelling under and around the nipple. It is very firm and nodular. These male patients will usually have a history of some drug use in the past, whether it be steroids, growth hormone, or other anabolic supplements. They can be patients who were treated for a medical condition in the past, such as congenital adrenal hyperplasia, or may be bodybuilders or very athletic.
In presentation, this type of gynecomastia is not large and is fairly small. The actual firm mass underlying the areola is not large and it is fairly discrete, although bothersome to the patient. Many men may not be that bothered by it but young body-conscious males are very aware of it. This is particularly relevant in today’s male culture where a very flat chest contour is desired. Even a slightly puffy nipple stands out by these standards. For bodybuilders, this nipple mass is accentuated on flexing and in certain poses.
It is important to appreciate that although this areolar mass is small, it is not able to be removed adequately by liposuction. It is tempting to do so and I have tried because it seems like it should be easy to extract. I have not been successful even with laser liposuction. (Smartlipo) It can be reduced but not flattened sufficiently to the satisfaction of these male patients.
The firm consistency of the young male areolar gynecomastia requires that it be removed by an open excision technique. Through a lower areolar incision, the mass can be easily excised in a circumferential manner around the base of the areola. The firm dense consistency of the mass can be quite surprising. While it is important to remove as much as possible, one must be careful to not remove too much, ending up after healing with a nipple indentation. Some tissue must be left on the underside of the nipple to prevent this potential complication. Depending on the size of the excision cavity, a small drain may be used for several days after surgery. If the underlying space is not too large, the ‘dead space’ can be tacked down and reduced so a drain is not necessary. The areolar incision is closed with internal dissolveable sutures and taped. A circumferential chest wrap is worn for several weeks after surgery.
Dense areolar gynecomastia is best approached by doing open excision. Liposuction is tempting but will not be successful as the consistency of the mass is too dense.
Dr. Barry Eppley
Indianapolis, Indiana