Gynecomastia

Gynecomastia is the benign enlargement of glandular breast tissue in men.¹ It differs from lipomastia, which is an increase in fatty tissue; the two can also occur together in the same person. It may arise from the temporary hormonal changes of adolescence, or in adult life it may be related to medication, hormone use or certain illnesses.²¹

Assessment therefore does not focus on the appearance of the chest alone. When the enlargement began, how it has changed over time, medication and performance-enhancing substances used, accompanying symptoms and examination findings are all considered together.² This article covers what gynecomastia is, what the examination looks at, when observation or medical treatment comes first, how the operation is planned, how recovery goes and which risks are involved.

What is gynecomastia?

In true gynecomastia the glandular tissue behind or around the nipple has increased. This tissue may be present on one side, on both, or in differing amounts between the two sides.

Gynecomastia is common. Reported frequencies range from 32 to 65 per cent depending on age and the definitions used.¹

Gynecomastia is a benign condition and is not regarded as a premalignant finding.¹

What is the difference between true gynecomastia and lipomastia?

Lipomastia, also called pseudogynecomastia, is an increase in the fatty tissue of the chest rather than growth of glandular tissue. At examination the distribution of the tissue, its consistency and its relation to the nipple are used to tell the two apart.²¹

Weight gain can increase the amount of fat in the chest. Losing weight, however, may not remove the firm tissue behind the nipple in someone with marked glandular tissue. Where the two occur together, the surgical plan addresses each component separately.

Why are adolescence and adult life not the same?

Gynecomastia in adolescence can arise from a temporary shift in hormonal balance. The guideline of the European Academy of Andrology (EAA) states that it affects roughly half of boys in mid-puberty and that in more than 90 per cent of cases it resolves on its own within 24 months.¹ These figures are general estimates pooled from studies using differing definitions, and they do not predict the course in any one adolescent.

Enlargement persisting beyond 2 years in an adolescent strengthens the case for assessing it as persistent. The decision to operate is not made on elapsed time alone, however. Completion of puberty, whether the enlargement has settled, pain, how marked the appearance is and how much difficulty it causes are all weighed together.²

In an adolescent, breast enlargement that is new, growing rapidly or causing marked symptoms may call for paediatric or endocrine assessment. In the practice described here, surgery is not planned before the age of 18.

Where gynecomastia appears newly in adult life, the natural course seen in adolescence is not assumed. In a retrospective study of 786 adult men referred to one centre, an underlying and usually treatable cause was found in 43 per cent of those whose enlargement began after the age of 18; among those with earlier onset the figure was 7.7 per cent.³ These were men referred to a specialist centre and do not represent all men in the population. The finding nonetheless shows that enlargement beginning in adult life should not be treated as a question of appearance alone, without history and examination.

Who does it suit?

Surgery for gynecomastia may be considered in adults whose breast enlargement has become persistent, whose appearance has settled over time, and which has not regressed on its own or with treatment directed at the cause.²¹ Pain and tenderness, difficulty choosing clothes, discomfort during physical activity and the distress the appearance causes are all taken into account.⁴⁵

Suitability is not determined by chest volume alone. General health, expectations, smoking and nicotine use, changes in weight, the cause of the enlargement, skin quality and the scars a person is prepared to accept are assessed together.

When do observation or treatment of the cause come first?

Where gynecomastia has begun recently in adolescence and there is no atypical finding, observation may be appropriate. Because most cases in this period regress on their own, surgery is not the first option while the enlargement has yet to settle.²¹

Where a medication, hormone or performance-enhancing substance that may be related to gynecomastia is identified, its clinical significance is assessed first. Prescribed medication should not be stopped on a person's own decision; where a change is needed it is planned with the doctor who prescribed it.

The strength of the association between medication and gynecomastia varies from drug to drug. In a meta-analysis pooling randomised trials, the odds of gynecomastia were markedly higher in men taking antiandrogens, and increased odds were also reported for spironolactone and 5-alpha reductase inhibitors.⁶ For many other drugs linked with gynecomastia, however, the evidence consists of individual case reports and does not establish causation.⁷ For this reason no long list of drugs is given here; every medicine, supplement, hormone and anabolic steroid used is expected to be declared.

