Gynecomastia is the treatment of the prominent male chest that is commonly due to excess fatty deposits and sometimes even breast tissue development. New York City patients will have variable amounts of excess skin and have to be assessed for individualized treatment. Sometimes patients can be treated by liposuction alone, or liposuction can be combined with direct excision of the underlying fatty or breast tissue. Direct excision of tissue can be performed through a small incision along the areola-skin border on the chest. For patients that have had massive weight loss ( i.e post-bariatric surgery patients), excision techniques removing skin and subcutaneous fatty tissue is sometimes performed. There are several different techniques that can be used to accomplish this for Dr. Wallach’s Manhattan NY Plastic Surgery patients. The surgical procedure usually takes between two and three hours with a recuperation time of one to two weeks.
Liposuction is used for the treatment of gynecomastia in men that have good skin tone and a moderate fatty component. This can be performed using a tumescent technique. One or two small incisions are made to gain access for the procedure. Commonly the cannula is also used to disrupt the chest fold to allow for adequate re-draping. Patients will wear a compression garment after the procedure to help minimize the risk of seroma (fluid) collection. Recovery from chest liposuction is similar to other treated areas, and patients can usually go back to work in a few days. For more information regarding Liposuction and Gynecomastia, visit our blog.
Periareola Incision Technique and Liposuction
For male patients in New York with moderately good skin tone, a moderate amount of subcutaneous fat, but who also may have breast tissue under the areola, then liposuction performed along with a periareola incision is a good technique. A periareola incision usually involves an incision along the border of the darker areola skin and the chest skin from the three o’clock position to the nine o’clock position. This incision is used sometimes when patients have a component of breast tissue under their areola. Liposuction does not remove breast tissue well, and therefore the open technique is usually necessary. Sometimes this is staged when the patient is not sure they want an incision along the border of the areola, or it is unclear if there is sub-areola component of breast tissue. The liposuction compliments the procedure to treat the subcutaneous fat.
Male Breast Reduction Techniques
In general, formal breast reduction techniques similar to those performed for women might be used in men for one of two situations: 1) where there is actually a breast gland similar to a woman, or 2) where a man has undergone massive weight loss and has significantly redundant skin and soft tissue with ptotic (sagging) chest skin.
Pedicle-Based Breast Reduction
A technique for breast reduction similar to what is done for females is performed for men. The nipple areola complex is usually made smaller in diameter and “carried” on a pedicle of tissue, commonly inferiorly based. This pedicle, unlike what is performed for women, is thinned so that when it is placed into the appropriate position, it does not look like a female breast. An ellipse of skin is removed and the subcutaneous fatty and breast tissue is removed. The resulting scar is usually transverse with a small scar around the areola. For some thinner men with hanging loose skin, this may not be the ideal procedure, because even with the thin pedicle it still may look like a female breast. The benefit to this technique is that sensation to the nipple may be preserved.
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Free Nipple Graft Technique
This technique uses similar incisions as used in the pedicle-based breast reduction technique, but the nipple-areola complex is replaced as a free graft. There is no actual pedicle of tissue so there is less of a chance of having a chest look like a female breast. This is good for thinner men with mainly loose skin. The remaining scars are similar to the pedicle-based technique in that there is a final transverse lower chest scar and a scar around the border of the areola. The main disadvantage to this technique is that the nipple-areola complex will be insensate and may suffer from hypopigmentation (lighter skin) or even partial loss.
Gynecomastia Frequently Asked Questions
My 14-year-old son has some breast development. Can he have this surgically treated?
Many young men develop some breast growth during puberty and the majority of this growth resolves on its own. On rare occasion gynecomastia may be the result of a hormone imbalance, and evaluation by a pediatrician is sometimes recommended. If breast tissue still remains after puberty then I will treat the gynecomastia surgically. Sometimes it is treated with liposuction alone. Other times, a small incision at the areola border may be required to directly remove the tissue.
I am an adult male with large breasts. Will I need a lot of incisions to correct this problem?
The surgery is individualized for each patient. Some patients do very well with liposuction alone. Some patients require an additional excision of tissue underneath the nipple, which is more fibrous tissue and does not get removed successfully with liposuction. This can be accomplished with a small incision along the border of the areola and chest skin, and usually heals very well. Still, there are other patients who have significant skin redundancy and need a reduction with some skin removal.
What is gynecomastia, and is there a treatment?
Gynecomastia is a condition in which the male chest grows larger than normal. This condition is usually benign. It can be due to an increase in the fatty or glandular tissue content of the breast. Occasionally, male hormone levels are not normal and they develop glandular tissue. In these cases, the patient needs to be evaluated by an endocrinologist and possibly put on medications to regulate the hormone levels. Various techniques can treat gynecomastia surgically that are not hormone related. These specific techniques used are predicated upon numerous factors including: 1) the quality of the tissue being treated – if the tissue feels more fatty than glandular, 2) the quality of the skin – if the skin is loose or the chest skin is sagging, 3) the location of the nipple – if the nipple needs to be repositioned, and several other factors.
Can I have liposuction only to treat my gynecomastia?
