Gynaecomastia

Download PDF

What is gynaecomastia?

The word gynaecomastia is used loosely to describe enlargement of the breast in men. Strictly the medical term gynaecomastia describes enlargement of the glandular part of the breast, which can be caused by a number of medical conditions. Frequently men who feel that their breasts are too large have excess fat in the breasts rather than an over development of the glandular part of the breast. Breasts whcich become enlarged due to too much fat have are often referred to as man boobs or ‘moobs’ medically this is sometimes called pseudogynaecomastia.

What causes gynaecomastia?

Frequently there is no obvious cause for gynaecomastia. However, gynaecomastia may develop naturally at certain stages in life and this is called physiological gynaecomastia. Physiological gynaecomastia sometimes occurs following birth in breast-feeding babies due to hormones in their mother’s milk. It frequently develops in puberty but normally resolves once puberty is complete. Finally it may occur in old age. Medical causes include genetic conditions e.g. Kleinfelter’s syndrome, liver disease, disturbances of hormones, cancers of the testicle and as a side effect of a number of drugs.

Who should have treatment?

Gynaecomastia does not have to be treated. Treatment is usually a patient choice because they do not like the appearance. If there is an underlying cause then this does need to be identified and may require treatment.

How is male breast enlargement treated?

There are two main ways of treating male breast enlargement, depending on thte cause. An enlarged gland is usually excised surgically. Excess fat can be removed with liposuction. Frequently a combined approach is used. Where there is too much skin consideration may be given to removing it.

Direct excision (Webster’s procedure)

Glandular tissue is usually removed by surgical excision. An incision is made around the lower half (usually) of the areola (brown area surrounding nipple). The breast tissue is then excised and the skin closed with stitches. Liposuction may also be used to reduce fatty areas. A drain is often required (plastic tube to drain a build up fluid and blood from under the skin).

Liposuction

When the enlarged breast is due to a build up of fat this is usually best dealt with by liposuction. This enables the excess fat to be removed and so the breast is reduced. Sometimes an attempt is made initially to reduce the breast with liposuction, if this proves to be impossible then the operation is converted to a direct surgical excision. Liposuction may also have role in smoothing out the edges following a direct excision. With liposuction usually a small (6mm) incision is made at the bottom of the areola and a second one on the side of the chest.

Too much skin

Sometimes, if the breasts are particularly large, there may be too much skin which will be loose and hang following removal of the breast tissue. If this appearance is likely to concern you then consideration should be given to removal of some of the excess skin. This requires more extensive surgery and results in scars. Most surgical procedures for enlarged breasts in men do not involve a skin reduction procedure.

How can I prepare for surgery?

Are you physically suitable for surgery?

Firstly you should be assessed to ensure there is nothing medically wrong with the breast or that you do not have an illness causing the breast to enlarge. Clearly if there is a medical reason for your breast enlargement this should be treated or controlled before you have any surgery on your breasts to make them smaller. You must ensure that you understand what is involved with surgery, what it may be able to achieve for you, how long you are likely to need for recovery and the risks. If you are overweight or are planning to lose weight you should do so before your surgery. This will make your surgery safer and is likely to give you a better result in the longer term.

Do you smoke?

Smoking increases the risks of surgery so you are strongly advised to stop smoking 4 to 6 weeks prior to your operation.

What medications are you taking?

If you take medication you should discuss this with your surgeon before the operation. Certain drugs can increase the risk of bleeding and this needs special consideration with surgery. You should avoid aspirin and “aspirin- like” drugs for 10 days before your operation as these increase the likelihood of bleeding with surgery. (If you take aspirin for medical reasons stopping the aspirin should be discussed carefully with your surgeon before doing so). you should not take alternative, complimentary medicines or herbal remedies for 2 weeks before your surgery. Do not take omega fish oils. Homeopathic arnica if bought from a reputable source is safe.

Compression garment for after surgery

You will need a compression garment to wear for 4 weeks after your surgery. You should buy this well in advance so you can be sure it fits. Some people find a lycra sports top is sufficient but purpose made surgical support garments are better. Your surgeon can advise you on purchasing one.

How long will I need to recover?

People vary considerably in how long they need to recover from surgery. If you had complications then your recovery can take considerably longer.

When can I go home from hospital?

Most people go home from hospital either on the day of surgery or the day afterwards.

When can I shower or have a bath?

There is normally no problem in having a shower after 48 hours. Soaking the wounds for long periods in the bath is best avoided until the wounds are fully healed. This is usually at least 2 weeks.

When will I be able to drive?

It is illegal to drive with in 48 hours of a general anaesthetic. Most people return to driving after 1 to 2 weeks after surgery. The most important consideration is that you feel comfortable and safe to drive. You have to be able to react appropriately in an emergency. If you are taking medication such as painkillers you need to check and consider whether these may affect your ability to drive.