Where a hormonal disorder, thyroid disease, liver or kidney disease, or a testicular cause is identified, treatment is directed at that condition first.²¹ Correcting the underlying cause does not mean the gynecomastia will regress completely. In tissue that has been present a long time and has become firm, the chance of regression is more limited.²

When can medical treatment be considered?

Medical treatment is not standard for every person with gynecomastia.

In someone with proven testosterone deficiency, hormone treatment is assessed by the relevant specialist as treatment of that deficiency, independently of the gynecomastia. In a person whose testosterone level is normal, testosterone is not used as a treatment for gynecomastia.¹²

The drug named most often is tamoxifen. It was the one most frequently used in the studies covered by the review of children and adolescents.⁸

Tamoxifen is licensed for breast cancer. In the product information published in the national drug information system of the United States, the approved indications are limited to the treatment of breast cancer and the reduction of breast cancer risk; gynecomastia is not among them.⁹ Use for gynecomastia there therefore falls outside the approved indications. The licensing position in Türkiye cannot be inferred from that source; the current product information valid in Türkiye needs to be consulted.

The strength of the evidence varies with the cause of the gynecomastia. The strongest data come from gynecomastia caused by the antiandrogen drugs used to treat prostate cancer. In a systematic review of 4 randomised trials, tamoxifen markedly reduced the risk of gynecomastia at 6 months compared with no treatment.¹⁰ Here the drug is given in advance against a known cause; this is a particular group of patients.

The picture differs in gynecomastia of adolescence with no explained cause. A systematic review of tamoxifen in this group could find only 6 studies, none of them randomised, and all carried methodological flaws.¹¹

The guidelines do not speak with one voice either. The guideline of the Italian Society of Andrology and Sexual Medicine (SIAMS), prepared by expert consensus, states that medical treatment may be considered in selected cases that are painful or have no explained cause.² The guideline of the European Academy of Andrology does not recommend general use of this group of drugs; it makes that a strong recommendation, while grading the evidence it rests on as low quality.¹

Where medical treatment is judged necessary, it is assessed together with endocrinology or the relevant specialty.

A systematic review covering children and adolescents reported regression with some drugs, but found the methods, measurements and comparison groups of the studies inadequate.⁸ Those results cannot be applied directly to adults or to long-standing, firm gynecomastia. The need for and safety of medical treatment are assessed by endocrinology or the relevant specialty, separately from the plastic surgery consultation.

When can surgery be considered?

Surgery may be considered in gynecomastia that has been present a long time, has settled, has not regressed on its own, or persists after treatment directed at the cause.²¹ Pain, tenderness, a marked difference in appearance and discomfort affecting daily or social life are all part of the decision.

Studies of the psychological and social effects report improvement in body image, social comfort and quality of life after surgery.⁴⁵ The number of studies in this area is small, however, the samples are small and the measurement tools differ from one another; the review's own assessment rated the level of evidence as very low.⁴ Improvement has therefore been reported in some studies; with evidence this limited, the outcome for an individual cannot be predicted.

Surgery is postponed where body weight is changing rapidly, where the cause of the gynecomastia has yet to be investigated, where there is active illness, or where expectations cannot be met surgically. Surgery is not a way of skipping the underlying assessment.

What does the examination look at?

The examination assesses whether the enlargement is one-sided or two-sided, the difference between the two sides, the glandular tissue behind the nipple, the distribution of fatty tissue, excess skin, the position of the nipple and areola, and the shape of the chest wall.² Pain, tenderness, a lump, discharge and skin changes are also looked for.

The history covers the age at onset, how quickly the enlargement grew, recent change, changes in weight, medication and supplements used, use of anabolic steroids or hormones, sexual function and hormonal symptoms.²¹ Examination of the genitalia and assessment of the testes are also part of the clinical examination.¹

Which findings call for further assessment?

