Overview of Gynecomastia: The Big Picture
Gynecomastia refers to the appearance of female-like breasts in a man, ranging from simply puffy nipples to full-blown breast development, which, in 10% of patients can appear asymmetrically. Gynecomastia is caused by the proliferation of breast tissue usually related to an imbalance of the sex hormones estrogen and testosterone. There are 3 types of tissue associated with gynecomastia—fat, fibrofatty and glandular. Any single type or combination can be found.
Gynecomastia is a benign condition that can be hereditary, though it is not related to breast cancer in any way. In a small number of patients the condition may cause pain or tenderness. The true frequency of gynecomastia is unknown, but studies estimate that it occurs in 5-30% of all men. If we do some simple math and assume the lower end of the percentage, more than 8 million men have some form of gynecomastia in the United States, so those who suffer from this condition are certainly not alone.
The real problem associated with gynecomastia is not just the appearance of the chest, but also the negative psychological consequences. Being a man and having puffy nipples or the appearance of a female breast provokes confusion, anxiety, humiliation and the potential for long term psychological consequences. These include avoidance and antisocial behaviors, depression, anxiety and problems with interpersonal relationships, among many others.
The gold standard treatment for gynecomastia is a surgical procedure that typically involves some form of liposuction and the removal of tissue beneath the nipple-areola complex. The procedure takes about 90 minutes, the recovery is short and the pain is mild. The results of proper treatment are immediate, and patient satisfaction high. Full recovery from the negative psychological consequences, however is often not 100%. I am actively researching these psychological issues in the hopes that we can provide better solutions to this invisible aspect of gynecomastia. An abstract of my ongoing study Psychosocial Correlates of Idiopathic Gynecomastia in Young Males: Preliminary Findings From a Mixed-Methods Study has been just been published in the Journal of Adolescent Health.
Gynecomastia that develops during puberty is the most commonly occurring. The condition can develop in over 50% of young boys during early puberty (age 11-14). In most cases this fullness resolves spontaneously (within a year) but in 15% of cases it can persist into adulthood. If the gynecomastia has not disappeared in 18 months’ time, it is unlikely to improve or completely go away. If feelings of emotional stress, ridicule, shame or humiliation start to develop, it is best to seek an evaluation with a qualified medical practitioner and consider treatment. These young men may suffer from serious body image problems and secondary behavior disturbances, such as depression, withdrawing from their peers, and avoiding important social activities.
The second most common form of gynecomastia is caused by exposure to certain drugs or herbal compounds. These older patients develop gynecomastia for reasons that are not always clear or obvious. Drugs that contain estrogen-like compounds such as tea tree oil, lavender oil, and certain lotions, soaps and shampoos are implicated in gynecomastia development. Other potential causes include use of growth hormones, certain prescription medications like antidepressants, and illegal substances like marijuana and heroin. It is also an uncommon side effect of Propecia, a drug frequently used by men that appears in 1% of users. Even more frequent is the development of gynecomastia in body builders from use of hormonal supplements.
The third most common gynecomastia category is related to various medical conditions. Examples include hypogonadism, testicular trauma, Kleinfelter’s syndrome, testicular tumors, certain cancers, hyperthyroidism, alcoholism and liver disease. These patients are treated for their medical condition first and for their gynecomastia, second. These conditions tend to be readily apparent when a patient has them and the overwhelming majority of patients seen evaluating physicians do not suffer from an underlying medical condition.
The final category of patients is aging men. It is not uncommon for men in their late forties to sixties to notice puffy nipples and more fullness in their chest. This may be related to weight fluctuations and the normal aging process, during which testosterone is converted to estrogen by the fat in the chest area. Treatment of these folks falls into the category of “chest contouring” as opposed to true surgical gynecomastia treatment.
Pseudogynecomastia refers to the appearance of gynecomastia that is made up of fat only in obese men. I, however, believe this term should not be used as it only confuses the real medical issue of gynecomastia and could lead men to believe that weight loss can make gynecomastia disappear. I really don’t believe this phenomenon exists as a legitimate medical condition. Weight gain can certainly make more fat go to your chest, but that would not typically result in a female-like breast in a man who had been perfectly normal before weight gain.