When will I be able to return to work?

Usually people return to sedentary office-type work about one to two weeks after surgery. Some people are back sooner or work from home. More active work may require longer time to recover: Very active work will require 6 to 8 weeks off vigorous activity. You will need to be guided by your body, if you are causing pain or swelling you are doing too much!

When will I be able to exercise?

You should rest for 2 weeks following the surgery. However walking is good and protects you against clots in the legs. So taking regular short walks is recommended. 2-4 weeks following surgery you could start lower body exercise such as cycling or power walking. After 4 weeks you can start upper body exercise with a view to getting back to normal activity between 6 to 8 weeks following your operation. Some people may recover faster and others will require longer. You need to see how your body responds to activity. If you experience pain or swelling then you need to reduce your activity.

Swimming

You should avoid swimming until the wounds are fully healed. You should normally avoid swimming for 4-6 weeks following surgery.

Gym

Vigorous or strenuous use of the arms should be avoided for 4 weeks. If when you restart exercise you experience pain or swelling then you should allow more time before restarting that activity.

Walking only for 2 weeks after surgery. Light exercise 4-6 weeks. Back to normal 6-8 weeks.

When and what can I lift?

Lifting small things around the house is not a problem. It is best to be guided by your body, so if it hurts stop. It is best to avoid lifting anything heavy for 2 weeks. You should not be straining to lift anything for 2-4 weeks.

When can I have sex again?

Sex should be avoided until the wounds are fully healed and you feel comfortable and ready. If you are causing pain or swelling then you are overdoing it!

When will I be back to normal?

Recovery varies from one person to another. The majority of people feel they are mostly recovered by a month following surgery. However some areas of tenderness, lumpiness or swelling may take longer to settle.

What are the results of treatment?

Excision of glandular tissue and removal of fat by liposuction are effective methods for reducing breast size. The majority of people are pleased with the reduction. Sometimes people feel they would have liked more tissue removed. When the glandular tissue is excised it sometimes leaves a depression where the gland used to be. Liposuction may be used to reduce this by removing fat from the edges of the depression.

Will the results last?

Once either glandular tissue or fat has been removed it is unlikely to grow back. If you put on significant amounts of weight then the breasts may enlarge to some degree but you are more likely to put the fat on elsewhere.

What are the risks?

The great majority of healthy people undergoing a male breast reduction procedure have an uneventful recovery and are pleased with the outcome of their surgery. However, as with all surgery, there is the potential for complications. Complications include those of having a general anaesthetic, complications that may occur with any operation and those that need particular consideration for male breast reduction. Serious complications are rare but as with all surgery could be life threatening.

General anaesthetic:

There are the risks of having a general anaesthetic such as allergic reactions, chest problems, for example a chest infection and the possibility of clots in the legs (deep vein thrombosis or DVT). A clot in the legs can move to lungs causing a pulmonary embolus which is a particularly serious complication. Underlying medical conditions e.g. asthma can be aggravated. In general, if you are healthy, modern anaesthetics are very safe. If you are concerned about your anaesthetic we can arrange for you to meet with an anaesthetist before your surgery for an assessment and a discussion.

Bleeding and haematoma:

During surgery great care is taken to stop bleeding. However after the end of the operation, particularly if the blood pressure is raised, a bleeding point may start bleeding again. This causes a build up of blood under the wound called a haematoma. Small haematomas usually are absorbed by the body over time. Larger haematomas may need to be removed with a further operation. Most people will then recover normally. It would be most exceptional to need a blood transfusion following a male breast reduction procedure.

Infection and slow wound healing:

As with all surgery there is the potential for wound infection. Most wound infections settle down with a short course of antibiotics. If a wound becomes badly infected the wound may open up and take time to heal up. If this happened regular wound dressings would be required until it was fully healed. Serious infections are rare.

Nipple necrosis (loss of the nipple):

During the operation the nipple is undermined and this can damage its blood supply. It is possible for there to be insufficient blood supply for the nipple in which case the nipple can die. In healthy non smokers this is a very rare complication. Problems with the blood supply to the nipple are more likely with reductions of very large breasts. With very large breasts it may be advisable to use a free nipple graft technique where the nipples are removed and replaced as a graft.

Seroma:

Seroma is a build up of tissue fluid in the wound. This causes swelling which may need to be drained but usually resolves on its own. Draining a seroma is usually done with a needle and syringe as an outpatient.

Scarring:

It is important to understand that scarring varies from one person to another. Some scars can be thin pale lines but this can never be guaranteed. Poor scars may stretch and be wide or become lumpy, hypertrophic or keloid. Keloid scars are lumpy and grow out from the incision that caused the original scar. Hypertrophic scars are more frequently seen than keloids. Hypertrophic scars become widened, thickened and red for a few months after surgery. They then settle down to a pale widened scar although this may take many months and even several years. Scars may be itchy and occasionally tender or painful.

