Gynaecomastia and Male Breast Reduction

Gynaecomastia, often referred to as ‘male breast enlargement’, is a condition where the breast tissue in males becomes enlarged or overdeveloped. It can affect one or both breasts and is typically benign. While it’s common, affecting up to 50% of men at some point in their lives, gynaecomastia can cause psychological distress and emotional discomfort, particularly in adolescence and adulthood.

As a breast surgeon, I frequently encounter patients seeking advice for gynaecomastia and male breast reduction or so called “man boobs surgery”. In this blog, we’ll delve into the causes, symptoms and available treatment options for gynaecomastia, helping to demystify this condition and outline the best ways to manage it.

What is Gynaecomastia?

Gynaecomastia is the benign (non-cancerous) enlargement of male breast tissue. The condition is typically caused by an imbalance of hormones—specifically, an increase in oestrogen relative to testosterone.

• Unilateral vs. Bilateral: Gynaecomastia can affect one or both breasts. When it affects both, it is termed bilateral gynaecomastia, while involvement of just one side is referred to as unilateral gynaecomastia.

• Pseudogynaecomastia: Sometimes, excess fat can mimic the appearance of gynaecomastia. This is referred to as pseudogynaecomastia, and it is caused by the accumulation of fatty tissue rather than glandular breast tissue. 

Causes of Gynaecomastia

Gynaecomastia can be caused by a variety of factors, including hormonal imbalances, medication use, and underlying medical conditions. Some of the common causes include: 

1. Hormonal Changes:

Puberty: Hormonal fluctuations during adolescence are a common cause of temporary gynaecomastia. Many boys will experience some degree of breast enlargement during puberty, which typically resolves on its own.

Aging: As men age, testosterone levels naturally decline, and estrogen levels can become more dominant, leading to the development of gynaecomastia.

2. Medications:

Certain medications can disrupt hormone levels and lead to gynaecomastia, including:

• Anti-androgens (e.g., Duodart, finasteride, spironolactone)

• Hormones such as growth hormone, oestrogen, GnRH agonists, anabolic steroids (used in body building)

• Heart medications (e.g., nifedipine)

• Antipsychotics/antidepressants

3. Health Conditions:

Liver disease: Liver dysfunction can affect hormone metabolism, leading to increased oestrogen levels.

Kidney disease: Chronic kidney disease and dialysis can also affect hormonal balance.

Hyperthyroidism: Overactive thyroid can lead to an imbalance in hormones that might trigger gynaecomastia.

Tumours: Certain tumours, such as testicular tumours and lung cancer, can increase oestrogen production. 

4. Substance Use:

Alcohol and drug abuse, including marijuana, heroin, and amphetamines, have been linked to gynaecomastia due to their impact on hormone regulation.

5. Obesity:

Excess fat tissue can convert testosterone into oestrogen, which may contribute to breast tissue enlargement.

Symptoms of Gynaecomastia

The primary symptom of gynaecomastia is the development of swollen, enlarged breast tissue in males which is often tender to touch. Firm glandular tissue is often palpable underneath the nipple. The breast enlargement may be different on each side, leading to asymmetry. Moreover, many men with gynaecomastia experience psychological distress, including embarrassment, low self-esteem, or anxiety related to their appearance.

Treatment Options for Gynaecomastia

The treatment for gynaecomastia depends on the underlying cause, severity of symptoms, and the patient’s goals. The options include:

1. Watchful Waiting:

In cases where gynaecomastia is caused by puberty or temporary hormonal changes, the condition often resolves on its own over time. In these scenarios, I would recommend monitoring the condition before considering more aggressive treatments.

2. Medications:

Tamoxifen may be prescribed to block estrogen’s effect on the breast tissue. It is generally effective for pain management and may help reduce swelling if prescribed early. However, after the first 12 months, gynaecomastia typically enters a fibrotic phase, in which case surgery becomes the only effective option for addressing the swelling.

In men with low testosterone levels, testosterone replacement in the form of tablets or gel may be prescribed. However, there is no role for testosterone replacement in men with normal testosterone levels.

3. Surgery (Including Male Breast Reduction):

Surgery for gynaecomastia can range from liposuction alone to a full male breast reduction. The type of surgery performed depends on the severity and composition of the gynaecomastia, the patient’s goals and co-morbidities, as well as the surgeon’s expertise. 

Bilateral gynaecomastia. Top left before, top right and bottom pictures 1 year after open excision through semicircular periareolar scars.

Liposuction alone is an effective option for pseudogynaecomastia with mild to moderate skin excess. However, with true gynaecomastia, an open excision is needed to remove the fibrotic tissue behind the nipple. This can often be performed through a small, well-hidden periareolar scar. In cases with severe skin excess and/or ptosis (droopiness), a full breast reduction, often combined with liposuction, is required.

Right gynaecomastia. Top left before, top right and bottom pictures 1 year post open excision with circular periareolar incision.

Gynaecomastia surgery is not to be taken lightly. Hiding scars on a male chest is much more challenging than on a female chest, and there is often a gap between the surgeon’s knowledge of the condition and their skillset. Dr. Tourani’s expertise as an oncoplastic breast surgeon, coupled with his experience in all aspects of breast surgery—including benign, malignant, reconstructive, and aesthetic surgery—along with his compassionate and caring approach, makes him an excellent choice for an individualised discussion regarding your gynaecomastia concerns.