Gynecomastia & Male Breast: Causes, Treatment & Liposuction

Male Breast Development: Physiology and Pathology

Men naturally possess breast glandular tissue, which under normal hormonal conditions remains small and functionally inactive. At certain stages of life, however, a visible or palpable enlargement can occur. Pubertal gynecomastia is the most common form: it occurs due to the hormonal changes of puberty, affects an estimated 50 to 70 percent of all boys, and typically resolves spontaneously within six to 24 months. Later in life, a declining testosterone-to-oestrogen ratio can again lead to breast enlargement.

If breast enlargement persists beyond puberty or develops in adulthood without a physiological trigger, it is referred to as pathological gynecomastia. It can occur on one or both sides and requires investigation of the underlying cause.

Causes of Gynecomastia

The decisive hormonal imbalance is an increased oestrogen effect relative to androgen activity, which stimulates the rudimentary glandular tissue to proliferate. Possible causes include hypogonadism, liver or kidney disease (which impairs oestrogen breakdown), endocrine-active tumours of the testes or adrenal glands, and a range of medications – including anti-androgens, certain antihypertensives, spironolactone, tricyclic antidepressants, proton pump inhibitors and anabolic steroids. Drug use, particularly cannabis, is also a known trigger. In some cases, no clear cause can be identified (idiopathic gynecomastia).

Pseudogynecomastia – also known as lipomastia – is not a hormonal condition but a pure increase in fatty tissue in the chest area, often associated with being overweight or a genetic predisposition. Clinically, it can be distinguished from true gynecomastia by palpation: glandular tissue is firm and often palpable directly behind the areola, while fatty tissue is soft and diffusely distributed. In cases of doubt, ultrasound or mammography can be used for differentiation.

Pre-Operative Diagnostics

Before any surgical treatment, the underlying cause should be carefully investigated: medical history, physical examination, hormone status (LH, FSH, testosterone, oestradiol, prolactin, hCG), liver and kidney parameters, and imaging diagnostics if needed. If a treatable underlying cause is found, it should be treated first; in some cases the gynecomastia then regresses or reduces on its own.

Surgical Treatment of True Gynecomastia

If gynecomastia is pronounced, persistent, or causes psychological distress, surgical removal of the gland is the treatment of choice. Through a small incision at the edge of the areola (periareolar approach), the excess glandular tissue is removed directly and completely. The scar lies discreetly at the transition between the areola and the surrounding skin and is usually barely visible once healing is complete.

The procedure is often combined with liposuction to reduce excess fatty tissue in the chest region and along the lateral chest wall, achieving an even, flat, masculine result. The surgery is usually performed under general anaesthesia; afterwards, a compression vest is worn for several weeks, which helps the skin settle, reduces swelling and supports the result. Patients are usually able to work again after a few days; the final result becomes visible after the swelling has subsided over a few weeks.

Possible complications include impaired wound healing, haematoma, temporary sensory disturbances around the areola, irregularities of the skin surface, or asymmetries. In the hands of an experienced surgeon, serious complications are rare.

Chest Liposuction for Pseudogynecomastia

For pseudogynecomastia – when the breast enlargement is due solely to fatty tissue – liposuction is the appropriate and sufficient method. Through small, well-concealed access points, a thin cannula is introduced into the fatty tissue of the chest; using suction, the excess fat is gently removed. The result – a flatter, firmer chest – is permanent provided body weight remains stable.

If glandular tissue is also increased at the same time, liposuction alone is not enough; in this case a combined procedure of liposuction and gland removal must be performed. Differentiating between the two tissue types before surgery is therefore essential for planning the correct procedure.

Aftercare corresponds to that following gynecomastia surgery: a compression vest for several weeks, physical rest, and avoidance of sport and heavy physical exertion for at least four to six weeks. Possible risks include swelling, haematoma, irregularities of the skin surface, numbness and, rarely, infection.

Psychological Significance

Pronounced breast development in men is often associated with considerable psychological distress: feelings of shame, avoidance of situations in which the upper body is exposed (swimming pool, sport, intimacy), reduced quality of life and a negative body image are typical accompanying effects. In well-indicated cases, surgery leads to a marked improvement in quality of life and self-esteem.