Gynaecomastia Correction (Male Breast Reduction)

Gynaecomastia is a term meaning male breast enlargement. It is quite a common condition and can cause embarrassment and self-consciousness. It may be on one side only or present on both sides. 

Gynaecomastia surgery is surgery to reduce the male breast. Before going ahead with any treatment or surgery it is important to run through a basic health check, as gynaecomastia can be due to problems with weight, hormone disorders or imbalance, some medications or tumours such as a testicular tumour. In most men there is no medical reason, but these potential causes of gynaecomastia must be out ruled before going ahead with surgical treatment. Pre and post surgery clinical photographs of your chest will be taken.

Indications for Gynaecomastia Surgery:

• Male breast enlargement that has failed to respond to other relevant treatments such as weight loss or stopping medications

Limitations of Gynaecomastia Surgery:

• If significant fibrous tissue or extra skin is present, it will not be possible to reduce this tissue via minimally invasive means (i.e. liposuction alone). There will be some external scars usually around the nipple area.
• If a large amount of extra skin is present, more extensive incisions (scars) may be necessary to reduce the skin and breast tissue sufficiently

Types of Gynaecomastia Surgery: 

Gynaecomastia or male breast reduction is usually done under general anaesthesia although milder cases may be suitable for local anaesthesia. The surgery takes between 1 and 3 hours depending on the extent and type of surgery required.

Liposuction:

Liposuction may be suitable for milder cases of gynaecomastia or for forms of gynaecomastia where the excess breast tissue is predominantly fatty.

Liposuction is carried out through very small incisions where fluid is infiltrated and then a suction cannula is used to remove the fat. A narrow metal tube (suction cannula) attached to a suction pump is inserted through the very small skin incisions and used to remove the unwanted fat by moving it through the area to be treated under the skin. Most surgeons inject a local anaesthetic and adrenaline solution beforehand to help reduce pain and bleeding.

Liposuction has the advantage of using very small scars and of being very effective in removing subcutaneous tissue. It does rely somewhat on the ability of the skin to snap back and this is something that varies from individual to individual and lessens with age. Mostly power or suction assisted liposuction is used. Variations of liposuction utilise ultrasound or laser to assist in breaking down and removing the fat.

Open Gynaecomastia Reduction Surgery:

When the breast tissue is more solid and fibrous or there is a significant amount of extra skin, open surgery is necessary. Liposuction alone will not sufficiently remove this tissue. An incision is placed just underneath the nipple or towards the side under the armpit and the excess tissue is removed. This will leave a scar in the area, which will be red at first and will slowly fade.   In severe cases a more extensive scar may be needed to remove sufficient skin and tighten the area.   If necessary, the size of the areola (pigmented area of skin around the nipple) is reduced as well. In severe cases, the nipple may need to be moved and repositioned in to a better location on the chest.

Combination Surgery:

Sometimes both techniques are combined for optimal effect. Liposuction effectively removes the fatty tissue present, while the more fibrous tissue is removed via an incision under the nipple. This can reduce the amount of open surgery needed and contour the rest of the chest nicely.

Post-Operative Course:

You will have bruising and swelling in the treated area afterwards which will peak at day 2 to 3 and slowly resolve over the weeks following this. Most of this will go in the next 4 to 6 weeks but swelling can persist for up to 6 months. You will have small scars in the areas the suction cannulae have been inserted if liposuction was used and you often have some temporary numbness of the overlying skin. Some fluid may ooze from these areas in the beginning. Surgical tapes will be placed over any incisions for open surgery and these will usually have been placed along the underside of the nipple. If having open surgery, a surgical drain will have been placed on each side of the chest and will remain in place for 24 to 48 hours. You may shower over the tapes but they need to dry or be dried (with a hairdryer on a cool setting) before dressing again.

You will need to wear a compression garment (vest-type garment) for 4 to 6 weeks postoperatively. This helps to provide support to the skin and to keep swelling controlled. It can be removed to shower but should be worn at all other times.

Liposuction alone is often done as a day case procedure. If open reduction with or without liposuction is performed, then you will normally stay 1 night or occasionally 2 nights in hospital.

Recovery:

Most people return to work after about 2 weeks depending the extent of the surgery and the nature of their work. Light activities can be resumed within 2 weeks and normal activities are usually unrestricted after 4 to 6 weeks.

Complications:

While most gynaecomastia correction surgeries go very smoothly and patients are delighted with the results, as with any procedure there are some risks associated with gynaecomastia surgery.