What Causes Gynecomastia?
Gynecomastia is ultimately caused by an imbalance of the sex hormones estrogen (female) and testosterone (male). These hormones are very similar in structure and can be converted to each other in the body. When testosterone levels are low or estrogen levels are high, the tissue on the chest can proliferate and grow. Humans of both sexes have breast buds present at birth. Because the tissue that responds to these hormones lives just beneath the nipple areola complexes, the fullness starts there and then spreads in a round pattern with the center being the nipple.
Puffy nipples are caused by the growing mass of tissue sitting just beneath the nipple-areola complex. The mass puts pressure on the skin and stretches it so that the overall appearance is dome-like. This is the tip of the iceberg, as deeper tissue masses make the entire chest appear fuller. If enough tissue accumulates, the chest area can actually appear like the female breast.
The tissue can be painful and sensitive for a period of time, which is an indication of inflammation. This process of inflammation typically subsides after weeks or months as the tissue becomes “burned out” and fibrotic. At this time, the mass can only be removed surgically.
How is Gynecomastia Diagnosed?
Gynecomastia is diagnosed by the appearance of the chest. Physical examination will reveal excess fullness of underlying tissue compared to the normal person. For an experienced surgeon like myself, I can see it a mile away. The diagnosis is not made by feeling a certain firm, nodular tissue. Blood tests, endocrine studies, CT, MRI scans and ultrasounds are not necessary in establishing the diagnosis.
The most common presentation of gynecomastia is the persistence of chest fullness after its development during puberty. Parents can always bring their child to the medical doctor for evaluation. Most cases will resolve after 18 months or sooner. If the appearance of gynecomastia persists after an 18-month waiting period, and the child is beginning to show signs of anxiety or embarrassment, I would recommend an evaluation for treatment so the child does not continue to suffer mentally.
Thorough medical testing is only necessary in patients who may also be at risk of having a medical condition that is the cause of the gynecomastia. You need to be truthful when answering any of your physicians’ questions about your use of medications, hormones or pro-hormones. You may even be taking “homeopathic remedies” or supplements from GNC that your surgeon needs to be aware of. The doctor may also ask questions about your use of drugs and alcohol, as well as symptoms of liver dysfunction, decreased sexual desire or impotence.
What is the AGC Gynecomastia Scale?
Most patients who present to me at the AGC generally give themselves a 7-10. It’s not a standardized scientific scale, but it helps me understand how severe your burden is so I can gauge the effectiveness of my treatment, and so I can keep my eyes on the big ball. Ultimately, it helps me empathize with my patients on a more emotional level, the area where it hurts the most.
Gynecomastia Treatment Options
The gold standard treatment for gynecomastia is surgery. Medical treatment with hormones and medications (prescription, over the counter or from the Internet) will not effectively treat established gynecomastia. Self-treatment with diet and exercise will not cure your gynecomastia because it is resistant to both. Trust me on this one my friends: you will be wasting your time and money attempting to treat your gynecomastia with non-surgical methods.
Surgical treatment of gynecomastia is straightforward, but requires great technical skill and artistry. Every case is different to some degree, challenging your surgeon to make appropriate adjustments and modifications so that the best result is realized.
The primary goal of gynecomastia treatment is to reduce excess volume in the chest area, which is usually accomplished with a combination of liposuction and tissue removal. Skin removal is usually unnecessary, because it retracts impressively well after the removal of excessive chest tissue, even in patients who actually have saggy skin. If loose skin does persist after treatment, however, it is always possible and even advisable to contour the excess skin as a secondary procedure.
Patients should be advised that removing skin may result in scarring across the chest and under the arms. Inexperienced surgeons simply don’t know what to expect in advanced cases and often assume that skin needs to be removed when, in reality, it doesn’t. I always recommend that you consult with several surgeons before making the decision to have skin removed for gynecomastia surgery.
