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Elliot W. Jacobs, MD, FACS - Diplomate, American Board Of Plastic Surgery

Specializing in Primary &
Revision Gynecomastia Surgery

815 Park Avenue New York, NY 10021

GYNECOMASTIA FAQ’s

1 What exactly is gynecomastia and how do I know if I have it?
2 Can I determine if I have gynecomastia simply by feeling my chest?
3 Can I treat my gynecomastia with diet and exercise?
4 At what age can surgery be done? Can a youngster or a teenager qualify for surgery? Is there an upper age limit for surgery?
5 Are there any other methods of treatment of gynecomastia?
6 Do I have an increased risk of cancer if I have gynecomastia?
7 What should I know about male breast cancer?
8 Is gynecomastia more common in any particular race or ethnic group?
9 I have only one enlarged breast — what can be done?
10 Is there a relationship between gynecomastia and drugs or medications?
11 Is a complete hormonal workup by an endocrinologist required prior to surgery?
12 I have an underlying medical condition (HIV positive, prostate cancer, heart disease, etc.). Can surgery for gynecomastia still be done?
13 What are “bitch tits” in body builders?
14 I am taking Propecia (Finasteride) to prevent hair loss. What are the implications of this?
15 Does insurance cover the cost of gynecomastia surgery?
16 What do the scars look like after surgery?
17 What are drains and when are they used?
18 What are the most common complications after gynecomastia surgery?
19 If surgery is performed, will the results be permanent? What if I gain weight after the surgery?
20 Can liposuction be performed on other areas of the body (for example, abdomen or love handles) at the same time as the gynecomastia surgery?
21 I have very large areolas — what can be done to reduce the size?
22 What can be done for “puffy nipples?
23 What can be done for very large, female-type nipples (not the areolas)?
24 I have very long, narrow, pendulous breasts. What can be done for this?
25 What can be done for scarred nipples after nipple rings have been removed?
26 Why do I have post-operative diminished feeling of the skin and nipples?
27 Why is it necessary to wear a compression garment after surgery?
28 Will my chest be symmetric after surgery?
29 When should I massage my chest after surgery?
30 What is done with the tissue removed during surgery?
31 When can I return to my usual exercise routine after gynecomastia surgery?
32 What will happen to my chest if I lose weight after surgery?
33 Will the presence of chest acne affect my eligibility for gynecomastia surgery?
34 What is skin elasticity and why is it so important in consideration for gynecomastia surgery?
35 Am I more prone to develop gynecomastia if I am overweight?
36 How will I view myself after gynecomastia surgery?
37 I have had prior surgery for gynecomastia by another surgeon and I am not pleased with the results. Can anything be done?
38 What is a prolactinoma?
39 Should I lose weight in preparation for surgery?
40 I am a vegetarian – am I still eligible for gynecomastia surgery?
41 Should I work out and build up my chest muscles prior to surgery?
42 How does smoking affect gynecomastia surgery?
43 I have gynecomastia but am afraid of surgery. What can I do?
44 I was formerly very heavy. I have lost weight but still have enlarged breasts and lots of loose skin and droopy nipples. What can be done?
45 Is all the breast tissue removed during gynecomastia surgery?
46 Are there any guarantees as to the outcome of gynecomastia surgery?
47 What is Dr. Jacobs’ policy on revision surgery?
48 How is payment made for surgery? Are payment plans available?
49 How can I locate a doctor who does this procedure in my area?

 

1. What exactly
is gynecomastia and how do I know if I have it?

Gynecomastia can be defined as the presence of any excess tissue on a male chest and it is often breast tissue mixed with fatty tissue. It frequently occurs in three phases of life. It can occur in a newborn but frequently disappears. It often occurs during puberty and disappears in many young men, although it may persist forever in some of them. It can also occur later in life due to a variety of factors, which include various diseases (including some cancers), hormonal irregularities, use of bodybuilding (anabolic) steroids, various supplements, marijuana, side effects of various medications, etc.

Oftentimes there are strong hereditary factors as well. Gynecomastia is not related to obesity but may coincide with it. It may be as small as a firm area of tissue just under the nipple or as large as a DD cup pendulous breast.

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2. How is your procedure performed?
Sometimes one can feel firm breast tissue directly under the nipple or in the surrounding chest area when the arm is stretched over the head. But this can be misleading – sometimes breast tissue can feel firm and fat feel soft – and other times the fat can feel firm and the breast tissue feel soft. Even a surgeon’s educated hands can be wrong. It is therefore a fool’s errand to try to self diagnose one’s gynecomastia by simply feeling the chest.

If one has excess tissue on the chest, that alone is sufficient alone to diagnose gynecomastia. Regardless of what is felt, the only definitive treatment for the excess tissue will be surgery.

Some guys feel that if their chest is soft, that it is all fat and then they can remove it by diet and exercise. Not true — for an explanation, please see below.

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3. Can I treat my gynecomastia with diet and exercise?
First, diet and exercise are to be strongly recommended – they are great for your general health. But neither will do too much for your gynecomastia. Why?

EXERCISE: Many times, men with gynecomastia have worked out to build up their chest muscles only to be disappointed in their contour. Actually, the excess gynecomastia tissue on the chest sits on top of the muscle and is therefore pushed further out as the muscle enlarges – thereby continuing to mask the muscle contour. It is only after appropriate surgery, when the excess tissues have been removed, that the skin will tighten spontaneously (oftentimes right on the operating table during surgery) and will then shrink down and reveal the nice contours of the underlying chest muscles.

