Your Questions
Your Questions
Q: Dr. Eppley, I am interested in pectoral implants. I had gynecomastia reduction done twice in the last 10 years. I still have divets because I think too much tissue was removed on the outside areas of my pecs. I am also considering pectoral implants to even this out and provide a more contoured even look. I work out often and I still am not able to get my pecs looking good. I have read about your expertise with male cosmetic enhancements.
A: It sounds and looks like the combination of pectoral implants combined with some fat grafting to the nipple-areolar divots would create a more contoured chest result. It is hard to argue with the immediate and dramatic improvement in chest shape that pectoral implants can create. But they alone would not fix any indentations from over resection from gynecomastia surgery. That will need to be addressed directly with fat grafts put right into the soft tissue defects.
Gynecomastia reduction, particularly if done by liposuction, can often leave the chest looking deflated particularly in older men. Pectoral implants can make for an instant change in chest size through muscle enhancement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to get a better idea if insurance will cover my gynecomastia reduction procedure. I have had gynecomastia since I was a teen, but it has bothered me enough lately to visit a Doctor. Up until the past few years it has only caused me a little discomfort. I have never been able to sleep on my stomach because of it. Lately I have had occasional pain in my right breast and a sharp pain when bumped into or after exercising, but mainly in my right breast. My Doctor confirmed that I had gynecomastia after a mammogram and x-rays. The radiologist diagnosed it and ruled out cancer. I have fibrous mass centered under my right nipple and smaller nodular lumps on my left side. Really only the right side causes me the most pain. I think insurance should cover it, since I have had the gynecomastia since I was a teen and it is causing me discomfort. I would like to know what if there is any chance that insurance will cover it?
A: Insurance coverage for gynecomastia surgery is a frequently asked question of men considering the surgery. No plastic surgeon can answer that question definitely since your health insurer has their own criteria for coverage and ultimately they have to make that determination based on their criteria…not whether you nor I think it should be covered. This is a process known as predetermination in which the treating doctor submits a letter requesting the surgery, lists the diagnosis and procedure codes and provides pictures of the patient’s chest. From this information, they will make a decision and notify you in writing since you are the subscriber of the policy.
Having said that it is important to know what the criteria are that insurance companies use to make that decision about gynecomastia reduction surgery to see if you have any chance of success. First, the size of the gynecomastia problem must be a grade III or IV in adults based on a well known assessment scale. (yours by the way is a Grade II) Second, you must have had a endocrinological blood panel done to determine if there is any hormonal abnormalities that have not perviously identified and treated. Third, the breast enlargement must pose serious health concerns, such as being a tumor, that has a significant impact on the patient’s health or will so in the foreseeable future.
As you can see, unless there is compelling medical evidence, most insurance companies view most gynecomastia reduction surgeries as a cosmetic procedures and not something that is done to treat a medically necessary condition.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in gynecomastia reduction surgery. I’m a 36 year old who has had man boobs my whole life. I’ve tried dieting and exercising to try and get rid of them with no success. They’ve caused great embarrassment for me over the years. I won’t swim in public and am very unconfident when it comes to dating and any sort of relations with the opposite sex.
A: Your feelings of embarrassment and some degree of social restriction is not rare and exactly replicate what many men with similar problems state about their gynecomastia problem. Once gynecomastia has formed, there is no diet or exercise regimen that is going to get rid of it. While in extreme weight loss cases, breast tissue can be lost in a male, many men with gynecomastia do not need extreme amounts of weight loss. Gynecomastia reduction surgery can be very effective and is usually most effective when open excision is combined with liposuction. This is an outpatient procedure done under general anesthesia that takes about two hours to perform.
The success of gynecomastia reduction surgery is based on how completely the removal of breast tissue is done. There is always the risk of removing too much breast tissue causing a crater deformity or not taking enough leaving a residual areolar protrusion after all the swelling has gone down. This is the delicate balance plastic surgeons walk when performing this type of male chest surgery. For these reasons, there is about a 15% to 20% risk of desiring a revisional or touch-up surgery to optimize the chest contour.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had gynecomastia reduction surgery for what a plastic surgeon told me was a minimal grade 1. He said he would first try with liposuction and excision would be considered during surgery. After surgery, he told me he took 200cc fat from each side (totally 400cc) and there was no need for excision. He then advised to wear garment for six months. I wore the garment for two weeks full time 24×7, now wearing it during day time. Now its exactly 3 months after surgery and I feel not satisfied with the result. Please advise will I need revision or is it ok? I am still wearing garment. How long should I continue ? Shall I do some light weight exercise to maintain weight or will the exercise cause chest to bulge out?
