Adult Gynecomastia Surgery in Boston

The indication for treating gynecomastia is that it is causing you a visual problem. Do you feel your clothes are tight in your chest? If you are sweating does your shirt cling to your nipples? Is the contour of your chest as nice as it should be relative to the rest of your body? Most patients can easily answer for themselves if they have enough of an issue with gynecomastia to investigate whether they want to treat it.

Men who have a chest that is disproportionately large from some combination of fat or glandular tissue. This process can be normal in adolescents and subside by the late teens. But surgery can be done on mid-teens if the deformity is so severe that in consultation with the patient’s pediatrician it is agreed that the patient would benefit from male breast reduction surgery.

It is obviously best for overweight people to have plastic surgery at their ideal weight. From a practical point of view, that should be refined to mean that surgery should be done at the weight a patient is most comfortable maintaining because it allows the plastic surgeon to contour the chest out to the surrounding areas so that it blends most beautifully. Some later weight gain or weight loss would not noticeably impact the result. Many men who are much more overweight decide to do liposuction of their chests before losing their weight because it gives them a nice jump start. They feel better about wearing tight or clingy athletic clothing and the surgery really can boost their self-esteem and get them on their way to perfecting their bodies.

Many patients undergoing gynecomastia surgery are overweight. Obviously it is much healthier and contour is better if a patient loses weight on their own. Surgery cannot make someone look as good as they would look with their own weight loss. But even with weight loss, oftentimes some excess chest fat remains, and so overweight men often still want to have surgery on their chest after they have lost weight. Finally, it is important that when men are overweight that only enough is removed from their chest to make it proportional with the abdomen. There is a tendency among patients and plastic surgeons to remove as much as possible, but when the chest is made much less prominent than the abdomen, this does not look good. And this can become even worse if the patient loses weight after their gynecomastia surgery.

The key issue is whether it bothers a patient enough to be worth undergoing surgery. Usually men will talk about being embarrassed to take their shirt off at the beach, their shirt clinging too tightly to their chest and looking odd when working out, and puffiness developing in the nipples, particularly when their nipples are warm.

True gynecomastia is caused from hormones causing a growth of breast tissue in the male chest. This can be from normal hormones made within the body or from steroids such as those taken by body builders. Being overweight can sometimes lead to a disproportionate amount of chest growth, and even after weight loss this can remain in some men.

Losing weight can help overweight men, though it doesn’t necessarily cure gynecomastia. But for men that are fit and thin, surgery is the only option for reducing gynecomastia.

A patient will be made comfortable, and chest numbed just local anesthesia. VASER probes are introduced into breast area through small incision in arm pits and applied until the fat is softened and almost like a milkshake which is then debulked and contoured using Power Assisted Liposuction. The small arm pit incisions are left open to drain excess fluid and usually close spontaneously over the following few days.

Whether fat or gland, the goal of good gynecomastia surgery is the restoration or creation of a nice contour to the chest. While there is often the desire by both the patient and surgeon to remove as much as possible, in actuality it is normal for there to be some glandular tissue beneath the areola and some fat throughout the chest. The goal should be to create just a normal configuration, which means removal of the bulge and creation of a smooth contour. A complicating issue is that the chest looks different when the arms are at the sides than when they are raised above the head. Just try raisingyour arms now and you will look a lot flatter. Sometimes when the chest is made to look flat with the arms at the side there can be a bit of a depression deep to the areola when the arms are raised above the head.

Excision means cutting out tissue. This is done with local anesthesia. That decision will be based upon a patient’s particular anatomy and preference. A small incision is made from about 5-8 O’Clock on the areola and the glandular tissue carefully dissected and removed. Stitches are placed that will dissolve.

There are often two very small incisions that are used for the liposuction portion of the procedure. If an excision needs to be done, there will be a scar at the border of the areola from between 5 and 8 o’clock. Dr. Ishoo is very careful with how he closes the incisions and usually the scars are quite excellent. It seems many patients today shave the hair on their chest. If you can grow chest hair, it is good to let it grow before surgery so that it can help conceal the scars during the early healing process before the scars have had a chance to fade.

It is always possible to lose some sensation, but it is very uncommon to have complete numbness of the nipples.

Some patients just need one procedure, and some need a combination of the two. There are two types of tissue that can be responsible for the enlargement of male chests. In true gynecomastia, the cause of the chest enlargement is purely glandular tissue. This is a very firm and rubbery tissue, and it cannot be removed by liposuction; it must be excised. On the other extreme there can be just a localized excess of fat. Fat is easily removed with liposuction and thus liposuction is the choice. Some patients have a combination of both. Men that are very thin will rarely have fat and thus won’t need liposuction. Men that are overweight will invariably need liposuction. Steroid use causes the development of firm tissue that requires excision. Dr. Ishoo will evaluate your condition and make his recommendation at the time of your consultation.

When you raise and lower your arms, you will see that your chest will somewhat smooth out when your arms are up. So if your chest is smooth after surgery when your arms are down, sometimes there can be a bit of a depression when you raise your arms all the way over your head. In some situations – though uncommonly so – there can be a bit of a depression even with the arms down. With gynecomastia surgery, the surgeon is obligated to remove the entire piece of  glandular tissue, no matter how big it is. When large, it may have compressed the normal tissue around it. Dr. Ishoo is excellent at sculpting this tissue. Nonetheless, it is possible to have some bit of a depression in that area. If the skin is loose after a large weight loss, or if there are lots of stretch marks, then the skin may not tighten up well after the gynecomastia tissue is removed. These patients still have a big improvement, but they may not get a chest that is as tight as ideal. If a lot of liposuction needs to be done and the skin isn’t tight, then sometimes some subtle waviness or irregularity in the contour is possible. All in all, these problems are mild when taken in context of the huge improvement of the surgery, but each patient deserves to know going in the likelihood they may have one of these issues.

When the tissue is soft and just fatty, then liposuction is the ideal treatment. But pure glandular breast tissue is too dense to be removed by liposuction and must be surgically cut away. There are some cases in which the problem seems to mostly be fat because no firm mass can be felt before surgery. But after doing the liposuction, gradually the firm area emerges like an almond in the center of a melting chocolate bar. In some situations, there is a combination of fat and glandular tissue, but the patient may opt to just do the liposuction, accepting that the result will not be as complete but preferring to have a slightly easier recovery.

If your problem was glandular, then gaining weight will not be a problem. If the problem was fat, then it is possible that some of it will come back, if you gain a lot of weight back. But whatever was removed is forever gone.

All gynecomastia patients are warned that it can come back. But the only gynecomastia patients in whom Dr. Ishoo has seen it return were men who took anabolic steroids after having their gynecomastia surgery. Some patients may have had inadequate initial treatment, such as doing liposuction but not an excision. Such patients didn’t really have a recurrence of their gynecomastia, but merely need more done.

Gynecomastia patients are warned about the possibility of it coming back. But after performing a great number of gynecomastia cases, the only cases Dr. Ishoo has seen reoccur were in men who went onto anabolic steroids after surgery. There have been cases in which a decision was made to just do liposuction and not excision in which the patient later wished that excision would have been done. That is why a careful preoperative assessment and discussion with the patient are so important.