Mr Demetrius Evriviades explains how to correctly diagnose gynaecomastia and effectively treat male patients with the concern
An article released by The British Association of Aesthetic and Plastic Surgeons (BAAPS)1 on the excessive development of male breasts, known as gynaecomastia, reports that the condition is thought to affect 40% of men. According to a separate article by BAAPS, male surgery continues to account for nearly 10% of all cosmetic surgery treatments2 and gynaecomastia procedures have increased in popularity as the third most common procedure for men.3 The condition can be very distressing to some men and can affect confidence and body image, making it difficult to carry out everyday activities such as going to the gym, swimming or even just removing one’s shirt. It is often assumed that ‘man boobs’ are simply linked to obesity, however, there are a number of possible causes.
In Greek, ‘gynae’ means ‘woman’ and ‘mastos’ means ‘breast’. Gynaecomastia is caused by glandular proliferation (the firm and dense tissue) and fat deposition (soft tissue). The ratio of glandular to fatty tissue in any breast varies between individuals, but in gynaecomastia cases there may be an excess of both.4 The condition can be provoked by an imbalance of the hormones oestrogen and testosterone, and can also be triggered by certain medication such as antidepressants and heart and liver treatments. It has been linked to some cancer drugs, which cut levels of male hormones, and research5 also indicates that anabolic steroids can cause further breast tissue growth. Unfortunately, some men are genetically predisposed to gynaecomastia in the same way that some women can have larger breasts than others.6
The main characteristics of gynaecomastia are breast swelling, increased areolar diameter, presence of an anomalous inframammary fold, glandular ptosis and skin redundancy.7 To touch, the area can vary from small, firm enlargement of breast tissue just behind the nipple to a larger, more female-looking breast. It can affect the breast unilaterally or bilaterally and the area can be painful or tender to touch.7
Characteristics of gynaecomastia can often be seen in adolescent males. This is common around the age of 14, but will usually resolve spontaneously within one to two years. It may be due to the relatively delayed testosterone surge with relation to oestrogen at puberty, or due to a temporary increase in aromatase activity.8 If the symptoms are still obvious once adulthood has been reached, it could be a genuine case of gynaecomastia and advice could then be sought if required.
A medical questionnaire will be completed so patients should be prepared to discuss any existing medical conditions, medications being taken and any previous surgeries carried out. I will usually show prospective patients case studies from previous gynaecomastia surgeries and we will discuss any risks or complications that the patient should be aware of when undergoing surgery. I will then carry out a physical assessment of the breasts, looking for glandular or fat predominance by doing the ‘pinch test’ – if a hard lump can be felt when you pinch the breast, then that signals the condition. I also look at the degree of glandular ptosis, skin excess, nodules/masses, and nipple abnormalities or discharge.
I will then grade the condition using the Rohrich grading system outlined below (Figure 1). This ranges from Grade I: an increased diameter and slight protrusion limited to the areola, to Grade IV: severe hypertrophy with skin redundancy, severe ptosis and the nipple area complex (NAC) positioned more than 1cm below the inframammary fold.
At this stage I will usually take pre-operative photographs for the patient’s medical records. The ideal candidate for gynaecomastia surgery10 would fit the criteria below, however providing that the patient fits the admission policy of the operating facility, patients with Grade I to IV are suitable:
In preparation for gynaecomastia surgery, patients may be asked to stop smoking and to avoid taking aspirin, anti-inflammatory drugs11 and herbal supplements12 as they can increase bleeding.
The success and safety of any cosmetic procedure depends very much on complete candidness during consultation.
The aims of surgical treatment are to restore normal chest contours, eliminate the inframammary fold, correct the NAC position, remove redundant skin, create symmetry between the two halves of the chest and minimise scarring.
If there is predominantly a diffuse fatty enlargement of the breast, liposuction is the usual treatment. This involves a small incision on each side of the chest depending on the result required. Incisions may be located along a portion of the edge of the areola or within the armpit. Through these incisions excess fat and/or glandular tissue is removed and, at the same time, a new chest contour is sculpted that looks natural to the patient’s body shape.