Breast tissue that is new or growing rapidly in adult life, a lump that is firm or fixed to surrounding tissue, discharge from the nipple, retraction of the nipple or skin, ulceration of the skin, a lymph node in the armpit and a mass in the testis all call for further assessment.²¹²

One-sided or markedly asymmetric enlargement does not by itself indicate cancer. Where a finding falls outside the typical appearance of gynecomastia, however, the diagnosis needs establishing before a surgical plan is made.¹²

Unexplained weight loss, marked fatigue, change in sexual desire, erectile difficulty, change in testicular volume, symptoms suggesting thyroid disease, or findings pointing to liver or kidney disease also widen the scope of assessment.²¹

When are laboratory tests and testicular assessment carried out?

There is no strong evidence requiring the same broad laboratory panel in every person. Tests are selected according to age, the pattern of onset, medication use, examination findings and accompanying symptoms.²¹

In gynecomastia that has no explained cause or is atypical, testosterone, oestradiol, LH, FSH, SHBG, TSH, prolactin, beta-hCG and liver and kidney function tests may be considered.¹ Which tests are requested varies with the clinical findings, and part of this approach rests on expert opinion.²

Examination of the testes is an integral part of the assessment. The guideline of the European Academy of Andrology recommends adding testicular ultrasound to the examination, because the sensitivity of palpation for detecting a testicular tumour is low.¹

When is breast imaging needed?

In the criteria of the American College of Radiology, every imaging modality is rated "usually not appropriate" in a man whose examination findings are consistent with gynecomastia or lipomastia.¹² In a typical presentation, therefore, routine breast imaging is not performed.

Imaging is used where the examination finds a lump whose nature cannot be determined, or where findings raise the suspicion of cancer. In the same criteria, for a palpable lump of indeterminate nature, ultrasound is rated "usually appropriate" in men under 25, and mammography and digital breast tomosynthesis are rated "usually appropriate" at 25 and over. Where an examination finding raises the suspicion of cancer, all three are considered appropriate.¹²

Where the examination raises the suspicion of cancer, or the imaging result does not establish the diagnosis, confirmation by tissue sampling is needed.¹³¹

Does gynecomastia mean male breast cancer?

No. Gynecomastia is a benign condition and is not regarded as a premalignant finding.¹ That does not mean an independent breast condition can never be found in someone who has gynecomastia.

Soft or rubbery tissue sitting behind the nipple is consistent with gynecomastia. A lump that is firm, fixed to surrounding tissue or sits markedly outside the nipple, together with discharge, skin retraction and a lymph node in the armpit, is assessed separately.²¹² The aim is not to raise the suspicion of cancer in everyone with gynecomastia, but to tell typical findings from atypical ones.

How is the operation planned?

There is no single method applied to everyone in gynecomastia surgery. The operation is planned according to the ratio of fatty to glandular tissue, the firmness of the tissue, excess skin, the position of the nipple and the difference between the two sides.²¹⁴

Most published surgical studies are retrospective. In a systematic review of treatment options, none of the 17 studies meeting the criteria was randomised, and the level of evidence was rated as very low.¹⁴ The aim is therefore not to choose the name of a technique but to determine the appropriate method for each of the anatomical problems that person has.

Is liposuction enough on its own?

Where fatty tissue predominates and the skin is judged able to retract sufficiently, liposuction can be used to reduce chest volume and refine the surrounding contour.¹⁴¹⁵ Liposuction is performed through small incisions; it cannot, however, reduce dense and firm glandular tissue sufficiently in every person.¹⁴

When liposuction is planned, not only the centre of the breast area but also the surrounding zones where it meets the chest wall are assessed. The aim is to refine the chest contour as a whole without creating an abrupt step on one side.

Does the glandular tissue need removing?

Where dense or firm glandular tissue behind the nipple is marked, it may need removing directly.²¹⁴ Removal can often be performed through an incision placed at the border of the areola; the site and length of the incision vary with the amount of tissue to be removed.

Removing too little tissue leaves the fullness behind the nipple in place, while removing too much can cause a hollow beneath the nipple.¹⁶¹⁷ Removal of the tissue and preservation of the transition to surrounding tissue are therefore planned together.

