Gynaecomastia is the enlargement of the male breast. Whilst gynaecomastia can be caused by certain medications and diseases, the most common cause is an imbalance between circulating male and female hormones which often happens in newborns, adolescents and the elderly. In many patients, no known cause is found. 

Many cases of gynaecomastia settle spontaneously, but long-standing gynaecomastia is unlikely to resolve and patients may benefit from surgical reduction of the gynaecomastia. Men may feel embarrassed about their feminine looking chests and avoid tight fitting shirts. Many bodybuilders with mild gynaecomastia are concerned about the puffiness around the nipple. Some gynaecomastias tend to be painful and tender to touch. 

Gynaecomastia may be due to excess gland or excess fat. Gynaecomastia may be classified according to size as mild, moderate and severe, and if there is excess skin. Surgical treatment options range from liposuction of fat, microdebriders to excise gland, mini excision, open excision or subcutaneous mastectomy and skin reduction in one or two stages.

Men with gynaecomastia may be embarrassed about their feminine chests and avoid wearing tight clothings. Body builders with even a small degree of gynaecomastia often complain of the puffiness under their areolas. Some men with gynaecomastia work out more at the gym by benchpressing in a belief that the fat would be burnt off, but by making the pectoral muscles larger, it pushes up the gland making the gynaecomastia more prominent.

Physiological causes during certain phases of life; newborns, adolescence and the elderly. This occurs due to the imbalance between the hormones estrogen and testosterone, and often resolves within two years.

Diseases that result in hormone imbalance such as liver diseases, testicular tumors, pituitary disorders.

Medication such as cimetidine, digoxin, verapamil.

In many situations, there is no identifiable cause (idiopathic).

Your doctor would take a history and perform a physical examination. Breast imaging like mammograms and ultrasounds may be indicated to rule out any pathology. Blood tests like a hormone profile may be indicated to rule out hormone imbalances. Your doctor would review the results and counsel you on the surgical treatment options.

Gynaecomastia may sometimes resolve spontaneously. However, long standing gynaecomastia that has been present for more than two years is unlikely to resolve, and patients may benefit from gynaecomastia reduction surgery. 

Depending on what tissue predominates, gynaecomastia may be glandular, fatty, or a combination of both. True gynaecomastia is glandular in origin, whereby the enlargement is due to enlargement of the breast gland. Breast enlargement due to fat is often termed pseudo gynaecomastia.

Gynaecomastia may be graded according to size:

Grade 1: Minor enlargement without skin excess

Grade 2: Moderate enlargement without skin excess

Grade 3: Moderate enlargement with skin excess

Grade 4: Marked enlargement with skin excess

This is usually performed under general anesthesia and patients usually stay a night in hospital. A tube connected to a bottle may be inserted to drain post-surgical fluid, which is removed when the levels are low, usually the next day. A pressure garment must be worn after the surgery and is recommended to be worn for a few months. This reduces swelling, fluid collection, and provides a better shape. Patients should avoid exercise for six weeks. It takes about three months to see the final result.  

Fat may be removed through liposuction. 

The breast gland is harder and is generally unable to be removed through liposuction cannulas. It needs to be excised through open excision, mini excision and microdebriders. The incision made for open excision is usually at the junction between the pigmented areolar and the chest skin, the scar to be concealed. Microdebriders are narrow instruments somewhat like liposuction cannulas but with rotating teeth that are shrouded at the tip that cut and suck hard tissue like the breast gland. 

In cases where there is no skin excess, the skin generally recoils when the fat or gland is removed.

In cases where there is skin excess, several options are available. The skin may be left alone during the gynaecomastia reduction surgery and if the skin tone is good, it may recoil sufficiently over the next few weeks to months to a degree that is acceptable to the patient. If excess skin remains, it may be excised in a second surgery. The other option is to reduce the redundant skin in the same sitting as the gynaecomastia reduction. If the skin excess is little, the scar may be concealed around the areola. In cases of severe skin excess, an additional scar in the shape of an inverted T or an anchor is required. 

There is a risk of bleeding, bruising, fluid collection, numbness of the chest area, wound healing problems, nipple areolar slough, over resection, under resection, asymmetry, irregularities.