The American Society of Plastic Surgery (ASPS) has created a descriptive classification system that enables specialists to discuss the issues and treatment of gynecomastia in a more standardized fashion.
Small breast enlargement with localized button of tissue around the areola
Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest
Moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with excess skin
Marked breast enlargement with excess skin and feminization of the breast
Generally, the goal of gynecomastia surgery is two-fold: To restore the normal contours of the male breast and to correct any type of deformity of the breast, nipple, or areola (the colored circle around the nipple). The choice of surgical technique depends largely on the likelihood of "skin redundancy," a term for the excess skin that does not contract following surgery.
Standard surgical treatment for gynecomastia
The most common treatment for gynecomastia, also referred to as "male breast reduction" is a combination of breast gland removal and liposuction. This dual approach works to better blend the fat component into a more natural looking male chest and can successfully treat roughly 80% of men with true gynecomastia.
The key to an optimal outcome is higher skin elasticity and contractility - the type of skin typically found in younger men. However, there are a variety of surgical techniques that can address "skin redundancy".
Conditions affecting skin quality and surgical outcome:
- Obesity or excessive weight gain
- Massive weight loss
- Natural aging
- Photo-aging or sun damage
Limitations of liposuction
In general, male breast reduction surgery is a straightforward surgical procedure. The key is to employ an approach that results in the best outcome - and liposuction alone is not the answer.
True gynecomastia has a breast gland component that is quite dense and highly resistant to removal by liposuction alone. While the sharp liposuction instruments manufactured today are designed to break down the breast gland and suction away the breast tissue, this is not the correct treatment for gynecomastia. In fact, it is the number one reason for gynecomastia revision.
On the other hand, liposuction can be a very successful treatment for patients with pseudogynecomastia. Typically, this is a patient who has experienced an increase in the male breast volume as a result of overall bodyweight gain.
The pull- through technique is a minimally invasive procedure usually recommended for men with a Grade I and Grade II gynecomastia. A small incision of approximately 5 mm is made at the lower edge of the areola and the breast tissue is separated from it. The glandular breast tissue is pulled through the incision as tissue is trimmed away. Liposuction may be used for breast fat removal and blending. The major advantage of this procedure is the small incision.
Results After Pull-Through Procedure
Treatment of gynecomastia skin redundancy
Generally, men with Grade III or Grade IV gynecomastia also have a significant amount of excess skin. These cases are often the most challenging to treat because the degree of skin contractility is highly unpredictable.
Younger men tend to have skin that is more elastic and contracts easily and thus may not have excess skin that would need to be removed; however, this is not often the case for older men. If skin redundancy is an issue, treatment may also involve surgically removing the skin. Scarring is inevitable, yet every effort is made to keep scarring to a minimum. A more experienced surgeon will be able to give you an accurate prediction of your outcome.
This is an ideal procedure for men with mild to slightly moderate skin laxity who require minimal skin improvement. The first procedure uses liposuction and an incision around the areola edge to remove gland, fat, and fibrous tissue and create a pleasing contour. The second procedure is safely performed 4 to 6 months later and involves tightening the tissue and raising the nipple. The incision is done around the areola edge to limit scarring. In most cases, skin removal is unnecessary. There is some support for performing both procedures at the same time.
Direct skin removal for severe gynecomastia
Direct skin removal is often recommended for patients who have experienced massive weight loss or who have substantial skin redundancy. The actual procedure is quite straightforward, however, it does result in significant scarring.
One of the most important issues to address is the position of the nipple and areola, often referred to as the nipple areola complex. This can be done in one of two ways: A free nipple graft can be performed by temporarily removing the nipple areola complex (see the photo below) and reattaching it to the chest or by keeping it attached to a vascular blood supply. Both options yield excellent results.