Causes of Gynecomastia
Diagnosis of Gynecomastia
History of gynecomastia treatment
Treatment of gynecomastia


First, it is well to point out that many cases of gynecomastia require no treatment at all. The majority of adolescent gynecomastias regress to the point of aesthetic insignificance within two years. Also, most breast growth produced by medications will respond to withdrawal of the medicine if the correlation is detected early in the course of use. For those with HAART-related gynecomastia, HIV therapy may be modified to see if different drug combinations will help. Happily though, the majority of these will regress on their own within a year, whether modifications are made to the drug regimen or not.

Cases of pre-adolescent gynecomastia stemming from use of topical's containing tea tree or lavender oils have been noted to also regress months after use of the offending soap or cream has ceased.

Non-surgical Treatment

Medical treatments can have a role to play under certain circumstances, particularly when gynecomastia has not been present for long. When gynecomastia moves from its early, "florid" stage to its more "fibrous" form, (containing more fibrous protein), it is less likely to respond to medical manipulation. If treated early, those with testosterone deficiency are among the groups most likely to respond to medical therapy. Testosterone replacement is particularly helpful in those with testicular failure from orchitis, absence or injury. Since "aromatization" of testosterone can lead to an actual increase in peripheral estrogens, however, (see Causes), hormone replacement/supplementation can be problematic, particularly in the obese and those with liver disease.

"Selective estrogen receptor modulators" (SERMs) like tamoxifen (Nolvadex) and raloxifene (Evista) have been shown to reduce breast volume to some degree and can have a role in the treatment of severe or painful gynecomastia. Although aromatase inhibitors such as anastozole (Arimidex) might be expected to provide some benefit, they have not seemed to do so when studied.

Since breast development is so common in men receiving anti-androgen therapy for prostate cancer, studies have been performed to see if prophylactic radiation of the breast can help prevent gynecomastia in that setting. While there does appear to be benefit from this approach, it is not known what affect the use of ionizing radiation may have on the incidence of breast cancer in men so treated.

While the majority of anti-retroviral therapy-related gynecomastias will resolve without therapy, (see above), there is unfortunately, a "Catch-22." Early alterations in the drug regimen are much more likely to produce acceptable improvement than are those manipulations carried out after the gynecomastia is long established.

Surgical Treatment

Surgical therapy is indicated when spontaneous regression does not occur, or when medical therapies are unable to impact an established gynecomastia. It is particularly worth consideration when there are appearance-related psychological problems for the patient, or where the cosmetic abnormality is significant. Naturally, it ought only be considered in those situations where any underlying medical condition has already been diagnosed and addressed appropriately.

The emotional impact that a persistent adolescent gynecomastia may have on a teenage boy cannot be over-stated, and it is quite reasonable to offer such a patient a surgical solution once an appropriate wait for regression has been completed, (i.e. > 2 years). Adults with recalcitrant gynecomastia may have their lives similarly impacted, becoming limited in their forms of dress and their activities, and hampered in intimacy with partners.

When discussing any form of surgery with a patient, it is important for the surgeon to point out that gynecomastias caused by ongoing drug/medication use may not respond permanently to surgery. (For example, men who have used anabolic steroids must be reminded that gynecomastia can recur if steroids are again employed post-operatively.) However, there may be instances where gynecomastia has sufficiently egregious aesthetic effects and symptomology as to justify surgery, even if the offending medical therapies must continue, (e.g. anti-androgenic therapy for prostate cancer). In such cases, the patient must simply be willing to accept the potential impermanency of the surgical change.


The purpose of surgical treatment is to return the chest to as near normal and masculine an appearance as possible. Its purpose is not the complete removal of breast tissue, (as would be done in the treatment of a cancer). The surgical approach will depend upon several factors determined by physical examination. The pertinent factors are:

  • The "degree" (size) of the gynecomastia
  • The composition of the gynecomastia
  • The quantity and quality of skin on the breast/chest

Grading Gynecomastia

gynecomastia grades I and IIA

A commonly used classification system is that originally put forward by Hoffman and Simon. This system assigns each case of gynecomastia to one of four groups based upon the degree of enlargement and the amount of skin excess:

  • Grade I- small, subareolar enlargement with no skin excess
  • Grade IIA- moderate enlargement with no skin excess
  • Grade IIB- moderate enlargement with extra skin
  • Grade III- marked enlargement with extra skin
gynecomastia grades IIB and III

These authors reported the need to remove skin excess in the last two groups. However, further experience has shown that removing skin from patients in the Grade IIB group is often not necessary.

The experienced surgeon will find himself first evaluating the composition of the gynecomastic mass. Lipomastias can be very effectively treated using suction-assisted lipectomy alone, (liposuction), provided the skin envelope is not too loose or redundant. liposuction of the male breast Because gynecomastias of long standing also come to be more and more fatty in nature, they may also be candidates for a minimally invasive approach, Many surgeons have found that they are able to achieve easier and more complete extirpations of fat when employing assistive technologies such as power-assisted liposuction (PAL) or ultrasound-assisted liposuction, (UAL). PAL employs a reciprocating engine to mechanically disrupt fatty connection to tissues, while UAL employs a piezoelectric ultrasonic probe to emulsify fat before it is suctioned from the wound. These techniques make it easier to free fat from surrounding fibrous attachments in the male breast. Whatever techniques are preferred, however, liposuction alone will only achieve an adequate contour when there is minimal fibro-glandular tissue present. If the patient wishes to limit the intervention to one performed using liposuction alone, it is important to determine that the bulk of the contour problem is caused by fat, and that the persistence of fibro-glandular elements after suctioning will continue to produce an unappealing, post-areolar prominence.

Although some surgeons have advocated the use of sharpened cannulae to avulse fibrous tissue and aspirate it along with fat in a straight suction procedure, the great majority feel that the fibro-glandular component is best removed via a separate, peri- or intra-areolar incision.

Gynecomastias that have a large fibro-glandular component are best treated by direct excision performed via a peri-areolar incision. Care must be taken to preserve a modest amount of subareolar soft tissue to avoid the "dish" deformity that can follow overzealous resection. Once the direct surgical resection is complete, it can usually be "feathered" at its edges using liposuction, improving the smoothness of the overall contour. When a broad area of resection has been necessary, some surgeons will place a suction drain within the wound to discourage serum accumulations, ("seroma"). It is well to note that for some discreet gynecomastias in young men and body builders, no suction whatever is indicated. For these individuals, there may be a pure, fibro-glandular element behind the areola that must be sharply excised via a peri-areolar or trans-areolar incision.

unilateral gynecomastia excision via Webster incision

Whether direct excision is performed, or liposuction alone, the skin must accommodate the new reduced contour on its own, since the surgeon has not altered it in any way. If the patient is young and the skin relatively undamaged, (no striae, or "stretch marks"), it may be expected to slowly shrink and produce acceptable cover in even relatively large gynecomastias. However, in older patients with more damaged skin, and particularly in those with more tubular shaped breasts and pendulousness, the skin is unlikely to tighten and re drape sufficiently for an acceptable result. In these cases, one of several patterns of skin excision can be entertained, all of which will call upon the patient to accept more cutaneous scarring.

Below is an example of an operative plan for a man with a large gynecomastia that required skin excision and nipple-areolar transposition.

Skin excision in gynecomastia