Complementary Information on Gynecomastia

Gynecomastia is defined by an increase in mammary gland volume in men. It corresponds to uni- or bilateral hyperplasia. Generally it is idiopathic, meaning there is no identifiable cause; however, in some cases it may be related to abnormal hormone production or to certain medications. An assessment is necessary to rule out a potential cause. This assessment will aim to measure the various known hormones, to screen for a testicular or pituitary tumour. A mammogram or ultrasound may be requested to analyse gland density, or to rule out breast cancer in older men, particularly in unilateral forms. If a cause is found, it must be specifically treated. When an aetiology is identified, treating it may allow more or less complete regression of the gynecomastia.

Increased breast volume in men, particularly during adolescence, is often poorly experienced and can pose numerous psychological problems. This physical condition in an adolescent, at the very moment he is building his male image, can lead to withdrawal or even a genuine complex. Moreover, gynecomastia can prove painful.

From an anatomical and pathophysiological standpoint, the mammary gland exists in the normal male, but it is infantile in type, reduced to a simple breast bud. In some cases, this mammary gland can develop if the hormonal environment is favourable.

When no cause has been found and the patient is bothered, surgery may be proposed, provided the patient is in good physical and psychological condition. This type of procedure is called a "gynecomastia correction."

It involves mammary gland enlargement centred on the areola, most often bilateral and symmetrical, of firm consistency and tender on palpation. Gynecomastias must be differentiated from adipomastias, which are much more frequent and correspond to localised fat accumulation. Adipomastias are not centred on the areola, their consistency is soft, painless, bilateral and symmetrical; the two conditions may be associated (adipo-gynecomastia).

A transient gynecomastia may appear in adolescents, related to a hormonal imbalance favouring oestrogens, disappearing within a few months.

Breast cancers have a different presentation; they are rare, typically affecting men generally over 40. They are unilateral, hard, painless lesions, associated with nipple deformities or retractions or even bloody discharge.

The goal of corrective surgery is to restore normal anatomy as best as possible with the principles of:

• Reducing breast volume by direct surgical excision (subcutaneous mastectomy) for glandular forms, or by liposuction for fatty forms. In mixed forms, the surgeon must combine both techniques.

• Reducing skin excess: generally, the decrease in glandular volume will allow skin retraction. This retraction is favoured by liposuction but is more marked in younger men with good skin quality (firm, elastic, without stretch marks). Certain postoperative measures such as massage may aid skin retraction.

In some cases, when skin excess is too significant, the surgeon may need to reduce it, but at the cost of visible skin scars. This skin reduction can be performed during the initial procedure or secondarily.

The assessment to identify a cause for gynecomastia has been discussed previously.

In obese or overweight men, a diet combined with physical exercise is initiated as weight loss may cause regression or even disappearance of gynecomastia (adipomastia). Based on the anatomical context, the surgeon's preferences and habits, and the patient's expressed wishes, a surgical strategy will have been decided. The technique employed and scar placement will thus be predetermined.

A standard preoperative assessment is carried out. The anaesthetist will be seen in consultation no later than 48 hours before the procedure. Your surgeon and anaesthetist must be informed of all medications you take.

Unless in special circumstances, no medication containing aspirin or anti-inflammatories should be taken in the ten days prior to surgery.

Smoking cessation is recommended at least one month before and one month after the procedure.

Type of anaesthesia: most often a standard general anaesthesia. In some cases, "twilight" or even simple local anaesthesia may be used.

Hospitalisation: usually 24 to 48 hours. The duration depends on the surgical technique. A simple liposuction requires shorter hospitalisation than a subcutaneous mastectomy. In some cases, the procedure may be performed as a day case.

Each surgeon adapts their technique to each case. In the standard procedure, an incision is made at the lower edge of the areola. From this incision, the surgeon can remove the mammary gland (subcutaneous mastectomy) and excess fat. Often, liposuction is also performed peripherally to harmonise the result.

For predominantly fatty gynecomastia, excision may sometimes be performed by liposuction alone. Scars are then very short and may be located at a distance from the gynecomastia.

When gynecomastia and skin excess are very significant, longer and more visible scars may be required. In extreme cases, the surgeon may need to graft the areola and nipple.

A drain may be placed. At the end of the procedure, a shaping dressing is applied, often with elastic bandage. Procedure duration varies from a few minutes (isolated liposuction) to two hours for complex forms. In some cases, health insurance coverage may be sought.

Postoperative recovery may sometimes be painful in the first days. Analgesic treatment will be prescribed. With isolated liposuction, the patient may feel local pain similar to "intense muscle soreness." Oedema (swelling), ecchymoses (bruising) and difficulty raising the arms are common initially.

The first dressing is removed after a few days, replaced by a lighter one with a compression vest to be worn day and night for a certain period. This compression aids skin retraction and promotes uniform healing.

Total work stoppage varies from five to twenty-one days. Sports activities should be resumed after one to two months.

Scars evolve over one or two years: initially white and fine in the first month, then pink or red and indurated until the fourth month, then progressively fading. Sun protection during the first year is imperative.

Scar length and location vary according to the operative technique. Their quality depends on surgical technique and patient-specific factors (age, skin quality and type).

Improvement is often immediately noticeable. However, two to three months are needed to appreciate the definitive result. Beyond this period, tissues will progressively gain suppleness.

The reduction in breast volume provides physical comfort, particularly when dressing. The result is often very beneficial psychologically as gynecomastia is frequently perceived as a blight on masculinity.

For pure glandular forms, glandular excision generally prevents recurrence. However, significant weight gain may be accompanied by renewed breast volume increase, particularly for predominantly fatty forms.

Certain imperfections may occasionally be encountered: residual volume asymmetry, height asymmetry of areolas and nipples, areolar cupping, skin excess, hollowed areas or small nodules beneath the skin. As for scars, their evolution must be rigorously and prolongedly monitored.

Nipple sensitivity is generally unaffected, or only transiently for a few months. When the surgeon must graft the areolo-nipple complex, it may become permanently insensitive and may present colour anomalies (dyschromia).

A gynecomastia correction, although performed for essentially aesthetic motivations, remains a genuine surgical procedure, implying the risks associated with any medical act.

A distinction must be made between complications related to anaesthesia and those related to the surgical procedure.

By choosing a qualified and competent Plastic Surgeon, you minimise these risks. In practice, the vast majority of gynecomastia corrections proceed without any problems. However, complications may sometimes arise:

• Postoperative bleeding and haematoma: if significant, evacuation may be required.
• Phlebitis and pulmonary embolism: early mobilisation minimises this risk.
• Serous effusion: may require one or more punctures.
• Postoperative infection: may require antibiotic treatment and sometimes surgical drainage.
• Skin necrosis: treated with adapted dressings and care.
• Pneumothorax: very rare, will receive specific treatment.
• Abnormal scars: hypertrophic or even keloid scars may occur.
• Skin sensitivity disorders: frequent in the first months then usually fade.

Overall, risks should not be overestimated. Choosing a qualified Plastic Surgeon ensures the training and competence required to prevent or treat these complications effectively.