Introduction to Gynecomastia and Gynecomastia Surgery
Gynecomastia, or excess male breast tissue, is a very common condition. In fact, at Neinstein Plastic Surgery, gynecomastia surgery is one of the most common treatments we offer.
Approximately half of our liposuction and body contouring patients are male, and we’ve found that it often comes as a surprise to patients that most forms of gynecomastia can be treated with liposuction, alone.
At our practice, Dr. Neinstein tends to use different types of energy in gynecomastia surgery. More specifically, he uses Vaser or ultrasound liposuction along with plasma skin tightening because we have found this approach achieves the most predictable gynecomastia surgery results with minimal downtime and virtually no scarring.
Below we’ve gone into depth about what gynecomastia is, how it is caused, and how it can be treated.
What is Gynecomastia?
All men have breast tissue; many people do not realize this, but it’s completely normal. In addition, there are three times in a man’s life when they have more breast tissue than normal.
- The first time is at birth. When men are born they have extra estrogen from their mother, so technically, newborns have gynecomastia. Breast tissue in men and women is hormonally sensitive so as testosterone starts to outweigh the estrogen the tissue shrinks.
- The second time is during puberty. As we all know, there are all types of hormones being produced during pregnancy including estrogen. This estrogen will go to the breast tissue and activate the glands to grow. Similar to earlier in life the gland should shrink in most men. However, the most common cause of gynecomastia or excess male breast tissue is when the breast tissue does not shrink after puberty. This is called idiopathic gynecomastia. We start seeing men in their early teens become self-conscious about this. They start to wear multiple t-shirts to try and hide the appearance and can become withdrawn from activities such as swimming or gym class.
- The third time is in older age. As men age they tend to deposit more fat than muscle. Many men in their elderly years will develop more breast tissue because some of this excess fat gained in their 60’s and 70’s contains a special enzyme that creates estrogen.
How is Gynecomastia or Male Breast Tissue Classified?
There are a few different classification systems for gynecomastia in plastic surgery literature. The reason why we have classification systems is that it allows surgeons to communicate with each other and perform research on procedures in order to always be improving outcomes for patients. These gynecomastia classification systems also allow for a treatment algorithm.
- Grade I: Small breast enlargement with localized button of tissue that is concentrated around the areola.
- Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest
- Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy present
- Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast
What is the Psychological toll of Gynecomastia
The emotional and psychological toll gynecomastia can have is something Dr. Neinstein takes very personally. The psychological burden and impact on emotional growth is well documented. Recently, a large research project was undertaken on this. Results were compared to those of a group of boys without breast enlargement. Sixty-two percent of the gynecomastia patients had mild to moderate breast enlargement. As in previous studies, many of the boys with gynecomastia were overweight or obese: 64 percent, compared to 41 percent of the comparison group. Patients with gynecomastia had lower scores on a standard quality of life assessment, indicating problems in several areas. Even after adjustment for weight and body mass index (BMI), the patients had lower scores for general health, social functioning and mental health. They also had lower scores for physical health, but this was attributed to being overweight.
Breast enlargement was also associated with lower scores for self-esteem. This, along with impairment in emotional areas of quality of life, appeared directly related to gynecomastia, rather than being overweight. Luckily prompt treatment and gynecomastia surgery can dramatically increases the quality of life for these patients.
Causes of Gynecomastia
Gynecomastia is not always idiopathic. Sometimes excess breast tissue is caused by disease states and even medications.
The most common cause besides idiopathic that we see is a consequence of anabolic steroid use. Many men have used and will continue to cycle through anabolic steroids in effort to assist in weight training to help add muscle bulk or speed recovery. One of the consequences of using anabolic steroids is the increase in growth in male breast tissue or gynecomastia. There are some unique aspects of this. Typically these patients have very little body fat, as they are bodybuilders or gym enthusiasts. In these patients we typically simply remove the gland through a small incision since there is almost no excess fat or skin to remove. Unlike other medications that cause gynecomastia, the excess male breast tissue tends not to go away once the anabolic steroids are stopped. We find its important to remove the entire portion of the gland in these patients because if they continue steroid use there will be a recurrence or a re-growth of the male breast tissue or gynecomastia.
