Enlarged male breasts or gynecomastia affects nearly half of all men at some time in their lives. Some cases will resolve without treatment but often treatment is necessary. Although gynecomastia may be due to a systemic disease, heredity, steroids, or medications, the cause of it is often unknown and may not be related to body weight. For many men, large breasts cause social awkwardness, embarrassment, and lower self-confidence. Through a simple, outpatient procedure many men are able to regain a smooth, contoured, more masculine chest.
The ideal male breast is muscular and well-defined, giving the impression of masculinity and strength. In some men, the breast tissue grows, becomes fatty, and may even sag. This appearance looks feminine, unhealthy, and suggests that you are out-of-shape.
Many patients who have large breasts avoid the gym. They dress in two t-shirts at a time to disguise their extra breast tissue. After surgery, they often tell me how comfortable they feel exercising and on the beach.
Cause and Effect
Often the cause is never classified. It is common for 14-15-year-old boys to develop larger breasts during puberty but they often resolve within two years. Medical causes are secondary to hormonal imbalances due to a deficiency of testosterone or an excess of estrogen. Extra weight can lead to an increase production of estrogen and therefore an increase in breast tissue. The side effects of several medications may lead to enlarged male breasts. Common medications that lead to gynecomastia include estrogens, digitalis, clomiphene, ketoconazole, metronidazole, cisplatin, spironolactone, cimetidine, isoniazid, methyldopa, tricyclic antidepressants, and valium. Heroin and marijuana commonly cause an increase in breast tissue. Liver conditions may also lead to gynecomastia. All of these causes disrupt the testosterone pathway leading to a change in the ratio between estrogen and testosterone. Elevated estrogen will stimulate the breast gland to grow, leading to a fuller, cone-shaped breast and puffy nipple.
Many men have chosen to undergo gynecomastia surgery and are pleased with the dramatic results. It is essential to first confirm that your condition is not secondary to a treatable medical condition or a change in your daily medications. The best candidates are men who are healthy and are at a normal weight. It is important that your breast development has stabilized. It is wise to wait at least two years from the start of breast development in adolescents to confirm that their breast tissue does not resolve on its own.
To Cut or Suck
Depending on the extent of excess skin and the type of tissue found in the breasts, the procedure may only involve liposuction or may require skin excision as well. If the breasts consist of mostly fatty tissue, liposuction may be used to remove fat from inconspicuously placed incisions under the nipple or within the natural contours of the chest. For breasts with an excessive amount of skin, excision surgery is required. I will help formulate a treatment plan tailored to your body and the results you wish to achieve.
Patients who do not require a significant amount of skin to be removed may benefit from liposuction alone. Traditionally, most patients would require liposuction with the addition of a small incision around the areola (dark skin around your nipple) to remove excess glandular tissue. When necessary, the glandular tissue is separated from the skin and underlying muscle and removed through a very small incision hidden under your nipple. It is important that when removing glandular tissue that a small amount is left behind avoiding a possible contour deformity or inverted nipple. Recent developments in technology have dramatically changed the need for extra incisions in many patients. I have found that by using ultra-sound assisted (VASER) or laser-assisted (Slimlipo and SmartLipo) liposuction, I am able to break apart the glandular tissue, leaving a smoothly contoured chest without the extra incision around the areola. I often will use two entry sites which are less than one inch in length located under the arm and in the lower outer part of your chest. Liposuction involves moving a cannula, a thin, hollow tube, back and forth in a controlled motion to loosen and remove excess fat similar to a vacuum. The addition of heat via ultrasound or laser-assisted liposuction not only decreases the need for extra incisions but also causes skin tightening; converting some patients who may have needed a skin excision to patients requiring only liposuction.