If excess glandular tissue is the primary cause of breast enlargement, it may need to be excised, which will leave a scar, usually around the nipple edge. Tissue excision allows the surgeon to remove a greater amount of glandular tissue and/ or skin that cannot be successfully treated with liposuction alone. This excision can be performed alone or in conjunction with liposuction. The location and length of the incisions depends on the extent of surgery needed, but they are typically located around the edge of the areola (periareolar incision) or within the natural creases of the chest. Major reductions that involve the removal of a significant amount of tissue and skin may require larger incisions that result in more obvious scars and, in this case, suction drains will usually be in place for a minimum of 24 hours or until fluid has ceased to drain. As a surgeon, it is always important to take care when placing the incision to ensure that the resulting scars are as inconspicuous as possible; however, the patient’s wellbeing must always be the priority.
The success and safety of any cosmetic procedure depends very much on complete candidness during consultation
The procedure is usually carried out under general anaesthetic, although in minor cases (liposuction alone) local anaesthesia and sedation can be used – this is usually in a Grade I case. Depending on the technique used to correct gynaecomastia, an overnight stay in hospital is usually required, although in minor cases this can be carried out as a day case. This will usually be decided during consultation based on diagnosis.
During surgery, dressings or bandages will be applied to the incisions and drains placed in situ if appropriate. This will drain excess blood or fluid that may collect at the site. Following surgery, the area will be swollen and bruised for a while and it can be difficult to assess the full effect of the procedure immediately. To help reduce swelling, patients are instructed to wear an elastic pressure garment continuously for at least a week. This will help minimise swelling and will support the new chest contour.
Patients will be given specific instructions that will include how to care for the surgical site and any medication that should be taken to aide healing and reduce the potential for infection. Contact numbers will also be given should the patient have post-operative questions or in case of emergency.
Patients will usually be seen five to seven days post operatively by a nurse who will carry out a wound check to remove any stitches if required and ensure the operation site is clean, dry and healing well. This is also an opportunity ask questions or seek advice. If the nurse is happy with the healing process, at this stage an appointment will usually be arranged to return to see me within the next three months.
It is important that the surgical incisions are not subjected to excessive force, swelling, abrasion, or motion during the time of healing, normal healing may be resumed at six weeks.
Those who choose to undergo surgery do so in the hope that the result is permanent, but there is no 100% guarantee. If gynaecomastia resulted from the use of certain prescription medications, I would advise having a conversation with the patient’s GP regarding alternative prescriptive drugs in order to retain the aesthetic result. Patients should avoid drugs (including steroids), or weight gain and remain at a stable weight in order to maintain results.
As with all surgical procedures, there are risks. While in most cases these are rare, it is important to ensure the patient is aware of all the possible complications before undergoing surgery.
The possible risks can include infection, excessive bleeding, injury to the skin, extreme fluid loss, an accumulation of fluid or an unfavourable reaction to the anaesthesia used. If an excision has been performed, rather than liposuction, then a blood clot can form that may need to be drained in theatre.13 This form of surgery can leave obvious scars that can take time to lighten and fade. Scarring is very individual in nature and no two people heal in exactly the same fashion and at exactly the same rate. It is impossible to predict how well a patient will heal although there are silicone based scar treatments available on the market that aim to aid the healing process and reduce the redness of scarring.
Other risks of this surgery can include an uneven contour to the chest or breasts and nipples that do not heal equal in size or shape. Therefore, when asymmetry is present, it is sometimes necessary to carry out a second correctional surgery to remove more tissue. It is common to experience numbness or a loss of sensation in the breasts on a temporary basis. For some individuals this loss of sensation could last anywhere from a few months to a year.14
Surgery can be, and in most cases is, life changing.15 Suffering with gynaecomastia can affect body image and deter men from carrying out normal day-to-day activities where the condition is noticeable. Once recovery is complete, patients experience an enhanced quality of life and increased confidence, whereby going to the gym, playing sport and wearing more fitted clothes become an option, choices that they may have never considered pre-surgery.