Many patients will ask me to contour their abdomen and flank areas at the time of gynecomastia treatment. In general, the abdomen and flanks are areas that respond well to weight loss solutions, and if you are overweight, the simple solution may be to lose the weight. Liposuction of these areas in men who are overweight is not always appropriate and may lead to disappointment at some juncture. It is best to be close to your ideal weight before considering liposuction of your abdomen and love handles. When indicated, the treatment of the chest, abdomen and love handles is a really big transformation with exceptionally high satisfaction rates.
The Austin Gynecomastia Center Zone Map of the Male Chest
After examining thousands of patients, I have developed an AGC Zone classification system for gynecomastia that helps in doctor-patient communication and treatment. It is a simple and effective tool that I use when I evaluate patients in my office or via a Virtual Consultation.
Zone 0 or “ground zero” is the area immediately behind the nipple areola complex. This is almost always glandular tissue and is responsible for the “puffy nipples” seen in many patients. This is illustrated in my “golf ball gynecomastia” video.
Zone 1 is the anterior chest area that is usually shaped like a horizontal ellipse. This Zone includes Zone 0 and is the most commonly affected area in gynecomastia and creates the breast like appearance. It obscures or rounds off the lower pectoral muscle area that is more masculine if it is flat and linear, which is the appearance after treatment.
Zone 2 is the area lateral to the chest and under the arm. This is never actually gynecomastia tissue but it is commonly full in patients and when treated, the results are far more impressive, smooth and masculine. This can extend up to under the armpit area and is a region that I treat to remove the fullness you feel when you move your arms at your side.
Zone 3 is the area just at the apex of the fold or crease of the armpit. This can be full of fat that bulges from the lateral border of the pectoralis muscle. After treatment, the muscle is linear, well-defined and sculpted.
Zone 4 is located below the fold at the bottom of the chest and is shaped like a banana. This is seen in about 10% of my patients. It may be a part of a patient’s normal anatomy, but is also often associated with being overweight.
Zones 0 and 1 have true gynecomastia tissue present. Zones 2-4 only have fat and are included in my treatment as Chest Contouring to help you obtain the best, most symmetrical, natural-looking and masculine chest.
Gynecomastia Treatment Alternatives
There are different techniques that surgeons use to contour the tissue. Fat and fibrofatty tissue are easily contoured with some type of liposuction, while the dense glandular tissue that cannot be removed with liposuction requires removal through a small incision around the areola.
Ultrasonic liposuction has a long history in the treatment of gynecomastia and has been shown to be of significant benefit over standard liposuction. Ultrasonic liposuction uses sound waves to dissolve the fat and works more efficiently in the treatment of the fibrofatty tissue associated with most gynecomastia cases. I’ve found that the Vaser shrinks gynecomastia gland by a factor of seven! The addition of the Ultrasonic Vaser system in my practice has revolutionized the treatment of gynecomastia of all types, making the procedure smoother and more predictable with less pain and recovery time.
There are other liposuction machines available, including SmartLipo, Power Assisted Liposuction and others that can be used to contour the fat in gynecomastia. When used properly, any liposuction machine will be effective.
Liposuction alone will not effectively treat gynecomastia because in the overwhelming majority of cases, there is palpable glandular tissue or dense fibrous tissue that remains after liposuction. The remaining tissue is often mistaken as “recurrence” after treatment with liposuction alone.
Treatment of Gynecomastia with the Cartilage Shaver Technique.
A paper was published in the 1980’s describing the use of an orthopedic cartilage shaver that is inserted in the skin under the chest and manipulated to remove the firmer glandular tissue. I used the device in 60 patients and came to the conclusion that although the system was effective in removing this difficult tissue, there were more post-operative complications, like hard healing and scarring. I have subsequently stopped offering this to my patients because there are far more efficient and effective methods to treat gynecomastia.
Secondary Gynecomastia Treatment
A patient who has already had gynecomastia surgery may desire additional treatments to resolve problems or complications after an initial treatment. I am frequently asked to perform secondary gynecomastia treatment, which are generally more challenging and complex, because of my depth and experience. As someone who has performed thousands of treatments, I am well-versed at secondary cases.
