Gynecomastia is excessive enlargement of the male breasts. This is a very common problem in adolescents and usually resolves with no treatment as a boy grows. Genetics, hormonal imbalance, medications, obesity, steroid use, and marijuana use are all common causes of gynecomastia.
If the breast enlargement is mostly fatty, ultrasound assisted liposuction is an excellent treatment. If there is glandular breast tissue involved, most corrections include liposuction as well as directly excising the breast tissue. This is done through a small incision under the areola. Infrequently, a man may have so much loose skin associated with the breasts, as in the case of massive weight loss, a breast lift may also be needed.
Insurance does not cover this operation as there are rarely any functional problems associated with gynecomastia.
The operation is done on an outpatient basis and normally takes about an hour per side. Patients wear a compression vest for about two weeks afterwards to help reduce swelling and pain. During this time, physical exercise is limited. In some cases, a mammogram may be needed to be sure breast cancer is not present.
Read Episode Transcript
“Welcome to Plain Talk About Plastic Surgery, your source for down to earth honest and practical information about plastic surgery operations and procedures based on my 32 years of experience as a plastic surgeon. Today we’re going to talk about gynecomastia. Gynecomastia just means the female enlargement of the male breast. And it is a very common finding in adolescent boys and teenagers and, of course, young men and also in the older male age group as well.
So let’s get started.
Gynecomastia: Enlargement of the Male Breast
So what is gynecomastia? Gynecomastia is really just the female-like enlargement of the male breast. It is a physiological phenomenon that’s very common across all ages of the male and the newborn infant. It’s estimated that 60% to 90% of infants have transient gynecomastia, and up to about 50% of boys at puberty might experience the condition.
The gynecomastia of newborn usually occurs during the first week of life. And this is because there’s been a surge of maternal hormones released during delivery. And as these wear off, the process will resolve spontaneously, but you can have a little bit of breast tissue that will persist up to six months of age. I know both of my children had that visible for about four to six months of age.
What is Adolescent Gynecomastia?
Adolescent gynecomastia is usually during the early stages of puberty, most likely result of low testosterone levels in relation to circulating estradiol levels. This is a very normal development for boys and treatment mostly is reassurance of parents and the child that this will resolve.
Of course, it is complicated by the epidemic of childhood obesity that we have in the United States because fatty development around the breast will, of course, cause the breast to be quite large. In some of the adolescents that I see have significant breast enlargement, although most of it is just fat as versus true gynecomastia.
There was a study done back in the 1960s at a summer camp. They checked about 2,000 adolescent boys, I think ages 11 to 14, and about 40% of the boys had physical signs of gynecomastia. So as you can see, it’s very common.
Sagging Breasts: A Final Obstacle for Men Who are Working Out and Getting into Shape
There are also two other groups where I see gynecomastia frequently: One is in the mid to late 20s, and this may just be a persistence of adolescent gynecomastia. A common situation would be the young man who’s lost weight, gotten into shape, but still has persistence of a small bud of tissue under the aerola.
And this is highly aggravating as he’s invested a great deal of time and effort to improve his physique and, of course, can’t make the breast gland go away, because you can’t make that go away, just by exercise. And the other would be you’re a middle aged man who is tending more towards an obese stature who’s begun to deposit more fat in his breast.
So now he has fuller breasts that hang just a little bit. For the later, of course, weight loss would be the number one consideration. Many of these men also have low testosterone, so having that checked and getting on testosterone may also be of significant help to them.
Drug-Induced Gynecomastia, and also Diet
There are also medicines that are known to induce or cause gynecomastia, and this is quite common: Up to a quarter of all of the cases, especially those in children. The number of drugs are many, but they do fall into fairly broad categories. There are several antibiotics that induce gynecomastia, medicines like ketoconazole, which is used for fungal disorders, can inhibit testosterone development or synthesis in the body, and that can induce gynecomastia.