Where fatty and glandular tissue are both marked, liposuction and tissue removal can be used in the same operation. In a systematic review examining the frequency of complications with different approaches, the count of reported complications relative to the number of patients in the group where both were combined was reported as lower than in the group having surgical removal alone.¹⁶ That result does not come from a direct clinical comparison in which patients were randomly allocated to the techniques. The groups were pooled from separate studies and were not adjusted for patient characteristics; patient selection, the degree of enlargement, the techniques used and follow-up periods also differ. It therefore cannot be concluded that one method is safer in every patient.¹⁶¹⁴

The glandular tissue removed is sent for pathological examination, meaning assessment of the removed tissue under the microscope.

How are excess skin and the position of the nipple managed?

In mild and moderate enlargement the skin may adapt to the new contour over time once volume has been reduced. How much the skin retracts depends on age, skin elasticity, the degree of enlargement and changes in weight.

Where excess skin is marked, liposuction or tissue removal alone may not be enough. Removal of skin may then be needed, and in advanced cases repositioning of the nipple and areola.²¹⁴ Removing more skin is a decision to be weighed against longer and more visible scars.

Surgical classifications can be used to organise these variables. In a systematic review of 11 classification systems, however, none was found to cover all the features needed to guide surgical decisions.¹⁸ What matters is not the name of the classification but which incisions and corrections the excess skin, nipple position and tissue composition call for.

Where do the incisions and scars lie?

Where liposuction alone is performed, the incisions are the short access points through which the cannulas pass. Where glandular tissue is removed, the incision can often be placed at the border between the coloured skin of the areola and the surrounding skin. Where skin needs removing, scars form around the areola, beneath the chest, or along a longer line joining the two.

The sites of the incisions are planned at the examination before surgery. More extensive removal of tissue and skin leaves more scarring. There is no gynecomastia operation without scars.

How do you prepare for the operation?

Smoking and nicotine: Smoking is a risk factor for wound healing problems after surgery. Direct surgical data on nicotine products other than cigarettes are scarcer. The practice reference of the American Society of Plastic Surgeons notes a lack of clinical data on e-cigarette use and surgical risk, but states that because nicotine is known to reduce blood flow, e-cigarettes and other nicotine products are regarded as a potential risk factor.¹⁹ Stopping smoking, vaping and other nicotine-containing products at least 1 month before the operation, and not using them after surgery until healing is complete, is therefore advised. The studies below concern smoking cessation; their results do not establish the same reduction in risk for every nicotine product. A review pooling 6 randomised and 15 observational studies showed that every week of abstinence added benefit, and that studies with at least 4 weeks of abstinence produced markedly better results than shorter ones.²⁰ A study appraising systematic reviews together reported that cessation interventions beginning at least 4 weeks before surgery and combining multiple behavioural support sessions with pharmacotherapy reduced complications. The same study notes that interventions with only one component, even when started more than 4 weeks before surgery, raise quit rates without reducing complications.²¹ Shorter intervals are not useless either: in a meta-analysis of 55 studies covering adults undergoing a range of operations, the risk of pulmonary complications was 27 per cent lower in relative terms among those who stopped at least 2 weeks before surgery, and 29 per cent lower among those who stopped at least 4 weeks before, compared with those who continued smoking.²² The benefit therefore grows as the interval lengthens; being late does not make stopping pointless. The interval applied and the nicotine policy can vary from surgeon to surgeon.

Weight: Weight is expected to have settled before the operation. In someone who is still losing weight, the amount of fat in the chest and the excess skin can change, so the timing of the operation may be reassessed.

Coexisting illness: Diabetes and blood pressure are expected to be under control before surgery. Where there is an active infection in the body, surgery is postponed.

Medication: Blood thinners and some herbal products can increase bleeding. Every medicine and supplement you take needs to be declared. Prescribed medication should not be stopped on your own decision.

Hormones and performance-enhancing substances: Testosterone, anabolic steroids and hormone or performance products sold without prescription matter both as a cause of gynecomastia and for the chance of regrowth.² The contents of every product used, and when it was last taken, should be disclosed before surgery.

Tests: A standard anaesthetic assessment is carried out before the operation. Where the cause of the gynecomastia has not previously been investigated, hormone tests, testicular assessment or breast imaging may be requested according to the history and examination.²¹²

What is recovery like?

