The Blog

This is Dr. Jonathan D. Hall, reporting from Boston with another episode of “A Thoughtful Patient’s Guide to Plastic Surgery.”

What is Gynecomastia?

Today, I am discussing gynecomastia, which is the development of breast tissue in a genetic male, leading to a female-like breast appearance. This is a frequent concern among my patients, and we regularly address and treat it in our practice. Gynecomastia is a prevalent condition during adolescence, peaking at around 14-14.5 years of age, and it usually resolves within two years. For cases that do not resolve naturally, gynecomastia surgery can be effective in restoring a typical body image. Gynecomastia is not a form of breast cancer, although it can slightly increase the risk of developing breast cancer in one or both breasts because of the higher occurrence of glandular breast tissue.

Gynecomastia is not a recent issue. The earliest recorded description dates back over 1800 years by the renowned Greek physician, Claudius Galen. He described it as an enlargement of the male breast due to an abnormal accumulation of fat. This definition has been updated to describe palpable male breast enlargement due to increased glandular and stromal tissue.

How Common is Gynecomastia?

A study published in JAMA in 1961 by Nydick and colleagues examined 1,890 normal boys in a Boy Scout camp. After excluding obese boys, data from 1,855 examinations were analyzed. The overall incidence of gynecomastia was 38.7% in Caucasians and 28.9% in Blacks. The peak incidence of 64.6% was observed in boys aged 14 to 14.5. In 27.1% of cases, it persisted through two seasons, and in 7.7% for three seasons. They advised that adolescent gynecomastia should not be immediately treated surgically or with hormones, but rather, the boy and his parents should be reassured that this is a normal part of puberty that will typically resolve within one or two years.

In all cases of gynecomastia, 30-50% are bilateral. In adolescent patients, the incidence of bilateral cases increases to 75%.

What Causes Gynecomastia?

The most common presentation is termed “idiopathic gynecomastia,” which is a medical term meaning “unknown cause.” However, hormonal changes typical during puberty can cause breast changes and lead to a temporary enlargement of the “breast bud.” As mentioned earlier, gynecomastia has been reported in up to 65% of boys aged 14 to 14.5. For most boys, this breast enlargement will resolve on its own over 12-18 months. If it hasn’t been resolved within two years, it is unlikely to go away on its own. Persistent gynecomastia can interfere with this crucial period of social and emotional development. Adolescents may avoid activities that require them to remove their shirts in front of peers, such as swimming, sports teams, and gym class. While it may seem reasonable to wait until the age of 18 for treatment, surgical intervention is often important when social behaviors are negatively impacted. I frequently treat adolescents with persistent pubertal gynecomastia when they are emotionally ready to proceed with surgery. A common scenario is a young man who developed gynecomastia at the start of puberty at age 11 or 12 and seeks to treat gynecomastia at 16 or 17.

Adolescent males with obesity can often experience gynecomastia due to obesity-induced elevated estrogen levels, which can lead to persistent gynecomastia and breast development. Being overweight can also exaggerate the breast form, although it may be more fatty in nature. It is advisable to consider weight loss first in obese adolescent boys. These boys are often already struggling with the physical and emotional consequences of obesity, and success with weight loss programs can vary greatly. Surgery may be considered for obese males with gynecomastia who have been unsuccessful with weight loss, with the hope that correcting the embarrassing breast contour can lead to a more physically active lifestyle.

Another common scenario involves young adult bodybuilders who develop gynecomastia related to supplements they have taken – an instance called drug-induced gynecomastia. These patients usually present in their early 20s, often with a firm thickening of the breast bud under the areola. In older males, a decline in circulating testosterone combined with increased estrogen levels leads to gynecomastia in up to 35% of older male patients (J Clinical Endocrinology 1979).

There are rare cases of gynecomastia related to testicular tumors and pituitary gland tumors. These are less common, but patients who do not fit the typical pattern can benefit from a testicular exam and an endocrinology workup from their doctor. Prostate cancer patients and those with chronic liver disease can be at risk of noticeable gynecomastia.

Gynecomastia Treatment

The goal of gynecomastia treatment is to restore a normal chest contour. Most patients benefit from a combination of liposuction and direct excision of breast tissue through an incision around the inferior areola. Some patients’ breasts are primarily fatty and can be treated entirely with liposuction. My preference is for power-assisted liposuction, which reduces the risk of dents and irregularities that can sometimes occur with ultrasonic liposuction (Vaser) or laser-assisted liposuction. However, even in breasts that appear mainly fatty, it is common to find some stromal tissue that benefits from direct excision. I often cannot determine this until I have completed the initial liposuction portion of the procedure.

I find that bodybuilders with a firm breast bud from supplements and less fat also benefit from the initial step of power-assisted liposuction. Although not as much fat is removed, this helps to separate a more even layer of fat and skin from the breast tissue and allows for a smoother layer and contour when excising it through the periareolar incision than can be obtained by simple excision without liposuction as a first step.

One challenge with gynecomastia is in patients with excess skin or decreased elasticity from age and/or significant weight loss. I have heard it said about plastic surgery that “it’s not just the tailor, it’s the fabric they are working with.” Patients in their 20s who haven’t been overweight have better skin elasticity and tend to have a smoother contour. The “fabric” is better. As patients present with decreased skin elasticity from significant weight loss or increasing age, we are presented with a choice. The only way to significantly tighten loose skin is to remove some, which can leave a noticeable scar on the chest.

It is important to understand our goals with surgery. Most patients want to look better in fitted shirts and be able to take their shirts off at the beach. So my bias is that in many patients, it is better to have some loose skin on the chest that gives the appearance of weight loss but still allows them to take their shirt off at the beach without noticeable scars. After reviewing photos in the office and discussing it carefully, this is the trade-off that most of my patients choose.

When patients have severe laxity and want the flattest chest possible, skin excising procedures are the solution. This gives the flattest chest in fitted clothing, but these patients rarely feel comfortable taking their shirt off at the pool or beach. If you have a hairy chest and gynecomastia, don’t have the hair removed with laser—it can help camouflage minor irregularities and loose skin after gynecomastia surgery.

What Happens During Gynecomastia Surgery?

Gynecomastia surgery in our practice typically takes 2.5 hours under general anesthesia as an outpatient procedure. Foam blocks and a compression vest are placed at the end of surgery. The patient is seen two days after surgery, at which point the foam blocks are removed, and the compression vest is reapplied. I typically have patients add a sleeveless compression shirt under the vest, one size smaller than they typically wear. Patients are allowed to shower two days after surgery, but it is important to put the compression vest and garments back on after the shower and wear these continuously for six weeks. Most patients resume office work or school after one week but avoid the gym and strenuous physical activity for six weeks. The compression garments are discontinued after six weeks, and most patients can return to the gym and their normal activities. It is important to limit sun exposure for a year to prevent scars from darkening, and I have patients use topical silicone to help scars settle more quickly.

Gynecomastia Treatment with Dr. Jonathan Hall

Gynecomastia is a common condition in adolescence, peaking in incidence at 14-14.5 years of age (in as many as 65% of 14-year-olds) and typically resolves within two years (8% of 17-year-olds). For cases that do not resolve on their own, gynecomastia surgery can help restore a normal body image. To schedule a gynecomastia consultation, contact my office today by calling or filling out a contact form.