Calcium channel blockers for the older male; medicines such as verapamil, diltiazem, or nifedipine are known to be gynecomastia stimulators. The amphetamines, valium, dilantin, tricyclic antidepressants; cimetidine, which is used for ulcers. Chemotherapy drugs, such as vincristine, or methotrexate are well known to have a gynecomastia effect.
And, of course, hormones are the big one. Androgens, which would be like testosterone can sometimes be changed into estrogen in the body. So even though you’re thinking, “I’m going to take testosterone and that will reduce my estrogen”, sometimes it has an opposite effect. Estrogens, of course, have a direct stimulation of the breast tissue, and older men that are on estrogen therapy for prostate cancer, gynecomastia is one of the number one side effects, besides unfortunately hot sweats.
Fad Diets, Millennials and Marijuana Use
Or HCG (the Human Chorionic Gonadotropin diet). So the HCG diet, which was so very popular a few years ago: BIG influence on gynecomastia, because this stimulates the testicles to produce estrogen. Marijuana, another big androgen problem because it antagonizes androgen receptor status.
So testosterone is there and it can’t link up to the cell; therefore you have an underbalance of testosterone overbalance of estrogen. In the millennials, I see this a lot. Marijuana use, and they’re very surprised that they have gynecomastia. And if they’re unwilling to stop marijuana, the gynecomastia treatment will not be successful for them.
Lung Problems and Drug-Induced Gynecomastia; Testicular and Adrenal Tumors
Individuals that have lung problems and are on theophylline, or spironolactone also have issues with gynecomastia. If a person comes in for a consultation, and they’re on these drugs, of course, the first thing we will do is try to stop the medicine and see if the gynecomastia will resolve spontaneously.
Serious causes of gynecomastia could be testicular tumors or adrenal tumors, but they’re really quite rare. I think I’ve only seen one or two cases in my entire career where testicular tumor was the cause of gynecomastia.
Male Breast Cancer
I’d like to say just a quick word about breast cancer with gynecomastia. It is certainly possible that gynecomastia could be the presenting symptom and sign of male breast cancer.
As you might know, male breast cancer is about 1% of all breast cancers in the country. It is woefully under-diagnosed because most men don’t even think that they have the possibility of getting breast cancer.
But a male breast cancer, unlike gynecomastia, is usually a discreet nodule that’s much firmer, and gynecomastia is more of just a thickness and fullness under the areola. But if a male presented and there was an abnormal feeling, we would certainly get a mammogram to evaluate that.
Medical Insurance Coverage for Gynecomastia
This sort of segues into, “Does insurance cover gynecomastia?” And the quick answer on that is, “No.” They will cover removal of the breast gland, if there is biopsy-proven breast cancer, because now you’re doing a mastectomy for the treatment of breast cancer. But removal of the male breast for gynecomastia, at least in my experience with all the major insurance carriers, is unfortunately no longer covered.
It does not matter the amount of psychological anguish, or the fact that the patient is undergoing therapy, or there’s interference with school, the emotional distress, none of that matters. They just say this is a cosmetic condition. And honestly, it really sort of is a cosmetic condition, so we can’t get insurance to cover this operation anymore.
If a young male comes in, I will do a testicular exam just on the off chance if there’s a tumor, or if their family practitioner or pediatrician has done that, then that’s fine with me. Also in the adult, I would check.
I don’t usually have patients get a mammogram before surgery for gynecomastia as the yield is so low, because a mammogram can cost several hundred dollars and the likelihood of picking up a breast cancer is so extremely low, it doesn’t seem like a good use of money. Now, in their physical examination, if I felt there was something abnormal on the breast tissue, absolutely, we would have a mammogram done.
How do you treat gynecomastia? Well, if a patient comes in and they’re on marijuana, or they’re on another medicine that is known to have gynecomastia as a common side effect, the first step would be to see if we could stop the medicine or go to a different medicine.
If they’re obese, which is quite often the problem in the older male, counseling them for weight loss is my first step. Just like with women that come in and want liposuction and really need to lose weight, this doesn’t go very far. Most people want a quick fix. And although they know they need to lose 20 to 30 pounds, they’d rather just have an operation than do the work to lose the weight.