DIET: If a man is overweight, there is predictably an excess of both fat and breast tissue on his chest. Should he lose a significant amount of weight, the fat component will diminish somewhat but the breast tissue will remain intact. Thus, his breast will become slightly smaller but so will the rest of his body and therefore the disparity of his chest to the rest of his body will remain. In fact, the breast tissue will persist and become even more compacted and prominent, since the intervening fat tissue has been lost.

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4. At what age can surgery be done? Can a youngster or a teenager qualify for surgery? Is there an upper age limit for surgery?

Gynecomastia. Before and After Photos - patient 1 (frontal view)

There is no right or wrong age for surgery to be performed. All too often, teenagers with this problem are given a pat on the shoulder by their pediatrician and told to wait it out until it disappears by itself, often by the “magical” age of 18. Unfortunately, many teenagers spend their entire teenage years waiting in vain for this to occur and are subject to ridicule and embarrassment during this critical time in their lives. On the other hand, one should give adequate time for the condition to resolve by itself.

Pediatricians may also be concerned about the possibility of recurrence of gynecomastia if surgery is performed at too young an age. This has proven not to be the case. Not one of several hundred treated adolescents has ever had a recurrence!

If gynecomastia has been present for two or more years and is stable and has not increased in size, then surgery may be considered. The decision to operate is based not only on the diagnosis of gynecomastia but also on the maturity of the youngster and his capability of understanding the surgery as well as the ability to cope with the post-op pain and to follow the post-op care regimen. Surgery has been successfully performed on hundreds of young men from age 12 through 18. Obviously, this decision is made is on an individual basis. Please read about Adolescent Gynecomastia Surgery elsewhere on this website.

Older men suffering with this condition are also candidates for surgery, but must understand that the skin may not totally tighten after the surgery is performed since they may have lost some elasticity in their skin through the natural process of aging. If deemed necessary by Dr. Jacobs, various alternative procedures will be discussed at the time of consultation. Again, decisions must be made on an individual basis.

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5. Are there any other methods of treatment of gynecomastia?
Male breast reduction surgery for established gynecomastia is the only known and recognized treatment. Creams, lotions, massage, injections, exercise and “magic pills” all will do nothing for established gynecomastia. However, they will succeed in making
your wallet slimmer.

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6. Do I have an increased risk of cancer if I have gynecomastia?

Gynecomastia. Before and After Photos - patient 2 (oblique view)

The presence of gynecomastia does not make you more prone to breast cancer. Several studies have concluded that there is no increased risk of male breast cancer in those men with gynecomastia. It is important to note, however, that one percent of all breast cancers do occur in men. While it is very rarely seen in young men, older men must be made aware of this possibility. Therefore, any new lump, one-sided growth (asymmetry of the breast), skin changes of the breast or nipple, or bloody nipple discharge should be immediately investigated by a physician. A biopsy, a mammogram or a sonogram (ultrasound) examination may be advised.

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7. What should I know about male breast cancer?
Male breast cancer (MBC) tends to be diagnosed at a more advanced stage than female breast cancer. Some of this is thought to be due to men’s frequent disregard of any lumps
or changes in their bodies.

MBC usually occurs in older men, the median age is 67 years old. Jewish men have a slightly increased risk, which is thought to be due to hereditary factors. Risk factors for MBC include a positive family history (another relative with the disease), lifestyle, occupation, etc. Some genetic mutations have been linked to hereditary forms of MBC,
including BRCA-1 and BRCA-2 genes.

There are some conditions which may predispose to MBC. These include Klinefelter’s Syndrome, Cowden’s Syndrome and liver disease or dysfunction. Occupational hazards include exposure to hot environments (ie steel mills, blast furnace), work in the soap or perfume industry and work exposure to petroleum and exhaust fumes.

The diagnosis of MBC usually involves the discovery (by the patient or his physician) of a one-sided, painless lump or mass under the nipple/areola. Skin changes (orange peel-like skin) and/or bloody nipple discharge can also be a tip-off. If any of these symptoms are found, one should consult a breast surgeon immediately. As in many diseases, early
diagnosis and treatment can save your life!

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8. Is gynecomastia more common in any particular race or ethnic group?
No. Gynecomastia can affect anyone – it is an “equal opportunity” misery.

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9. I have only one enlarged breast — what can be done?

Gynecomastia. Before and After Photos - patient 3 (frontal view)

True one-sided gynecomastia is rare. Careful consideration must be done to consider other diagnoses, such as a tumor. Once that possibility is removed, then a decision must be made about treatment. Often, one side is much larger than the other — but both sides are frequently affected. In the past, only one side may have been treated — and the patient then returned asking for treatment of the now-larger “normal” side as well.

Therefore, careful examination of both breasts is performed and surgery on both breasts considered if need be. If this smaller amount of gynecomastia is not addressed at surgery, then the end result may be that the operated side will look completely normal and the un-operated side may then be objectionable. It is extremely difficult to operate on the larger side and reduce it just enough to match the other side. Thus, appropriate surgery should be done to optimize both sides at the same time.

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10. Is there a relationship between gynecomastia and drugs or medications?
Many drugs and medications produce gynecomastia as a side effect. If you are taking any medications, you would be wise to read about any potential gynecomastia-like side effects online. Recently, there has been a flurry of media exposure about the drug Risperdal, a psychotropic medication which produces gynecomastia as a side effect when given to adolescents.