My approach to a secondary case is based on the findings after an evaluation. Additional liposuction or tissue removal can often improve things significantly. Scar release techniques, skin excision, fat grafting or internal flaps can all be helpful in selected cases. Patients are often told to wait up to 2 years to heal before any additional procedures are considered. However, I have found that I can offer treatment after around six months when the tissues are soft with little chance for changes with additional waiting.
The most common reason why a patient has more than one gynecomastia procedure is lack of satisfaction with the initial results. These patients feel that they did not have enough tissue removed and continue to have fullness and a breast-like appearance. They were often told to wait one year for the “swelling” to go away when in reality, the problem is with the remaining tissue.
Non-Surgical Treatments for Gynecomastia.
Medical treatments offered to treat gynecomastia are not particularly effective. Several studies have shown a small reduction in the size of gynecomastia and less pain, if present, when anti-estrogens are used. To be effective, treatment must be started early in the course of the condition.
After a year, the tissue becomes fibrous and it is unlikely that medical treatment will help matters. In my experience, visible or palpable breast tissue present after medical treatments will almost guarantee dissatisfaction.
The internet is loaded with non-surgical solutions to gynecomastia because there are many gynecomastia sufferers out there who want a solution to this sensitive problem that doesn’t involve a surgical procedure. There is money to be made on this vulnerable group of consumers: the market will fill you with wonderful success stories, enticing photographs, great testimonials and provide you with hope. The reality of the situation is entirely different. As I’ve learned time and time again, gynecomastia will not go away without effective surgical treatment from a qualified and experienced gynecomastia surgeon.
What is the Goal of Gynecomastia Treatment?
I treat patients with gynecomastia to liberate men who are suffering from the burden of a chest that appears abnormal. This condition causes mental distress that can affect their daily lives, and if present long enough, can cause mental health disorders and maladaptive behaviors. By contouring the chest to a normal appearance, a surgeon can help prevent the mental consequences of the condition and free patients from the burden of gynecomastia.
From a technical standpoint, treatment often involves some form of liposuction and tissue removal. My Gynecomastia Zone classification system helps me communicate and work with my patients in defining the treatment areas. The goal then is to treat all the Zones involved so the final result is smooth and masculine. Most, if not all, of the actual glandular tissue is removed at the time of treatment.
Consider the chest like a peanut butter and jelly sandwich. The top slice of bread is the skin, the bottom slice is the muscle. The peanut butter is the gynecomastia tissue and the jelly is the fatty tissue. My goal is to remove all the peanut butter and to contour the jelly so it’s the right amount and it’s evenly spread. I don’t touch the underlying muscle and I only remove excess skin in rare cases.
The goal is to make for an even result: the fatty layer that remains needs to be just the right amount. Removing too much will appear overdone, and leaving too much will not help. The goal with contouring the upper chest in all affected Zones is to match the abdominal area. Patients with larger, fuller abdomens are encouraged to lose weight before treatment so matching the chest and abdomen is less of a challenge. Liposuction can be performed on the abdomen and love handles in select cases. These patients are generally close to or at their ideal BMI.
When gynecomastia occurs during adolescence and does not resolve itself within a year or so, I highly recommend that he consider treatment. This is a critical time in the emotional and social development of young men. The longer the gynecomastia persists, the greater the potential for permanent negative psychological consequences. Don’t be like most patients I see, who often wish they had sought treatment many years ago! To delay is not only to deny yourself the benefits of treatment, but also to subject yourself to potentially damaging consequences. Unfortunately, many medical practitioners don’t fully comprehend the psychological damage resulting from persistent gynecomastia. Read my blog about satisfaction rate after gynecomastia surgery.
Austin Gynecomastia Center Innovations
Over the years, I have developed several surgical techniques that have withstood the test of time and have helped me immensely in keeping my procedures as complication-free as possible. I consider these maneuvers innovations because they have not been described in the gynecomastia literature. I apply them on a case-by-case basis, as each patient’s condition is unique. My high quality results, happy patients, and low rate of complications are directly related to the use of these techniques.
