Gynecomastia

Gynecomastia is the medical term for enlarged male breasts. The causes of gynecomastia are extremely varied, and although certain diseases or the use of specific medications are clearly associated with gynecomastia, in many cases the cause cannot be precisely determined; thanks to recent research in the field, gynecomastia now has a well-established treatment. Gynecomastia affects between 40 and 60 percent of men in one or both breasts.

Gynecomastia usually appears during puberty and can cause serious psychological problems in both adolescents and adults. There are many theories regarding the causes of gynecomastia; while in many cases a congenital or hereditary cause may be to blame, in many others, the cause remains unknown.

Gynecomastia can be an extremely sensitive issue for a man of any age, as well as a particularly emotional experience. Unlike women, the ideal male chest is considered to be flat and muscular, with minimal fatty and glandular tissue overlying the pectoral muscle. In practice, very few people (and especially athletes, in fact) come close to this ideal. In the case of athletes, once excess tissue is removed, the “ideal chest” can be achieved thanks to the well-developed pectoral muscle, which will thus be more prominently displayed. For other men, optimal results are achieved by removing as much fat and glandular tissue as possible. A patient who is not a professional athlete can achieve the ideal “muscular, athletic chest” if he follows an intense exercise and fitness program after surgery.

As with any other surgery, realistic expectations are extremely important. As a result of gynecomastia, some men experience feelings of frustration, embarrassment, and withdrawal from public life and certain social activities; unfortunately, these are precisely the patients who tend to delay seeking a solution to the problem. All these emotional and physical factors must be taken into account by the surgeon and analyzed with the utmost seriousness.

In athletes, gynecomastia caused by the use of anabolic steroids poses a real impediment during competitions. In these cases, gynecomastia consists primarily of glandular tissue, since athletes have minimal body fat. Once the glandular tissue is removed, the skin will conform to the muscle and highlight the pectoral muscle. The likelihood of gynecomastia recurring is therefore very low, as the mammary gland rarely reforms.

Many boys and men find surgery to be the ideal solution to their problem.

1. 1. Non-hereditary causes include:
      • puberty
      • obesity
      • Klinefelter syndrome
      • Gilbert's syndrome
      • advancing age
      • testicular hormonal problems
      • use of estrogen-containing medications
      • use of anabolic steroids
      • use of supplements containing testosterone
      • liver dysfunction

In the cases described above, treatment is not surgical. It may involve medication. When the surgeon suspects one of the conditions listed above, he or she must refer the patient to an endocrinologist; surgery should be performed only after all issues have been clarified and with the endocrinologist’s approval.

Cases of unilateral gynecomastia must be investigated very thoroughly, as they often indicate a tumor of the mammary gland.

If gynecomastia is caused by obesity, the appearance can be improved through weight loss. However, surgery may also play a role in these cases, as the excess fat cannot be completely eliminated through weight loss alone. It is indicated for anyone over the age of 18; however, ideal candidates are those with adequate skin elasticity. Obese patients must lose weight prior to surgery; furthermore, the use of alcohol, marijuana, and anabolic steroids must be discontinued several months before surgery to allow the breast to stabilize in size.

After the consultation, the doctor will order a mammogram or X-ray to determine the proportion of glandular and fatty tissue in the breast. Any suspicion of breast cancer must be ruled out. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), vitamin E, ginkgo biloba, and spirulina should be avoided for at least 2 weeks prior to surgery. You must also stop smoking for at least 2 weeks before and after surgery, as smoking reduces blood flow and impedes healing.The surgical procedure typically requires a one-day hospital stay and usually lasts between one and two hours, sometimes longer depending on individual factors that may extend the duration of the surgery. Anesthesia is either general or local combined with sedation.

When excision of the gland is planned, a semicircular incision is made at the lower edge of the areola; the excess glandular tissue beneath the areola is excised from the upper, lower, and lateral parts of the gland, along with the excess skin. If liposuction is also required, cannulas are inserted through separate, minimal incisions of approximately 2–3 mm; excess fat is suctioned out through these incisions. If skin excision is also required, the incisions will be longer—and the longer the incision, the greater the amount of skin that needs to be removed.

There are situations in which the patient’s areola is larger than normal. This issue can also be resolved, either by simply thinning the areola—which will cause it to retract—by excising its edges, or by using special sutures to reduce its diameter to a size appropriate for the breast.