Some illicit drugs such as marijuana, heroin and bodybuilding steroids can also produce gynecomastia. It may also occur while taking seemingly harmless “supplements”, some of which may have hormone-like qualities. In some cases, stopping the medication may result in a diminishment of gynecomastia but most often, once the gynecomastia is present and established, it usually will remain unless corrective male breast reduction surgery is performed.

Some men knowingly take anabolic steroids and attempt to prevent the development of gynecomastia by self medicating themselves with other drugs to block the side effects of the steroids. Most often this is done without a doctor’s supervision. It is our strong professional opinion that tampering with one’s delicately balanced hormonal system – particularly without appropriate physician supervision and blood testing — is totally inappropriate, dangerous to one’s health and should not be done.

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11. Is a complete hormonal workup by an endocrinologist required prior to surgery?

No. Commonly, gynecomastia patients note that it commenced during puberty and then remained with them. In the vast majority of these gynecomastia patients, hormonal tests reveal normal levels of testosterone and estrogen.

Dr. Jacobs will take a complete medical history during the consultation. If there is anything suspicious, then further investigation may be necessary. The patient’s history of the problem may indicate that abnormal hormone levels may be present (eg sudden development of gynecomastia in a healthy 20-something male) and that hormonal evaluation is necessary. The other possible causes such as illicit drugs (marijuana, body-building steroids), side effects of prescribed medications, adrenal tumor, pituitary tumor, testicular tumor, cancer, etc must also be evaluated. Dr. Jacobs will never refuse to have complete hormonal testing performed prior to surgery if the patient requests it. However, in most instances, all the tests will come back as normal.

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12. I have an underlying medical condition (HIV positive, prostate cancer, heart disease, etc.). Can surgery for gynecomastia still be done?

Successful gynecomastia surgery can be performed despite an underlying medical condition. A thorough evaluation by your personal physician is most important to clear you for elective male breast reduction surgery.

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13. What are “bitch tits” in body builders?
Body builders are a unique sub-set of patients with gynecomastia. For the most part, they have very low percentages of body fat and are in excellent physical and nutritional shape. Many of them have taken anabolic steroids without proper physician supervision. The obvious goal of these steroids is to help bulk up muscles but the frequent side effect is the development of excess breast tissue (commonly called “bitch tits”). This is due to the conversion (termed aromatization) of the testosterone they have taken into estrogen. The estrogen, in turn, then promotes the growth of breast tissue. They complain mostly about very localized gynecomastia (just under or around the areola) and/or puffy nipples, although some very large growths of breast tissue have been encountered.

In these patients, a peri-areolar incision (incision around the edge of the areola) is done 100% of the time. Liposuction is often done to help re-distribute the skin. Drains may be used to promote faster healing and prevent build-up of fluids. The results are usually permanent providing that additional illicit drugs are not used in the future.

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14. I am taking Propecia (Finasteride) to prevent hair loss. What are the implications of this?

Propecia is an excellent medication to stop the progression of hair loss – but it will not result in hair re-growth in areas where hair has been totally lost. In essence, if you have advanced balding, don’t bother.

On the other hand, many young men, when faced with early hair loss, may decide to take Propecia — and it will usually work for them. Unfortunately, in a small percent of individuals, there may be a side effect. The company calls it “swelling of the breast,” which would seem to indicate fluid accumulation. That is definitely not the case. It is actual growth of breast tissue – called gynecomastia. The problem is that there is no way to know, to predict or to test which individuals may develop this side effect ahead of actually taking the medication – and then it may be too late. Once the tissue develops, it very rarely disappears, even if the medication is stopped.

Two scenarios have been observed. These are all anecdotal and based on a few cases only. There are no definitive medical studies available and no guarantees that individual results will be the same:

A) For men in whom gynecomastia developed prior to taking Propecia (eg, during puberty) and then took Propecia with no apparent added growth of the breasts, gynecomastia surgery has been performed and there has been no recurrence of gynecomastia even if the patient continued on Propecia.

B) For men in whom gynecomastia developed directly after commencement of Propecia, gynecomastia surgery can be performed but continuation of Propecia after surgery is not advised for fear of recurrence.

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15. Does insurance cover the cost of gynecomastia surgery?

Gynecomastia. Before and After Photos - patient 4 (oblique view)

Unfortunately, insurance companies over the past few years have adopted a position that this is a purely cosmetic procedure and therefore refuse to pay for it. Indeed, if the term “liposuction” is mentioned in the operative report, the claim will be automatically denied, despite the fact that liposuction is just one adjunctive instrument (like a scalpel or a scissor) which is routinely used in this type of surgery by every medical professional — and has been used routinely in this manner for the past 30 years. Yet, the insurance companies term liposuction as investigational and thus deny coverage.

Some insurance companies will indeed provide limited coverage for surgery, but have such demanding requirements for coverage that it is virtually impossible for the average guy to qualify.