The intervals below are a general framework. They can vary with the extent of the operation performed, the person's job, how quickly they heal and the surgeon's practice.

• The operation is performed under general anaesthetic and usually takes 1 to 2 hours
• The hospital stay is most often 1 night
• The first check is 1 week after surgery
• Stitches that need removing are taken out within 2 weeks; dissolving stitches do not need removing
• Returning to work takes 2 to 3 weeks for most people
• Wait at least 1 week before driving
• A compression garment is worn for 2 months
• Heavy lifting and strenuous sport are deferred for 6 weeks
• Full return to daily life can take 6 to 8 weeks

In the first days there is swelling, bruising, tightness, tenderness in the chest and a temporary difference in appearance between the two sides. Because of the swelling in this period, the final contour of the operation cannot be judged.

A drain is not usually used. Where glandular tissue has been removed and bleeding during the operation makes it necessary, a drain may be placed; it is then usually removed within 1 to 2 days.

What should you pay attention to after surgery?

The following is a general framework. Where the instructions you were given differ, your surgeon's instructions apply.

Compression garment: A compression garment suited to the chest is worn for 2 months after surgery. The team that performed the operation determines its size and how it is worn each day. If the garment causes excessive tightness, increasing pain, colour change in the skin or numbness, the team needs to be told.

Sleeping: Lying on the back, or with the upper body slightly raised, is more comfortable for most people in the first weeks. When you can move to sleeping on your side or front depends on how healing is going and on your surgeon's advice.

Showering, wound and dressings: When you may shower depends on the dressing used. If there is a skin incision, once allowed you can shower without rubbing the wound and pat the area dry gently. Baths, swimming pools and the sea wait until the wound has closed completely.

Arm movement: The arms can be used for everyday tasks within the limits of pain. In the first weeks, sudden and forceful arm movements, heavy lifting and activities that stretch the chest are avoided. Staying still for long periods is not right either. Short walks are encouraged early on and lower the risk of clots.

Pain: Pain and a feeling of pressure in the chest are expected in the first days and are controlled with the painkillers provided. The pain is expected to ease a little each day. Pain that keeps increasing despite painkillers, or comes with rapidly developing one-sided swelling, needs early assessment.¹⁷

Returning to work and sport: Desk work is mostly resumed within 2 to 3 weeks. Work requiring physical effort may need longer. Light activity such as walking can begin earlier; heavy lifting and strenuous sport are deferred for 6 weeks. Returning to exercise starts with walking and low-impact movement, leaving chest work until last.

Driving: At least 1 week is allowed. You can drive once you can wear the seatbelt comfortably, perform steering movements and an emergency stop without pain, and are no longer taking painkillers that cause drowsiness.

Sexual activity: Sexual activity can resume once you feel comfortable and everyday movements no longer cause marked pain. In the first weeks, pressure on the chest and forceful movement should be avoided.

Smoking and weight: Smoking impairs wound healing after surgery as well; cigarettes and nicotine products should be avoided until healing is complete. A marked change in weight after surgery can alter the contour of the chest.

What is normal: Swelling, bruising, a feeling of firmness and tightness in the chest, numbness at the nipple and in the chest skin, occasional stabbing pains and a temporary difference in swelling between the two sides are all expected. Although full return to daily life can take 6 to 8 weeks, the chest contour takes longer to approach its final form.

How do the scars change?

Gynecomastia surgery is an operation that leaves scars. Where the scars lie varies with the extent of the liposuction, tissue removal and skin removal performed; there is no correction without scars.

The scar looks red and raised in the first months, then fades and softens. This can take up to 1 year. Its final appearance depends on how the person heals, on skin colour and on the area; how well it will settle cannot be predicted with certainty beforehand. The incision site and the extent of the operation are also considered when assessing the scar.

Some measures can be used to reduce the chance of a scar becoming raised, widened or prominent. Once the wound has closed completely and on your surgeon's advice, silicone-based gel or silicone sheeting and scar massage may be suggested. These measures do not guarantee the outcome. Starting too early can harm the wound, so your surgeon sets the timing.

Direct sun darkens a scar, so it needs protecting during the first year.