A: If you are not happy with your gynecomastia reduction at three months after surgery, it is unlikely that further time is going to change that perception. At this point, there is no benefit to continuing to wear your garment. You should resume all physical activities including exercise as this will not adversely affect the result at this point. I would wait until you are six months after your surgery and then purse a gynecomastia reduction revision which will likely involve an open excision as part of it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking steroid injections after gynecomastia reduction surgery. I had gynecomastia surgery almost two years ago. The surgery was fine, but of course I dealt with scar tissue problems afterwards. I got Kenalog shots and it really reduced it alot! I have a bout a pea size piece sticking literally right behind the nipple itself. When my nipple is hard or semi hard the scar tissue is jagged and literally sticks out just like my nipple (protruding my nipple out too much for me to live with for the rest of my life and extremely bothers me) But this is so small for surgery so I don’t want to risk it. I was wondering if you would hit me with a 5FU or 5FU/Kenalog controlled shot to flatten this jagged connective tissue that makes my middle nipple area still stick out.
A: It is very common after gynecomastia reduction surgery to have scar tissue form behind/beneath the nipple. When the initial gynecomastia problem is relatively small, any nipple scar tissue formation can leave one with a still persistently nipple protrusion problem. In the first year after surgery (really the first six months) steroid injections can be very helpful in breaking down any scar tissue formations. After one year the success of steroid injections to reduce prominent scar tissue diminishes considerably as the bonding of the collagen in the scar tissue becomes very mature. There is no harm in doing further steroid injections but be aware that the success of them at this far out from surgery may not be like what had occurred earlier after surgery. Should this fail you should consider a small revision through an open incision under local anesthesia as an office procedure. This can remove the problematic small area of scar with little risk of recurrence. I have done this numerous times in secondary areolar gynecomastia reduction surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had gynecomastia reduction surgery 2 months ago and I am not happy with the results. It was initially very flat right after surgery but I have subsequently developed hard lumps under the nipples that now make them stick out a bit. This makes me mad since I paid good money to have a flat chest. What can I do about it now?
A: What you are describing is very common after gynecomastia reduction surgery in young men. Many open gynecomastia patients will develop a scar lump under the nipple after their procedure even though it looked initially quite fat. Whether this scar lump will go away or not takes time to see and two months after surgery is too early to tell. About 10% of open gynecomastia reduction in young men will develop these persistent scar lumps that may require a revision to remove and make completely flat if it persists. This is not reflective of a poor surgical technique or even a poor surgical result but is the unknown and uncontrolled variable of how one forms scar tissue in the space where a small or large lump of tissue had been removed. What I would recommend now is to have either Kenalog (steroid), 5-FU or combination kenalog/5-FU injections to try and soften the scar and make it go flat. Now is the time to do this, not 6 months after surgery where it would be much less effective when the scar tissue is mature. Whether this will be completely effective can not be predicted but at least this provides a chance for success. If not, you are going to require a revisional gynecomastia reduction procedure to remove the scar that has developed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had gynecomastia reduction surgery performed back in March of this year. The results immediately afterwards were amazing, everything was completely flat. A month or so after I started developing scar tissue which hasn’t gone away and has made my nipple area protrude once again. My plastic surgeon said I probably needed a steroid injection to help with the scar tissue. Since it is much further to travel back to him I went to a local plastic surgeon, but he thought it was just some leftover breast tissue and didn’t want to do the Kenalog injection. No offense to him, but I don’t feel like he had much experience with gynecomastia and I definitely feel like it is scar tissue since the results after surgery were a completely flat chest with no feeling of any tissue whatsoever. That led me to come across your website where some people had asked about Kenalog injections for scar tissue after gynecomastia surgery. Based off what I have told you, does it sound like scar tissue to you or is it possible that the gynecomastia has actually grown back? I would be interested in seeing you for Kenalog injections if you believe they would be beneficial. I have attached a picture of the before and immediately after surgery. I would really appreciate any information you could give me so I can get this behind me for good.
A: I have done a lot of open areolar gynecomastia reduction surgeries in young men just like yours. What you are experiencing is not uncommon. It looks really flat in the beginning but a slow nipple protrusion develops. The tissue under the nipple-arolar complex feel firm, sometimes harder than before the initial surgery. You are correct is that it is scar tissue and not breast tissue. But often considerable scar tissue develops and the mass effect is almost like it was before surgery in some cases. I have done my fair share of steroid injections into this scar tissue and that seems to be the logical approach to do. But I have yet to see a case in which the steroid injections were successful, particularly at over six months after the initial procedure. My experience is that the only thing that solves the problem is to surgically remove the scar tissue, very much like the original surgery. While there is no harm in doing steroid injections, and the protocol would be a series of three injections spaced three weeks apart, I have little optimism that it will lead to a complete resolution of the problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking gynecomastia reduction by liposuction only. I am 24 years old with a body mass index of 26. I have developed glandular gynecomastia with enlarged areolas. All my endocrine labs are normal. Can I have Smarttlipo done using the axilla as access for the probe? Will this work for male breast reduction? I have attached pictures for your review.