The New Suit…Skin Tailoring
For some men, there is not only extra fat and glandular tissue but also a significant amount of excess skin. In others, they have poor skin quality to due to dramatic weight change or age, which is less likely to tighten after liposuction alone. For these patients, I will often start the procedure using liposuction to feather the edges of the breast, removing fat and glandular tissue. Afterwards, it is necessary to remove excess skin. This is done through an incision that will later reside at the base of your pectoralis muscle, under your breast. An excision technique is also helpful when the areola needs to be reduced or repositioned to create a more natural male contour. The incision will fade over the course of the year. If a patient is borderline, I often will use liposuction only first to see how much skin contraction is obtained. If necessary, a small skin excision is performed several months later often in the office.
LIPOSUCTION AND SURGICAL REVISION
Most patients are concerned about not being left with a smoothly contoured chest. When removing tissue from behind the nipple it is essential to leave behind a small amount of tissue to create a foundation for the nipple to rest upon. If too much tissue is removed, the nipple may appear inverted. It is also important to use small liposuction cannulas. I am very particular about using precise, small diameter cannulas to ensure that lumps and bumps are not left behind.
Male breast reduction is performed as an outpatient procedure in a surgical suite or surgery center. The surgery usually lasts for one to two hours depending on the size of your breasts. You will go home later that day dressed in a compression garment.
Immediately after surgery, your chest will be bandaged and wrapped with a compression vest. Sometimes, drains are used to remove any extra fluid and to help train the skin to lie flat against your muscle. For the first few days, you will experience swelling and discomfort. Most patients will take pain medication for the first few days and return to work in 4-5 days.
You can begin light exercise on day one but it is best not to over exert yourself as it will lead to increased swelling. You can resume strenuous activity in three weeks.
The fat cells removed via liposuction and the skin and glandular tissue excised are permanently removed from your body. Although the results from surgery are visible immediately, as the swelling subsides you will see a flatter, more defined chest. Tissue retraction, definition, and contouring will continue to improve for one year. The results will be long lasting if you maintain a stable weight.
A Picture is Worth a Million Words
A picture may be worth a million words but in the age of the internet, online photos can be viewed by billions of eyes. In respect of patient privacy, a before and after section was not created on our website. Several patients have agreed to allow their photos to be viewed by prospective patients in the office. You may request to view photos during your consultation. Some patients have also agreed to speak with prospective patients if you would like to learn more about the procedure from a patient’s perspective
What is the first step?
If you are considering gynecomastia surgery, please call our office at (212) 600.4109 to arrange for a consultation. Our New York City practice accommodates out of town and international patients who need to travel in for surgery as well as those who are local to Manhattan.
I thank you in volumes in the manner in which you handled this procedure from the initial consult to post-surgery. I doubt I would have been comfortable enough with any other physician. It was as much an emotional journey as a physical one. I am sure many, if not all of your patients with body image issues need your comforting guidance.
Dear Dr. Doft,
Perhaps, I should entitle this note, “Better late than never”. First, because it has been a year since you performed surgery for my gynecomastia and I promised to update you. Second, because I waited until I was 60 to overcome the fear and doubt associated with the condition and the medical procedure.
As you can imagine, there are so many things a man my age can identify as life changing events. Marriage, children, grandchildren, career, and retirement are all there. But, looking back over the past year, I must place this procedure among them.
While almost all who know me would label me the extremely self-confident sort, few knew how low my self-esteem was regarding my body image. Of course, I could rationalize the genetics, weight issues, and social-economics that leant to my condition. The problem was that even as I improved my health, exercise and lifestyle, the problem lingered. Perhaps just as much in my mind as my body.
You know the fortuitous event the led me to your office. Stepping through your office door was the most difficult part of the whole procedure. I could not imagine a more comforting hand leading my way. Your office and staff, the operating procedure, the recovery and follow up were simply amazing.
In the past year I have tossed so many “undershirts” out, purchased slim fit shirts, swam the Great Barrier Reef bare chested, and hung pool side in Positano. I can now do all this with confidence, comfort, and a smile.
I am sure that many of your male patients may be hesitant about this procedure so please feel free to share this note with them and wish them luck. As an inside joke for us “dudes” tell them that I now look forward to being picked by the “skins” for a pick up basketball game!