Treatment

Medical Therapy

Although medical therapy is offered as a viable treatment option in some cases, I generally do not find acceptable long term outcomes. Medications for treatment of gynecomastia fall into three categories: androgens; estrogen blockers; and aromatase inhibitors.

The most studied medical therapy for gynecomastia is Tamoxifen which is an anti-estrogen compound.

Generally, it is acknowledged that Tamoxifen is effective for cases in which there is an acute increase in gynecomastia with attendant tenderness. In a randomized placebo controlled study lasting only 1-month, 70% of patients experienced improvement in symptoms of painful gynecomastia but only modest reduction in gland size (LN Parker, DR Gray, MK Lai, ER Levin. Treatment of gynecomastia with tamoxifen: a double-blind crossover study: Metabolism 1986 Aug;35(8):705-8). Larger double blind studies of longer duration show reduction in gland size but never complete regression of the gland (Alagaratnam TT. Idiopathic gynecomastia treated with tamoxifen; a preliminary report. Clin Ther. 1987;9:483–7).

In my practice, I see increasing numbers of young men who are being diagnosed with “low testosterone” and subsequently treated with testosterone supplements. However, unless the patient is diagnosed with hypogonadism, it is unlikely that testosterone supplements will benefit patients with gynecomastia. Testosterone may in fact contribute to gynecomastia by its conversion to estradiol.

In summary, medical therapy may offer symptomatic relief for patients experiencing tenderness of the gland but is unlikely to correct the gynecomastia by reducing gland size.

Surgical Techniques

Mild to Moderate cases (Simon’s Class 2a or 2b)

Surgery remains the gold standard in the treatment of gynecomastia.

For mild or moderate cases of gynecomastia, we offer the Awake Tumescent Minimal Access technique for treatment of gynecomastia. This means the procedure is comfortably, safely, and effectively performed under local anesthesia. The term tumescent technique refers to the method of anesthesia. Tumescent anesthesia is used in virtually all surgeries involving liposuction and is a dilute solution of a local anesthetic combined with epinephrine. The tumescent solution is infiltrated through the fatty and glandular tissues and achieves numbing within a few minutes.

In keeping with our slogan that the only evidence of surgery should be a flat chest, the majority of procedures are performed through single incision, or adit, placed below the nipple but within the areola or an intra-areola incision. The incision is created with a 2mm skin biopsy punch – in other words no scalpel is used. The areola is the pigmented disc of skin that surrounds the nipple. In this position, the incision heals without any visible scarring.

The first step of the procedure is to infiltrate tumescent anesthesia throughout the chest wall and gland. This is followed by treatment of the chest and gland with Power Assisted Liposuction (PALS). Liposuction of the chest wall creates attractive contours to the chest wall by creating negative spaces and transitional zones at the periphery of the chest. In essence, we are framing the pectoralis muscle. Power Assisted Liposuction with a specialized cannula also disrupts the architecture of the glandular tissue. In most cases, I find PALS is effective in removing the body and tail of the gland.

The second stage of the procedure is to resect the gland which is accomplished by delivering the gland into the small skin opening and dividing the attachments to the surrounding tissue. In this way the gland is completely removed with almost no bleeding.

After the gland is completely removed, internal flaps are rotated and approximated with sutures beneath the nipple-areola complex (NAC) in order to prevent derotation or cratering of the NAC. The small skin incision is precisely closed with absorbable sutures.

Immediately after the procedure, patients are placed in a compressive vest with lipoplasty foam inserts. No drains are used. After a period of monitoring, the patient is discharged home from the clinic.

I developed the minimal access technique in order to minimize unsightly scars on the chest as well as to avoid the peri-areolar incision. The peri-areolar incision can potentially alter NAC sensation as well as create a trap-door deformity. In essence, I wanted to avoid replacing one problem with another.

Severe Gynecomastia (Simon’s Class 3)

For more severe cases of gynecomastia, it is necessary to address the excess skin in addition to the severe gland proliferation and this generally requires a procedure under General Anesthesia. Cases requiring General Anesthesia are performed at the outpatient surgery centers of Northside Hospital. We have started offering this procedure under local anesthesia in selected patients with smaller Simon’s 3 gynecomastia.