Puffy nipples are the result of excess glandular tissue beneath the nipple-areola complex. In some cases, removal of all this tissue may result in a depression, or noticeable concavity. Leaving tissue behind, however, which is not uncommon with inexperienced surgeons, often results in recurrence of the puffy nipples because remaining tissue has a tendency to “clump” as a mass. The best way to get rid of puffy nipples once and for all is to use my waffle technique to break up the “spring” in the tissue. The result is a flat and even nipple area.
Removal of the glandular tissue can result in a depression or divot, while leaving the tissue behind could result in residual fullness of the chest or puffy nipples: either scenario can leave a patient unsatisfied. In order to create an even chest contour and to support the overlying nipple-areola complexes, I like to create internal flaps with the normal chest tissue. I can often rotate this tissue and suture it to other areas of normal tissue so the tissue layer is even and smooth. The whole idea is to leave an even layer of normal tissue on the chest once the unwanted tissue has been removed.
In cases where a large gland is present and removed, there is what is called “dead space” afterwards. Blood or other bodily fluids will naturally fill this space during the healing process. This accumulation of fluid can cause some post-operative complications, such as hematomas or seromas. Left around for long enough, this fluid can cause “hard healing” leading to excess scarring and, at times, contour irregularities. Drains are often helpful but don’t work as well as suture closure of this dead space. The technique of quilting sutures has been used in other areas of plastic surgery with proven success, and is equally effective in gynecomastia treatment.
In cases when there is a large amount of gynecomastia tissue, or when there is very loose skin after notable weight loss, I may use pleating sutures to help gather and redistribute the skin during the early healing phase. This has been proven to be very effective in achieving an even chest contour, even in the most complicated cases. It can even elevate the nipple-areola complexes to a higher, more normal location on the chest. This comes in very handy when there is significant sagging of the chest tissue not uncommonly seen in weight loss patients or overweight patients who have always had larger chests with saggy skin. The goal of the pleating suture is to move the skin to a better location and allow it to heal down to the deeper layer so it stays put at the ideal place. This may prevent the need for later skin removal with large scars.
This refers to the surgical technique of dissecting beneath the chest tissue to sever the attachments to the overlying skin. This allows the skin to spread out in a larger area during the healing phase, promoting an even, wrinkle-free, crease-free contour. Think of it as spreading out excess tissue in a larger area so it is more likely to lay flat as opposed to being bunched up with creases and folds.
I often use these surgical techniques in various combinations depending on the circumstances at hand. From performing a high volume of gynecomastia procedures, I’ve been able to develop and perfect these innovations for the benefit of my patients.
It should be noted that the above innovations are related to the “open technique” of tissue removal with the use of several instruments, a lighted retractor and the electrosurgery device. The Vaser Ultrasonic liposuction technique that I currently use now for the vast majority of my gynecomastia cases has rendered these innovations often unnecessary. Read my blog to learn more about the Vaser Ultrasonic Liposuction at the Austin Gynecomastia Center.
Read my blog about my experience and innovations in gynecomastia surgery.
Gynecomastia and Bodybuilding
The gynecomastia that occurs in body builders who use steroids or pro hormones is uniquely different. These patients typically have very little body fat, and their gynecomastia is mostly firm, rubbery gland that is easily felt upon examination.
These patients display puffy nipples and an odd shape to the chest, with the nipple-areola complex looking downwards and an area of fullness along the bottom of the chest muscle. Needless to say, this is a very disturbing feature to men who have spent an enormous amount of time and effort working their bodies to a state of strength and muscular definition.
The physiology of the development of breasts in body builders can be complex. However, as a simple explanation, the hormones or pro hormones are partly converted to estrogen (the female sex hormone), which can cause gynecomastia in some men. Pain in the area of glandular tissue is more common in these patients. Pain indicates inflammation and irritation of the adjacent nerves. The chest area can be sensitive to touch and even something rubbing on the area can be quite painful. This pain often subsides with time as the tissue “burns out” and becomes less inflamed and more fibrotic.
From a treatment standpoint, these men have tough, well-localized glandular tissue that must be removed in its entirety. The gland can adhere to the overlying skin and to the underlying muscle. The goal is to remove as much of the gland as possible so that recurrence is uncommon even in those who continue to use hormones or pro hormones. These cases are often more challenging, as it is more difficult to work with the chest tissues after you remove a firm, adherent mass. The surrounding area needs to be contoured so the result is smooth and even.