For example, some insurance requirements include:

  • It must be gland related and not related to obesity or drugs
  • The procedure must describe glandular excision
  • For adolescent males, a bone age test must be done to show that the gynecomastia is not expected to resolve itself post-puberty
  • Must show a risk towards eventual manifestation of any or all of the following: depression and isolation, weight issues, potential adolescent diabetes and cardiovascular issues
  • Klinefelter’s Syndrome (patient has XXY chromosomes rather than XY)
  • Hormonal causes have been excluded or, if present, are being treated
  • Gynecomastia persists despite correction of any underlying causes
  • The condition is associated with persistent breast pain despite the use of analgesics for a reasonable period of time
  • Glandular breast tissue confirming true gynecomastia is documented on physical examination and/or mammography
  • Gynecomastia is American Society of Plastic surgeons classification Grade II, II or IV
  • Use of potential gynecomastia-inducing drugs and substances has been identified and discontinued for at least one year when medically appropriate
  • Photographs (front and side views) confirm the presence of gynecomastia
  • Patient must be age 18 or older or have demonstrated a completion of puberty
  • Coverage for surgery for gynecomastia when performed solely to treat psychological or psychosocial complaints is considered cosmetic in nature and not medically necessary – thus the claim will be denied

Unfortunately, the insurance companies remain immune and uncaring as to the emotional damage that this condition engenders.

Dr. Jacobs does not accept insurance for his surgery. However, he will cooperate with the patient in submitting an insurance claim on the patient’s behalf after surgery is completed. There is absolutely no assurance that the claim will be approved by your insurance company. Any reimbursement from the insurance company will then go directly back to the patient.

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Gynecomastia. Photo - nipple
Gynecomastia. Before and After Photos - patient 5 (oblique view)

16. What do the scars look like after surgery?

Every effort is made to minimize the scars for surgery. Usually a 3 mm (1/8 inch) incision is made on the side of the chest just down from the armpit. This heals so well that, in time, it will resemble a small blemish rather than a scar.

If an incision is made around the bottom edge of the areola, it tends to heal extremely well and, although permanent, is virtually undetectable in most patients. Please view the photos of peri-areolar scars in the photo gallery elsewhere on this website. Every single
photo is that of a post-operative patient with a peri-areolar scar.

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17. What are drains and when are they used?
Drains are used at the discretion of the surgeon. They are plastic tubes which may be left inside the chest and which exit through the skin. They are usually attached to a rubber bulb which serves to exert a suction effect and then collects any fluids. Drains may remain in place for a brief or an extended period of time.

Some surgeons use drains routinely. Dr. Jacobs uses drains only rarely, depending on need. His instruments, surgical technique and post operative care regimen combine to make the use of drains largely unnecessary.

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18. What are the most common complications after gynecomastia surgery?
Gynecomastia surgery is very safe surgery. The operation is conducted just under the skin and not into any body cavity, such as the chest or the abdomen. However, as in any surgery, complications may arise. Fortunately, the possible complications are treatable and non life-threatening. There are three common possible complications:

  • Bleeding/Seroma. Bleeding occurs during surgery but it is stopped by the surgeon before the operation is completed. No patient is allowed to leave the operating room if actively bleeding. Rarely after surgery, a blood vessel may open up and bleed – this is called a hematoma. This may happen within hours, days or even a week or two afterwards. Sometimes it is associated with a patient being non-compliant with the post-op instructions – and sometimes there is no explanation. Should bleeding occur, Dr. Jacobs should be notified and the patient will be asked to return ASAP for evaluation. Small amounts of bleeding may just be observed. Large collections of blood may require a brief return trip to the operating room to remove the blood. A seroma is a collection of clear, yellowish fluid, which may also occur after surgery. These are usually removed by syringe aspiration.
  • Infection: Infection is exceedingly rare. Gynecomastia surgery is clean surgery and antibiotics are routinely used for prevention. Should it occur, appropriate medical care will take care of it.
  • Irregular contours: Irregular contours, including the “crater” deformity (in which too much tissue is removed directly below the areola), are best treated by recognition and prevention. Dr. Jacobs’ philosophy is to spend whatever time is needed in the operating room so that the chest contours at the end of surgery are as good as possible. Irregular contours after surgery rarely improve spontaneously and may require revision surgery. Dr. Jacobs’ personal revision rate is near zero.

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19. If surgery is performed, will the results be permanent? What if I gain weight after the surgery?
Surgery will remove much but not all of the breast tissue and it will not re-grow (much as a woman’s breast will not re-grow after a mastectomy for breast cancer). Should you gain substantial weight after surgery, then some amount of fat will return to the chest but it will also be distributed over other parts of the body so that you will not regain the specific enlargement on the chest that you had prior to surgery. Conversely, if you lose weight after gynecomastia surgery, the results of the surgery will be enhanced.

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20. Can liposuction be performed on other areas of the body (for example, abdomen or love handles) at the same time as the gynecomastia surgery?
Yes. This is called a Torsoplasty and it is performed quite often. A torsoplasty can take a good body and make it a great body – but it cannot be performed on obese men. It is designed for men who are at or close to normal weight but who have stubborn areas of fat that detract from their overall appearance. Since a torsoplasty is a longer operation, with additional anesthesia, the decision to do it must be based upon Dr. Jacobs’ best judgment of your overall health.

Please read further about Torsoplasty elsewhere on this website.

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21. I have very large areolas — what can be done to reduce the size?
In the majority of cases, the chest skin will spontaneously tighten after the excessive tissue beneath (breast and/or fat) has been removed in the course of surgery. Since the nipple/areola is also a skin structure, it too will tighten and diminish in size. In fact, the average areolar shrinkage is about 15-20%. The areola will also darken somewhat in color after surgery. Hard to imagine this? Just think of a balloon with a circle drawn on it. Then let some of the air out — the circle (think of the areola) will be smaller. One added bonus: if an incision has been made in the areola to help remove glandular tissue, the resultant scar will also shrink in size.