In some cases, when deemed necessary, the surgeon may insert suction drains, which are usually left in place until the following day.After the surgery, the patient will experience some discomfort, which is not necessarily pain; this discomfort can be easily managed with pain medication prescribed by the surgeon.

During the first week, swelling and bruising may give a misleading impression of the surgery’s results, as everything will appear as it did at the beginning. However, as the swelling subsides, changes will become apparent. The swelling subsides largely within the first 2 weeks, but the final result cannot be fully assessed until at least 3 months or more have passed.

After surgery, it is recommended to wear a compression garment for at least 2 weeks, day and night, and then for another 2–3 weeks at night only.

The sutures are removed 10–14 days after surgery. Movement is recommended on the very day of surgery, and normal activities can be resumed within a day or two.

You can resume physical exercise in about 3 weeks. Scars should not be exposed to the sun for 6–9 months.

Below is a complete list of instructions that patients must follow after gynecomastia surgery:

1. 1. It is recommended that you have someone with you for the first 2 days, as you may feel a little dizzy. It is best not to get out of bed on your own at first.
   2. Start walking as soon as possible after surgery. While in bed, move your knees and ankles as often as possible. Prop your legs up on 2–3 pillows. Do not cross your legs, as this position increases the risk of blood clots.
   3. Take 15–20 deep breaths as often as possible to oxygenate your lungs.
   4. It is very important NOT TO SMOKE.
   5. Start with a light meal on the first day, then gradually return to your normal diet over the following days.
   6. Most patients experience discomfort rather than pain. Take pain medication only if necessary. Take antibiotics and anti-inflammatory medications exactly as prescribed. Do not consume alcohol while taking medication.
   7. Avoid strenuous physical activity for 3 weeks. You may resume light physical activity starting in the second week.
   8. Wear the compression garment for 3 weeks, DAY AND NIGHT. It is very important to wear it at all times, as it aids in healing, helps achieve a good result, and improves the quality of the scars. You may shower starting on the third day after surgery. You may remove the vest while showering and put it back on afterward.
   9. After 3 weeks, it’s a good idea to continue wearing the vest for another 2 weeks, but only at night. It provides extra comfort.
   10. You can apply creams containing arnica, vitamin E, and vitamin A to the areas to soften the skin.
   11. You can apply scar-healing creams to the scars as directed by your surgeon after the stitches are removed (which takes place 10 days post-surgery). Do not expose the scars to the sun for at least 6 months. If you go to the beach or must be in the sun, use sunscreen with an SPF of at least 15, even on cloudy days.
   12. The discomfort described by patients is similar to what they feel after an hour of intense exercise.
   13. During the first 2–3 weeks, the treated areas will be swollen, so do not expect to see results sooner than 3 weeks.
   14. For the first 2–3 months after surgery, you will experience a sensation of numbness. This is normal and will gradually subside over time.

a. Hematomas, seromas: accumulation of blood or interstitial fluid; if present in small amounts, they resolve on their own; in larger amounts, they must be drained; They occur more frequently in people who take aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), in people with high blood pressure, and in those who use anabolic steroids;
b. unsightly scars: usually, the scar is minimal and nearly invisible to the untrained eye if the procedure is performed by a surgeon experienced in the field; they rarely pose a problem; in any case, if necessary, revisions or corticosteroid injections can be performed later to improve the appearance; pigmented
scars may also occur c. minor asymmetries: between the breasts or nipples
d. decreased sensitivity in the areola or numbness: this is normal and usually reversible (resolves) within about 6 months to 1 year after surgery; it is generally not a major
problem e. unevenness or depressions in the areola or breast: these may be:

static—visible when the pectoral muscle is relaxed
; dynamic—visible only when the pectoral muscle is contracted or when the patient raises their arm; this is usually less bothersome for the patient;
Correction of this condition can be achieved with autologous fat transfer, fat and dermis, or minimally resorbable fillers.

f. Recurrence (reappearance) of the condition: According to the literature, gynecomastia recurs in 10% of patients after gland excision and in 30% after liposuction; Recurrence does not result in the return of the initial appearance, and the risk is increased by the use of corticosteroids for other medical conditions