Risks and complications

Complication rates reported in gynecomastia surgery vary markedly between studies. Because surgical techniques, the degree of enlargement, the definitions of complications and follow-up periods are not the same, published averages do not represent one person's individual risk.

The scale of that variation is as follows. In a systematic review pooling 7,294 patients from 94 studies, the count of reported complications relative to the number of patients was 14.9 per cent in the group having aspiration alone, 30.6 per cent in the group having surgical removal alone, and 11.8 per cent where the two were combined. These figures are not the percentage of patients who had at least 1 complication; more than one complication may have been reported in the same patient.¹⁶ In another review pooling 5,345 patients from 53 studies, the rates ranged from 12.1 to 22.3 per cent, with the lowest rate reported for the least invasive methods.¹⁵ In a review of 1,112 patients from 17 studies, the rate of major complications ranged from 0 to 33 per cent. Among the 906 patients for whom haematoma and seroma could be counted separately, the most frequently reported complication was haematoma at 5.8 per cent, followed by seroma at 2.4 per cent.¹⁷

Patient selection, the techniques used, the definitions of complications and follow-up periods all differ between these three reviews. One notes a relatively high risk of bias arising from missing data,¹⁵ and another notes the absence of a common classification and the variety of techniques as a limitation.¹⁶ The rates therefore cannot be used to compare techniques directly. The headings below are grouped by the area they concern rather than by frequency.

Bleeding and fluid collection

Blood collection (haematoma): It shows itself in the first hours or first days after surgery as rapidly increasing swelling, firmness and pain on one side of the chest. It is the most frequently reported early complication in the reviews.¹⁷¹⁵ A return to theatre may be needed to drain what has collected and control the source of bleeding.¹⁶

Fluid collection (seroma): Fluid collecting in the operated area. Small collections may settle on their own; large collections need draining.¹⁶¹⁷

Using a drain does not guarantee that haematoma or seroma will be prevented. In a review comparing the results of authors who did and did not use drains, the rate was higher among those who used them, but that difference was noted as possibly arising from the far higher proportion of advanced-grade cases in the series where drains were used.¹⁷ These data are therefore not suited to determining the effect of drains.

Wound, skin and nipple circulation

Infection: Presents with redness, warmth, increasing pain and discharge. Treatment may require dressings, antibiotics or a further surgical procedure.¹⁶¹⁵

Delayed wound healing and wound separation: This is among the complications reported in surgical series.¹⁶ Where skin is removed and the wound closes under tension, healing is monitored particularly closely.

Circulation problems of the nipple and areola: The blood supply to the skin or to the nipple and areola can be impaired. In advanced cases partial or complete tissue loss can develop. This risk forms part of the surgical plan particularly in operations requiring extensive removal of tissue and skin.¹⁶¹⁴ Smoking is one of the modifiable risk factors that impair wound healing; nicotine products other than cigarettes are also regarded as a potential risk factor.¹⁹

Contour, symmetry and residual tissue

Residual tissue: Where part of the glandular or fatty tissue remains, the fullness behind the nipple can persist. Because swelling in the early period can also give the impression of residual tissue, the result is not judged before healing is complete.

A hollow beneath the nipple: Removing too much of the tissue beneath the nipple can leave a hollow under the areola and an abrupt contour transition to the surrounding tissue.¹⁶¹⁷

Asymmetry and contour irregularity: A pre-existing difference between the two sides in volume, nipple position or chest wall shape may not disappear completely. Rippling, stepping and surface irregularity can be seen after liposuction or tissue removal.¹⁶¹⁵

Persisting excess skin: If the skin retracts less than expected, looseness can remain in the chest. Removal of skin at a second stage may be considered; that decision is weighed against additional scars.

Sensation, scars and the need for further surgery

Change in sensation: Numbness, increased sensitivity or reduced sensation can develop in the nipple and areola or in the chest skin. This change may be temporary, and it may also be permanent.¹⁶¹⁵²³

A conspicuous scar: A scar can become raised, wide, darker in colour or more conspicuous than expected. Individual wound healing, skin characteristics, the site of the incision and the extent of the operation all affect its final appearance.

