Many overweight or obese men in New York are concerned about their breasts and seek evaluation and treatment for their gynecomastia. They imagine themselves with a bodybuilder’s type of chest and seek surgery with the most minimal of scars. When treating these men, a very careful physical examination and discussion are needed to determine what their specific goals are. Realistic expectations will be discussed, for being overweight or obese will absolutely limit some of their goals.
Some men are content with their weight and simply want to reduce the size of their breasts. Others simply want to lose weight but their breasts provide too much embarrassment for them to go to a gym and exercise. For these men, compromise surgery, to minimize the size of their breasts with minimal scars, may provide an answer. Their results will not be a trim, taut, masculine chest but they will be much more comfortable.
There are other overweight men, however, who seek a taut, masculine chest. For these men, there are basically two options:
Lose weight to a comfortable and stable weight – and then have surgery. The surgery may require additional scars to deal with any lax skin and to correct the position of the nipple.
Have minimal scar male breast reduction surgery and allow their skin to tighten as best possible. Then re-evaluate at 6-8 months after surgery and consider if additional surgery to tighten the skin and re-position the nipple is desirable. This is called staged surgery.
Finally, there are men with huge, pendulous breasts who simply want to be rid of them despite their being overweight. These men will require some type of mastectomy with a reconstruction of the chest. These operations result in major scars, which are a trade-off for a trimmer and more comfortable chest
It is only after a detailed physical examination and thorough discussion with the patient that a surgical plan can be devised – and that plan will be unique and specifically designed for every individual patient. Attention will also be paid to any excess fat which extends onto the sides of the chest or into the armpit – and a recommendation will be made to address these areas as well. See below for examples of various surgical options.
THE DOUBLE WHAMMY OF WEIGHT GAIN
As men gain weight, fat is preferentially deposited on the chest as well as the abdomen and love handle areas. And unfortunately, when weight is lost, these are often the last areas in which the fat decreases. Weight loss is also unpredictable – one cannot dictate to one’s body where the fat should be lost.
Once one becomes overweight, the excess fat tissues will produce estrogen through a series of complex biochemical reactions. Then, the increased estrogen will stimulate the growth of additional breast tissue.
Therefore, being overweight results in fat deposits on your chest and additional growth of breast tissue as well – a double whammy.
WEIGHT GAIN STRETCHES THE SKIN
Consider a rubber band that has been stretched around a package for a month. When released, it does not return to its original state – it remains somewhat stretched out. The same may be said for the billions of elastic fibers in the skin. When the skin is stretched due to weight gain, those elastic fibers are stretched out and the skin loses its elasticity. This loss of elasticity then becomes permanent – there is absolutely no way to restore elasticity once it has been lost.
In fact, the extreme example of stretched out elastic fibers is stretch marks, technically called striae, which are skin areas where the elastic fibers actually broke! And just like a broken rubber band, the ends of the broken elastic fibers cannot be re-attached. Thus, to this date, there is no cure or treatment for stretch marks.
Skin elasticity is also diminished through smoking, excessive sun exposure, and naturally during the process of aging.
When overweight men consider male breast reduction surgery in New York, careful attention must be paid to the quality and elasticity of their skin. Since minimal scar gynecomastia surgery depends upon having excellent intrinsic elasticity of the skin, and since that elasticity has been diminished due to weight gain, the decision for the proper procedure must be made after extensive discussion with the patient. Compromises must be made – either a less than perfect result but with minimal scars or an excellent, contoured result, but with additional scars on the chest. 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.
SHOULD I LOSE WEIGHT PRIOR TO GYNECOMASTIA SURGERY?
Many men question whether losing weight is preferential prior to surgery. The answer is a resounding yes. It is far better to operate on men who are at their best and most comfortable weight. They are also healthier as well. Of note, if one wishes to lose only 5-10 pounds, that can be done either prior to or subsequent to the surgery, with no effect on the outcome of the operation.
On the other hand, if one has surgery when overweight and then loses substantial amounts of weight, then the results of the surgery will be compromised, the skin will become lax, the nipples will droop and additional surgery may be necessary to deal with these problems.