A: This is one of the more challenging types of gynecomastia to treat because of the enlarged areolas and the skin excess on the chest. Trying to do gynecomastia reduction with liposuction only, regardless if the incisional access is not likely to result in the best outcome. With glandular tissue present under the areolas, any form of liposuction is not going to be able to completely remove it. I would do a combined open gynecomastia excision with liposuction and see what happens with the areolas and skin excess. (how much shrinkage occurs) One has to be prepared for the potential of the need for a secondary procedure that may involved a periareolar reduction with scars around the areola. One could argue that should be combined with the intial procedure but that would depend on he patient accepting those scars from the beginning.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking gynecomastia reduction. I have hard lumps bilaterally under each areola. I am a 32 year old male and would like to have them surgically removed. I have a toned muscular body and It is somewhat annoying. I’ve had this condition since puberty and it hasn’t resolved. They are visible through shirts and when I’m shirtless or in the water it is somewhat noticeable. What is involved in getting this condition resolved?
A: It certainly sounds like you have areolar gynecomastia which appear as isolated hard lumps under the nipple. There may also be extra breast tissue that is softer that extends outward from these hard lump areas. This type of gynecomastia reduction is done through inferior areolar incisions including the liposuction portion if needed. Most such areolar incisions heal imperceptibly. This is done as an outpatient procedure under general anesthesia. Drains are not usually used for such limited male breast tissue excision procedures. Recovery will take a few weeks until you can return to full activities including strenuous exercise.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, In reading about gynecomastia surgery, there seems to be an issue about the doctor removing too much tissue thus developing a “crater” look to the chest with fat pockets under the breast. How does the doctor address this?
A: The best way to avoid that problem to be aware of it and not create it. When deciding how much breast tissue to remove in an open gynecomastia operation, it is a matter of pure judgment. There is no scientific way to really know how it will look until it heals based on how much tissue is removed. Because an open procedure has the potential to remove more of the breast tissue in a central position (under the nipple) than around the perimeter, it is important to not over resect (remove too much) from this area.Since solving the gynecomastia crater deformity is more challenging than having to take more should a revision be needed, it is always better to use caution rather than indiscriminate aggression in gynecomastia reduction.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am a 34 y.o. male who has suffered with gynacomastia since puberty. I have not taken my shirt off in public since I was a boy – not for the pool, the beach, or even to get a suntan. I am ashamed to take my shirt off at home except to get into the shower. I’ve worn multiple layers of clothes to hide it, even when the weather is stifling hot. I’ve tried wearing super tight under shirts, Spanks and wrap-around girdle (which helps only slightly); and I’ve even tried wrapping tape around my chest but that only created bulges on my back. I have always been interested in surgery, but I have a couple of concerns that I was hoping you could address. First, most of the “after” photos I’ve seen on the net are horrendous. It’s as if either the surgeon has never seen a normal male chest before, or he’s so repulsed by the male body that he couldn’t care less how ugly he leaves it. Secondly – and this the most important issue – I have always had very sensitive nipples; they are a major erogenous zone for me and a very important part of my sexual experience. I’ve heard that there are some guys out there who have no erotic sensation in the nipples and I really feel horrible for them. My biggest concern about gynecomastia surgery is the loss of nipple sensation. I know that no guarantee can be made for perfect success in any surgery, but is their any gynecomastic procedure that can be done that doesn’t harm the extremely sensitive nerves? It would seem to me that liposuction involves an inserted wand that is moved willy-nilly about like a bull in a china shop. I don’t want to suffer from this condition any more; it’s been a daily humiliation. But to lose nipple sensation from surgery would be as horrific to me as being castrated. Thank you for any advice you can offer.
A: Thank you for your inquiry and I am certainly empathetic to how you feel. The first question is what is the anatomic form of your gynecomastia and what technique is needed to address it? While it would ultimately be beneficial to see some photos of your chest, my experience has been that most cases of gynecomastia require some form of open excision…with or without liposuction. Using this approach does raise some concerns about what could happen to your nipple sensation. That is an unpredictable risk. On the one hand, I have never had a male complaint about loss of nipple sensation. But that may be because most men had little to no significant nipple sensation…so no complaints does not mean that it does not occur. Given your level of focus in this area, I do have reservations about any gynecomastia procedure with your nipple sensation concerns.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a male with gynecomastia, I am wondering if you have any experience in gynecomastia removal. I have some bothersome buildups on my chest that I want removed. Here are two pictures of my chest, the tissue build up is most noticeable below and lateral to the nipples. Thank you for your time and help.
