Gynecomastia in Chicago
Enlargement of the male breast can occur whenever there is an imbalance between the male and female hormones. For example babies are under the influence of their mother’s estrogen when they are born and can display temporary breast enlargement.
At puberty the hormones are not in balance and again enlargement of the breast can occur. It usually regresses when the hormones become readjusted. The enlargement occurs in around 75% of teenagers and regresses completely in 75% of them.
In slightly older males, when testosterone levels start to drop, some enlargement of the breast can appear more frequently as a result of medication intake. There is a whole list of medications that can cause enlargement of the breasts and regular use of marijuana has also been associated with glandular enlargement.
What is the tissue made of?
Under microscopic examination it is essentially fat and fibrous bands made out of collagen. There are no glands in general that are found in that tissue.
If upon examination the enlargement is mainly fat, then liposuction can be very helpful. However when there is a fibrous component, than we need to resort to sharp excision. An incision is made in the lower part of the areola at the junction of the skin and the areola. It allows access to the involved tissue so it can be removed.
If the areola is significantly enlarged it can be reduced as well. With technical refinement over the last few years we have limited our incision to the area of the areola – in all circumstances.
The procedure is performed in an outpatient setting under intravenous sedation or general anesthesia. The sutures are self dissolving and if drains have been placed it would be removed once the drainage has ceased.
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Treatment for Gynecomastia
You can appreciate the glandular tissue in the female breast inside the circles and its absence in the male gynecomastia tissue, where there is duct tissue proliferation but no true gland.
1. Skin laxity and the position of the nipple-areola complex.
Unless there is an excessive amount of weight loss or significant skin stretching, I would not move the nipple to a new location. Instead, I allow the tissue to tighten around the nipple to position it in an acceptable location. It’s important to understand that there is a range of acceptable positions for the areola. When there is a scar all around the nipple, the blood supply needed for its survival depends on the glandular tissue below and limits the amount that can be excised. This is why I try to avoid a scar around the nipple, using it only if significant elevation is needed. Moreover, there will be a resultant vertical scar below and likely a horizontal component. It will take a long time for these scars to become acceptable in appearance.
2. The amount of excess tissue present.
Next, when evaluating the tissue, one needs to decide whether there is a large fatty component. If so, it will be treated with liposuction. If there is a significant component of male gland tissue, this will require an incision in the lower half of the areola at its junction with the skin. This approach allows for tissue excision. In the majority of situations, a combination of both liposuction and male glandular tissue removal will be performed.
3. The size of the nipple and areola.
There are different maneuvers available to reduce its size:
1. By removing the tissue underneath, the nipple will contract as it is no longer under stretch.
2. Placing a suture in the dermis to tighten the circumference of the areola and make it smaller.
3. Removing two wedges of areola and then closing the incision, thereby diminishing the circumference and diameter of the areola by the amount removed.
To visualize this maneuver, imagine ordering a circular pizza, removing two slices, and then putting it back together.
4. The amount of fat versus gynecomastia tissue is an estimate based on the history of the appearance of gynecomastia, the weight of the patient historically, and the feel of the tissue on examination. It is an estimate and that is why we plan on doing both liposuction and gland excision. We start with the suctioning, and if we obtain enough fat, we know that the gynecomastia tissue removed will be small.
photo Credit: Core biopsy showing ductal epithelial and stromal proliferation. by Elaine Zhang, M.D.
photo Credit: University of Michigan Histology. “Mammary Gland Histology.” Histology Guide
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