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Male Breast
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MohanThomas andJamesD’silva
9
It is very embarrassing for a man to have a chest that looks
like a female breast and this can happen and does occur in a
lot of men. This condition is called “gynecomastia” and it is
a combination of breast tissue and fat accumulation. It originates from the Greek words for “women-like breasts.” It is
estimated that approximately 50–70% of the male population has palpable breast tissue during adolescence. The male
chest should ideally be at with accentuated pectoralis muscle. In a patient with gynecomastia, the male breasts are
pyramidal in shape with feminine features.
9.1 Causes [1]
Gynecomastia usually affects both breasts, but sometimes one
breast may only be involved. The most common cause is pubertal; in majority of cases it resolves on its own by 20years of age
when the growth of the male body is complete. Enlargement of
male breasts can be caused by certain drugs such as anabolic
steroids, medications containing estrogen, alcohol, thiazides
and marijuana, and medical conditions including cancer,
impaired liver function, to name a few.
Pathophysiologically, gynecomastia involves an imbalance between free estrogen and free androgen actions in the
breast tissue. This imbalance can happen during mid-to-late
puberty when more estrogen is produced by the testes and
peripheral tissues before testosterone secretion reaches adult
levels, resulting in the gynecomastia that commonly occurs
during this period.
Supplementary Information The online version contains supplementary
material available at [https://doi.org/10.1007/978- 981- 19- 4997- 5_9].
Some testicular tumors such as Leydig-cell or Sertoli-cell
tumor may secrete a higher level of estradiol. Tumors producing human chorionic gonadotropin (HCG) or a tumor
derived from a non-trophoblastic tissue, such as a large-cell
carcinoma of the lung or some gastric or renal-cell carcinomas (also called ectopic HCG production), can also indirectly increase the production of estradiol causing male
breast enlargement.
Primary or secondary hypogonadism, which increases
with advanced age, can reduce the free testosterone in a
male. In case of any adrenal neoplasm there may be overproduction of the weak androgen androstenedione and other
androgen precursors such as dehydroepiandrosterone, which
are converted into estrogens in peripheral tissues.
Aromatase activity increases with age and with an
increase in body fat, and is also seen in thyrotoxicosis,
Klinefelter syndrome, and adrenal and testicular tumors.
There is a progressive increase in the prevalence of gynecomastia with an increase in the body mass index (BMI),
which is also seen in aging, probably reecting the local
paracrine effects of estradiol production in the subareolar fat
on the breast glandular tissue due to increased aromatase
activity [2].
Drugs such as spironolactone displace estrogen more easily from its binding protein than testosterone increasing its
bioavailability. Similarly, testosterone will be more bound to
its protein if the sex hormone binding protein level is
increased in diseases such as hyperthyroidism and liver
disease.
There are multiple processes that can alter the pathways
of estrogen and androgen production and action, which may
result in gynecomastia from an enhanced estrogen effect or a
diminished androgen effect at the target-tissue level.
M. Thomas (*) · J. D’silva
Cosmetic Plastic Surgery, Breach Candy Hospital and D.Y. Patil
University, Mumbai, Maharashtra, India
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Thomas, J. D’silva (eds.), Manual of Cosmetic Surgery and Medicine, https://doi.org/10.1007/978-981-19-4997-5_9
151
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M. Thomas and J. D’silva
9.2 Anatomy oftheMale Breast
• Normally, the male breast resembles that of a prepubescent female chest.
• It extends superiorly from the second rib to the sixth anterior ribs inferiorly with the sternum as the medial border
and the mid-axillary line demarcating the lateral extent.
• The predominant tissue in the male breast enlargement
is fat, especially in an overweight individual, and there
is an absence of gland, duct, and lobules as seen in
females. Male chest enlargement is usually a combination of fat and scar tissue caused by involution of the
gland (Fig.9.1).
Fig. 9.1 Lateral view of a male chest showing an
illustration of the fatty and glandular components
• The shape of gynecomastia excised specimens has been
found to have a head, body, and tail (Fig.9.2). The head,
which is semicircular in shape, is located more medially
toward the sternum. The majority of the glandular tissue
consists of a body located immediately deep to the nipple
areola complex (NAC). The tail tapers off from the body
more laterally and continues toward the insertion of the
pectoralis major muscle onto the humerus bone [3].
• The arterial supply, venous drainage, lymphatic drainage,
and sensory supply mimic those of the female breast.
These are all situated in a radial fashion with the nipple–
areola complex supplied by the third to fth intercostal
nerves but predominantly by the fourth intercostal nerve.