A: Thank you for sending your pictures. It appears that there is a fairly well defined mass below and to the side of the nipple-areolar complexes. I suspect that this may feel like a discrete mass. What you have a form of areolar gynecomastia where the breast tissue buildup is largely restricted to the periareolar area. These could be removed by a gynecomastia surgery technique in which the masses are excised through an inferior areolar technique. I can not tell whether any feathering of the chest beyond the masses is needed based on the angle of the pictures taken with the arms raised. This could be done as an outpatient procedure under IV sedation or general anesthesia. The recovery would be fairly quick with you only having to refrain from working out for several weeks after surgery.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley. I am a 40 year old male with bilateral gynecomastia of undetermined origin dating back to puberty. I had surgery for it over 20 years ago which was not unsuccessful. By the surgeon’s baffled admission, it resulted in regrowth of breast tissue well beyond the original (pre-surgical), size. Since I had fully understood the procedure’s potential risks and could hardly blame the surgeon for the result, I dropped the issue altogether resigning myself to a lifetime of gynecomastia. However, having just come upon your site, particularly your discussion of the link between gynecomastia and temporal lobe epilepsy in King Tut's case, I cannot help wondering if a similar involvement has been a hidden factor in my own condition. Although I was never diagnosed with epilepsy, I had a fainting episode at 15 (coinciding with gynecomastia onset) followed by severe headaches, blind spells, and dysphoric moods. This was attributed by a neurologist to a “temporal lobe dysfunction due to damage to the sella turcica region of the brain,” possibly as a result of either meningitis or encephalitis. The antidepressants and anticonvulsants I have been prescribed to control what subsequently became recurrent major depression seem to implicate the condition further even as they themselves can either cause or aggravate gynecomastia as a side effect. I am wondering what your thoughts or suggestions might be in my perplexing case.
A: In regards to the cause of your gynecomastia, it is always an elusive question for most patients. Drugs are a common culprit although for most patients the exact reason is unclear. Whether there is any relationship between your neurological history and gynecomastia is speculative. I have never heard of regrowth of gynecomastia around a prior excision site and I would question that diagnosis anyway. I would wager it most likely represents inadequate resection that only become more evident after all the swelling went down months after the surgery. One of the hardest elements of open gynecomastia surgery through an areolar incision is getting adequate resection of the involved tissues well away from the areolar access area. A common aesthetic complication is to have adequate areolar resection but a surrounding donut of residual tissue that may not become evident until many months later when all the swelling has subsided and the skin has adequately contracted down, revealing the extent or lack thereof of the resection margins. This would suggest that further efforts at gynecomastia reduction may still be successful.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my son had gynecomastia surgery last year and has developed severe scarring from this surgery. We have tried creams, silicone sheets, several rounds of shots and laser treatments as well. Nothing has helped for his scarring. It is so sad that a 17 year old young man is unable to remove his shirt in front of anyone, due to the embarrassment from these scars. He often has sharp pains from the scarring that requires him to rub out the pain. As you can tell from the attached pictures, the scarring on his right side is much worse than the left. This is due to the fact that he formed a hematoma under his right nipple after surgery and required a second surgery on the right side to remove the hematoma. I would appreciate your opinion to see if a scar revision and possibly radiation to prevent new keloids from forming is a possibility.
A: Thank you for sending your son’s pictures. I can clearly see that he had an initial periareolar approach to his gynecomastia reduction surgery. Due to the maturity of his scars, it appears that surgery was done at least a year ago. While I have no idea as to the magnitude of his original gynecomastia problem, I see the following current problems; wide hypertrophic periareolar scarring, a residual mega-areola deformity and some persistent gynecomastia fullness. His periareolar scarring does not represent keloids but rather is hypertrophic scarring, a not uncommon reaction to periareolar mastopexies in general. This is normal scarring that develops from tension and/or suture reactions from this type of procedure. It is not pathologic scarring nor would ever merit being treated by radiation after revision. While I can appreciate all of the scar treatment strategies done after his surgery to try and improve his scarring, re-excision was only ever going to be a strategy that has a chance to work. No scar treatment other than excision will ever make wide scarring more narrow. The main benefit to all these other scar treatments was that they have allowed time to pass for the scar tissue to settle down as well as being proactive along the way.
He clearly would benefit from periareolar scar revision combined with further areolar reduction and maybe some additional gynecomastia tissue reduction. The burning question is will this scarring problem recur and what can be done to prevent it. While I have my own techniques for how I do this surgery, it is always helpful to know what was done in the past. As the old motto goes ‘past history predicts future behavior’. From that perspective, I would need to see his previous operative note to understand what closure techniques were done so what didn’t work well would not be repeated.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had gynecomastia reduction surgery one month ago. While I have fairly large boobs to begin with I am disappointed with what I see so far. I see very little difference. I thought all my chest fat was going to be removed and the saggy skin tightened. I expected a flat chest but that is not what I have. What do I do now?
A: While I have no idea what you looked like before and now after surgery, your description leads me to give some general comments. As was likely discussed during your initial consultation, gynecomastias that have more significant mounds and hanging skin are difficult problems. In such cases the problem is the amount of extra skin that you have and not so much the fat which has likely been significantly reduced from your surgery. (you can not remove all fat from any body site anywhere so this is not a realistic concept) In these larger gynecomastias the choices are to place large scars across your chest to adequately remove the extra skin in a single operation or to limit the scars to around the nipples and see how much improvement can be obtained being restricted by this approach. Large scars that extend out from the nipples are not acceptable in men in my opinion and a choice you would regret later no matter how flat your chest became from that approach. Because of keeping the scars acceptable and to just around the nipples, the chances were likely that a second surgery would be needed for further skin reduction and the best result. Your gynecomastia problem is undoubtably a challenging one and one of the most difficult to treat without undue scarring.
