Understanding Gynecomastia when I completed my residency in Plastic Surgery back in 1992, gynecomastia and its treatment was a bit of a different animal than it is today in 2005. The condition itself has not changed significantly, but public awareness along with men’s attention to appearance and image has progressed, leading to a huge increase in the number of gynecomastia procedures performed by Plastic Surgeons in the United States in the past few years.
Back then, many young men—adolescents, late teens, and even men in their early twenties—would occasionally show up after seeing their primary care physician, whom they might have questioned regarding their fatty chest, or a lump on one side or the other, or maybe a question about why their nipples stuck out. These patients were often surprised to learn that they had a medical condition which was not uncommon, and which could be treated. Among the bodybuilding community, the condition was fairly well-known, since many bodybuilders who had engaged in anabolic steroid use went on to develop the condition, requiring surgical excision. In this arena, the surgery for gynecomastia is almost looked upon as a rite of passage in the trek to hugeness.
So what exactly is gynecomastia? In reality, this is a descriptive term, meaning “woman-like breast”. The term does not have meaning with regard to the cause or appearance, and there is a wide range in what is described, from a small lump under the nipple to a saggy c-cup breast. The latter situation tends to accompany obesity, though in some cases, individuals will actually keep their weight up so that they are “fat guys,” rather than “guys with breasts.” It seems an irony, but perhaps an understandable one, since this condition, which commonly occurs during puberty, can really create conflict in a young man who is trying his best to become a young man! The presence of breasts certainly interferes with the psychological aspect of this process. Similarly, among bodybuilders, the growth of breast tissue due to steroid use provides a shocking contradiction to the masculine physique which stands as the goal toward which the individual is striving.
This condition has been described in many series, with incidence ranging from 30 to 70% of all men. The majority of cases occur during puberty, with secondary peaks during the newborn period, due to circulating maternal estrogens, and during old age, when endogenous testosterone levels are lower. Fluctuating hormone levels in these periods are the most common cause of the condition, but other causes should be considered.
Some hormonally active tumors can cause this, including testicular, adrenal, and brain tumors. These conditions must be ruled out before considering other causes. Alternatively, medicines as well as anabolic steroids might be responsible. Some of the medicines include Digitalis (heart medicine), Sprinolactone (diuretic), and Finisteride (in Propecia for hair loss and Proscar for prostate troubles). There is also an association with alcohol and marijuana use. If no other cause is present, the condition is referred to as “idiopathic”, meaning there is no specific cause, though we understand that it’s related to physiologic hormonal shifts.
With the gynecomastia of puberty, 95% of these cases will resolve within a three-year period from the time of onset. The remaining patients are unlikely to experience resolution without surgical intervention. When one considers that the low estimate of incidence is 30% of all men, and 5% of these persist beyond puberty, it is no wonder that this is a common phenomenon. Administration of drugs during puberty to try and remedy the situation is not really an option, since the alteration of the hormonal milieu could throw off the delicate balance required to do all of the other things involved in the process of sexual development.
On the other hand, gynecomastia which occurs as a result of medication use, including anabolic steroids, can be minimized or stopped by stopping the drug, though in some cases this may not be an option. With steroids, many users don’t stop this elective use in spite of development of side effects, though they may try to block the development of gynecomastia with estrogen blockers or aromatase inhibitors. These latter agents are responsible for shutting down the enzyme, aromatase, which otherwise converts some of the excess testosterone to estrogens. These drugs may be effective, though little objective scientific evidence is present to confirm the anecdotal observations of most steroid users.
In cases where the condition fails to improve on its own, surgery is usually necessary to correct it. The surgical approach may involve liposuction, direct excision of the tissue, or frequently, a combination of both of these techniques. This surgery can be done either with a general anesthetic, or with sedation along with “tumescent anesthesia” (which is used in both instances, but can be used with the patient awake and mildly sedated). Liposuction is done to help to contour the chest area, and if there is a more solid lump of tissue in the area under the nipple, then this must be cut directly through a short incision along the edge of the areola.
A small button of tissue must be left deep to the nipple to maintain its blood supply and contour. This tissue, if stimulated with anabolic steroids in the future, could grow back into a larger mass, and it’s therefore recommended to discontinue steroid use, if that was the original cause of the condition. “Complete” removal of the gland isn’t really possible, since tissue under the nipple must be maintained to protect the blood supply of the nipple. Nonetheless, near complete removal is effective in most cases, giving an excellent contour.
Following the surgery, I have my patients wear a compressive vest or “Under Armor” for four weeks. Also, they can start doing cardio after an initial week of rest, during which time they shouldn’t engage in any strenuous activities. After a week of cardio, they can initiate some weight-lifting, avoiding chest training for four weeks, while slowly increasing other lifting activities.
Risks of the surgery are fairly low if performed by a Board Certified Plastic Surgeon who is fully trained in the techniques of liposuction and gynecomastia surgery. Bleeding is unusual except in those patients who have used anabolic steroids, where the risk is between 10 to 20%. Infection is also very unusual. The scars are barely perceptible in most patients. On occasion, the contour of the chest may require a touch-up suction procedure or further resection near the nipple, but this is also uncommon in most patients, and it can be done under local anesthesia in an office setting.
Some patients who have experienced massive weight loss, or who have an excess of skin may require skin removal. I generally will try to do this six months to a year after the initial treatment, allowing the skin to retract naturally for some time prior to surgery. In this way, I’ve been able to minimize the scar to just around the nipple, and I’m also able to do this under local anesthesia in the office.
The results of the surgery speak for themselves. Men who undergo correction of gynecomastia experience greater satisfaction with their appearance, often leading to improved self-confidence. Teen patients are frequently relieved of the need to hide their chests in gym class and in other potentially embarrassing situations, allowing for improved self-esteem. Because recurrence is rare (except in those cases associated with medication or steroid use), this is normally a one-time treatment which leads to a life-time of improvement.