Unfortunately, I can’t speak to the drugs or drug regimens designed to prevent or treat gynecomastia that are often used amongst body builders. There are no scientific studies that approve or disapprove of these drugs, or that attest to their safety. Please use good judgment when you are dealing with the unknown. If you want the best advice, I would seek the counsel of a real doctor and not the local “go to” guy in the gym.
Choosing Your Surgeon
The most important decision you will make is choosing your surgeon. Experience matters when it comes to any procedure, and in the case of gynecomastia, this is even more critical. Most surgeons see but a few gynecomastia patients every year. At the Austin Gynecomastia Center, I see over 200 patients every year for treatment, from across the nation and from overseas.
Consider only the surgeons who have proven expertise in this area and who have a reputation for treating gynecomastia successfully. You’re right to think twice about the surgeon who occasionally treats gynecomastia in his or her practice. In my practice, surgical treatment of gynecomastia is not only common and routine, but is also an art form. This isn’t something that I dabble in: I have treated over 1600 cases over the past 10 years, I understand what it takes to get great results and I know the degree to which my patients are suffering from this condition, both physically and mentally. In fact, I am studying the mental aspects of this condition with the University of Texas at Austin. How many “experts” can say that? As a general rule, if you don’t get a good feeling about your surgeon after you consult with them, I would move on.
Appropriate anesthesia is a compliment to any surgical procedure. Local anesthesia is best suited for only the smallest of cases, usually limited to those who have a small amount of fullness in Zone 1 of the chest. Adequate contouring of the chest area means treatment of tissue down to the sensitive area of the pectoralis muscle. Treatment of Zones 2 and 3 of the chest is difficult without general anesthesia because of the proximity of the Zones to the abundant nerves under the arm.
It’s important that your experience not be traumatic or barbaric. Your surgeon needs the best opportunity to perform expert contouring of your chest, which can only be achieved if you are immobile and relaxed. What’s the benefit of avoiding adequate anesthesia if your result is not good? Why not have your procedure performed without pain or anxiety, once and for all? Patients who only choose local anesthesia for their treatment often tell me they probably should have chosen IV sedation or general anesthesia. Most procedures take less than an hour and a half to complete. All my anesthesia services are provided by a very experienced board certified anesthesiologist who has the same attitude as mine: we don’t fool around when it comes to your health and safety, period.
The use of any form of anesthesia beyond local requires that you have a ride home after your procedure and that you have someone stay with you for 12 hours afterwards. Many of my out of town patients bring someone along to care for them, or seek a local caregiver who can stay with them. Click here to see my video on the “process” of treatment at the AGC.
Pain and discomfort after gynecomastia treatment is mild to moderate. On a scale of one to ten, it would be about a 5 at most. If general or IV anesthesia is used, you will feel somewhat foggy the first few hours afterwards. Patients are offered oral pain medications that are to be used for the first 1 to 3 days. Most patients take a day or two off before returning to work and other normal daily activities. Most patients return to moderate exercise after seven to ten days. Mild tightness and discomfort in the chest area will persist for up to four weeks.
Compression garments should be worn for two to four weeks to control swelling, provide support and facilitate skin retraction. I encourage all my patients to massage the treated area with their hands or a roller device to soften the scar tissue and help the skin lay out nicely. This should be done several times a day for 20 minutes or more starting two weeks after your procedure and working it for eight weeks or more if needed.
A plastic drain may be used after surgery to collect fluid and blood that tends to accumulate in the space formerly occupied by the tissue. The drains are removed after three to five days, depending on the amount of daily fluid accumulation. Drains are infrequently used in my practice because of I use techniques and technology, like Vaser liposuction and quilting sutures, which makes drains unnecessary.
It may take several months for the swelling to subside completely and for the tissues to soften or “relax.” Four to six weeks after the procedure, maximal scar formation can result in areas of firmness beneath the skin. This is normal. Massage helps to soften the scar, and if needed, small amounts of steroids are injected to soften the scar. Silicone scar strips or scar gels are recommended to ensure optimal healing of the incision but most incisions are so small, nothing is needed. The final position of the scar around the areola generally heals very well and won’t be visible to others, hence the beauty of the procedure.