Fig. 9.2 The arterial supply
to the breast comes from the
internal mammary artery, the
subscapular artery, and
branches from the
thoracoacromial and superior
thoracic arteries
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9.3 The Ideal Male Chest andNAC
The male chest should ideally be at with an accentuated
pectoralis muscle. There is a well-dened contour and natural fold just below the chest, which is the area where the
abdomen begins. The chest fold is predominately
horizontal.
The “ideal” male chest has the nipple located typically
5–6cm above the chest fold and facing forward. The areola
is ush with the surrounding skin. With certain types of
gynecomastia, the areola may protrude forward creating a
“puffy nipple.”
The “ideal” male chest has some glandular breast tissue
located directly underneath the areola. It is rm and glandular on palpation, whereas fatty tissue around it is soft and
squishy. This amount of breast tissue present is considered to
be normal.
The ideal NAC is marked using the sternal notch as the
landmark creating a triangle with its apex at the sternal notch,
but whose base length varies according to the chest dimensions based on the patient’s BMI (Fig.9.3). An arc is drawn
over the pectoral region with a radius of 20–22cm depending on the BMI (20cm for BMI less than 25, 21cm for BMI
between 25 and 30, and 22cm for BMI more than 30). The
second measurement and marking is of the anterior fold dis-
tance (AFD), which is multiplied by a factor of 0.65 to obtain
the inter-nipple distance (IND). This length is then superimposed onto the arc until it lies equidistant on either side of the
sternum and intersects with the arc previously drawn on the
chest. The point of intersection is where the NAC should be
placed. The areola should be close to 27mm in diameter and
the nipple, 7mm [4].
The ideal male NAC according to some general themes
that exist amongst the various formulas is [5]:
• Slightly oval (horizontal greater than vertical).
• Smaller (with diameter lesser than 3cm).
• Positioned around the fourth or fth intercostal space.
• NAC is positioned on an average 2.5 cm medial to the
lateral border of the pectoralis muscle and 2.5cm above
the inferior pectoral margin.
9.4 Classication [6]
Grade I: Minimal hypertrophy (<250g of breast tissue) without ptosis (Fig.9.4)
• Ia: Primarily glandular and fatty (Treatment of choice:
power-assisted or ultrasound-assisted liposuction).
• Ib: Primarily brous (Treatment of choice: direct excision
with touch-up liposuction).
Fig. 9.3 Location of the Ideal NAC specially required when NAC has
to be relocated or a Free NAC graft is undertaken
Grade II: Moderate hypertrophy (250–500g of breast tis-
sue) without ptosis (Fig.9.5)
• IIa: Primarily glandular (Treatment of choice: powerassisted or ultrasound-assisted liposuction with direct
excision).
• IIb: Primarily brous (Treatment of choice: powerassisted or ultrasound-assisted liposuction with direct
excision).
Grade III: Severe hypertrophy (>500g of breast tissue)
with grade I ptosis glandular or brous (Fig.9.6) (Treatment
of choice: power-assisted or ultrasound-assisted liposuction
with direct excision of tissue with immediate or delayed skin
excision and reposition of NAC).
Grade IV: Severe hypertrophy with grade II or III ptosis
glandular or brous (Fig.9.7) (Treatment of choice: breast
reduction with repositioning of NAC on an inferior pedicle
ap or a free graft).
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Fig. 9.4 Front and side views of a Grade I gynecomastia
M. Thomas and J. D’silva
Fig. 9.5 Front and side views of a Grade II gynecomastia
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Fig. 9.6 Front and side views of a Grade III gynecomastia
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Fig. 9.7 Front and side views of a Grade IV gynecomastia
9.5 Patient History andPhysical Findings
• A detailed history should inquire about:
– The onset and rate of breast tissue growth
– The onset of puberty
– Associated symptoms, including pain, tenderness,
weight loss, night sweats, and general malaise
– Any social, vocational, or psychological dysfunction
due to the breast enlargement
– Any family history of breast cancer or similar disorders
– Medication history, especially recreational and off-
the- counter drugs (e.g., marijuana and exogenous steroids specially with body builders)
– Symptoms suggestive of underlying thyroid, liver, or
kidney disease
• A detailed physical examination includes:
– The patient’s height, weight, and body mass index
– Check for development of secondary sexual
characteristics
– Examination of the gynecomastia
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Fig. 9.8 The breast tissue is palpated for rmness using the index nger and thumb and then moved on the underlying muscle to check for
deeper adhesions
M. Thomas and J. D’silva
• Standard breast measurements to highlight asymme-
tries, including the sternal notch to nipple, mid-clavicular to nipple, nipple to midline, and nipple to IMF
distances.