WHAT WILL HAPPEN TO MY GYNECOMASTIA WHEN I LOSE WEIGHT?
Gynecomastia in overweight or obese male always consists of varying ratios of fat and breast (gland) tissue. While the breast tissue is usually concentrated under the nipple, it does extend outward into the surrounding fat, similar to fingers which are interlaced with one another. When one loses weight, each individual fat cell will shrink in volume, but the fat cells do not disappear entirely. By contrast, the breast tissue will retain its own size – it doesn’t change. As a result, the breast will become smaller overall but the actual amount of breast tissue remains the same – it just becomes condensed as the intervening fat tissue has been reduced. At the same time, the body will also become thinner, and by comparison, the breasts will still be large.
In addition, as weight is lost, the breasts will droop due to loose skin which cannot tighten by itself due to the loss of elasticity. The nipples will frequently be too low on the chest as well. Surgery will then be necessary to remove the remaining condensed breast tissue, tighten any lax skin and elevate the nipples to a more normal position on the chest. This surgery is complex and is designed specifically for every individual. Unfortunately, this surgery will also include some additional scars while providing a trim and contoured chest. That will be the trade-off.
WHAT IS BMI AND WHY IS IT USEFUL IN GYNECOMASTIA EVALUATION?
The Body Mass Index, or BMI, is a good way to measure obesity and to determine the ideal weight for one’s height. It is a complex calculation of the ratio of weight to height and it can provide a guideline for those who wish to bring their body into a normal range. This is a better way to look at your weight than just your weight alone. The BMI calculation loses some accuracy for very young children as well as for very muscular men, who may have a higher BMI due to the higher weight of muscle versus fat.
Or, you can calculate your own BMI in the following manner:
BMI (metric) = your weight in kgs. divided by the square of your height in meters
BMI (English) = your weight in pounds multiplied by 703 and divided by the square of your height in inches
Many overweight or obese men are concerned about their enlarged breasts. These men fall into several categories:
Overweight (BMI 25-30)
Obese (BMI 30-40)
Morbidly obese (BMI over 40)
EXAMPLES OF VARIOUS SURGICAL OPTIONS
A. For men who are reasonably content with their weight, whose BMI is roughly between 27 and 33, who have reasonable skin elasticity and have nipples which are above the usual fold beneath the chest muscle, the best approach is to perform minimal scar surgery, as outlined in the procedure (described elsewhere on this website). One must understand and accept the fact that surgery cannot and should not remove all the excess tissue on the chest and leave the skin paper thin over the muscle. This would not be consistent with the surrounding areas of the body and the results would not be satisfactory. This reflects the idea that there is a certain amount of artistry in performing gynecomastia surgery – knowing how much tissue to remove and how much to retain.
The net effect of this surgery will be to significantly reduce the size of the breasts, raise the nipples slightly and make the nipple diameter a bit smaller – but oftentimes leave a natural looking fold beneath the chest muscle. The chest will not be tight as the head of a drum – but it will look normal for a guy who is overweight. These results, with minimal scars, may not be absolutely perfect – but may be perfectly acceptable.
This approach also allows time for the skin to tighten as much as it can. It also provides an opportunity to evaluate the results at 6-8 months after the operation. If the patient is satisfied, then nothing further need be done, and the results have been accomplished with minimal scars. If, however, the patient desires additional tightening and lifting, then a second, smaller operation can be done which will elevate the nipples and remove any lax skin. This would result in some additional scars – a trade-off of scars for a tighter, more contoured shape. Another advantage is that over time the skin will have tightened spontaneously so that there is less skin to tighten at a second stage and therefore shorter scars would be needed. This is an example of a two-stage procedure.
On the other hand, there are some men who wish to have everything done at once: removal of the enlarged breast, the elevation of the nipple and tightening of the skin. This can be done but at the cost of some slightly longer scars.
