SEVERE (EXTREME) CASES OF GYNECOMASTIA

Gynecomastia (gyno) is the term used to describe the swelling of the breasts in men. All of us have breast tissue, however in men it is generally so small that it does not form any noticeable boobs. However, as in women, breast tissue will respond to high levels of estrogen by growing. If anything changes the balance of the ‘male’ hormone testosterone and the ‘female’ hormone estrogen, then a man’s breast tissue may grow and gynecomastia will develop. In men with gynecomastia the levels of the hormones may be within the normal range, but if their balance changes – either an increase in estrogen or a decrease in testosterone  – then breast tissue may grow.

The other cause of man boobs is pseudogynecomastia. This is excess fatty tissue which builds up on the chest, and it is mostly found in men who are overweight or obese.
normal breast and pseudogynecomastia

Causes of gynecomastia

Man boobs can be caused by a range of factors. For men with pseudogynecomastia, weight loss through diet and exercise is often all that is needed. When boobs are the result of true breast glandular tissue, several things can be the cause.

  • Physiological – in male babies or adolescents
  • Medications – including stomach ulcer and some chemotherapy drugs
  • Hormone producing tumours
  • ‘Recreational’ drugs including bodybuilding steroids, marijuana and methadone
  • Liver or kidney disease
  • Rare genetic disorders such as Kleinfelter’s syndrome

When a man with gynecomastia goes to visit a doctor, he will be asked for a full medical history to try and work out what the cause of his boobs might be. In many men simply stopping or altering a treatment for a medical condition might be all that is needed. This should of course always be done with medical advice, as stopping treatments can be dangerous. In most cases the doctor will be able to prescribe a different treatment which will make sure the condition is still controlled, and at the same time the man boobs will disappear. The man will be asked to stop any recreational drugs which might be causing the problem.

For some men, particularly when the swelling is significant, the doctor might want to rule out more worrying causes of the swelling. This means he will get a full medical examination and may need blood tests or scans of the chest or other areas.

Extreme cases of gynecomastia

In some men gynecomastia can be very extreme. If breasts are ‘measured’ before treatment using women’s cup sizes, boobs up to size D or E are seen in some cases. This can obviously be extremely distressing for the man. If the swelling is the same on both sides, then severe gynecomastia is often due to a hormone imbalance. Swelling that is much bigger on one side should always be checked out, as either an abscess of the breast tissue or breast cancer are possible causes.

Severe gynecomastia can be seen in adolescents going through puberty. Cases like this, even with severe swelling, are likely to go away on their own after two years(on average). To a teenager with severe gynecomastia this may be too long to wait. Man boobs can be the cause of teasing or bullying, and may cause the teenager to avoid sporting activities where his chest may be seen either during the sport or in the locker room. Some young men may be happy to wait and avoid treatment, but for others surgery might seem like an attractive option. Clearly, any operation needs careful thought and discussion before proceeding.
gynecomastia-grades

Treatment options

For many men with gynecomastia, no treatment is needed. Simple reassurance with perhaps some changes in lifestyle to reduce weight and improve muscle tone will be sufficient to deal with the problem. In some cases, treatment with medications to reduce the amount of estrogen or increase the amount of testosterone may be possible. However, for many these hormone treatments have side-effects and are not widely recommended.

Surgery is also available, and is likely to be the most effective option in cases of severe gynecomastia. Agreeing to any operation is clearly a big step, and needs to be carefully considered before proceeding. However, men with severe gynecomastia may find the condition very distressing, and may alter their lifestyle and daily activities because of it. These men may decide that surgery is a good option.

Surgery for gynecomastia

There are two main types of surgery which are done for man boobs – liposuction and mastectomy. Liposuction is the sucking away of excess fatty tissue. It is effective for men with pseudogynecomastia, where the gyno is caused only by fatty tissue. It can also be used in addition to a mastectomy for men whose boobs are caused by a combination of true breast glandular tissue and some excess fat.

The operation for true gynecomastia is a mastectomy. This operation is either done through a traditional open operation or using keyhole instruments. Each approach has its advantages and disadvantages, which should be discussed with the surgeon who will be doing the operation. Generally for severe gynecomastia, the surgery is likely to need a traditional incision. In many cases this is made at the junction between the areola (the pink area surrounding the nipple) and the regular skin on the chest. The scar may be curved, meaning it is less visible after healing. In severe gynecomastia it may be necessary to make a larger incision (either vertical under the nipple or an inverted ‘T’ shape) to allow all the breast tissue to be safely removed. Again, the surgeon who is doing the procedure should discuss the position and the size of the scars that are likely so that the man knows what to expect.

In very severe cases and where the swelling has been present for a long time before the operation, the surgeon might discuss removing some skin. This may improve the appearance, as the man is not left with sagging skin when the breasts are no longer present. However, it does make the operation more complicated, and a plastic surgeon will be the best qualified person to undertake this kind of procedure.

Gynecomastia-Surgery

Outcomes after treatment for severe gynecomastia

It is vital to know what to expect after surgery. It can be extremely helpful to do research on the internet to look at before and after pictures for treatment as these can help give a really good idea of what is possible. The surgeon who is doing the procedure may also have some before and after pictures of their patients to show the potential outcomes of the operation. Although the surgeon will not be able to discuss specific cases, they should be able to talk about cases with a similar size of swelling and what they looked like after treatment.

The surgeon may also suggest taking pictures before treatment. These can be really helpful to show the man the results of the surgery, and may perhaps (if the man agrees) be used in the future to help other men understand what to expect.

After surgery the reduction in breast size is immediate. There will be some swelling and bruising in the first days and weeks which can mask the final outcome, but the man will see an immediate improvement compared to the appearance before treatment.

As with any surgery, problems or complications are possible, although these are very uncommon. Some pain or discomfort is normal, and the man is likely to need painkillers in the early days after the procedure. There will be some bruising and swelling – in rare cases this can cause problems (a seroma or haematoma) which need to be treated. Wounds can occasionally become infected, and in some men they may become bulky and unsightly. All surgery will leave scars of some description. Most men are very happy with the appearance of their chest after surgery, and the operation and recovery have no problems.

Even for men with the most severe swelling, an excellent post-operative appearance of the chest is possible. It is likely of course that the men with the worst swelling will most appreciate the improvement after their procedure. Ongoing weight loss (where needed) and exercise should mean that these results are maintained in the long term. Following a mastectomy, regrowth of the breast glandular tissue should not be possible.

Summary

Severe gynecomastia can be extremely distressing for the man involved. If the man decides he needs treatment, surgery is likely to produce the best results. Surgery involves removing the breast glandular tissue, and in severe cases it is usually done through a traditional scar over the breast area. Before agreeing to surgery, the man should discuss the operation and likely outcomes with the surgeon involved. Looking at photographs of other men before treatment and the results they achieved after surgery can be very helpful. Although complications are possible, most men see very good long-term outcomes following gynecomastia surgery.

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