In rare cases, when the areola is extremely large, surgery can be performed to reduce it to a more appropriate size. It requires a permanent suture to be placed under the skin to prevent post-operative spreading of the areola. The surgery requires an incision completely around the edge of the areola. Post-op problems can include spreading of the scar, distortion of the areolar contour and the possibility that one could feel the permanent circular suture under the skin.

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22. What can be done for “puffy nipples”?

Gynecomastia. Before and After Photos - patient 6 (oblique view)

“Puffy nipples” is a common complaint but one for which treatment is certainly possible. It refers to a “dome-like” or rounded shape of the areola, which projects outward from the surface of the surrounding skin. Puffy nipples can exist alone on a man who is very thin or it can exist on a chest that is already enlarged with gynecomastia.

As you know, your nipples and areolas will change in response to temperature changes or physical/emotional stimulation – the nipples will protrude more and the areolas will flatten and shrink in diameter. This ability to change has to do with tiny muscle cells within the areola (pigmented skin). These changes will still occur even after successful surgery for puffy nipples. No surgery, injection, pill, cream, etc can substantially alter this normal bodily physiologic change. Some guys may pinch their nipples to stimulate them and make them flatten – but this improvement is only temporary.

The usual cause of puffy nipples is firm breast tissue directly beneath the areola which is causing extra projection of the areolas. Surgery to remove this breast tissue must be done carefully, for if overdone, it can result in a depression (like a saucer) which is difficult to correct. In addition, the surrounding skin must be treated so that it will allow all the extra areolar skin to settle down and re-distribute over the chest wall.

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23. What can be done for very large, female-type nipples (not the areolas)?

Gynecomastia. Before and After Photos - nipples

Nipple enlargement (hypertrophy) can consist of abnormal length, abnormal width or both. A normal male nipple is rudimentary compared to females – just a few millimeters high and a few millimeters wide. Surgery can be performed to correct either or both of these conditions at the same time. Dissolving sutures are used which will fall out during the healing process. The scars resulting from this procedure are virtually invisible. These procedures can be performed alone or in conjunction with gynecomastia surgery.

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24. I have very long, narrow, pendulous breasts. What can be done for this?
This is a rare condition called “tuberous gynecomastia” in which the excess breast tissue is concentrated only behind the nipple/areola instead of spreading out over the entire chest. This is akin to the “tuberous breast” problem (breast shaped like a zucchini) that is seen rarely in women. There is a difference, however, between how this is treated in men and women.

In women we wish to preserve the breast tissue but make the breast rounder, fuller, larger and spread over the entire chest. This is achieved through an incision around half of the edge of the areola and then the placement of a suitably sized breast implant.

For a male, the opposite is desired. A male wants to be flat and contoured, with much smaller areolas and no excess tissue at all.

Gynecomastia. Before and After Photos - patient 7 (frontal view)

For minimal to moderate problems, the usual surgical approach would involve a minimal scar technique: aggressive liposuction and then glandular excision through a peri-areolar incision. Additional and substantial treatment of the surrounding skin must be done to aid in re-distributing the skin. The skin will then contract and tighten by itself and the areolar diameter will diminish in size. Skin tightening may take some time. Post-operatively, strenuous chest exercise to build up the size of the pec muscles is recommended – the bulkier muscle may take up some of the slack of the skin.

For more severe cases, the above technique will not work. In this situation, there is often a very wide areola with dense glandular breast tissue directly beneath it and excess skin that has nowhere to go. This will call for a different approach and technique which will, unfortunately, leave a few more scars on the chest – in essence a trade-off of scars for a trimmer, taut and contoured shape. You would certainly feel comfortable wearing a snug T-shirt.

In essence, the operation would consist of temporary removal of the nipple/areolas, which would be made smaller in the process. Then the breast tissue and excessive skin would be removed, leaving a horizontal incision on the chest. Then, the nipple/areolas would be replaced back on the chest as a skin graft. The anticipated net result would be a smooth, contoured flat chest but with a horizontal scar (hopefully not too long) on each side. The new nipple/areola would be in the middle of each horizontal scar. The nipple/areola skin graft would be “ornamental” in that it would be insensate – ie, it would have minimal feeling. This operation is a lengthy operation similar to a double mastectomy which would be performed on a woman.

These cases do not all fit into a specific niche – oftentimes the plastic surgeon must use all his ingenuity and experience to custom design an operation for the patient.

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25. What can be done for scarred nipples after nipple rings have been removed?
When nipple rings are removed, there is frequently a build-up of scar tissue projecting from either side of the nipple so that it has a dumbbell appearance. Very careful injections of cortisone can be of help to melt the scar tissue and provide a more normal appearance to the nipple.

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26. Why do I have post-operative diminished feeling of the skin and nipples?

Gynecomastia. Before and After Photos - patient 7 (oblique view)

No matter what method is used for surgery, there is ALWAYS post-operative numbness of the chest skin and the nipples. It will feel like your lip feels after a dental anesthetic injection — you can feel pressure but not fine, light touch. This is due to the temporary interruption of sensory nerve fiber conduction to the skin and nipples. There is not just one sensory nerve to the nipple – there are hundreds of tiny nerve endings. In essence, the nerves are “in shock” and need time to recover.