Best Candidates for Treatment
So then that comes to, “Who is a good candidate?” Well, the best candidate would be a male who is out of puberty, so we know that this is not just adolescent gynecomastia and is going to go away on its own. And who is weight-stable, who is not obese, doesn’t have a lot of fat on his breast, and just has a small area of breast tissue under the areola. Those are pretty much home runs. The candidate that I usually see come in is someone who is usually 10 to 15 pounds overweight, has a combination of fatty redundancy in the breast tissue, as well as a small area of breast tissue under the aerola.
Once the male breast becomes noticeably enlarged, so you look at the breast and think, “Wow, this could be like a 36B, Full B Cup, or Full C cup”, then the problem is how do we get the tissue out without causing collapse of the skin. That would mean folding and collapse of the skin which would cause indentions or valleys or looseness.
When I have a male with a large amount of fat and a large skin envelope, just like a woman who needs a lift, then we’re going to have to take excess skin out. And the problem for the male is the patterns that we take skin out and a female can’t be used because it creates a very feminine appearance of the chest wall. The problem for the male is how do we get the skin out and still keep the male chest to look masculine.
About the only way to do this is to do an incision around the areola, (remember, that’s the pigmented part around the nipple) to reduce the skin there. And sometimes that will be all that’s needed, especially if the nipple-areolar complex is a little bit droopy. We can bring it back up and place it on the chest wall where it needs to be.
Keeping the Male Chest Masculine in Appearance
If a man has lost a considerable amount of weight, then really a lot of skin has to be removed. And sometimes that results in the ‘anchor incision’, which is a circle around the areola to lift it up, a vertical scar, and then a fold along the crease, which is pretty noticeable.
Or, alternatively, occasionally we can do this with a long incision that goes out laterally towards the armpit from the areola.
Neither of these are good situations because they do create a permanent scar on the male chest which is very difficult to hide. Women are lucky because we have folds that we can hide scars in. And of course we leave breast tissue behind, so you don’t need to take as much skin out to keep the shape looking good. But a male, it’s just not quite so easy. This is the huge obstacle to making male breasts look good, subsequent to weight loss.
What’s the surgical technique? The easiest if it is a man who just has fatty redundancy is liposuction the chest. And this is done in the operating room, and I do put my patients to sleep. I make a small little incision along the outside part of the chest wall towards the armpit and then just liposuction the fatty tissue out. And that little cut is closed with a few stitches. Then the patient would wear a compression vest like a Spanx vest for three to six weeks. And that’s about it. During that time the swelling will go down, and then over the course of three to four months the skin will retract. And there’s the result!
Surgical Techniques to Treat Gynecomastia
If there’s a nubbin of breast tissue, then I would make a small incision under the areola, from about the three to nine o’clock position if you’re looking at the areola, and go in and remove the breast tissue directly, and then also do the liposuction, and that scar heals very well.
Side Effects & Recovery
Generally, there will be numbness of the nipple, most men don’t seem to be particularly bothered about it. But that’s usually about the worst side effect. And as I said before, if there’s a large amount of skin redundancy, then we have to talk about the benefits of removing skin versus the drawbacks of having a visible scar on the chest wall. And I find that to be a very difficult decision to help the patient make. This is not a hard operation.
It’s a pretty easy recovery. I would say most men are back to exercising, doing upper body exercising by four weeks and by six weeks there’s absolutely no restriction. And as I said, by four to five months, you’ve pretty much got your result and everybody usually looks pretty darn good. Drawbacks would really only be the scar and the potential loss of sensation in the nipple. And if you’re a good candidate, this is usually one of those home run operations.
So that’s it about gynecomastia. I hope this has answered a lot of your questions. If you have any questions at all, please call the office or look on our website, DrKerner.com and I hope you have enjoyed this presentation about gynecomastia. For other episodes and upcoming episodes, you can go to my website https://drkerner.com/Podcasts/ or you can subscribe to our newsletter to know when a new episode is available. And this is also on YouTube.
Have a great day and don’t forget to use your sunblock.
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