Male Breast Reduction (Gynecomastia)in Boston, MA.

A man with recurrent gynecomastia. He first presented at age 38 when he was 5’7 1/4 and 169 lbs. and had gynecomastia treatment by myself with external ultrasound assisted, power assisted liposuction combined with the direct excision of breast tissue through a periareolar (around the lower areola) incision with the specimen of breast tissue weighing 63 gms on the left and 70 gms on the right. He did well after surgery, with a good result at 5 months. He returned to see me two years later. He continued to smoke Marijuana (which can lead to gynecomastia) and also gained 15 lbs. and developed recurrence of gynecomastia, with new development of some firm breast tissue in the lateral lower breasts. This was a little surprising and not common in my experience, especially with direct excision of the breast tissue under the areola at the initial surgery. We returned to the operating room and performed liposuction again, along with the direct excision of 49 gms of breast tissue from the right and 40 gms of breast tissue from the left. The new breast tissue was located more laterally and inferiorly in the breast this time. He again did well. He is seen again, 5 years after this second procedure. He reports having one treatment of cool sculpting to his upper chest for a little more refinement. He has lost one pound since his second surgery, but has been spending more time at the gym. His case illustrates a few points. Recurrence of gynecomastia is uncommon, but can happen, and may be impacted by gaining weight and significant marijuana usage. I have other patients who have continued to use marijuana without recurrence of their gynecomastia, so a recurrence like this has been uncommon in my experience. Weight gain after surgery can certainly contribute as well.

A man in his mid 30’s who has had gynecomastia since middle school. He describes developing breasts at 11-212. He was smoking marijuana at that time, and continues to smoke marijuana on a regular basis. Marijuana use has been associated with gynecomastia development in some studies. He is bothered by the appearance of his chest with his shirt off and also in fitted shirts. He has worn compression garments to hide the appearance of his chest. He is shown before and again, just 6 weeks after bilateral gynecomastia treatment with A modified S.A.F.E. technique combined with a direct excision of breast tissue through an incision around the areola. External ultrasound is used to soften the fat before the finned cannula is used to mechanically disrupt the fat. Then liposuction is performed through an incision behind the pectoralis muscle and beneath the areolar. Remaining breast tissue is excised through the periareolar incision and then the fatty layer is mechanically smoothed with the finned cannula. Scars are at their thickest and reddest at 6 weeks and will now begin to fade and improve over the next 1-2 years. He is already thrilled with his improvement and is looking forward to going the beach this summer and wearing fitted shirts Update: Our patient is now seen 4 ½ months after surgery. Scars have continued to soften and fade.

A man in his early 30’s with gynecomastia. He first noted breast development at the age of 15-16. This bothers him with his shirt off and in fitted shirts. He wears additional shirts to camouflage the appearance of his chest. He does not have a history of marijuana or anabolic steroid usage. He has had endocrinology screening which is normal. He is shown before and again, just 6 weeks after a modified S.A.F.E. technique using power assisted liposuction and external ultrasound assist, combined with a direct excision of breast tissue through an incision around his areola. The S.A.F.E. technique (Suction Aspiration Fat Equalization) uses a cannula with fins to mechanically loosen up the fat followed by power assisted liposuction to remove fat and then the finned cannula again to smooth or “Equalize” the remaining fat. In my hands this allows the most aggressive removal of fat with less chance of dimples and irregularities. I modify this technique by starting with external ultrasound to soften the fat. After the liposuction is performed I check the chest and if there is a distinct mass of breast tissue (as in his case) I excise this through an incision around the lower aspect of the areola. A gynecomastia vest is worn continuously for 6 weeks along with micro-pore tape. We have just removed his tape in the office. Although scars are typically the reddest and thickest at 6 weeks, he already has an excellent contour. He is thrilled to have a normal appearance of his chest again.

A man in his early 30’s who developed gynecomastia at puberty. He does not have a history of significant marijuana use or anabolic steroid use, both of which can cause gynecomastia. Studies report that as many as 30% of young boys will develop some growth of the breasts at puberty. In most cases this goes away on its own by 18 months. If it has not resolved by that time it typically is not going to go away on its own. He is bothered by the appearance of his chest in fitted shirts and with his shirt off. He is shown before and again, 6 weeks after Power-Assisted liposuction using a modified S.A.F.E. technique combined with direct excision of breast tissue though an incision around the lower part of the areola. In the S.A.F.E. technique ( the letters stand for S uction A spiration and F at E qualization) the procedure is typically performed under general anesthesia. Wetting solution, sometimes called “tumescent” solution is injected under the skin. This is a dilute solution containing some local anesthetic and epinephrine. Then I perform external ultrasound to soften the fat. Then a cannula with fins called a “Becker” cannula is used without suction to mechanically disrupt the fat. I prefer the Microaire power system that vibrates this cannula rapidly back and forth. This loosens up the fat cells that remain viable however. Then the “aspiration” or liposuction is performed using an incision under the arm as well as the incision around the areola. After excising any remaining breast tissue under the areola, the fat is “equalized” or smoothed by using the finned cannula again to smooth the remaining fat layer around. In this manner the most aggressive liposuction can be performed without as much of a risk of leaving dimples or irregularities. A compression vest is worn for 6 weeks. Scars are at the pinkest and reddest at 6 weeks and then begin to fade and improve over the next 2 years. The peri-areolar scars are nearly imperceptible even at this time. The lateral access scars are typically the most visible early on, and I try and place these behind the border of the pectoralis muscle so they are not as noticeable. He will now wear topical silicone on the small access scars for the next 3-6 months. He is ready to go to the beach now at 6 weeks. Sunblock is recommended for the first 12 months because any scar that is exposed to the sun while it is still pink can turn brown. He is thrilled to finally have a normal chest.

A man in his early 20’s who has bilateral gynecomastia which started at the age of 16. He is right handed and muscular, with his right pectoralis muscle being larger and more prominent than his left. Arms up view demonstrates the prominent breast. He was able to be treated with Power assisted liposuction using the S.A.F.E. technique ( Suction Aspiration Fat Equalization) with the removal of 550 of fat from each side of his chest. There was no palpable breast tissue present after the liposuction was completed so an excision of breast tissue through a peri-areolar incision was not needed. It is difficult to tell before surgery whether or not an excision of breast tissue will be needed so we typically plan for this and make the final decision in the operating room after the liposuction is complete. Liposuction will not remove breast tissue, so this is the advantage of being in the operating room rather than under local anesthesia in an office setting. He is shown before and again, nearly 5 months after surgery. His pectoralis muscles are now able to be seen under the skin and he no longer has a feminine appearing chest. The S.A.F.E. technique uses a liposuction cannula with fins to mechanically break up the fat. This is used before suction is applied. Then the liposuction is performed with a traditional cannula. The fat cells are looser and easier to remove more precisely but any remaining fat is still viable. After liposuction is completed, then the fat is “equalized” again with the finned cannula to break up the remaining fat and move it around, giving a smoother final layer.