• Swelling and bruising. This will peak around day 2 to 3 post surgery and will gradually reduce after that. Most of the swelling is usually gone by 6 weeks but occasionally lasts longer than expected.
• Bleeding or haematoma formation. This is a relatively common complication of open gynaecomastia surgery, which may require a return to theatre to remove the build up of blood underneath the skin and stop any further bleeding.  It shows as increased swelling and/or pain in the breast area and there may be more drainage than expected into your drain. If treated promptly, it does not usually cause a long term problem but may lead to a slower recovery with more persistent swelling and bruising than normal. If it is not fully treated it can compromise the overall result.  If you have a tendency to bruise or bleed easily or take medications such as aspirin that make you more prone to bleeding, this may be a higher risk for you. It may be necessary to stop some medications in advance of surgery. This is a lower risk when liposuction alone is used.
• Infection can occur as with any other type of surgery and will be treated with antibiotics as required. It is less common when liposuction alone is used.  Occasionally further surgery is required to clean out or further treat the wound.
• Clots in the legs (deep vein thrombosis) can form due to the length of surgery and reduced mobility after the procedure. They can sometimes travel to the lung (Pulmonary embolus (PE)) and this can be very serious. While in hospital, you will receive blood-thinning injections and be asked to wear compression stockings. You should continue to wear the stockings for 2 weeks after discharge from hospital.
• Suture spitting. The sutures used are normally dissolvable. Sometimes parts of these sutures can take longer to dissolve than anticipated and can cause some irritation and spit out.  Any remnants can be removed in the outpatient clinic and the area should heal well after that.
• Delayed wound healing. Sometimes wounds take longer than expected to heal. It may be because of one of the other problems mentioned above e.g. infection or due to overdoing it after surgery.       This can usually be managed with wound care in the clinic.
• Change in nipple sensation. Numbness is more common but sometimes nipples can be over sensitive following surgery in the area.
• Problems with nipple healing.   If there is extensive surgery around or under the nipple or if the nipple has to be moved and repositioned on the chest, this carries a risk of problems with the blood supply to the nipple.  This can mean slow healing of the nipple area or even loss of all or part of the nipple in some situations.  Fortunately this complication is rare in gynaecomastia surgery. It is a more common situation in smokers and they will be advised to stop in advance of surgery. If this should happen, it can leave poor scarring around the nipple or require further surgery to improve the appearance or reconstruct the nipple.
• Fat necrosis. Sometimes small areas of fat may die within the breast. This may be apparent as a lumpy area or an oily discharge from the wound. This is usually treated with massage and/or dressings but occasionally requires further surgery.
• The skin can feel hard postoperatively. This should soften with time. Massage may be helpful to speed up resolution of this problem.
• Numbness or hypersensitivity of the overlying skin due to bruising or damage to the small nerves of the skin. This is usually temporary but may persist.
• Seroma. After surgery, the body naturally produces a certain amount of fluid as part of its reaction to surgery and attempts to heal the area.  Sometimes this fluid can build up underneath the skin after the drains have been removed and require drainage in the clinic with a fine needle. This may need to be repeated until it stops being produced.
• Over correction or a dished out appearance to the chest can become apparent once the swelling resolves. This is sometimes a difficult problem to resolve and may involve transferring fat to the area to build up the chest and correct the contour defect.
• Loose skin. The skin may fail to snap back especially if more fat is removed.  If this fails to settle it is only correctable by excision techniques, which will leave further scars in the area. Stretch marks and scars will not be removed by liposuction.
• Contour irregularities.
• Poor scar formation. Red or lumpy, more visible and slow to heal scars.  Various treatments are available to treat this but it can be a difficult problem to resolve particularly if hypertrophic or keloid scars develop.
• Under correction where less tissue than desired has been removed and sometimes a second procedure is required to remove further tissue.
• Asymmetry. Most people have asymmetry of some degree between each side of their body but not necessarily overtly noticeable. These differences will persist after surgery, but are usually small enough that they are not overly visible and do not require any treatment. Sometimes there is a more noticeable asymmetry and this may require a further procedure.
• Disappointment with the result. Sometimes after undergoing a gynaecomastia procedure, patients are disappointed with the result. This may be due to one of the problems described above occurring or due to unrealistic expectations of the surgery e.g. mild asymmetries, visible scars or some residual breast tissue. It is important that you discuss your expectations in advance of the surgery so that you can understand what to expect from the surgery and so this situation is avoided as much as possible.  (Additional costs may be incurred for further procedures.)

Longevity of Procedure:

Gynaecomastia surgery has a high success rate and is considered an excellent procedure for reducing and reshaping the male breast.

It is important to be aware that small revisions or adjustments are often needed after the main procedure to get the optimum result.

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