The nerves begin to “awaken” soon after surgery. As they begin to work and to fire signals, the patient will experience any or all of the following symptoms: tingling, intense itching, super sensitivity of the nipples and an occasional sharp shooting pain that comes and goes before you know it. There are all normal and indeed reflect that healing is occurring. There are no treatments to make these symptoms disappear.

Eventually the symptoms do subside and in the vast majority of men, normal sensation returns to the skin and nipples. But this is a very slow and gradual process so that you may not realize the return of feeling until your attention is directed towards it. It may take anywhere from 6 to 12 months for full sensation to be recovered. There are no treatments available to hasten this process – you just have to wait it out.

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27. Why is it necessary to wear a compression garment after surgery??
A post-op compression garment, worn 24/7 for one month (minimum) after surgery, is absolutely essential for appropriate healing and for an excellent result. Why is it so important? Despite the small incisions used for the actual operation, there is always a large area of injury under the skin. And after surgery, this injured tissue wants to ooze and swell. The only methods we have available to diminish this tendency is pressure – and lots of it. This pressure will stop any oozing, diminish swelling, help the skin to tighten and make sure the skin attaches to the underlying tissue. It also virtually negates the need for drains.

You will be provided with a snug compression garment appropriate to your body type at the time of surgery. Please wear it continuously 24/7 except when you shower. The body wants to swell for several weeks after surgery, so continued use of the garment will provide for better and much faster healing. Some patients complain about wearing it, but it is an absolute necessity.

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28. Will my chest be symmetric after surgery?
Maybe. There are very few absolutely perfectly symmetric human beings. We all have some minor (or major) discrepancies between our right and left sides. During your gynecomastia surgery, Dr. Jacobs does everything possible to make each side of your chest as good as that side can be. In reducing the excess tissue on the chest, minor asymmetries of the chest, which may have been masked by the excess overlying tissues, are then revealed. For example, one muscle may be larger than the other. The muscle itself may be attached to the ribs and sternum in slightly different ways on both sides. The rib cage may be different on each side. Posture and scoliosis (curvature of the spine) will also play a role.

Some men start off with asymmetric gynecomastia – one breast being larger than the other. Although surgery will reduce each side to be as good as possible, the (originally) larger side, with more stretched out skin and perhaps a larger diameter areola, will take longer to tighten and catch up to the smaller side – and it may never catch up 100%.

For the most part, there will be an overall significant improvement of the chest. Some men may have been mildly asymmetric to begin with – but they never noticed it. After surgery, and after carefully inspecting their chest 100 times a day, men may notice and dwell on certain minor asymmetries. Unfortunately, some of these post-op minor asymmetries cannot be corrected.

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29. When should I massage my chest after surgery?
One should NOT massage the chest unless instructed by Dr. Jacobs. Massage can actually cause more swelling. There may come a time in your healing phase, usually at least a month or two after surgery, when indeed massage may be beneficial. Dr. Jacobs will tell you when and how to massage if he feels it would be helpful.

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30. What is done with the tissue removed during surgery?
When aggressive liposuction is performed, the tissues are physically destroyed as they are suctioned as a thick liquid from the body. This liquid is then carefully disposed as “medical waste.”

When solid tissue is removed via a peri-areolar incision, that tissue is weighed and then sent to a laboratory for pathological examination (as required by New York State law). The lab always sends a report on the findings to Dr. Jacobs. The lab will also send a bill to the patient, which may then be submitted to insurance. The tissue is then disposed as “medical waste.”

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31. When can I return to my usual exercise routine after gynecomastia surgery?
Dr. Jacobs recommends at least four weeks away from strenuous exercise. Why? Isn’t exercise good for you? Yes, exercise is great — but when one exercises, the blood pressure always rises. And it is the rise in blood pressure, soon after surgery that can result in increased swelling. It might also open a blood vessel under the skin that had been sealed during surgery – and you might bleed and fill up with blood under the skin. This can happen even weeks after surgery.

With anticipated normal healing, one may gradually return to the gym after one month. There may be some swelling upon return from the gym – then overnight use of the compression garment would be helpful.

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32. What will happen to my chest if I lose weight after surgery?

Gynecomastia. Before and After Photos - patient 8 (frontal view)Gynecomastia. Before and After Photos - patient 8 (oblique view)
5 years after surgery with weight loss and exercise.

The results of the surgery will get even better.

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33. Will the presence of chest acne affect my eligibility for gynecomastia surgery?
Acne on the chest area will not affect your eligibility for gynecomastia surgery, as long as it is quiet. If there are active pustules or infection, these must be treated by a dermatologist until they are quiet. If surgery is performed with any active infection in the area, then it substantially increases the risk for infection after surgery.

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34. What is skin elasticity and why is it so important in consideration for gynecomastia surgery?
Think of skin elasticity as billions of tiny “rubber bands” in the skin. If the “rubber bands” are stretched too far and for too long, they become tired and lose their ability to bounce back and tighten by themselves. The skin sign of extreme loss of elasticity is stretch marks, which are areas of the skin where the elastic fibers have actually broken, just like stretching a rubber band until it breaks. There is no way to restore elasticity once it has been lost.

It is important to have sufficient skin elasticity in order to qualify for minimal scar surgery. In essence, the excess tissues are removed via the minimal incisions – but the skin has to be able to tighten by itself. This tightening ability is determined by the amount of elasticity in your skin.