At this point, it is too early to yet judge the final result from your initial gynecomastia surgery. It takes up to three months for all swelling to go away and the tissues to maximally contract to see the final result. Whether it will signficantly improve or not is unknown but you must give it that amount of time. I would suggest that you go back to your surgeon three months after the procedure for further follow-up and discussion.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking for an experienced surgeon to preform gynecomastia surgery. I have hard tissue build up under the nipples caused from weight lifting supplements. I have a muscular body but I am self conscious about taking my shirt off and people staring at my nipples.
A: Supplement-induced gynecomastia is an increasingly common type of gynecomastia that I see. The patient type is very typical having a fairly lean and more athletic type body with the localized development of hard nodules underneath and around the nipples. It is a very glandular-type restricted mainly to under and around the areolas. While it may feel small, it can be quite surprising as to the actual size of the masses when they are removed. (often being 2 to 3X bigger than what they feel like) Because of the firm tissue quality, these areolar gynecomastias are best removed through a lower areolar incision. Peripheral liposuction is rarely needed and direct excision of all hard tissue back to normal soft fatty tissue is done. Drains may or may not be used depending on the size of the excision. A chest compression wrap is important should be worn for up to two weeks after surgery. It would be important to avoid strenuous chest exercises/lifting for 3 to 4 weeks after surgery to prevent a fluid build-up which can convert to scar tissue creating a partial return of a mass effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a small area on my left breast of gynenemastia from use of steroids years ago. The lump is approximately 3/4 inch round 1/2 inch thick. Its not very noticeable but I would like to have it taken out. How is ti done and how easy is it to do?
A: With such a small gynecomastia on just one side, by description an areolar gynecomastia type, that could be simply removed as a short outpatient procedure done under either local anesthesia or IV sedation. Its removal would be done through a small inferior areolar incision. No drains would be used and no sutures would need to be removed. (all dissolveable sutures under the skin) You could shower the very next day without any problems getting the surgical site wet. You could also return to work the next day provided that it is not a highly physical job with a lot of arm motion. One could resume working out in a week or so with chest exercises deferred until two to three weeks after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 31 year-old male interested in chest reshaping. I have large man boob and pointy tits. I am specifically interested in the SmartLipo or VaserLipo male breast reduction. How many surgeries have been performed? Do you offer a consultation by video chat? It’s a pretty long drive to come into the office for a simple consultation.
A: I routinuely do Skype consultations for far away patients, or even patients locally, to make talking to a plastic surgeon as asy as from your own home. I will have my assistant contact you to schedule a convenient time for a Skype consultation. It would be helpful to have you send me some pictures of your chest so I can determine what the best option may be. Smartlipo my be it but that is not an assured treatment if you have ‘pointy tits’ and large man boobs, which suggests that there may be a significant glandular component to your gynecomastia. It may need to be combined with open excision as well. Gynecomastia is a surgery that I regularly perform for men who range with gynecomastia problems from the puffy nipple to actual large breasts. There is no one single treatment method that works for every gynecomastia problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in complete removal of the fatty tissue located in my chest area. I don’t know why I have developed actual breasts but it is very embarrassing. I am a 32 year-old male and I have to wear loose fitting shirts to hide my jiggling breast mounds. I am not really much overweight, no more so than some of the pro golfers that I have seen. I wanted to know the average recovery time. Also how long does the procedure usually last as well.
A: Thank you for your inquiry. Gynecomastia deformities the size of yours, where there exists a real breast mound, is a difficult challenge to get the flattest result with the least amount of scarring. It may likely require a two-stage approach. The first stage would be a circumareolar approach with nipple lift/reduction with open excision of underlying gland tissue and surrounding contouring liposuction. Depending upon how it looks and heals, this may be all that is needed. But I like to prepare patients for the high probability of the need for a revision based on how the circumareolar scar heals and contour of the chest looks. This would be known as the second stage if needed. (areolar scar revision, touch-up liposuction) It is difficult, although not impossible, to get a good symmetrical chest result with good-looking scars in one procedure.
This type of gynecomastia reduction procedure is done under general anesthesia as an outpatient. Drains would be needed for up to 5 days after surgery. Recovery time would depend on what type of work/activities you do. For a more physical job, it would be two to three weeks before one should actively stress the chest area. This restriction is done primarily to affect fluid build-up after the removal of the drains. The results of gynecomastia are fairly long-lasting and in many cases would be considered permanent…provided one does not gain a lot of weight.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my son who is in college has been very sensitive since he was in junior high to take his shirt off. Whether it is by the pool or playing sports, he has never wanted to take his shirt off. I actually have never seen his chest since he was a little boy but I think he is embarrassed by his man boobs. He is not really overweight but for some reason he has had some small breasts develop. I really want to help him and I know it involves surgery but I don’t know how big of a deal it would be for him to go through.