In many situations, liposuction is a great procedure to offer patients that have gynecomastia. The best candidates for liposuction are those that have primarily a fatty component to the chest, a good nipple position, and reasonably good skin quality. If a patient has excess, loose skin, or sagging in the chest, they are probably better off with an alternative technique that requires a skin excision or nipple repositioning procedure. Patients with a more glandular component and no loose skin might be better off with a direct excision of glandular tissue through a periareolar approach in conjunction with liposuction. In “borderline” patients where there is some glandular tissue and moderate loose skin, I often will do liposuction first to see how the tissues respond. This minimizes incisions and often gives a good result that patients are happy with, and avoids large chest incisions. If a second stage is needed to perform a glandular excision or a skin excision in these borderline cases, then they can be done three to four months after the first procedure.
When does someone require excision for gynecomastia?
There are different reasons why a patient may require an excision, and there are different techniques depending upon the various anatomical conditions. If a patient has a glandular component of tissue under the nipple areola complex that is not amenable to liposuction, then a small incision along the lower border of the areola is performed. This is called a periareolar incision. If the patient has large amounts of tissue that look similar to female breasts, or had massive weight loss which created sagging chest skin, then various excision patterns can be used to improve the appearance and flatten the chest. Techniques similar to some standard breast reduction techniques can be performed. The tissue can be excised and the nipple areola complex can be left on a thin tissue pedicle. The nipple areola complex is delivered into a position higher on the chest, so that there is an incision on the lower chest fold and around the border of the areola. A free nipple graft technique removes the excess tissue and skin, leaving an incision on the lower chest fold, and the nipple is sited onto a higher chest position. The incision closures are similar to the pedicled technique.
I have loose skin on my chest after massive weight loss. What type of operation will I need?
After massive weight loss, many men have loose, hanging skin on their chests. Treatment commonly requires excision of the skin and glandular/fatty tissue that remains. Two techniques commonly used are: 1) a thin inferior pedicle reduction, or 2) a free nipple graft reduction. Both use similar incisions on the chest. One incision runs transversely along the lower chest fold, and the other circumscribes the border of the areola. The inferior pedicle technique may leave a narrow base of thin tissue under the skin closure to support the blood supply to the nipple and areola. This technique may allow for continued nipple sensation. The free nipple technique leaves thinner flaps of tissue, but the nipple will not have sensation because it is completely detached and re-applied to the chest as a free graft.
Where is the incision made for gynecomastia surgery if one requires tissue excised?
For patients with moderately good skin tone that have little to no excess skin, and have some glandular tissue not amenable to liposuction, an incision along the border of the areola may be used to remove the glandular tissue in a periareolar fashion. This incision is like a smile along the lower border of the areola. Patients with loose or excess skin may require a free nipple graft procedure with another incision along the lower chest fold, or they may have a pedicled reduction with the incision in the same place.
What is a free nipple graft reconstruction for gynecomastia?
A free nipple graft procedure for gynecomastia entails removing the nipple areola complex from the chest skin and using an incision along the lower chest fold to elevate the skin away from the glandular tissue. The excess tissue is removed and the skin is pulled inferiorly towards the incision and tailor tacked. The nipple areola is then placed back on the chest and secured as a free graft. This technique will often get the flattest chest for those with excess skin and gland/fat. The main disadvantage is that the nipple usually will not regain sensation, and it may lose pigment.
What is a pedicled reduction for gynecomastia excision?
A pedicled reduction for gynecomastia is an alternative to a free nipple graft procedure when a patient has excess skin and gland/fat. A very thin pedicle of tissue is created around the nipple areola so it can survive, and the superior skin flap is elevated away from the underlying gland. The excess gland is removed, and the skin is brought over the pedicle. The skin is secured to the lower incision and the nipple areola complex is brought out through the skin at an appropriate site. The main disadvantage is it may leave a bit more tissue underneath the skin flap, which could be visible. However, sensation may remain in the nipple areola complex.
Will I need drains for gynecomastia surgery?
Drains are commonly placed in techniques that require undermining of skin flaps such as when using an inferior pedicle technique or the free nipple graft technique. It is not common to use drains after liposuction. However, some may be used when a periareolar access incision is employed for tissue excision. The drains are normally removed when the drainage is considered low enough.
What is the recovery like for gynecomastia surgery?
Recovery varies from patient to patient. In general, patients are placed in compression garments or ace wraps. If they had a free nipple graft procedure, then they will have small bolsters on their chest. The bolster is removed a week after surgery. Compression garments are worn for the other procedures usually for three to six weeks. Most patients can go back to work within a week. Light aerobic activity can resume within three to four weeks, heavy exertion and lifting within six to eight weeks.
Do I need a compression garment for gynecomastia surgery?
I prefer patients to wear compression in some instances, usually after a liposuction procedure. I recommend patients wear a compression garment for three to six weeks continuously. Depending on the type of procedure, I may have some wear one either immediately after surgery or a few days later. For free nipple graft procedures, I sometimes have patients wait until the bolsters are removed before wearing a compression garment.
Can I have nipple or areola reduction only?
During many gynecomastia procedures in which skin and glandular tissue are removed, an areola reduction can be performed. If a patient has an isolated issue like enlarged areolas, it is possible to perform a circumareola reduction only. For those with enlarged nipples, I reduce them directly. Nipple reduction can often be done under local anesthesia and has a high satisfaction rate.
Steven Wallach MD
Dr. Wallach is a board-certified plastic surgeon in New York City who specializes in performing cosmetic procedures of the face, breast and body. As one of the cutting edge experts in the field, Dr. Wallach consults on a regular basis with people in the beauty, media, and publishing worlds.