Gynecomastia is the enlargement of the male chest due to hormonal imbalance within or due to hormone therapy. The hormones whose imbalance can cause gynecomastia are estrogen and testosterone. Gynecomastia is treated through a procedure called male breast reduction. I recently presented at the 5th Annual UKAAPS Meet in London about a Vaser liposuction technique that I find delivers excellent results for my male breast reduction patients.
What Are the Causes of Gynecomastia?
In about 25% of cases, the causes of gynecomastia are unknown. In other cases, strong medications like methadone, spironolactone, HIV medication, cancer chemotherapy, hormone therapy for prostatic cancer, ulcer medication, CCB, antifungal medication, antibiotics and antidepressants tend to upset the natural hormonal balance and lead to gynecomastia.
Serious medical conditions like liver disease, renal failure, testicular tumors and lung carcinoma can lower the testosterone in the body and lead to breast tissue growth.
What Are the Physiological Characteristics of Gynecomastia in Different Age Groups?
Gynecomastia can appear at many ages. Although this may sound bizarre, many newborn babies of both sexes show breast development in the first week of birth. This generally resolves on its own within 2-3 weeks of birth.
Gynecomastia in adolescents usually starts at 10 to 12 years of age and commonly goes away after 18 months. Sometimes in cases like these, doctors may ask patients to simply calm down and let the body do its job on its own.
In the older age groups, the declining testosterone levels and an increase in the fibrofatty tissue lead to senile gynecomastia. When the human body is deprived of adequate nutrition, testosterone levels drop, while the adrenal glands continue to produce estrogens, thereby causing hormonal imbalance.
How Should a Doctor Evaluate a Patient with Gynecomastia?
The best way to evaluate a patient is through a one-on-one consultation. I use the following checklist to ensure a thorough evaluation before male breast reduction:
- Obtain a complete medical history of the patient and read through it carefully.
- Conduct a thorough physical evaluation of the patient which includes –
- Examine the male breast tissue via palpation for signs of for breast cancer and pseudo gynecomastia.
- Evaluation of penile size & development.
- Assessment of testicular masses ( suspicious of testicular cancer) and secondary sexual characteristics.
- Check whether the gynecomastia is unilateral or bilateral.
- Prescribe Liver Function Test to rule out liver pathology.
- Check for rare disorders like Klinefelters syndrome.
I also use the consultation time to explain the surgery, risks related to it and how it will benefit the patient in detail.
How Should the Patient Prepare for Gynecomastia Surgery?
Before surgery, a patient must undergo all prescribed medical tests. As part of the preparation, the patient should refrain from taking any medicine without prior approval from the surgeon. Consumption of nicotine should be stopped in the days leading up to the surgery.
The surgeon should explain why he has asked the patient to follow certain guidelines in the days preceding the surgery. This ensures that all the guidelines are followed without fail.
What’s the Difference between Excision and Vaser Liposuction Techniques?
The excision technique is the traditional procedure to remove excess breast tissue and resolve the problem of gynecomastia. In this technique, the surgeon will make an incision around the nipple-areola complex and remove the excess glandular tissue and excess skin from the male breast.
Excision technique is also useful if the areola will be reduced or the nipple will be repositioned to a more natural male contour. Incision patterns vary depending on the specific conditions and surgical preference. I do not prefer this technique because it leaves a marked scar on the chest of the patient. Instead, I most often perform the Vaser liposuction technique.
Before the surgery, I draw topographical markings on the patient’s chest. This ensures the gland is marked well in advance and surgery is performed more efficiently. The administration of local or general anaesthesia is the next step in the surgery. Once the patient is comfortable, the Vaser liposuction surgery begins. I keep the Tumescent Infiltration solution (cocktail) ready before the surgery itself. It is a combination of 1 liters Ringer lactate + 2cc Adrenaline+ 20cc Xylocaine 2%+10cc Soda Bicarbonate+ 1 amp Hyalase. According to my calculations, 1 liter of solution per breast is prepared with a goal of removing 250-300 gms of gland per breast. To achieve this the next step is very crucial.
The Tumescent solution is infiltrated in the area which needs to be Vasered. I like to over-infiltrate the gland. When the gland is over-infiltrated, the fatty tissue inside breaks down easily or melts away quickly when the Vaser liposuction is performed.
The next part involves using the Vaser machine at 90% power with a single ring cannula. This is a powerful setting hence one should not be very superficial or else chances of skin damage/burns can be high. Typically 2-4 minutes of Vasering is sufficient for gynecomastia surgery.
The two previous steps of over-infiltration of tumescent solution and Vaser make removal of fatty tissue easy and quick. The use of Vaser ensures that the gland has melted away under the high power and can be suctioned out like fatty tissue. This eliminates the need for an excision altogether.
Liposuction or debulking the major portion of the gynecomastia is done using a 3.7 – 4.6 mm cannula. As with any other body area, the debulking initially using larger cannulas eases the finesse required at the end of the procedure. The next aspect of the surgery is feathering. Feathering is a surgical technique performed by the sensory hand of the surgeon to achieve a smooth transition from the area that is liposuctioned and the untreated area. I believe if feathering is done with precision then a lot of times it eliminates the need for excision.
Post debulking one should feather or tunnel the entire marked area to be liposuctioned so as to redistribute the fat/breast tissue as reduce chances of unevenness. I then reassess the remaining gland post feathering. Most surgeons would opt for excision in this scenario, but I choose the pinch technique with a 3 mm cannula.
In the final reassessment, once again evaluation is necessary to see if any tunneling/redistribution of tissue is required or not. Also, checking of whether repositioning of the nipple is necessary needs to be evaluated at this stage. A word of caution for Grade 1 gynecomastia Surgery – be careful to not over-suction the gland because it may lead to an inversion of the nipple.
What Do Patients Experience during Recovery?
After surgery using the Vaser technique, a pressure garment (like a corset) must be worn by the patient for 3 weeks after the surgery and at least for 12 hours after that. The results are generally visible after 3 months and if liposuction is performed, a single stitch is required which is almost invisible.
As the entire breast tissue has been removed, the possibility of gynecomastia returning is very rare and the results of the surgery are long-lasting. Patients do not experience a lot of pain or discomfort post this surgery. They are comfortable and resume their daily activities in a week’s time. Of course, no heavy exercising is permitted for a minimum of 4-6 weeks.
Dr Santosh Bhatia is a Board-Certified, Plastic Surgeon who has worked wonders on patients in Mumbai, New York, Toronto, London, Chicago, Miami and Pune. His practice – Vanity Cosmetic Clinic is one of the top Plastic Surgery clinics in Mumbai.