A: Gynecomastia is a common problem in both young and older men alike. A surprising number of young men have it and I suspect it parallels the increase in obesity in society although it occurs in many lean men as well. It can be caused by a variety of factors although in most young men the cause is never known.
Male breast reduction is fairly simple and does not require much downtime. How it is treated depends on how much and what type of breast tissue that exists. When the breast tissue is soft and is mainly fat, liposuction may be all that is needed. When there is a firm lump or glandular tissue under the nipple and around it, then an open excision is needed through an incision on the underside of the nipple. It is an outpatient procedure that only has a few weeks of recovery until one can return to full activities.
Of equal interest is that it can produce a thrilling result particularly in younger men and teenagers. The sign of success is when they confidently wear fitted shorts and are no longer embarrassed to go shirtless.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m a skinny guy with puffy areolar tissue. I’ve had it my entire life. It is not steroid induced. Considering surgery, I am a student covered under Anthem Blue Shield insurance. I am not sure if it will be covered. I hunch my posture to conceal the protrusion in shirts, and it has lead to a lot of neck and back pain. I do not have a picture of it, but my build and areolar shape look exactly like the case study on your website for gynecomastia reduction for athletes/body builders.
A: The amount of gynecomastia the patient to which you refer had is the most type that I see. It is a harder type of gynecomastia that causes the puffy nipple appearance due to its mass effect. The amount of breast tissue present is much more significant that it looks on the outside. It must be removed through an open approach using a lower areolar incision. This smaller type of gynecomastia is not covered by insurance in my experience and is considered a cosmetic procedure. The overall cost of an open gynecomastia reduction procedure done under general anesthesia taking one and a half hours of operative time is in the range of $4500 to $5000.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had gynecomastia reduction surgery two years ago. Breast tissue was removed through incisions on the underhalf side of the areola. No liposuction was done. The incisions healed well and, while it looks a lot better than it was, my nipples are still a bit puffy. My doctor said it was swelling for several months after surgery but it never got better. I want my nipples completely flat with no puffiness at all. I don’t want to see them poking out through a shirt. I can not feel any hard lumps under the nipples so I think it is just fat. The puffiness has a soft feel to it. It pushes in easily. I am thinking this residual fat may be able to be gotten rid of by exercise or losing some weight. Do you think this will work?
A: Gynecomastia surgery, when done through an open resection of glandular breast tissue, is an art form in terms of how much tissue to remove. There is no precise method during surgery, when the patient is laying horizontal on the operating room table, to determine if the nipples will lay completely flat afterwards. The one thing a plastic surgeon wants to avoid is over-resection or removing too much breast tissue. This will create a crater deformity after surgery. To avoid this problem, surgeons will be more conservative rather than aggressive in tissue removal. This means that in some cases after surgery that most of the nipple protrusion is gone but it does not lay completely flat. This is due to residual breast tissue or incomplete resection not fat. This can only be improved by secondary gynecomastia reduction surgery to remove more breast tissue. It will not respond to any method of fat burning or weight loss.
Dr. Eppley
Indianapolis, Indiana
Q: Hello, I am a 27 year-old athletic male who is bothered both my puffy nipples. Some days they don’t seem that bad. But other days they really stick out. I don’t know why they are so different on different days. I am not sure whether I need my nipple cut down or the tissue under the nipple removed. Whatever it takes to do it I don’t care as I just want it gone. What do you recommend and what is the surgery like and how quick will I recover?
A: Puffy nipples are different than pointy nipples as patients often describe these two male chest problems. A pointy nipple is when the centrally located nipple within the areola sticks out like a small sharp point. It is small protrusion and is managed by a simple nipple reduction which is an office procedure done under local anesthesia. There is no real recovery as small dissolveable sutures at placed and one goes about their activities as normal immediately afterward. A puffy nipple refers to the development of a small mass of breast tissue underneath the nipple-areolar complex that makes it stick out or be puffy. This is known as areolar gynecomastia and is a limited gynecomastic reduction. It is treated by an outpatient procedure in which the enlarged breast tissue is removed from under the nipple by a small lower areolar incision. Patients wear a chest wrap for a week or so and show refrain from exercise or strenuous exercise for a few weeks to avoid a fluid collection or excessive scar tissue formation which will wipe out the benefits of having the puffy breast tissue removed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am a 59 year old male that has developed breasts from my cancer medication. I have prostrate cancer and am on Casodex. I am told by my doctor that I can not go off this medication for the rest of my life. I want to do something with my breast enlargement not only because of the way it looks but also because they hurt all the time. I have been told by one doctor that I can’t have the surgery unless I stop the medication as it will just come back. What do you think?
