What gynecomastia is, when it needs surgery, and what to expect.

Gynecomastia is the benign enlargement of glandular breast tissue in males and the most common male breast condition. It reflects an imbalance between estrogens and androgens.¹ Enlargement from fat alone, without extra gland tissue, is called pseudogynecomastia.^1,3

Breast growth in males is normal and temporary at three stages of life. It is seen in many newborns, in up to 65% of adolescent boys and in up to 65% of older men.¹ Estimates vary widely by definition. In a population study of 531,686 boys aged 12 - 15, about 1% had a recorded diagnosis.⁵

No cause is found in many patients, and these cases are called idiopathic.^1,2

• Medications: Anabolic steroids, testosterone, some antiandrogens and certain heart, psychiatric, antacid and HIV medications are linked to breast growth.^1,3
• Recreational Drugs: Marijuana, alcohol, opiates and amphetamines are documented causes.^1,3
• Medical Conditions: Liver and kidney disease, thyroid disorders, low testosterone, Klinefelter syndrome and some hormone-producing tumors can cause it.^1,2
• Obesity: Excess fat increases conversion of androgens to estrogens and adds fatty enlargement.¹

When a medication or drug is responsible and is stopped, the gland should soften within about a month, before fibrosis sets in.^1,2

Evaluation includes a full medication and drug history, a breast examination to separate firm gland from fat, and examination of the testicles, thyroid and abdomen. Blood tests and imaging are added when the history or examination suggests an underlying cause.^1-3 Clinical practice guidelines recommend the same structured approach, with targeted hormone tests and imaging when appropriate.⁶

Fewer than 1% of breast cancers occur in males, but a hard lump away from the nipple, skin dimpling, nipple retraction, discharge or bleeding needs further workup.¹ Gynecomastia itself is not linked to a higher breast cancer risk, except in Klinefelter syndrome, where the risk is much higher.^1,3

Observation is recommended for newborn, pubertal and recent-onset cases, and any causative medication is stopped or changed when possible.^2,6 Weight loss helps when the enlargement is mostly fat.¹

Medications such as tamoxifen have been studied for pubertal gynecomastia. A systematic review found them generally safe and effective in small studies, but the evidence is limited and high-quality trials are lacking.⁷ Guidelines suggest drug therapy may be considered in selected idiopathic or painful cases.⁶

Surgery is considered when gynecomastia persists for at least a year after causes are addressed, or when it causes significant psychological distress.^1,6 The goal is a flatter, more masculine chest contour.¹

When skin excess is moderate, surgeons often remove the tissue first and wait at least 6 months to see how much the skin contracts. Most patients have enough retraction that they do not need further surgery.^1,2 A small cuff of tissue is left under the nipple to avoid a sunken, saucer-like contour.^1,2

Bodybuilders and anabolic steroid users usually have firm, fibrous gland with little fat, so liposuction alone is less effective and direct excision is often needed.¹ In a series of 964 patients, 11% had used anabolic steroids, and they needed revision gland excision more often than nonusers (3.8% vs 1.1%).⁸

• Markings: Areas of gland and fat, the chest fold and the edge of the pectoral muscle are marked while the patient sits or stands.^1,2
• Anesthesia: The procedure is done under general anesthesia or local anesthesia with sedation.²
• Liposuction: The whole chest is treated in a fanning pattern, and the breast fold is intentionally released because it looks feminine.^1,2
• Excision: Remaining firm gland is removed through a small areolar incision, often with a pull-through technique.^1,2
• Closure: A drain may be placed after excision, and a compression garment is applied.^1,2

Recovery milestones come from surgical textbooks and vary by surgeon. Compression helps the skin settle onto the chest wall and limits fluid buildup.^1,2

Another review of 5,345 patients found complication rates of 12.12% - 22.30% across approaches, with minimally invasive techniques lowest and hematoma and bruising the most commonly reported problems.⁹ Hematoma is most likely after excision through a small incision, where visibility is limited.¹

Other risks include seroma, removing too little or too much tissue, a sunken nipple, contour irregularity, asymmetry, scarring and changes in nipple sensation.^1-3 When the nipple is moved as a graft in severe cases, partial or complete nipple loss and pigment changes can occur.¹

In 71 adolescents treated with gland excision and liposuction, 98.6% were satisfied with the result, 19.7% had a complication and 4.2% needed revision.¹⁰ In a matched cohort of 390 adolescents followed for a median of 4.33 years, new psychiatric diagnoses were less common after surgery than without it (7.7% vs 20.0%).¹¹

Reviews report improvements in quality of life and several psychological domains after surgery, although the evidence is of low quality.¹² When asked to choose, 86% of patients in one study said they would rather have more scars and a flatter chest.¹³

• Drug Therapy: High-quality trials of medications for pubertal gynecomastia are lacking.⁷
• Best Technique: Studies use different classifications and techniques, which makes direct comparison difficult.^4,14
• Psychological Benefit: The size of the psychological benefit of surgery needs better studies.¹²