• The patient’s neck, abdomen, and testicles for any masses
or irregularities.
9.6 Imaging
• In suspected cases of gynecomastia, appropriate imaging
(mammogram, ultrasound, etc.) should be carried out
based on the identied or suspected abnormalities. This
will help differentiate the glandular, brous, fatty, or
mixed gynecomastia. It will also help in diagnosing any
cyst or presence of tumor in the breast.
9.7 Non-operative Management
The best way to clinically differentiate a true gynecomastia from fat deposits is by palpating the area (Fig. 9.8).
Pseudogynecomastia is characterized by increased subareolar
fat without enlargement of the breast glandular component.
The patient is asked to lie at on his back with his hands
clasped under his head. Using the separated thumb and index
nger, slowly pinch the tissue in the retro-areolar area of the
breast. A rubbery or rm mound of tissue that is concentric
with the nipple–areola complex is felt in patients with true
gynecomastia, whereas no such disc of tissue is found in
patients with pseudogynecomastia.
The other important differentiation is between breast carcinoma and gynecomastia. The tissue in gynecomastia is
usually soft, elastic, or rm but generally not hard; the area
involved is concentric to the nipple–areola complex, and
presents bilaterally in approximately half of patients. Breast
carcinoma, although very rare in males, is usually hard or
rm. It is located outside the nipple–areola complex, and is
most often unilateral in presentation.
Skin dimpling and nipple retraction may be seen in
patients with breast carcinoma, which are not present in
gynecomastia. Tenderness may be present in gynecomastia
of less than 6 months’ duration, but it is unusual with breast
carcinoma. Nipple bleeding or discharge is present in
approximately 10% of men with breast cancer, but it is not
expected with gynecomastia.
• Check for overall breast aesthetics, including the shape,
size, and symmetry of the breasts and NACs, the degree
of ptosis, excess skin, and the position and symmetry of
the inframammary folds (IMFs).
• Almost 90% of adolescent cases spontaneously resolve
and treatment is advised only if the gynecomastia has
been persistent for at least 2 years or the child has functional, medical, or psychosocial concerns that warrant
earlier intervention.
• The offending medication (anabolic steroids, medications
containing estrogen, alcohol, thiazides, marijuana, etc.)
should be stopped if it can cause gynecomastia.
• Weight loss to be advised for people who are obese.
• Medical treatment in the form of danazol, tamoxifen, and
anastrozole may be effective in growing stages of gynecomastia but is ineffective once brosis has taken place.
9.8 Surgical Management
9.8.1 Liposuction Withor Without Direct
Tissue Excision
9.8.1.1 Marking oftheElevations, Depressions,
andScars
The patient is examined in a standing position in good light
and in oblique light so that shadows in the chest area can be
well assessed. This is particularly so in people who have
undergone gynecomastia surgery before. The elevations and
the extent of surgery have to be well marked with permanent
markers, as seen in Fig.9.9a–c. The scarred and depressed
areas should be marked in another color, as seen in Fig.9.10.
Assess the chest in a relaxed position as well as with the
pectoralis contracted so that any adhesions can be marked
(Fig.9.10).
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a
b
c
Fig. 9.9 (a–c) Preoperative marking for gynecomastia surgery made using a permanent marker in a standing position
a
Fig. 9.10 (a) Patient being examined with the pectoralis muscle con-
tracted showing the scar and the skin attachment to the muscle. (b)
Preoperative marking for elevations and depressions made using differ-
b
ent color permanent marker in standing position so as to prevent inadvertent liposuction in the area of deciency
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M. Thomas and J. D’silva
9.8.1.2 Painting, Draping, andMaking
anIncision forAccess
This surgery can be undertaken under general anesthesia or
local tumescent anesthesia. We always make it a point to
have a registered anesthesiologist to be present during the
procedure even if undertaken with tumescent anesthesia. The
patient is placed in a supine position with a head-end elevation of 30° at the waist. This allows the breasts to slide inferiorly so that an assessment of the shape can be done during
the procedure. Also, this positioning helps in taking the tip of
the cannula away from the deeper tissues of the chest
(Fig.9.11a).
Local anesthetic with adrenaline is injected (0.5 cc) at
each access point. The access points are made in such a way
that the whole area requiring contouring is easily accessible.
One incision is usually made on each side of the chest and to
facilitate cross-liposuction another incision may be planned
medially. After waiting for about 7 min, 5 mm incision is
made using either an 11 number blade or a 3mm skin punch
is used (Fig.9.11b, c).
9.8.1.3 Inltration ofTumescent Fluid
We use Klein’s solution to inltrate the breast soft tissue.