Results after treatment are immediate. It should not have to take “months” for the swelling to go away for you to notice an improvement. The contour will be flatter, with no puffy nipples and with good definition of the chest muscle. Fullness of the lateral chest and underarms should be improved dramatically if these areas were full before treatment.
Not much is known about the psychological recovery from gynecomastia. There is no doubt that surgery helps tremendously, but the degree to which it helps depends on the individual. Some patients tell me it never crosses their mind again, while others say it’s a lot better but that they are not 100% over the trauma. I take photos of the excised tissue, and allow patients the opportunity to actually feel the removed tissue as well. Why? It’s simple. I’ve learned that patients often need a sense of “closure” and want to know that it was real and fortunately, gone forever. Check out my blog on gynecomastia recovery showing two patients with their results after day 1.
Potential complications can be broken up into two categories: early and late.
Early complications include hematomas or blood collection in the chest area immediately after surgery, usually within 24 hours. This is noticed as increased chest size accompanied by pain and bloody drainage. Although not fatal, hematomas require removal of the collection, because blood left under the skin can form scar tissue or become infected over time. If small, the hematoma can be removed in a simple office procedure, and if large, it may require a visit to the operating room. It should be known that a surgical drain does not prevent a hematoma. Physical activity may provoke hematoma formation, which is why I recommend that patients avoid any strenuous activities for 3 days.
Late complications include seroma formation, “hard healing,” contour irregularities and infections. A seroma is a collection of watery fluid on the chest Some patients are just prone to seroma formation. I have observed that the rate of seroma formation is more frequent in those patients who consume a lot of fluids after their procedure. Many patients believe that drinking a lot of fluid will help the healing process, but this is not the case for gynecomastia recovery. Restrict your fluid intake after surgery to what is normal: 6-8 glasses of water a day. Drink if you are thirsty. If your urine is darker you can use more fluids. If it is clear you need less fluid. A small seroma the size of a walnut will generally go away by itself, but larger seromas, which can interfere with the healing process, can be removed with a small needle aspiration. Seromas can and do recur in an unpredictable manner, which may require several visits until resolved.
“Hard healing” is a term used to describe excessive and unusual healing in the treatment area. This is typically seen after the sixth to eighth weeks and is recognized as firmness of the tissues and palpable masses under the skin. The most common cause of this ‘over-healing’ is a patient’s unique healing response that is more aggressive than those of most other patients’. Hard healers will have to be patient during the healing phase as time is their friend.
Treatment options for hard healing include massage, rolling techniques, steroid injections and sometimes, additional procedures to treat the actual scarring. This is the most unpredictable aspect of gynecomastia treatment recovery and is the reason why I am a stickler about post-operative massaging of the chest and the use of the roller and compression garments.
Contour irregularities that can occur after treatment are caused by a variety of reasons. This is often related to the quality of your skin and how your surgeon performs the procedure. Excessive tissue removal may result in a depression while inadequate removal may result in excess fullness. “Recurrence” of gynecomastia is uncommon in an expert’s hands as it is often the result of undertreatment (not removing enough tissue and leaving gland under the nipple-areola complex.) After the swelling of surgery subsides weeks later, it then appears that a mass is still there. Treatment for recurrence requires a secondary procedure to remove this residual tissue. Recurrence is most likely to occur in those patients who have only had liposuction to treat their gynecomastia without tissue removal.
In experienced hands, infection after gynecomastia surgery is uncommon, rendering post-surgery antibiotics unnecessary. Treatment of a rare infection would require a drainage procedure, antibiotics or both.
Loss of the nipple areola complex is unlikely in standard treatment, but is more common in complex cases involving skin removal and relocation of the nipple areola complexes. This procedure is typically left to the most experienced surgeons who have performed this multiple times and understand the dynamics of this procedure in men as opposed to experience with the female breast.
Loss of sensitivity in the nipple areola complex is common post-procedurally, but usually returns to normal after several months.
