In men who have lost a lot of weight or in overweight men in general, breast enlargement is a common problem and concern. As a general rule, these forms of more severe gynecomastia are not just about having large breasts but having breasts that are large enough to have significant sagging. This form of gynecomastia poses much different problems than lesser degrees due to the low nipple position and excessive hanging chest skin. While traditional forms of gynecomastia respond well to liposuction or open excision through a nipple incision, these more complicated forms will not.
The fundamental surgical concept that must be incorporated in improving this form of gynecomastia is that of a breast lift…..and the scars that will be created. Not only must breast tissue be removed, but skin as well. In addition, the nipple must be repositioned and the overall chest reshaped to be as flat as possible rather than end up looking like a female breast mound. When breast lifts are involved, it is all about how much the nipple must be moved upward and how much scar can be tolerated to achieve this reshaping.
The most effective radical gynecomastia procedure is a simple mastectomy with free nipple grafting. Unlike a mastectomy for female breast cancer which would leave a straight line scar across the center of the chest, the ‘male mastectomy’ removes the overhanging breast tissue and places the scar along the inframammary fold, which is in a more natural skin crease. The nipple is first removed and then put back as a skin graft in a farther northern position at the end of the procedure. While nipple sensation will be lost (which isn’t that useful to most men anyway) and the nipple will never look quite normal, this approach is the most assured way to get a dramatic improvement in a single operation.
Using the traditional anchor or inferior pedicle approach is another radical gynecomastia surgical approach. This is the least desireable from a scar aesthetic standpoint (vertical and horizontal scars are more obvious) but its primary benefit is that it keeps the nipple alive because of the underlying attached pedicle. Because you can’t thin out the breast tissue under the pedicle very much, for fear of having the nipple die afterwards, a second liposuction procedures may be needed to bring the chest mound prominence down further.
The most aesthetically pleasing, but the most difficult gynecomastia operation to perform, is the periareolar (around the nipple skin excision or donut procedure) operation. The whole purpose of this approach is to not only keep the nipple alive but keep the scar limited to around the nipple only. What makes it difficult is not the surgery per se, but that it will take at least 3 and sometimes 4 operations to get the final result. Only some much skin can be removed in a donut fashion each time as well as only so much breast tissue. This is a long road to go in severe gynecomastia cases and poses some obvious economic hardships. But for those men who want the least scar possible, this is the only way to go.
Dr. Barry Eppley
Indianapolis, Indiana