Gynaecomastia is the enlargement of the male breast and the term is often applied to the fat accumulation in this area as we men get older. Surgery for gynaecomastia is one of the most common procedures I perform in the NHS for under 18’s who are still eligible for treatment (as current guidelines stand); in this short article I will outline the causes and potential treatments for this.

The cause in the majority of men is an accumulation of fat in the chest area with little or no true breast tissue. In younger boys, the breast tissue can form due to an imbalance of hormones during in puberty. True breast tissue in older men (60’s plus) can also occur due to a similar hormonal imbalance. More commonly in men, the use of cannabis or anabolic steroids can cause breast tissue to form. Obviously, stopping these substances usually reverses the changes in the chest. Along with a number of medications that can cause gynaecomastia, there are rare medical causes that lead to breast tissue forming and a thorough examination will be performed to rule out these causes before cosmetic surgery is considered.

As with all cosmetic surgery in order to achieve the result you want the main thing is to have think about what exactly is your issue and what do you want to achieve. Is it that the nipple is too visible? Is it the shape of your chest in a tight T-shirt? How you look topless on the beach? Is it affecting your confidence even though nobody else has ever commented? Answers to these questions are really useful for a surgeon to understand what you want to achieve.

Once we have understood your aims then we have to think about what procedures will best achieve them. As with all cosmetic surgery, we need to adjust the skin, the fat, the breast tissue (if present) and then take into account the underlying bony skeleton and muscles. In short, if there is mainly fat then liposuction can remove this through tiny well-hidden incisions. However, if there is lots of fat then removing the fat alone may result in a “deflated balloon” appearance with left over sagging skin. In such a case, we would need to remove skin as well to take up the slack. If there is firm, hard breast tissue present (especially in younger men and body builders) then liposuction is unable to deal with this and therefore surgery to remove this via an incision at the border of the nipple is required. For those of you who are not squeamish, a teaching video for surgeons I have produced is available online here. All these procedures are performed as day case surgeries under general anaesthesia.

Liposuction: Like the name suggests, it literally sucks the fat out with a narrow tube through incisions that are typically hidden in the armpit and at the border between the pigmented nipple-areolar and adjacent skin. After having liposuction you are able to put the fat back on, so having this procedure as part of a diet and exercise regime is the best way of dealing with the problem long term. In my experience, most patients are too self-conscious of their appearance to go to the gym and following surgery plan to increase their exercise regime.

Excision of breast tissue: this is required because true breast tissue is hard (like the flesh of an unripe pear) and can’t be sucked out though a small tube. In these instances, a small incision at the border between the pigmented nipple-areolar and adjacent skin is made and the nipple lifted up like the lid of a box. Underneath, the breast tissue can be removed along with any fat to recontour the chest. It may be combined with liposuction to give the best result.

Removal of skin: this is performed with one of the other procedures and is used to gather up the slack. The skin is normally removed in a circular fashion around the nipple so that the resulting scar sits around the nipple and is hidden at the border between the areolar and normal skin.

After any of these surgeries, you will be sore and bruised and require 2-5 days off from most office-based jobs. If you have a very physical job, you may require two weeks or more off work depending on the nature of the procedure and job you perform. In most cases, dressings are minimal and you can shower the next day. I usually ensure that a tight cycling top is worn for six weeks following surgery to ensure the shape is maintained and fluid does not collect under the skin. Normally it is six weeks when you are back to sports and unrestricted physical activity. The main risks associated with this are under- or over- correction and asymmetry of the two sides. Remember, after surgery you will be looking for all the tiniest differences between the two sides that you otherwise would not notice. In the vast majority of cases, patients are really happy with their result – so long as the exact problem and the aim of surgery has been discussed in detail.