If the nipples are located at or below the fold, then a two-stage procedure is not appropriate. The minimal scar surgery (first stage) would undoubtedly result in an unsightly smaller, flattened, very droopy breast. These situations are best treated in a single stage operation with nipple elevation and excess skin removed at the same time.
B. For men whose BMI is roughly between 33 and 38, compromise surgery may provide some help. In essence, this is minimal scar surgery used to reduce the size of the breasts so that they are less embarrassed about going to the gym or removing their shirt in public. This approach will simply make the breasts smaller, but the breasts will droop somewhat and will have a visible fold under the chest muscle. This surgical approach is useful for some men as an end in itself, or it may provide other men with the incentive to exercise, lose more weight and then return at a lower weight for more definitive surgery to re-contour their chest.
C. For men whose BMI is roughly between 35 and 40, the best option would be to defer surgery and lose weight, either through a dedicated program of exercise and diet or via any type of gastric bypass surgery, which is now safer and more effective than ever. Once you have lost the weight and been stable at that weight, you will be much healthier and you can then consider definitive gynecomastia surgery. Unfortunately, there will still be residual breast tissue present – even after much of the fat tissue has diminished. There will also be lax skin and nipple malposition. Since the pattern of weight loss is decidedly individual, one must return to Dr. Jacobs for a re-evaluation in order to determine the best surgical option for you. In all cases, though, surgery will consist of removal of all remaining excess breast tissue, the elevation of the nipple to a more appropriate position and removal of all excess skin. And yes, there will be scars – again, a trade-off for a tighter, trimmer shape.
D. For men with large and very pendulous breasts, minimal scar surgery is not an option. Rather, they will require mastectomies (removal of both entire breasts) and then reconstruction of the chest and placement of the nipples at a more normal location. There are various alternative techniques for this procedure, which will be described to the patient at the time of consultation. In these cases, the actual BMI may not matter. It may be a guy who has already lost substantial amounts of weight or a guy who is overweight but still cannot deal with his problem.
E. For obese adolescents, with BMI’s up to 35, minimal scar surgery can be beneficial. Although obesity takes its toll on skin elasticity, adolescents have youth on their side and frequently, over time, the skin will tighten surprisingly well so that no additional skin tightening (with additional scars) is necessary. Dr. Jacobs prefers to avoid placing scars on a young man’s chest if at all possible.
Frequently these young men, after surgery and now feeling more self-confident about themselves, will hit the gym, build muscle, watch their diet and lose additional weight. The end results can be remarkable.
F. For men whose BMI is roughly between 25 and 30, who have lost large amounts of weight (ie over 80 pounds or more) and who have remained stable at their new weight, reconstructive plastic surgery can restore their shape and provide trimmer, tighter contours. These men will undoubtedly need reconstruction of their chest. In addition, many other areas of the body may require attention: sagging necks, lax and flabby arms, lax tissues on the back which resemble festoons, flabby overhanging abdomens, lax thighs, etc. There are specific operations designed to address each of these concerns, such as an arm lift, tummy tuck, neck lift, etc. Dr. Jacobs will be pleased to explain them to you.
On occasion, appropriate reconstruction of the chest can be combined with tightening of the upper trunk (sides of the chest) and even continue into the armpit and down the arm to tighten it as well. These are all lengthy procedures and are performed in a hospital under general anesthesia.
G. For men whose BMI is roughly between 25 and 30, who have never been significantly overweight and whose skin has reasonable elasticity, a torsoplasty (described elsewhere on this website), may be a viable option. This is a single operation which combines gynecomastia surgery with liposuction of the abdomen and love handles. It is not an operation for an obese person. Rather, it is best performed on a man who is at or near his ideal weight but who has stubborn areas of fat that cannot be lost. It can turn a good body into a great body!
H. Finally, for men with a BMI of 40 (ie morbidly obese) and above, gynecomastia surgery is truly not an option. Rather than focus on your chest, it would be wiser to concentrate on losing substantial amounts of weight, for your health and longevity are much more in jeopardy. From a purely medical perspective, your chest is really secondary to the overall health threat of your obesity. Treatment of your obesity should be your priority.