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Age, activity levels drive gynecomastia procedural decisions

Key iconKey Points

  • In older, overweight men, combination of liposuction and excision tends to be effective
  • In young patients with gynecomastia, physicians should evaluate for other pharmacologic or endocrine influences

The popularity of gynecomastia surgery has skyrocketed in recent years. One estimate indicates that the procedure has experienced a 48 percent increase, with 16,500 men having had the procedure in 2001 (compared to a prior estimate taken in 1997).

This isn't surprising, considering the incidence of benign enlargement of male breast tissue — at least a third of males are affected at some time during their life.1 Surgical treatment includes liposuction for primarily fatty cases or direct excision when glandular tissue is predominant.

Fair Oaks, Calif., surgeon Sydney E. Garfinkle, M.D., who specializes in gynecomastia, says he sees three categories of males affected by the condition. "Most commonly, the gynecomastia patients I see are young men between the ages of 19 and 30 who are bodybuilders, and the gynecomastia is a result of taking anabolic steroids. The next group comprises overweight men, usually aged 50 and above who have mostly excessive fatty tissue that is responsible for breast development.

"The third group is represented by young boys who have enlarged breasts because they are either overweight or simply have excessive breast tissue," he says.

BODY BUILDERS The development of gynecomastia among bodybuilders comes as a result of the body making estrogen, Dr. Garfinkle says. "These men take anabolic steroids and when they are broken down, some of it changes to the female hormone estradiol, and the result is breast enlargement," he says.

"Oftentimes, these men will attempt to reverse the breast development by taking an antiestrogen drug such as Nolvadex (tamoxifen, AstraZeneca). If they take it early enough, it can reverse their gynecomastia, but when that doesn't work, they come to me," Dr. Garfinkle says.

In these cases, Dr. Garfinkle performs a straightforward excision. "I make a periareolar cut right around the edge of the nipple, usually inferiorly in the lower part of the nipple, and from there I remove the excess breast tissue," he says, adding that in these cases, no liposuction is necessary. "It's a straightforward operation."

One of the potential complications during the postoperative follow-up period is bleeding, because these patients tend to return to the gym sooner then recommended, he explains. "They are not the most compliant patients, and they'll often return to lifting weights quite soon afterwards, and this can result in bleeding. I have had a few patients who developed a little fluid or a little blood in the operative area afterwards, and I have them come back to the office for a needle aspiration, which has been effective each time."


A male patient before (left) and eight weeks after subcutaneous mastectomy with liposuction. (Photos credit: Sydney Garfinkle, M.D.)
OLDER AND OVERWEIGHT In older, overweight men, Dr. Garfinkle says he tends to perform a combination of liposuction and excision because they tend to have a certain amount of fat in the periphery of the breast tissue. "In some cases, especially in older men, it is not necessary to remove any breast tissue because the gynecomastia is due primarily to fat, so we perform liposuction in those cases," he says. In most cases, however, "A combination of liposuction and surgical tissue removal is most effective."

When performing liposuction for gynecomastia, Dr. Garfinkle uses tumescent anesthesia and oral anxiolytics. He uses a 3 mm or 4 mm cannula and usually makes a couple of puncture wounds in the inframammary crease, for cannula entry points. In some instances, he will also enter through the deltopectoral groove.

"Typically, you can't see those incisions afterwards," he says. "I usually have three points where I approach the fatty tissue, and I aim to leave it relatively flat. I tend to leave approximately 4 mm of thickness of residual tissue because if you leave it too thin, it is possible that the skin will adhere to the underlying muscle or fascia and the patient will end up with a dimple."

In older, formerly obese patients, rather than removing the excessive skin that is inevitable after fat and/or breast tissue removal, Dr. Garfinkle says it's important for patients to have realistic expectations. "I tell them that there may be some residual sagging skin and that they shouldn't expect an A-plus result. They understand that our aim is to shrink things down or reduce the size, and that that is the best we can do."


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