GYNECOMASTIA 101

Plastic surgery has recently surged into the mainstream discourse, especially with the ubiquitous use of social media. We now have more exposure to and education about plastic surgery procedures, how they are performed, and what happens afterwards. Largely though, this is a female-dominated conversation despite the fact that men are actually a hearty percentage of patients that Plastic Surgeons care for. One of the most common procedures that males seek out is gynecomastia correction. Enlargement of the male chest is a common condition that, despite its usually benign nature, can be incredibly distressing and embarrassing to male patients. In this blog post, I want to dispel the common misconception and address the root causes of, workup for, and treatment for gynecomastia. 

WHY DOES THIS HAPPEN? 

Gynecomastia is characterized by enlargement of the male chest. We tend to have this picture in our heads of who gets ‘man boobs’-- older, overweight, maybe kinda hairy (or maybe that is just me?) Unfortunately, that generalization could not be further from the truth. The most common scenario I encounter as a Plastic Surgeon is actually a super-fit, younger male who has literally tried everything for his chest–diets, cardio, weightlifting– with no resolve. As a result, they are equal parts frustrated and insecure. 

There are a variety of reasons that gynecomastia can occur, the most common being some sort of hormone imbalance. The development of male breasts parallels that of a female breast– a rise in circulating estrogens stimulates breast tissue growth. Therefore, any process or medication that disrupts the hormone balance in men between testosterone and estrogen, tipping the scale in favor of estrogen, can cause an increase in male breast tissue. Examples of this include anabolic steroids, drug use, and weight gain. Because fat secretes an enzyme that can convert testosterone to estrogens, obesity is a leading cause of gynecomastia in our current society. 

There are certain age-related stages in male development during which gynecomastia is more prone to develop. Many infants have a high level of circulating maternal estrogens, causing enlargement of the newborn breast tissue which resolves during the first few years of life. Hormone surges during puberty can also trigger the growth of male breast tissue. Lastly, as testosterone levels decline in older ages, fatty tissue can accumulate in the chest causing enlargement.  

MAKING THE DIAGNOSIS: 

Commonly, patients seeking gynecomastia correction noted enlargement during puberty that did not resolve as hormone levels stabilized with increasing age. This is usually a benign process, however more nefarious causes such as testicular hormone-secreting tumors or actual breast cancer must be ruled out first. Generally, a primary care provider will perform the initial screening for patients before they land in my Plastic Surgery office. This will typically involve a thorough history and physical examination, and may include additional imaging studies if warranted. 

TREATMENT OF GYNECOMASTIA: 

Obviously I am a Plastic Surgeon, so I am here to talk primarily about the surgical treatment of gynecomastia; however, for completeness sake, I will briefly touch on some of the medical treatments. Since we have established that breast tissue growth is stimulated by increases in male estrogen levels, medications to help correct gynecomastia are aimed at either increasing testosterone or decreasing estrogen. There are three classes of medications that serve this purpose: androgens, anti-estrogens, or aromatase inhibitors. Androgens are basically testosterone or its analogues, anti-estrogens are exactly as they sound, and aromatase inhibitors prevent the transformation of testosterone to estrogen. Your primary care physician and likely an endocrinologist are best equipped to initiate and manage these types of medications. 

From a surgical perspective, management of gynecomastia is an outpatient procedure that generally takes up to 2 hours to perform. Which type of surgery is performed, however, is completely dependent on 3 important characteristics of the chest that are evaluated during consultation. 

1. Glandular tissue. Glandular breast tissue is dense, fibrous, and cannot be removed by liposuction. If male chest enlargement has glandular tissue present, it must be directly removed through an incision placed along the areolar border. 

2. Fatty tissue. Fatty tissue differs from glandular breast tissue in that it can be removed with liposuction cannulas and does not require direct incision. This allows it to be removed through small, 2-3 mm long incisions. 

3. Degree of Skin Laxity. This can make a fairly simple and straightforward gynecomastia correction much more complicated. As the breast tissue grows larger, the skin stretches and expands to accommodate. With tissue removal, as in the case of surgical correction, what will happen to the stretched out skin? Will it tighten up over time or stay loose? Skin recoil will never happen instantaneously in the operating room. As a consequence, Plastic Surgeons must use our best professional judgment to predict what will happen to the skin envelope over the subsequent months post Plastic Surgery procedure. If skin removal is required, the incision will be placed around the areola if mild, or along the base of the pectoralis major muscle if more severe. 

SKIN EXCISION PATTERNS:

1. With mild skin laxity, a small incision can be placed along the areolar boarder.

2. More moderate skin laxity may require the incision to extend past the areolar boarder, onto the sides of the areola.

3. If significant skin laxity is present, an incision may be placed along the inferior boarder of the pectoralis major muscle.

CONCLUSIONS:

Gynecomastia is a common condition encountered by Plastic Surgeons that can be incredibly distressing to male patients. Alternative causes must be ruled out first before considering surgical intervention. The surgical treatment of gynecomastia depends on its contributing elements– breast tissue, fat and/or excess skin. The procedure can easily be performed as an outpatient procedure (meaning you get to go home afterwards) and takes less two hours on average to perform. Recovery length can vary by the type of procedure determined by your Plastic Surgeon, but typically involves around one week off from work and up to 4 weeks off from upper body exercises. 

Correction of gynecomastia can be life changing for patients. If you are considering this procedure and want to learn more, schedule your consultation today. 

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Dr. Megan Dreveskracht is a Female Plastic Surgeon in Seattle, Washington who specializes in Aesthetic Surgeries of the Breast, Body & Face. To schedule your consultation, call 206.860.5582 or fill out a contact form here.