Gynaecomastia
when is surgery needed?

The difference between true gynaecomastia and fat, which cases settle on their own, and why steroids bring the problem back.

Gynaecomastia is one of the least talked-about reasons for seeing a plastic surgeon. Men rarely discuss it, yet it affects things that may look trivial to others — the beach, the swimming pool, the changing room, a close-fitting T-shirt.

The first question, however, is not whether to operate but what exactly is enlarged.

True gynaecomastia or pseudogynaecomastia

In true gynaecomastia, it is the glandular tissue that is enlarged. It usually feels like a firmer area beneath the nipple and is sometimes tender when pressed.

In pseudogynaecomastia, the problem is fatty tissue. It is soft and diffuse, with no clear edge, and usually goes hand in hand with being overweight in general.

Feeling the area alone does not reliably tell the two apart. The distinction is made by clinical examination and, where needed, by ultrasound and laboratory tests. The difference matters in practice: fat can be removed with liposuction, glandular tissue cannot. Firm tissue is not affected by the cannula and remains as a disc beneath the nipple unless it is excised surgically.

Before surgery is discussed

Gynaecomastia is sometimes a symptom rather than a diagnosis, so the possible causes are investigated first.

• Pubertal gynaecomastia — very common, and in a large proportion of cases it resolves spontaneously
• Medication — some drugs for blood pressure, stomach conditions, psychiatric conditions and others
• Anabolic steroids
• Hormonal disorders
• Liver or kidney disease
• Significant weight gain

In some patients, removing the cause resolves the problem without surgery.

When to wait

In boys going through puberty, the usual approach is to wait until the age of 18. A significant proportion of cases resolve on their own, and surgery during the active phase risks recurrence.

Surgery is also deferred while steroids, or a medication that causes the condition, are still being taken — otherwise you are operating on a problem that will come back.

When to operate

• The condition has been stable for at least 12 months
• The cause has been identified and, where possible, removed
• Your weight is stable
• There is physical discomfort or tenderness
• It restricts your everyday life and choice of clothing

What the operation involves

Most often a combined approach is used: liposuction for the fatty component and a small incision along the lower edge of the areola to remove the gland. The excised tissue is always sent for histological examination.

A key point is to leave a thin layer of tissue beneath the areola. Removing too much creates a hollow, which looks worse than the original condition and is harder to correct.

Recovery is relatively easy — office work after five to seven days, a compression vest for four to six weeks, and lifting weights after a month and a half.

A note on age

You do not need to wait until you are thirty to make this decision. If the condition has been stable for more than a year and causes marked discomfort, surgery is discussed on an individual basis, including in younger men.