For severe cases, the patient is marked in the upright standing position and every attempt is made to position the incision in the natural shadow of the chest. The new NAC position is carefully marked in order to achieve the ideal aesthetic result.

Most surgical techniques for treatment of severe cases of gynecomastia are derived from breast reduction techniques. The goals of surgery are complete removal of the problematic gland; tightening of the chest skin by resecting extra skin; repositioning the NAC; and position of the incision in order to minimize its visibility.

After the patient is comfortably asleep and under General Anesthesia, the chest is first treated with PALS. The vascular pedicle supporting the NAC is then mobilized and de-epithelialized and this is referred to as the inferior pedicle. The redundant skin is then resected, or removed, and a new opening in the chest skin is created to position the NAC. The vascular pedicle and NAC are then delivered and secured into the new opening. The lower chest incision is then closed in layers with a technique known as progressive tensioning. A closed suction drain is placed prior to final closure. The NAC is then inset into the new position with fine absorbable suture. The incisions are dressed with a waterproof acrylic dressing (Dermabond).

The patient is awoken from General Anesthesia and transferred to a recovery area. After an appropriate period of monitoring, the patient is discharged home to the care of a responsible adult.

Simon’s Grade 3 Surgical Approaches

Adjunctive Procedures

Areola Reduction

In some cases, men are concerned with the size of the areola even if they do not have gynecomastia. In these cases we can offer an areola reduction which is performed under local anesthesia. The ideal areola diameter is 26-28 mm based on surveys. Reduction of the NAC may also be combined with correction of gynecomastia in order to optimize the aesthetic outcomes.

Nipple Reduction

Some clients seek nipple reduction in order to de-project the nipple. In my experience, many of these clients are runners who experience chaffing and discomfort of the chest due to an over projected and hypertrophic nipple. The goal of nipple reduction is to deproject the nipple and achieve and improved chest contour. This is accomplished under local anesthesia. This procedure may be safely combined with correction of gynecomastia.

Beckenstein MS, Windle BH, Stroup RT. Anatomical parameters for nipple position and areolar diameter in males. Ann Plast Surg. 1996 Jan;36(1):33-6.

Pectoral Augmentation with Autologous Fat

In order to refine and shape the chest, some patients request augmentation of the pectoralis major muscle. In the past, this has been accomplished with customized chest silicone implants. I do not prefer this method due to length of the access incisions as well as the possibility of mechanical complications associated with the chest prostheses. Instead, we offer autologous fat grafting, sometimes referred to as fat transfer. The fat is harvested from the abdomen and hips and is grafted directly into the muscle (intra-muscular) in order to add volume to pectoralis major muscle. Compared with fat grafting to the female breast, fat grafts to the male chest enjoy a higher survival, or take, rate. The post-operative care for patients undergoing fat grafting is slightly different and may require the use of drains during recovery.

Complications of Gynecomastia Surgery

As with any surgical procedure, complications are always a possibility. In the case of correction of gynecomastia, I characterize the complications as being possible but uncommon.

Complications can be divided into early and late. Early complications include hematoma, ecchymoses, and infection. Hematoma rates have been reported as high as 7.8% although I would estimate a rate of 1-2% in my personal experience. I believe that hematoma rates are probably lower in our practice as we incorporate hemostatic agents into our tumescent solutions.

Infection rates for any surgical procedure are quoted as 1% but are far lower in our practice. I am frankly surprised that infections in gynecomastia patients occur at a frequency far less than 1%. I ascribe this to the fact that most of our patients are healthy and young as well as to meticulous skin prepping and surgical technique.

Long term complications include the development of scar tissue which I estimate to around 3%. Contour irregularities are reported to be 9.2% in the general literature although the number is much lower in my personal experience – perhaps due to the routine application of the technique of SAFE (Separation Aspiration and Fat Equalization) liposuction. Residual gland was reported as 12.6%. Nipple necrosis is a rare complication of gynecomastia surgery and one that I have personally not seen. Sensory changes of the chest and NAC may occur, as with any surgical procedure where liposuction is used or the skin manipulated, but these changes resolve between 4-12 weeks.

McNamara et al. Complications and Quality of Life Following Gynecomastia Correction in Adolescents and Young Men. Plastic Reconstr Surg. 2022 Jun 1;149(6):1062e-1070e.