The term ‘gynaecomastia’ is derived from the word Greek 'gynaik'-meaning woman and 'mastos' meaning breast. Gynaecomastia is an unusual enlargement of the male breast whereby the breast begins to appear as a female breast and embarrasses the person who develops this condition. Enlargement of the male breast is quite common and affects up to 50-60% of males. Gynaecomastia is usually a benign condition but sometimes it may be the sign of underlying diseases and can happen at any age.
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Gynaecomastia- why does it occur?
In general gynaecomastia results from an imbalance of the circulating sex hormone or the way in which the body tissues respond to these hormones. The circulating sex hormones in the male body may be affected by a number of factors. Sometimes the condition appears soon after birth and this happens from the circulating female hormones that pass from mother to child. Pubertal and adolescent boys often present with gynaecomastia. The changing hormonal patterns besides other factors lead to an increase in the breast size and cause them to be emotionally distressed. Gynaecomastia resulting from hormonal changes occurs in a number of medical condition like aging, hypogonadism (reduced testosterone production), hormone producing tumors or cancers, hyperthyroidism and failure of organs like liver or kidneys. Male hormones are also lowered in malnutrition and starvation resulting in gynaecomastia. Body builders and athletes commonly resort to available steroids to increase their stamina and muscle mass. However this can lead to excess testosterone which is converted to estrogen a feminizing hormone that results in Gynaecomastia. The advent of fast food, beverages and high calorie snacks has led to a large number of the population becoming obese. Along with obesity the breast size often increases from fat deposition leading to gynaecomastia. A large number of drugs or medications like Digoxin, Frusemide, Spironolactone, etc are capable of causing Gynaecomastia as a side effect. While most of these conditions result in Gynaecomastia affecting both breast, enlargement of only one breast may also occur. In such cases one should specifically rule out the start of cancer or malignancy and other diseases. Pollutants such as lead can add to an increased risk of Gynaecomastia. In about 20 to 25% of patients with gynaecomastia there is no detectable cause.
Gynaecomastia – Where do we start?
Once a proper history and thorough clinical examination is done, your surgeon may ask for a few investigations to confirm the diagnosis. Blood test will help to rule out kidney, liver or thyroid disease. Evaluations of hormonal levels may be needed if feminizing syndromes are suspected. Other tests like ultrasonography and mammography may be asked for if a definite breast disease is though off. Sometime a biopsy or fine needle aspiration cytology (FNAC) may be carried depending on the case. If no disease is suspected as in pubertal gynaecomastia or asymptomatic one, no further tests are needed but the patient can be reevaluated after 6 months.
For physiological Gynaecomastia as in newborns and pubertal gynaecomastia the individual and parents need to be reassured that this condition is temporary and will most likely go away. These cases should be reevaluated every six months. During puberty there is a transient increase in the estradiol concentration and hence pubertal gynaecomastia starts at 10 to 12 years. However it generally regresses over one to two years and uncommonly persists over 17 years. If the gynaecomastia is painful and persisting after two years then surgical removal must be considered. Markedly obese individual who have gynaecomastia should undergo weight reduction, diet and exercise regimes. Sometimes Bariatric Surgery may help when diet and exercises fail. Though bariatric surgery will help to reduce the weight, in some individuals the breast tissue will begin to sag down as the skin fails to contract. These cases will need plastic surgical intervention for treating their gynaecomastia. If a specific underlying cause like those discussed previously is identified, it should be addressed. In hormonal imbalances, hormonal manipulation such as testosterone replacement or anti estrogens may be needed. Medical treatment of gynaecomastia includes Clomiphene- an anti estrogen, Tamoxifen, Danazol, Testolactone and others. However the success rates are variable and a large number of side effects have been reported in the case of these drugs-rashes, nausea, visual problems, epigastric discomfort, weight gain, acne, muscle cramps, fluid retention, abdominal liver function tests, vomiting, edema and worsening of hypertension.
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Gynaecomastia- How can the plastic surgeon help?
The plastic surgeon will first evaluate which tissue is contributing to the breast enlargement- gland fat or skin excess, and then decide on the mode of treatment. In individuals who exercise a lot or one actively involved in body building , the pectoral muscle underlying the breast area increases in size and can mimic a Gynaecomastia though the actual breast size in normal. Sometimes the regions of the areola and nipple are enlarged in size appearing as puffy nipples, while the rest of the breast area is normal. In some individuals the Gynaecomastia is a result of rapid glandular enlargement. In obese patients Gynaecomastia often occurs from an increase in the breast fat (also called Lipomastia). Excess skin can hang loosely and give an appearance of Gynaecomastia in some patients. In most patients there is often a combination of these possibilities. Once we know the cause, a treatment plan can be chalked out. If the glandular element is responsible an excision or removal through a cosmetically placed scar will be carried out. Sometimes fat will be the culprit causing breast enlargement. In such cases Liposuction or removal of fat using a canula or tube through a small opening with the help of a suction machine is carried out. When skin excess leads to sagging of the breast, the skin will to be removed. Often a combination of these problems exists and the treatment options will be added up.
The patient is usually admitted a day prior if the surgery is planned under general anesthesia. The anesthetist will review the patient's fitness for this procedure. Small sized lesion can be removed under local anesthesia. Once the patient is put to sleep, the surgeon will make a small incision (1 cm) near the breast area. He will then introduce a canula (Metal tube) to inject a special fluid and then apply suction force to suck the fat out. Once the appearance is pleasing and symmetrical on both sides, he will evaluate if excess skin is present. If so then the skin will be removed by a cosmetically placed incision. If after removing the fat the surgeon finds that the glandular element is still present, he will remove it in addition to the skin and fat excess. Postoperatively moderate pain can be expected which can be treated with analgesics. Antibiotics are given to avoid infection. Some bruising, redness and edema are expected, but they usually settle over few weeks. A pressure garment must be worn for three months or more as directed by the surgeon. The patient is discharged on the same evening of surgery or after a few days depending on the nature and extent of surgery. Smoking should be strictly avoided and exercise regimens must be delayed for 6 weeks or more. Weight lifting and heavy exercises must be avoided for 3 months. As with any surgery a few risks are associated with gynaecomastia surgery- infection, haematoma (blood collection), Seroma (Serum collection), operated site asymmetry, uneven contours, scars, sensory changes, persisting pain and swelling. Fortunately these risks are not common and the surgeon takes utmost care to prevent them. Sometimes an additional touch up procedure may be needed to correct minor residual defects, especially when a combination of procedures is carried out.
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A large number of individuals with gynaecomastia suffer from cosmetic problems as well as psychological issues. Young boys and men avoid exposing their chest while swimming or otherwise for fear of being ridiculed. Some even wear tight undergarments and loose outer clothing to mask their breast enlargement. Sometimes parents are distressed by the growing breast in their male children and wonder if they are facing gender issues. Plastic surgery helps to correct the gynaecomastia thereby providing superior cosmetic results. Patients are able to wear tight fashionable clothing and interact with their peers in different social circumstances. Post surgery patients have an increased self confidence, good body image and feel better psychologically. Creating awareness about this simple condition is necessary in our society and making the treatment available to all sections of society should be an important agenda of any health program.
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