There are many common medications that can cause gynecomastia, as well. These medications are used in treating allergies, high blood pressure, HIV, and depression. What is interesting with these medications as compared to anabolic steroids is the excess male breast tissue tends to shrink when the medications are stopped. That is why a detailed medical history is required when assessing patients for excess male breast tissue or gynecomastia. Many times when we see patients on these medications we will call their prescribing physician to see if there is an alternative medication to treat the medical condition that will not cause excess male breast tissue or gynecomastia.
Any time there is an imbalance between estrogen and testosterone production where there is an increase in estrogen, gynecomastia will develop. These situations are rare but it is very important for your examining surgeon to rule all of these out as some can be life threatening.
The pituitary gland or other glands in the body can develop tumors that can be benign or malignant. These tumors may produce estrogen. Many times these patients will develop other feminizing features along with excess male breast tissue. A thorough work up with blood work, imaging and prompt appropriate referrals is essential. Disease states within the liver or kidney can also cause a production of estrogen through creation of enzymes that help build estrogen. These situations will also cause an increase in gynecomastia. It is not just medical conditions that cause extra estrogen, but also medical conditions that cause a decrease in testosterone and thereby increase male breast tissue. If there has been any trauma, infection or disease of the testosterone producing testicles this can lead to gynecomastia as well. Again, your surgeon will ask you about these and perform a physical examination as needed.
How is Gynecomastia Treated Through Surgery?
Once medications and medical conditions have been ruled out as causes, the mainstay of treatment is gynecomastia surgery
There are many types of gynecomastia surgery procedures available to patients. Dr. Neinstein simplifies things by by thinking in terms of two main categories with the overall goal being to remove the excess gland tissue and contour the male chest to improve the appearance and self esteem of the patient.
Liposuction for gland removal and contouring (sometimes requires small incision to get out remaining gland). The aim here is minimal or virtually no scarring.
How is Liposuction used in Gynecomastia Surgery
The goal of the procedure is to shape and contour the male chest in order to improve shape and thus self esteem. Traditionally, liposuction was used to remove excess unwanted fat and than an incision was made to remove the extra breast tissue and or skin. These operations were successful in reducing fat, gland, and skin. However, there was significant scarring and therefore many men were left unhappy because they had an excellent shape and contour while in clothing but were uncomfortable because they never wanted to take their shirt off because of the scars on their chest.
Liposuction was never thought to be able to remove any of the gland tissue or tighten skin. Just like other industries technology and techniques have evolved. The first evolution has been the addition of ultrasound technology to the liposuction platform. Currently we use third generation ultrasound liposuction on the Vaser platform. Once the chest has been filled with numbing solution the small Vaser or ultrasound liposuction probe can be introduced through a tiny incision. The same incision that will later be used for fat and gland removal. The ultrasound liposuction offers a few advantages over traditional liposuction. It is particularly efficient in the removal of the dense, fibrous male breast tissue while at the same time contributing to skin retraction. Outside of patients who have lost a lot of weight (usually over 75 lbs) most males will have excellent collagen in their skin and therefore will respond well to ultrasound liposuction. The procedure can be done under general anesthesia or with light sedation and scarring/downtime is minimal.
Dr. Neinstein has performed hundreds of ultrasound-assisted liposuction of the male chest and have found it to be the highest patient satisfaction for the majority of patients because I can remove excess fat and gland and get a significant amount of skin tightening through a tiny virtually scar less incision.
Why Add Additional Techniques, Incisions, or Devices?
Dr. Neinstein feels that choosing the operation that is right for the individual patient is a balance of trade offs. It all depends on how much scarring and downtime a patient is willing to tolerate as we can keep adding adjuncts to ultrasound liposuction to enhance the results.
What is the Pull-Through Technique?
