Since the very young age I was more overweight than my peers. I can remember well when at the end of my primary school I was not eager to take part in sport classes irrespectively of whether there were some classes in the gym or in the swimming pool. Every time I needed to take off my clothes and my body evoked slight smiles on the faces of my friends not to mention some malicious remarks as – You look like a girl.
My father was always busy with his own business. Even at home he did not devote much time to my sister and me. So, I had no one to talk to about my different look and share with my doubts. I always admired my father. He was never fat and always looked great. His body was well-built even though he was not so young. My biggest problem was overdeveloped breast. Even my sister from time to time laughed at me saying that they are as large as hers. Was there anything wrong with me?, I thought. One Saturday afternoon I decided to talk seriously with my mother. She always understood me and could always find the best solution. That day my father went for a business trip, and my sister went with her boyfriend to the cinema. I was then 14 years old. I offered my mother some doughnuts and coffee that I bought thanks to my pocket money. My mother was nicely surprised and eager to chat. I told her about my doubts. I asked her whether my problem was due to a disease, overeating and what I should do in that case. She promised me to talk to her colleague who was an internist. On Monday evening she told me that female breast is called gynaecomastia and she scheduled an appointed with the doctor the following week.
What is gynaecomastia?, I thought. In those days there was no Internet so I could not obtain any extra information. I was quite curious and I could not sleep all night. However, there was no other solution but to wait patiently for the scheduled appointment at my mother,s known doctor.
On Thursday afternoon my mother and I arrived at the doctor,s office. The doctor examined me carefully and calmed down saying that there was no need to worry. He explained me in details that gynaecomastia at my age (I was then 14) is something natural and is called youth gynaecomastia caused by overgrowth of the adipose tissue in adolescence. It occurs quite often and refers to 30% of the boys at my age. He also comforted me that with my development my excessive breast would disappear and the boy breast would change into a male breast as soon as the adolescence finished. Calmed down I went out of the doctor,s office. I was happy and dreamt that soon I would look like my handsome and well built dad. I also fell asleep fast and quietly that day.
A few years passed since then. I started studying law. Then I had a lot of studies and no time to take up any sport. My body also changed as the doctor promised but not the way I expected. Still slight breast was visible and after more careful examination one could feel some slight swellings over the areola. After I completed the first year of my studies which by the way was the most difficult one and I could not take up any extra sports, I decided to change my lifestyle and devote more time to physical activities. I started visiting the gym regularly. At first once a week, then during next years of my studies twice or even three times a week. The effects of my hard work were visible soon. The shape of my breast changed significantly and the adipose tissue disappeared almost completely. I was very happy. While measuring my size I resembled more my dad. Well-built shoulders, strong breast muscles, flat abdomen with well visible straight muscles of my abdomen, nice and firm buttocks and thighs. Just an ideal man. I was extremely happy about my appearance. Finally, I believed in me. Unfortunately, I was talked to take some medications because as my friends told me they could enforce the effects of my hard work. They offered me a set of medications and supplements which contained a large dose of synthetic protein and slight amount of steroids. I also had to change my diet completely eating mainly chicken or turkey meat adding more vegetables and fruits eliminating carbohydrates and fat. After a few months my appearance looked even better. However, my happiness did not last long. I was really scared on detecting that on both sides under the areolas and nipples larger swellings than at the beginning of my adventure in the gym. I started to get worried. Was there anything wrong?, I thought. First I asked my friends than my trainer whether they suffered from similar symptoms. Unfortunately they did not know anything and could not help me. Then I reminded myself that when I was a teenager I also had problems with breast. I decided to visit the same specialist as it was 10 years ago when I went with my mother. To my surprised he remembered me very well. The doctor examined me carefully and again detected gynaecomastia but this time it was caused by overgrowth of the gland tissue, not the adipose tissue as it was earlier. While noticing the changes of the shape of my breast he asked me whether I had taken any anabolic drugs. I needed to admit that I took some slight doses in the gym. The doctor informed me that the best solution would be to stop taking the supplements and medications that were one of the causes of gynaecomastia and recommended me to visit a surgeon as the overgrowth tissue could be removed surgically.
As soon as I came back home I started searching in the Internet for some information on surgical treatment of gynaecomastia. I found some addresses of some clinics and scheduled and appointment. When I arrived at the clinic a few patients were already waiting there. After several minutes it was my turn, and I entered the doctor,s office and met a friendly doctor. I took off my jacket and shirt as he ordered. The doctor examined me and said there was no other solution but to excise and the excised material sent to further histopathological examination to be sure that it was not a dangerous change. Actually I made up my decision at once. I needed to perform other examinations like blood and urine tests, the heart beat test and have my lungs x-rayed.
A few weeks passed. On the established day I arrived at the clinic and I must admit I was a little nervous. I did not eat that day as the surgery was to be performed under a general anesthetic. The surgeon examined me one more time and circle the places of the operation. The surgery lasted 1,5 hour. I knew it consisted in suction of the excessive amount of the adipose tissue from a slight cut in the subpectoral fold. In the case when breast gland is of quite huge size, the incision may be enlarged to 5 mm or additionally, semicircular cut down on the border of the areola with the skin surrounding. Just after the operation I woken in a good mood. I wore a special pressure dress, namely a vest that stick firmly to my breast. Next day I came back home.