A: Gynecomastia is a known complication of the prostate cancer medication, Casodex. Bicalutamide (Casodex) is usually used with a luteinizing hormone-releasing hormone to treat metastatic prostate cancer (cancer that started in the prostate and has spread to other parts of the body). This medication is in a class of drugs known as nonsteroidal antiandrogens. It works by blocking the effect of androgen (a male hormone) to stop the growth and spread of cancer cells. Because of its antimale hormone effects, it is no surprise that male breast enlargement can occur with its use.
The question with doing gynecomastia reduction on a patient taking this medication is will it come back? That would depend on several factors including the type of gynecomastia reduction (extent) and the dose of the medication. But all those issues aside, the bottom line is there is definitely some risk that recurrent gynecomastia could develop after surgery. However, as long as you are aware of this possibility, the benefits of reduced pain and a more comfortable chest contour would seem to outweigh that potential risk. If it returns the surgery can always be repeated. But there is also the possibility that it may not come back as no one can predict with absolute certainty what may happen after your gynecomastia surgery.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi, I need your help. Three months ago I had a gynecomastia operation done and now I have a problem. The problem is that my nipples are folded in now and going inside. My skin is also very dry around nipples and my nipples have become cracked. This looks like a serious problem. How can I fix my nipples?
A: Gynecomastia reduction procedures can be done two fundamental ways; liposuction or open excision (removal) of excess breast tissue. Sometimes the two techniques are done together to get the best result. With the open excision technique, breast tissue is removed through an incision on the underside of the nipple. (technically the areola) Removal of this breast tissue is largely an art form. How much to remove and how to shape what is left behind is more of matter of experience than an exact science.
One of the known complications of open gynecomastia removal is over-resection, removing too much breast tissue. This make look alright in the very beginning (or not) but as the swelling subsides and scarring sets in, the nipple gets pulled into the over-resected space where breast tissue once was. This is called nipple inversion or a retracted nipple. It most commonly appears underneath the nipple since this is closest to the incision but it can appear outside the diameter of the areola if the over-resection goes beyond just that area.
Correction of the inverted nipple after gynecomastia reduction requires replacement of the missing tissue to support the projection of the nipple. This is best done by a fat graft or a dermal-fat graft using the patient’s own tissues. This requires a donor site and a scar elsewhere on the body to do it.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am the parent of a son who is suffering terribly. He is developing breasts like a woman. This started when he was fifteen years old and he will now turn twenty next month. The doctor said that it is Gynecomastia and that he will require surgery to correct it. Although he is not in any danger medically, this is a source of embarrassment for him as it shows no sign of going away and he is not happy with it. We would like to know what it will cost for the surgery.
A: Gynecomastia is extremely emotionally disturbing for many young teenagers and men that are afflicted with it. This has become particularly so in our current youth culture in which the very flat chest is exemplified in many ads aimed right at teenagers. (e.g., Abercrombie Fitch) Given the obesity and overweight issues that now exist in the young American population, gynecomastia problems and young males seeking treatment exist now like never before.
The cost of gynecomastia reduction surgery is in direct correlation to its size and the type of surgery needed to correct it. Smaller gynecomastias may be removed with liposuction only or simple areolar excisions. Larger gynecomastias require both excision of skin and breast tissue as well as liposuction. Without seeing pictures of the gynecomastia problem, it is impossible to give an accurate fee for the surgery. Generally, the will be somewhere between $5,000 to $8,000, which includes the associated costs of operating room and anesthesia expenses.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am 54 years of age and have dealt with large breasts since I was in high school. I exercise daily, diet and nothing makes them go away. Even though my wife says it doesn’t bother her, it bothers me a lot. I have still not psychologically gotten over being told in high school gym class that I had bigger boobs than the girls! Is 54 too late to have something done? I hate taking off my shirt at the gym or anywhere else, including the doctor’s office. I actually had them liposuctioned and they were flat for a few days but now that are big as ever. Please advise.
A: Age has nothing to do with whether gynecomastia can be surgically treated. It is only about how much the problem bothers you, there is no age limit for gynecomastia surgery. Gynecomastia, however, comes in many different sizes and the surgical techniques used to treat it are different. By your description and the fact that you had an unsuccessful liposuction experience indicates that your chest problem is just as much about too much skin as it is about too much breast tissue. In other words, when the chest starts to or has the appearance of an actual breast mound, the reduction technique must be more like a female breast reduction to be successful. This means that skin has to be removed which will result in visible scars on the chest wall. To be able to get you a lot flatter, you will have to accept the trade-off of scarring. That, rather than age, is the real rate-limiting consideration at your or any male age.
Dr. Barry Eppley
Indianapolis, Indiana
Cosmetic plastic surgery has long been unintentionally gender-biased. Since the field began, the vast majority of patients who seek cosmetic enhancements, albeit it surgery or office-based treatments, have been women. Men have always made up less than 10% of most plastic surgery practices. Hollywood would lead you to believe otherwise but it just isn’t so. The only rare exception to that has been the more recent popular treatment of laser hair reduction. When it comes to hair removal, men make up about half of the patients seen with the hairy back and shoulders being the prime targets.
