Gynecomastia Surgery

Although men like to have large, muscular chests, the presence of “man boobs” is certainly not what they are aiming for. Medically known as Gynecomastia, man boobs give even the manliest of men pause before taking off their shirts. It is defined as the increase in breast tissue development in men. This may be unilateral or bilateral. The most studied cause is due to a hormonal imbalance.

Studies have shown that the stimulation in the growth of breast tissue in men may be due to an increase in circulating estrogen and/or estrogen-like substances, a decrease in the production of androgens, or a defect in androgen receptors. In any case, the estrogen-to-androgen ratio is disrupted causing the unusual breast tissue hypertrophy.

There are three instances when gynecomastia is considered physiologic, which is considered normal and temporary.

1. Neonatal Gynecomastia
   This is when the mother passes on estrogen via the placenta to the fetus which develops more breast tissue. When the baby is born, the estrogen from the mother stops and the gynecomastia resolves in several weeks or months. Due to its self-limiting process, there is typically no need for any intervention.
2. Pubertal Gynecomastia
   During puberty, both males and females produce both androgens and estrogens. In females, there is more estrogen production than androgens while in males, the opposite is true. This balance is responsible for the secondary sexual characteristics that develop in teens. However, in some boys, the level of estrogen is enough for them to develop some breast tissue. It commonly resolves in a few months to years without any medical or surgical treatment.
3. Elderly Gynecomastia
   Much like menopause in women, at 50 years old and above, men also experience an increase in circulating estrogen compared to androgen. This is due not only to the decrease in testosterone from the testicles but also from the peripheral conversion of testosterone to estrogen. This hormonal imbalance causes breast tissues to enlarge. There are times when the hormonal imbalance is due to medications that the patients are taking. The mechanism of these medications may directly affect estrogen production, activity and secretion, or testosterone production, and androgen sensitivity. Some of the medications involved are antibiotics, blood pressure and heart medications, anti-asthma drugs, and chemotherapeutic agents.

Men who take anabolic steroids to increase their muscle girth for bodybuilding may also be shocked to discover that they may develop breast tissues as well. Although steroids are mainly synthetic testosterone, some of these may be converted to estrogen in the circulation.

Some Diseases that Cause Male Breast Enlargement

Some diseases may also cause enlarged breasts in males. These include:

• Endocrine conditions (hyper- or hypothyroidism, adrenal cortical hyperplasia)
• Hypogonadal illnesses (Klinefelter’s syndrome, orchitis, testicular trauma)
• Metabolic states (renal failure, alcoholic liver cirrhosis)
• Increased estrogen states (true hermaphrodism)
• Malignancies (bronchogenic carcinoma, testicular tumors).

Intervention for the gynecomastia is based mainly on treating the underlying cause. The only issue with correcting the main issue is that, especially if the condition has persisted for a long time, the breast tissues may have also developed some fibrosis and may no longer regress despite the resolution of the primary problem. In those cases, surgical intervention may be considered.

In some males, the enlarged chest may be due to fatty tissues and not strictly breast tissue enlargement. This condition is called Pseudogynecomastia and is caused primarily by weight fluctuations. Extra body fat stimulates a hormone called Leptin, which in turn inhibits testosterone production. Thus in treatment, the goal is to lose weight by lifestyle modifications which include, but are not limited to weight management.

Your Consultation with Dr. Nicdao

At the consultation, physical examination of the chest determines the amount of breast tissue, fat thickness, degree of ptosis, and excess skin. Any nodules, masses and/or nipple discharge are noted and further tested to rule out breast cancer. The incidence of breast cancer in males is only 1% but may still occur and present initially as gynecomastia. For patients with Klinefelter’s syndrome, the risk for breast cancer increases to 60%, hence it must be considered and ruled out accordingly. In order to ensure that the gynecomastia is not from a disease process, the patient is also examined for thyroid and liver enlargement, testicular size differences, abdominal masses and pulmonary abnormalities. Additional laboratory tests are individualized depending on physical findings (imaging of the chest, abdomen, thyroid, testicles, LH/FSH, HCG, Testosterone, Estradiol, etc).

Ideal Candidates for Gynecomastia Surgery

The best candidates for gynecomastia surgery are those with non-physiologic causes that have persisted for more than 12 months. For gynecomastia presenting less than 12 months, patients have advised observation. They are generally healthy males with no or well-controlled co-morbidities. Patients are instructed regarding medical risk assessment prior to surgery.

The Procedure

Depending on the amount and quality of breast tissue and excess skin, the treatment may be liposuction with a staged excision procedure or a straightforward excision. The primary goal of liposuction is to restore normal chest contour rather than removing too much breast tissue. Any redundant skin is addressed after 6 to 9 months after the initial liposuction to allow for some redraping, healing and retraction of the skin. Allowing for the time to heal may eventually lead to needing a smaller excision resulting in a minimized scar. Patients with Klinefelter’s syndrome must undergo a bilateral mastectomy due to the increased risk for breast cancer.

Recovery

Post-operatively, the patient is advised to wear a chest binder or a compression dressing to make sure that any potential space is obliterated to reduce the risk of seroma or hematoma. Patients are followed up periodically to see whether a second procedure (staged excision) is still needed.