Elasticity is diminished in several ways: by the natural aging process, by smoking, by excess sun exposure and tanning, and most importantly, by being overweight or obese and thereby stretching out the skin. Once elasticity is lost for any or all of the above reasons, there is no way to replace it. Thus, in certain cases, there may be a need for additional incisions during surgery to tighten up any loose skin.

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35. Am I more prone to develop gynecomastia if I am overweight?
No. There can be very thin patients with large breasts and overweight men with flat chests. However, overweight men often put extra fat on their chest, for that is one of the places that fat is first deposited. Frequently, obesity and gynecomastia will coincide.

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36. How will I view myself after gynecomastia surgery?
Prospective gynecomastia patients are always told that the surgery will affect two parts of their body: their chest and their head (ie, self image). What happens to the chest is Dr. Jacobs’ responsibility. But what happens to your own self image is different and is subject to variables which are not directly controllable by Dr. Jacobs.

For example, most patients rapidly adopt and accept their new chest contours and are totally delighted with their results. There are some others who take many months until their mental self image adjusts to the new physical image. And there are a few patients who, for whatever reason, never seem to accept the overall substantial differences and improvements in their chest, despite before and after photos which can often be quite dramatic. They may micro-scrutinize and nit-pick about their results, seemingly never able to be satisfied. In some of these patients, there may be underlying psychological reasons for this, which may best be explored with a mental health professional.

Unfortunately, there is no way to predict, pre-operatively, how a patient will react after the operation.

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37. I have had prior surgery for gynecomastia by another surgeon and I am not pleased with the results. Can anything be done?
Yes, oftentimes improvement can be achieved. Scars from prior surgery are permanent, although they may be improved by scar revision surgery. Contour irregularities, crater deformities, lax skin, malpositioned nipples, scar tissue under the skin can all be improved on occasion. Each of these possible problems must be individually evaluated at a consultation.

Please see the section on Revision Gynecomastia Surgery elsewhere on this website for further explanation.

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38. What is a prolactinoma?
A prolactinoma is a benign tumor of the pituitary gland in the brain. It secretes prolactin, a hormone which directly stimulates breast tissue to grow, lactate and produce milk Many times, the first sign of a prolactinoma is a male who develops gynecomastia at an odd time of life, such as in his 20’s or 30’s. Sometimes there may be actual secretion of milk, which may be a tip-off to the diagnosis.

The first step to diagnosis is usually a blood test to determine prolactin levels. If they are elevated, then additional tests (often a CAT scan or MRI) are ordered. If a prolactinoma is confirm by these tests, then a medication, Dostinex, can offer satisfactory long term treatment. Once prolactin levels have returned to normal levels, the patient may be a candidate for gynecomastia surgery.

39. Should I lose weight in preparation for surgery?
Losing just a few pounds or even 10 pounds will not affect your surgery one way or the other. An unhealthy crash diet is certainly not recommended. Rather, a good, healthy diet with lots of protein is worthwhile. Sometimes, supplements with extra Vitamin C and Zinc may be helpful.

However, if you plan on losing substantial amounts of weight, then surgery should definitely be deferred until the weight is lost and you are stable at the new weight. Then a re-evaluation may be necessary in order to assess the specific type of surgery required for your new shape.

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39. Should I lose weight in preparation for surgery?
Losing just a few pounds or even 10 pounds will not affect your surgery one way or the other. An unhealthy crash diet is certainly not recommended. Rather, a good, healthy diet with lots of protein is worthwhile. Sometimes, supplements with extra Vitamin C and Zinc may be helpful.

However, if you plan on losing substantial amounts of weight, then surgery should definitely be deferred until the weight is lost and you are stable at the new weight. Then a re-evaluation may be necessary in order to assess the specific type of surgery required for your new shape.

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40. I am a vegetarian – am I still eligible for gynecomastia surgery?
Absolutely yes. However, many vegetarians are low in protein, which is necessary for proper healing after surgery. Therefore, it is recommended that you increase your protein intake prior to and subsequent to surgery. This can be in the form of extra protein shakes. You might consider some lean poultry or fish as well.

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41. Should I work out and build up my chest muscles prior to surgery?
No, this is not necessary. If you wish to work out, that is fine but it will have no effect on the operation.

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42. How does smoking affect gynecomastia surgery?
Aside from its deleterious affects on the lungs, smoking contains nicotine. Nicotine acts on small blood vessels to tighten them, thereby narrowing them and reducing blood flow. Obviously, good blood flow is essential to proper wound healing. It is our firm recommendation that smoking be stopped for two weeks prior to surgery and two weeks subsequent to surgery.

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43. I have gynecomastia but am afraid of surgery. What can I do?
While surgery is a safe and established treatment for gynecomastia, some men have a fear of surgery. If so, then purchase of a snug compression garment can provide a better and more comfortable shape for you. There are many garments available in sporting goods stores and over the internet.

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44. I was formerly very heavy. I have lost weight but still have enlarged breasts and lots of loose skin and droopy nipples. What can be done?
This is often seen in patients who have lost some weight on their own or in extreme forms on patients who have had gastric bypass surgery and lost huge amounts of weight. Every case is different and must be evaluated independently. There is no question that we can successfully remove the underlying excess breast and/or fat tissue. The culprit here is that the skin has lost much of its elasticity and is unable to tighten by itself, so minimal scar surgery will not be applicable. Some amount of surgical skin removal and tightening will be necessary and the nipple may have to be elevated into a better position – all of this will result in permanent scars. The exact placement of the scars will vary with the individual. It then becomes a trade-off of scars for a better, tighter, trimmer shape.