But more men are finding their way into the plastic surgeon’s office in the past few years. Besides a steady increase in male numbers, what is noteworthy is the change in what what men are requesting. While there remains some traditional procedures that have always been of interest, technology, societal trends, and younger men have opened up new areas of the face and body for change and improvement. Here are four of the most popular younger male (teenage to early 40s) procedures today.
Liposuction still remains the most requested male procedure. The culprits are always the same, the stomach and love handle areas. But most men that want liposuction are not fat and many are not even overweight. To the contrary, they are lean but have fat collections at the side of the waist and flanks. Even in men that work out regularly, those love handles can be impossible to work off. Today’s liposuction techniques can even give that ‘six-pack’ look for those leaner men that are not opposed to a little surgical cheating.
Chest recontouring is the one male plastic surgery procedure that is really on the rise. Male breast enlargement, known as gynecomastia, has always been an issue. But with increasing teenage weights and the present young male aesthetic for a completely flat and smooth chest, improvement in the male chest is sought out like never before. Even small nipple protrusions can be bothersome for the teenage male. Obvious man boobs are not desireable at any age.
Nose reshaping (rhinoplasty) has always been a popular male operation and that has not changed. It is the one procedure of the face that young men are not afraid to change. Noses that are big with prominent humps and wide nasal tips are bothersome and distracting to an otherwise balanced face. Sports and recreational activities make the young male nose a good target for injury causing twisted and deviated noses that often pose problems for breathing as well.
One set of procedures that is really new and undoubtably influenced by movies and models is structural facial reshaping. Creating that chiseled and angular face is what some young men aspire to achieve. A good jawline in particular is associated with enhanced masculinity. While one perceived just as making a strong chin with an implant, modern plastic surgery implants can be extended all the way to the back of the jaw. With the development of jaw angle implants, the jaw line can become more defined than just with a chin implant alone.
A new generation is redefining male plastic surgery. Have a lean body, flat chest, and a nose and jaw line that creates a well defined face has probably never been out of style. But modern surgical developments make them more attainable than ever before.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in some form of gynecomastia surgery. At one time I was much heavier and have lost a lot of weight through the help of bariatric surgery several years ago. Since the weight loss, much of my chest has not only gone flat but it sags with nipples that are very stretched out. My chest needs to be reshaped. Help!
A: Chest changes after weight loss are common in men. Men suffer a deflation of the chest soft tissues after bariatric surgery which is magnified by the usual presence of weight-related gynecomastia. This results in a skin sag with enlarged nipples that is particularly unflattering in a man.
Correction of this type of male chest wall change is not really gynecomastia surgery per se. There is usually not much fat or breast tissue to contend with. Rather it is more like a breast lift in a female. Skin needs to be removed and tightened and the nipple needs to be lifted and usually made smaller. If the skin sag is very minor, a circumareolar skin lift with nipple reduction can be made. This has the advantage of keeping the scar relegated to around the nipple area. More significant chest skin sag, however, needs a skin excision pattern that goes beyond the nipple. This is always problematic in men where scars are not well hidden in the more flat topography of the male chest.
Chest wall reshaping is usually the second most requested change (abdominoplasty is number one) in men who have had gastric bypass.
Dr. Barry Eppley
Q: I am inquiring about breast surgery for my son who is 14. He has developed small breasts and is quite conscious of it. He will not go swimming or even take his shirt off during gym class. (so I am told by his brother) My family doctor said it is gynecomastia and that it goes away in most teenage boys. He said we should wait until he is 18 years old before considering surgery. Given that it bothers him so much, and has made him very shy and reclusive, I was wondering what your thoughts were. Can surgery be done sooner rather than waiting? I am just desperate to help him and make him feel better.
A: While gynecomastia, male breast enlargement, does go away in some teenage boys, many times it does not. The historic teaching is to wait until the teenage male is near full development. In analyzing that approach further, its intent is to not subject a teenager to unnecessary surgery. In the spirit of such waiting, however, the teenage boy may (likely) develop self-image issues and psychosocial issues.
Given the exposure to potential social pressures and ridicule, I not think that such waiting is worth the trade-off. Gynecomastia surgery can be repeated (although I have never seen that necessary) but the emotional damage can be very difficult to get past. Therefore, in my Indianapolis plastic surgery practice I am an advocate of surgically treating gynecomastia early (age 14 is an acceptable age) provided that it is significant enough and one is certain that there is not a hormonal reason for it. While a hormonal cause (endocrine tumor) is a very rare cause of gynecomastia, they do occur. If the gynecomastia involves both sides of the chest and is not subtle, I would recommend getting him seen by an endocrinologist first.
Many cases of teenage gynecomastia that I seen today are less significant than they used to be. This is undoubtably a reflection of the changing cultural standards from decades ago.
Dr. Barry Eppley