The pull-through technique is an excellent addition to liposuction for gynecomastia in the male patient. Basically, “the pull-through” technique is using some sort of small plastic surgery instrument to remove extra gland tissue that was not removed with liposuction through the liposuction incision. This works very well for many patients and we have some great instruments that allow us to do this procedure.
What is Plasma Liposuction?
Many men will have some extra loose skin from gynecomastia or pseudo gynecomastia, which is excess male breast tissue that is fat, and not extra gland. Our practice has recently begun adding ionized helium gas or plasma to our liposuction platform. This device goes through the same small incision that was used for Vaser liposuction and the pull through technique but adds skin tightening capability. The ionized helium is able to add a significant amount of heat to the bottom of the skin to cause the collagen to tighten and remodel during the liposuction procedure. This can dramatically improve the results of the procedure and has been an excellent addition to the liposuction treatment of gynecomastia
What is Direct Gland Excision?
This is still a great method of treating gynecomastia and along with liposuction is the most common treatment for gynecomastia. Many surgeons who do not use energy devices in their liposuction practice will typically perform traditional non-energy based liposuction of the male chest along with direct excision. Direct gland excision for gynecomastia is making an incision in the areola from the 3 pm to 9pm of you think of the areola as a clock. This allows the surgeon to flip the areola open just like lifting a man hole on the street. Excess breast tissue or gynecomastia can be directly removed because the surgeon can directly visualize the gland.
The downsides to direct excision to me are 1) the scar- typically it heals well but there is a psychological burden for men to have a scar on their chest and it does not always heal perfectly 2) The chance of a contour deformity- if too much gland is removed from just under the areola a divot or depression can develop.
What about Body Builders?
Body builders are a unique group of patients who seek treatment for gynecomastia or excess male breast tissue. Given that they typically have very little body fat and they frequently have gynecomastia because of anabolic steroid use I will will typically do a direct gland excision only as to remove all extra gland which is the only concern and reduce the chance any more tissue will grow if they take another cycle of anabolic steroids.
Gynecomastia Skin Removal & Liposuction
Skin removal along with liposuction and complete gland removal
This is all about trade offs. We all have extra skin. I have found most men are willing to tolerate some extra skin instead of having large scars that even when they fade they are noticeable on the chest. My approach to this is for the average patient to maximize vaser/plasma liposuction with the pull through technique and wait 6 months at that point if the patient hates the extra skin we can add a skin removal procedure in the office and the psychological burden of the scar is a lot less than if we had done it at the beginning. If a patient is a massive weight loss patient or has been “yo-yo” dieting for several years and has a lot of extra skin at the bottom we will discuss removing the nipple cutting out all the extra skin/fat/gland associated with the gynecomastia and putting the nipple back down as a graft. This can be a great procedure in the proper patient when they re fully informed of the risks, benefits, and associated risks
What type of Anesthesia is Used in Genecomastia Surgery
Having a fully accredited operating room in my office allows me to use all types of anesthesia. If we are treating the chest alone we will typically use oral medication and simply numb the area. Many men prefer this because they do not have the nausea/vomiting and prolonged recovery of a general anesthetic and can have the procedure done very discreetly with having one of our chaperones take the patient home so nobody else has to know they had it done. However, some patients prefer a general anesthetic or are having multiple procedures done and require a general anesthetic and we will bring in a board certified anesthiologist to provide safe general anesthesia
We ask patients to take 2 days off of work but they will be able to work at home the day after surgery using a lap top and taking calls on the phone if they wish. Dr. Neinstein requests no exercise for 3 weeks to allow the small blood vessels to heal so there is no significant bruising after surgery. Most patients take pain medication for 24-48 hours than switch to ibuprofen or extra strength Tylenol.
Gynecomastia Surgery Cost
The typical cost for gynecomastia surgery near New York, New York is about $7,000. For more details regarding liposuction surgery costs, please visit our cost page.
If you are interested in gynecomastia surgery and have any additional questions, please contact the Neinstein Plastic Surgery team at 212.249.0949. We are eager to help, and look forward to hearing from you.