Asymmetry:

Many men have some difference in size or shape of their breasts. One breast may be larger, the nipple may be at a different position on the breast or at a different level. The brown area around the nipple called the areola may be a different size. With a breast reduction the aim is to produce breasts which are as similar as possible. However, particularly where breasts are different before the operation, it is not uncommon for there to be some difference after the operation.

Over- or under- correction:

The amount of fat to be removed with liposuction is a matter for clinical judgment. There is the possibility that too much fat is removed or that you feel not enough fat has been removed. It is generally better to remove too little rather than too much as it is easier to remove more later than to put fat back.

Skin irregularities, skin laxity and skin excess:

The elasticity of the skin is a very important factor affecting the end result from liposuction. If the skin has little elasticity it is more likely that the skin will show irregularities following liposuction. With larger amounts of fat removal there is the possibility that the skin will be loose and wrinkled following the procedure. If you have loose skin which has lost its elasticity then the skin may not retract when the fat or glandular tissue is removed. This skin may then hang and leave a crease or fold under the breast. This often an issue following large amounts of weight loss or where a large volume is removed from the breast. Sometimes a better result will be obtained by removing the excess skin. However this will result in additional scars.

Lumpy tenderness:

Following liposuction the tissues under the skin tend to swell, may feel hard and be tender. This usually settles over a few weeks. In some people this may take longer but usually settles over a few months. Permanent lumpy tenderness is rare but possible.

The appearance of having had surgery

When a large glandular area is removed it leaves a gap in the tissues under the skin. Sometimes this results in a depression which gives an un-natural appearance. Frequently liposuction is used to smooth the edge of this ‘gap’ but it may not be possible to get rid of this appearance.

Changes to the nipple

Usually there no significant changes to the nipple. However you should be aware of some possible changes which may or may not be of concern to you. The feeling in your nipples may be changed following surgery and it is possible that they could be permanently numb. Occasionally the nipple may invert after surgery. The nipples or the areolae (brown circle around the nipple) may not be the same size after surgery and they may be asymmetrical.

Tenderness and pain

Following surgery the breast area will be painful and remain tender for several weeks. In some people the these symptoms may last several months. It is very unusual for symptoms to last longer than this or be permanent.

Deep vein thrombosis (DVT) and pulmonary embolus (PE)

Deep vein thrombosis is a blood clot forming in the veins, usually in a leg vein. A pulmonary embolus is where one of these clots breaks off and travels to the lungs. They are a recognised complication of surgery and they are serious complications: A pulmonary embolus can be life threatening. There are many factors that can increase the your risk such as a family history of clots, having previously had a clot yourself. Taking various medications or having certain illnesses can also raise the risk of developing DVT’s or PE’s. Being overweight or obese, having an operation and being inactive are some of the most common factors that increase the risk of deep vein thrombosis. For patients undergoing male breast reduction surgery precautions are routinely employed to reduce the risk. You can help to protect yourself by getting up and walking around as soon as you can following your operation and continuing to take regular short walks during the early stages of your recovery.

What else should I know?

Testicular self examination

Rarely gynaecomastia may be caused by an underlying cancer in the testicle. The great majority of men with large breasts do not have testicular cancer and the great majority of men with testicular cancer do not have large breasts. However, although it is rare, testicular cancer is becoming more common. It is extremely important to understand that if testicular cancer is found early it is very treatable and often curable. As such, all men should regularly examine their testicles and if there is any doubt about a lump they must see a doctor. Testicular cancers are not necessarily painful.

What are the alternatives to surgery?

Do nothing

As long as there is no serious abnormality in the breast and no underlying medical problem there is usually no medical necessity to treat large male breasts or gynaecomastia.

Choice of Clothing

Careful choice of clothing may help to cover up or disguise large male breasts.

Lose weight

If you are overweight or obese then losing weight may be helpful in reducing your breast size. It is also likely to be very helpful for your future health.

Treat the cause

If there is an underlying medical problem then this should be treated first as this may be helpful.

Where can I get further information?

Speak to your General Practitioner

Your General Practitioner has a broad knowledge of medicine. Your GP will be able to examine you to decide if you should have any investigations. Your GP may recommend a surgeon or a hospital where they feel you will get good advice about surgery.

Outpatient consultation with a Consultant Plastic Surgeon

An outpatient consultation with a Consultant Plastic Surgeon will enable you to discuss what result you would like to achieve. They will also be able to make recommendations as to how best to treat you and whether there are any special considerations for you.

Department of Health (England and Wales):

www.dh.gov.uk search under – Cosmetic surgery and non-surgical cosmetic treatments. Independent and objective advice on cosmetic surgery from the department of health.