This is done by using an inltration pump and a 2.5 mm
blunt cannula with multiple holes. We inltrate at the rate of
75–100mL per minute slowly.
The uid is rst inltrated at the muscle level (deeper)
and beyond the extent of the marked area, which provides
generalized anesthesia and analgesia in the area especially in
people who undergo this procedure under local anesthesia.
Please note that the tip of the inltration needle should
always be felt by the non-dominant hand and is directed
toward the skin. After waiting for 5–7min, tumescent uid is
inltrated supercially into the glandular tissue to make it
tense.
Once all areas have been inltrated, we have to wait
patiently for 15min for the local anesthetic and hemostatic
to work (Fig.9.12a–c).
9.8.1.4 Tissue Disruption
After waiting for a minimum of 15min for the tumescent
uid to cause vasoconstriction, “tissue disrupters” designed
by Dr. Tony Mangubat (Fig.9.13a, b) are used to grate the
brous and glandular tissue in the retro-areolar area. When
grating in the areolar area, it is necessary to hold the tissue as
a tube in the non-dominant hand so that there is no injury to
the dermal plexus (Fig.9.14a–c). This is undertaken till the
tissue turgor is lost in the area (the area is soft). Once the
a
b
c
Fig. 9.11 (a) The patient being painted, draped, and positioned. (b) Local anesthesia has been injected at the access point. (c) Number 11 blade
is used to make an access incision
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a
b
c
Fig. 9.12 (a) Tumescent inltration being undertaken in the deeper layer. Please note the tip of the cannula is raising a tent near the sternum. (b)
Tumescent uid being now inltrated into the supercial layer. (c) The completed inltration
a
Fig. 9.13 (a, b) “Tissue disrupters” as designed by Dr. Mangubat
retro-areolar area has been grated, the peripheral tissue
extending into the breast extensions is disrupted so that the
fat evacuation can be completed.
9.8.1.5 Aspiration ofFat
Once the tissue has been disrupted mechanically, technology in the form of vibration amplication of sound energy
at resonance (VASER) or power-assisted liposuction can be
undertaken. We usually undertake suction-assisted liposuction after tissue disruption. The retro-areolar area is rst
liposuctioned aggressively by holding the tissue in a tube
b
using a non-dominant hand (Fig.9.15a). Care is taken that
there are no tissue deformities and cannula track marks by
constantly changing the cannula position in a fan-like
pattern.
Once the central area has been evacuated to the surgeon’s
satisfaction, liposuction of the peripheral area is completed
using curved and straight 3mm cannulas (Fig.9.15b, c). All
the marked areas are liposuctioned on one side followed by
the other side. If required, another access is made on the
medial aspect of the chest or the midline so that all areas can
undergo cross-lipocontouring.
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M. Thomas and J. D’silva
a c
Fig. 9.14 (a–c) Tissue disrupters are used to grate the tissue rst in the retro-areolar area, over the whole breast, and also in the breast
extensions
a c
b
b
Fig. 9.15 (a–c) Suction-assisted liposuction being carried out of breast using curved and straight 3mm Mercedes cannula
9.8.1.6 Assessment oftheTissue andFinal Tissue
Grating and/or Excision
Once the area has been liposuctioned, adequacy of tissue
removal is checked by the pinch technique (Fig.9.16a). If a
lump or a nodule is palpable, it is further disrupted using the
grater as shown in Fig.9.16b. The nal assessment about the
completeness of the surgery is undertaken by the pinch technique, palpation of the tissue with the at of the palm, and
visual assessment of both sides for symmetry. If the assessment shows incomplete removal (Fig.9.17a) with a palpable
lump present in the retro-areolar area, then a curvilinear
incision is made at the edge of the areola usually inferiorly
(Fig.9.17a). Subcutaneous dissection is carried out to excise
the bro-glandular tissue leaving a 3–4mm thickness of tissue in the retro-areolar area (Fig.9.17b). Complete excision
of the tissue is undertaken taking care that there are no tissue
defects and the area looks smooth. In case there is tissue
unevenness, then deep fascia above the pectoral muscle
should be mobilized and repair or bridging of the tissue
defect undertaken. Hemostasis should be achieved and a
two-layer closure should be undertaken preferably using
interrupted sutures. Small suction drains can be used if
incomplete hemostasis has been achieved and in smokers/
people on blood thinners. Figure 9.17c shows that tissue
excised may not be symmetrical.
9.8.1.7 Patients withGrade III Gynecomastia Will
Require Immediate or Delayed
Reposition ofNAC
Patients with Grade I breast ptosis and excess mammary skin
will require repositioning of the NAC either at the same time
or after 3 months to achieve the perfect shape.
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