What Results Can You Expect After Gynecomastia Treatment?
The best way to determine what you are likely to see after treatment is to find a similar patient on my website and see his before and after pictures. Ultimately, once all the tissue and fat are contoured on your chest in the affected Zones, your skin will then retract over your anatomy: your chest muscles and the shape of your underlying ribs. Some patients have never experienced the movement of their chest muscle because it had always been covered by so much tissue. Contouring of the fat in Zones 2 and 3 will nicely shape up the lateral chest and under arm areas. Your entire chest area will look more sculpted and you will be able to move your arms at your side without rubbing against your body.
It’s important to understand there is flexibility in treatment. I ask my patients what results they desire because I can be more or less aggressive depending on their goals and fears. Leaving more tissue will result in potentially fewer irregularities, while removing a lot can result in skin folds or contour irregularities. My goal is to find just the right endpoint to treatment so my patient is maximally happy with my work. To that end, I ask a lot of questions to make sure I am tailoring the treatment to your requirements.
The most important issue concerning gynecomastia is the lingering psychological scars from having to cope with it for many years. The stigma of having prominent breasts can lead to antisocial behavior, anxiety, self-hate, poor self-esteem, poor body image, and problems with interpersonal relationships. It’s real and I hear about it every day.
Defense mechanisms persist in gynecomastia patients: wearing two shirts, taping the nipple areola complexes, being selective about what shirts to wear, not putting themselves into situations where they may have to expose their chests to others and slumping their shoulders. These are just a few behaviors adopted to avoid embarrassment. It often takes a lot of courage for these patients to seek care.
The longer the condition persists without treatment, the greater the chance for psychological damage. This is the main reason I urge men to seek treatment after an appropriate diagnosis has been made. I encourage all patients who suffer from gynecomastia to seek evaluation as soon as possible. Put simply, if a mound in your breast area causes psychological distress, I would strongly recommend that you remove the source of distress. In my experience, the benefits and cost of treatment far outweigh the risks of no treatment.
How Does the AGC Evaluate an Out of Town Patient?
You don’t have to live in Texas to benefit from the very best gynecomastia treatment. In fact, most of my AGC patients are from out of town. Yet another AGC innovation is our Virtual Consultation. This allows you to show me what you have with pictures and tell me a bit about yourself and your medical history, all at no cost to you and in the privacy of your own home. Then, I will get back to you with my recommendation and an estimated fee for your procedure.
My Email Consultation is the ultimate in letting me review your case without a need to travel to Austin before treatment. Upload images of your areas of concern and I can evaluate your situation and make recommendations. It’s private, secure and free. I have been using Email for consultations for over two years now, and my patients absolutely love it.
Surgical treatment of gynecomastia at the AGC is straightforward and has helped thousands of patients from all over the world. Most cases take about an hour or so and the majority of them require anesthesia. Patients arrive the evening before their day of procedure and leave the day after their procedure. Follow up is by phone, email and Skype. In this manner, we have successfully treated hundreds of patients from all over the world. Check out my video of the process.
If you decide to start your journey with the AGC after your free consultation, it’s a simple trip to the great city of Austin, Texas and a brief stay for your procedure. Before you know it, you will be at home, back to your new life — a life without gynecomastia! There is no better place than the AGC to rid yourself of gynecomastia once and for all. You know you want it done, and you want it done right the first time.
The Austin Gynecomastia Center has been so successful because I am well versed in both the experiences of my patients and the art of gynecomastia surgery. Quite simply, we take great care of you. My staff of professionals all understand the unique nature of gynecomastia and they know how to make you feel comfortable and at home. You will know that you are in great hands.
Gynecomastia can often be like cancer in how it affects patients’ mentality. Patients are very anxious about their condition and all want the best result possible from the most experienced surgeon. I am truly honored and humbled to be able to practice my art on patients who appreciate what I bring to the table. Beyond my technical skillset, I also have a strong desire to reduce fears and uncertainties with my personality and candor. The successful treatment of gynecomastia has been my most professionally rewarding procedure and is a constant reminder of my duty as a physician to help patients in need.