Further surgery: A corrective operation may be needed for bleeding, infection, a wound problem, marked asymmetry, residual tissue, a hollow beneath the nipple or persisting excess skin.¹⁶¹⁷ Because the methods of the studies differ, no reliable individual revision rate can be given.¹⁶

Blood clots: A clot forming in the leg veins and travelling to the lungs is serious. One-sided leg pain and swelling, sudden shortness of breath or chest pain need urgent assessment. Deep vein thrombosis and cardiac and pulmonary complications appear in the list of risks published by the American Society of Plastic Surgeons for gynecomastia surgery.²³

Anaesthesia and other risks: Problems related to general anaesthesia, allergic reactions and pain persisting after surgery can occur. Anaesthesia risks and persistent pain are listed among the same set of risks.²³

Does gynecomastia come back?

Fullness that persists or is noticed again after surgery is not always a true recurrence. Swelling in the early period, glandular or fatty tissue left at the first operation, persisting excess skin and contour irregularity are distinguished from one another.

Marked weight gain can increase the fatty tissue in the chest and alter the contour achieved by surgery. That does not mean the glandular tissue has grown again.

Long-term data are very limited. In a follow-up study 10 to 19 years after surgery, 41 patients were invited and only 16 could be assessed. In that study recurrence was more frequent where the enlargement had been predominantly fatty than where it had been predominantly glandular.²⁴ The groups are not large enough to calculate an individual chance of recurrence.

Resuming anabolic steroids or hormones, and continuation of an underlying hormonal cause, can contribute to regrowth.² Long-term data sufficient to estimate the size of that risk reliably after surgery are limited.²⁴ No assurance can therefore be given that the result will not change again.

What can be expected from the result?

The aim of the operation is to reduce the excess of glandular and fatty tissue, create a more balanced transition to the chest wall, and manage excess skin appropriately. Making the right and left sides exactly the same, or making the chest match a particular image, is not the aim.

The swelling, bruising, firmness and temporary asymmetry of the first weeks do not reflect the final result. Although full return to daily life can take 6 to 8 weeks, the tissues softening, the scars maturing and the contour approaching its final form take longer.

Systematic reviews report improvement in body image, social comfort and psychological well-being after surgery.⁴⁵ The number of studies is small, however, the samples are selected and the measurement methods differ from one another. Published satisfaction rates therefore cannot be used as an individual success rate.⁴

Keeping weight as stable as possible, avoiding anabolic steroids and unsupervised hormone use, and continuing follow-up where a hormonal cause has been identified all matter for maintaining the result over time. Ageing, changes in weight and the loosening of skin over time also alter the appearance of an operated chest.

When should you contact your doctor?

You need to contact the team that performed the operation in the following situations:

• Fever
• Increasing redness, warmth, discharge or a bad smell at the wound
• Rapidly increasing swelling, firmness or pain on one side of the chest
• The wound opening noticeably
• Paleness, a bluish change or darkening in the colour of the nipple or the skin around it. These suggest a circulation problem and are distinct from the ordinary bruising expected in the first days
• Pain that keeps increasing despite painkillers

The following findings appearing months after surgery also call for assessment:

• A marked lump that reappears or is growing
• Discharge from the nipple
• Retraction of the skin or any other change in it

The following two findings call for urgent assessment:

• One-sided pain or swelling in the leg
• Sudden breathlessness or chest pain

About the figures in this article

The operation taking 1 to 2 hours, a hospital stay of 1 night, stitches out at 2 weeks, returning to work at 2 to 3 weeks, waiting 1 week before driving, wearing a compression garment for 2 months and returning to sport at 6 weeks describe the general timetable of this practice. These intervals vary with the extent of the procedure performed and with how quickly a person heals.

In the published studies on gynecomastia, patient selection, surgical technique, the degree of enlargement, the definitions of complications and follow-up periods are not the same.¹⁴¹⁶¹⁵ The averages reported in different studies therefore do not predict one person's chance of a complication, of recurrence or of satisfaction.

The evidence on regression of gynecomastia in adolescence, on the effect of medical treatment and on long-term surgical results also differs from study to study.²⁸²⁴ Rather than giving definite success rates, this article sets out the limits of the evidence and which decisions call for individual assessment.

References

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