In many cases, there is only a little skin laxity to be anticipated after surgery. In these cases, we will recommend the standard liposuction procedure with minimal scars (with or without glandular removal as needed) as a first stage. Then we wait and observe for a minimum of 6-8 months to give optimum time for skin tightening to occur by itself. Then the patient and Dr. Jacobs will evaluate the results and decide whether further skin tightening (admittedly with scars) will be necessary or desired. If surgery is to be done, then the scars will be far less extensive than had it been done at the first stage (because some skin would have tightened during the healing time) and it would be a much smaller operation. On the other hand, sometimes the patient is quite satisfied simply with the results of the first procedure — maybe not perfect but perfectly
acceptable — and then no further surgery would be done.

Please see the section on gynecomastia surgery for overweight men elsewhere on this website.

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45. Is all the breast tissue removed during gynecomastia surgery?
A certain amount of breast tissue is present in 100% of men – that is the normal condition. Gynecomastia is an excess of tissue, including breast tissue. Proper surgical treatment is aimed at reducing the excess tissue to a more normal amount.

Gynecomastia surgery is not cancer surgery, where every last cell of breast tissue need be removed. In fact, if surgery for gynecomastia were aimed at removing all breast tissue,
the results would be near mutilation of the chest.

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46. Are there any guarantees as to the outcome of gynecomastia surgery?
No surgeon can provide a guarantee or warrantee as regards the outcome of surgery – there are just too many variables. Aside from the surgery itself, there is a question of appropriate patient compliance with post-operative instructions, the vagaries of individual healing characteristics, and of course, the influences of Mother Nature.

The only guarantee that Dr. Jacobs can make is that he will use all of his energy, experience, diligence and skills to provide the very best operation possible for every one of his patients.

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47. What is Dr. Jacobs’ policy on revision surgery?
It is Dr. Jacobs’ policy to stand behind his work. No effort is spared in the operating room to provide the patient with a smooth, flat and contoured chest. Recurrence or re-growth of breast tissue is extraordinarily rare. More commonly, though still rare, is the unpredictable development of scar tissue on the chest or directly beneath the nipple/areolar complex as a result of the patient’s unique and individual healing processes. This may require one injection or a series of injections of cortisone to “melt away” the scar tissue. If these are done at all, they will not begin until at least three to four months or longer after surgery. There is no charge for these injections.

If revision surgery is recommended by Dr. Jacobs, then there will be no charge for the surgery but there will be a charge for sedation anesthesia provided by the anesthesiologist and for the surgical facility. Revision surgery will not be performed solely at the insistence and demand of a patient, unless agreed upon by Dr. Jacobs. Dr. Jacobs’
revision rate for his own gynecomastia patients is close to zero.

It is the policy of this office to offer these free services for up to one year after surgery.

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48. How is payment made for surgery? Are payment plans available?
Major credit cards such as American Express, Visa, Mastercard and Discover are welcome. Payment can also be made by cash, bank checks and money orders. Personal checks are accepted but all types of checks must be received at least 10 business days prior to surgery. Wire transfers are not accepted.

Dr. Jacobs also works with several outside companies, including Care Credit, to provide long-term, low-interest loans directly between the patient and the company. These are companies that provide loans for elective medical procedures. Applications for these loans are made directly to the company by the patient in complete privacy. Please contact the office directly for further information – (212) 570 6080.

49. How can I locate a doctor who does this procedure in my area?
It is strongly recommended that you consult a board-certified plastic surgeon. In particular, seek a plastic surgeon who has demonstrated significant interest and experience in performing gynecomastia surgery. Make sure that you visit several surgeons for their opinions and ask to see their personal photographic collections of before and after gynecomastia patients. Make sure the surgeon is willing and capable of employing any and all methods, including liposuction and direct excision of gland, during the operation.

Do not make your decision based on fee alone. Fees vary tremendously among various surgeons. Talent, skill, judgment, experience and technique also vary significantly between surgeons. Dr. Jacobs has often seen patients choose the least expensive surgeon, only to end up with fair, poor or terrible results. Then, they consult with him and pay additionally to correct the problem, and sometimes it is permanent and can’t be corrected. Please accept some words of wisdom: when it comes to surgery, like many things in life, you do get what you pay for! The best suggestion is to choose the surgeon with whom you feel most comfortable and confident. The fee, while important, should be the least of your considerations. Remember, you will enjoy and appreciate your new chest for many years to come – and long after the fee is forgotten. For a referral, you may call the American Society of Plastic Surgeons’referral line 888 475 2784 or visit their website, www.plasticsurgery.org

In many cases, there may not be a gynecomastia specialist near you. Many people will travel to secure appropriate services with an expert and Dr. Jacobs has treated patients from across the United States and around the world. If you are interested in having an email evaluation by Dr. Jacobs prior to travelling to New York City, kindly contact him at (212) 570 6080 or by email, info@drelliotjacobs.com and you will be provided with all necessary information. You may also fill out the contact form on this website and provide any personal messages as well. Finally, you may write to him at 815 Park Avenue, New York, New York 10021.

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