After a week I went for a control visit at the clinic. The operated places were swollen, bruised and hurt me. In the subpectoral fold, almost invisible 3 mm cuts were covered with a plaster and from the semicircular cut the doctor removed the itches. The special dress although not so much comfortable I needed to wear 5 more weeks. After a week I started massaging the operated regions to fasten their healing. After one month I could come back to the gym. The first effects were visible after 6 weeks. The results were really good. Under the areolas no swellings could be felt and the traces after inserting needles in the subpectoral fold and cuts in the areolas disappeared quickly. I felt like a real man. Then I decided to change my lifestyle and I started eating everything that my mother was preparing for me, and the exercises in the gym limited to once a week. Every day before going to school I practiced push-ups. After several weeks I could do 100 push-ups. To be in a good shape it is enough.
A properly-developed breast of an adult man contains scant amount of gland tissue situated just under the mammal and areola that can be usually detected with fingers or just felt under the fingers as a slight swelling. The male areolas together with the mammilla is from 2-4 cm long in its diameter and is situated at the level of 4th intercostals space, 4th rib or slightly lower. The gland can have a form of a slight swelling located just below the areola or just a split gland tissue grown with adipose tissue without its detectable limit. The largest growth of gland tissue occurs in the case of men taking anabolic drugs. Whereas, the growth of adipose tissue occurs in the case of the men with overweight.
By definition gynaecomastia is uni- or bi-lateral growth of gland tissue and adipose one in the case of men that results in breast growth that finally resembles female one. It is a purely cosmetic and psychological problem. Many men, especially young men, find the presence of huge breast very embarrassing. Especially during summer sunbathing and swimming is connected with showing one,s breast. Also many women pay attention to that part of men,s body.
The name itself derives from Greek gyne meaning a woman, and mastos, i.e. female breast. 32-36% of adult men suffer from gynaecomastia. Usually it is something natural and proper. Gynaecomastia occurs in the adolescence at young boys as well as in male,s menopauses at men at older ages. In both cases we have to deal with overgrowth of gland tissue. The growth of adipose tissue accompanied by obesity can be one of the reasons of gynaecomastia at various ages. Gynaecomastia refers to 38,7% of boys at the ages from 13-17. It achieves its climax at the age of 14. There is also gynaecomastia that occurs together with some genetic diseases as the Klinefelter,s syndrome as well as other diseases related to gender hypoplasia (hypogonadism), endocrinological diseases as well as post alcoholic cirrhosis.
It is estimated that enlarged breast at young men is most often diagnosed as gynaecomastia and at older men obesity or changes connected with testicles tumor. Not rarely cancer occurs. Hyperplasia, i.e. smooth growth of gland tissue consists in moderate proliferation of the canals, the so called out-taking canals of the breast and the growth of the fibrous tissue. It is commonly believed that the factor responsible for stimulating this process are estrogen circulating in blood or similar to estrogen substances.
The classifications of gynaecomastia according Simon, Hoffman and Kahn are most often used classifications. According to them male breast can divided into the following categories: small, moderate, significant and big. The last ones usually require plastic surgery connected with the excision of its excessive amount. Pitanguy additionally divided gynaecomastia into fat and gland one. However, this classification is difficult to estimate before the surgery.
The only way of treatment of gynaecomastia is surgical removal of excessive amount of adipose or gland tissue. Gyneacomastia was first mentioned in 625-690 (Paulus Aegenta). However it was not until the 20thc. that gynaecomanstia could be treated properly thanks to some advances in surgical techniques. In the first stage a cut around the areola was made or via the areola and mammilla. In the year 1928 Dufourmentel described a cut on the border of the areola and the surrounding skin. His article, however, was not made popular and the technique was rejected. Next years Webster specified semicircular cuts inside the areola that left slight almost invisible scar. The technique allowed to leave sufficiently thick layer of tissues below the areola that prevented its collapse and deformation. Careful preparation prevented from eventual post-operational irregularities. For the following years many combinations were tested concerning the placement and shape of the skin cut. Balch in order to avoid any scars in the region of the chest, proposed surgical approach from under the armpit.
In the case of big and falling breast, the excision of gland and adipose tissue is made with simultaneous plasty, i.e. removal of the excessive amount of skin and eventual moving of the areola with the mammilla upwards.
The breast gland in gynaecomastia consists of gland and adipose elements and the surgical procedure depends on the excessive amount of one or the other. Every men with gynaecomastia detected undergoes ultrasonograph examination of breast. In the case when adipose tissue is bigger, it is enough to remove the excessive amount of the tissue by liposuction. However, when gland tissue is bigger, the surgical procedure should consist in removal of the whole gland. In this case liposuction is ineffective.
Nowadays thanks to the advancements in plastic surgery, the surgical treatment of gynaecomastia consists in the first stage on suction of adipose tissue and finishes with it if the growth does not refer to gland tissue. However, when after liposuction have been performed, and under the areola a swelling is still felt, then the surgery is expanded. Then in the subpectoral fold under the armpit or on the border of the areola and the surrounding skin a cut is made from which the gland is removed. In the case of huge and falling breast, the excessive amount of skin is removed and the areola is moved upwards so that the excessive amount of falling skin would not be left after the surgery leaving unaesthetic effect.. This plasty is performed extremely rarely as during liposuction the skin shrinks significantly by stimulation of its elastic fibres.
After every surgery the removed tissue is examined histopathologically to exclude neoplastic changes. The operated regions are covered with sterile dressings and a special pressure dress is put on the breast and the patient needs to wear it for 4-6 weeks. Directly after the surgery such symptoms as swelling, bruises or pain may remain for several weeks. Some hardening and swelling of the operated regions vanish about 12 week after the surgery.
Liposuction surgery facilitated the treatment of gynaecomastia in the case of men. It allows for a careful and gentle removal of the excessive amount of adipose tissue and gland tissue. On the contrary to the traditional surgical methods it does not leave any irregularities or unaesthetic scars.
Małgorzata Kolenda, M.D., Ph.D.