Treating men who are dissatisfied with the appearance of their breasts has become a specialty in Dr. Berman’s practice. Dr. Berman explains what gynecomastia is, what are the causes of gynecomastia, and most importantly, addresses the practical aspect, which is what can be done to improve the appearance of a man’s chest so that he is more comfortable with himself. In addition to the knowledge Dr. Berman has acquired through medical literature, Dr. Berman’s pragmatic approach to gynecomastia is based on the large number of male patients he has treated for this specific concern. He will also address the effect Ozempic and significant weight loss may have on the treatment of gynecomastia.
WHAT IS GYNECOMASTIA?
Basic internet research will provide a myriad of articles which explain gynecomastia to be a condition where there is an increase in glandular tissue in the male breast. This is due to an imbalance between estrogen and testosterone. It may even be noted that newborn baby boys are often born with short-term gynecomastia due to the high levels of estrogen from the mother while in utero. A basic research on gynecomastia may also point out that adults sometimes possess glandular enlargements, which can be tender or painful.
In Dr. Berman’s experience, almost all of the men he has treated had normal testosterone and estrogen levels (he feels that it is NOT necessary to test these levels since abnormal levels are rarely the cause of the gynecomastia and furthermore, even if there is a hormonal imbalance, surgery would still likely be necessary since it usually does not correct, even if the levels are brought into normal range) and are not considered to have true gynecomastia. Regardless though, Dr. Berman is sensitive to his male patients and realizes that almost all of the men he treats will have normal hormone levels. Dr. Berman has a very pragmatic approach – a man needs to feel confident enough with his appearance to be able to take his shirt off in public and not be self-conscious. When a man doesn’t feel comfortable taking his shirt off at the pool, or wearing a tightly fitted shirt, Dr. Berman empathizes and understands it is of no comfort to tell the patient that his testosterone levels are normal and that he does not have true gynecomastia. Or even that he may look “normal” to many people. What counts is the patient’s self perception.
WHEN DOES GYNECOMASTIA START?
For the vast majority of patients, gynecomastia begins at puberty. There is a small subset, where it will start later in life due to another cause – sometimes weight gain and sometimes drug related, such as anabolic steroids used to build muscle. Significant weight loss either through dieting or medication such as Ozempic can cause sagging of the breast area.
CAN MEN GET BREAST CANCER AND HOW DO I KNOW IF HAVE BREAST CANCER AND NOT GYNECOMASTIA.
Breast cancer is very rare in men. It also will almost always be unilateral. Therefore, unless you have a one sided mass that is still enlarging in size, it is very unlikely you have breast cancer. Breast cancer will likely have started in the past few months and certainly not for many years since puberty. If you notice bilateral issues, it is almost certainly not breast cancer, and is more likely to be related to gynecomastia.
WHAT ABOUT DRUG USE CAUSING GYNECOMASTIA?
There is an extremely long list of drugs that are said to be associated with gynecomastia. There are a few drugs that have an obvious link because they lower testosterone levels or raise estrogen levels – drugs used to treat prostate cancer or prostate hypertrophy or finasteride (Propecia), anabolic steroids and some AIDS medication. There is a long list of herbal supplements that are said to cause gynecomastia, but Dr. Berman is moderately skeptical about the link to herbal supplements, as there is very little proof of this association. It is mostly anecdotal suppositions.
If there is any link to medication and gynecomastia, it is unlikely that the appearance of your chest will improve without surgery even if you stop taking the medication.
WHAT TESTS ARE REALLY NEEDED?
Dr. Berman boldly and unabashedly tells his patients that if there are bilateral concerns about his chest appearance, no blood tests or radiological tests are needed. (if you are over 50 years of age and general anesthesia is required, you will still need a pre op clearance, bloodwork and a cardiogram)
Insurance companies will almost never cover gynecomastia. Dr. Berman does not take insurance.
WHAT DO MEN REALLY COMPLAIN ABOUT IN THEIR CHEST APPEARANCE?
The complaints that Dr. Berman most frequently encounters are (in order of frequency) are:
1. My breasts look too large
2. My nipple-areolar complex (NAC) is too puffy
3. My nipples stick out too far.
Each of these require a different surgical solution.
My breasts look too large:
It is very easy for an outsider to underestimate how important this can be to a man. It is also important to understand that the psychological importance is not related to the size of the breast. Dr. Berman has operated upon numerous, extremely fit males, who have a relatively small degree of breast enlargement but who were exceptionally self conscious. Hours at the gym lifting weights and doing push ups will not change the appearance of what lies above the muscle. With the correct surgery, virtually all of the men Dr. Berman has treated have felt better about themselves and now feel comfortable taking off their shirts in public or wearing a tighter fitting shirt.
Although liposuction is commonly done for this problem, Dr. Berman rarely uses liposuction alone. Liposuction can only reduce fat and much of the time, fat is only part of the problem – there can be both fibrous tissue and glandular tissue and if this is left the breast will look too full. In Dr. Berman’s experience, when liposuction alone is used, many patients will be left dissatisfied, feeling that too much tissue remained post-op.
For these cases, Dr. Berman treats his patients in the operating room under general anesthesia, makes a periareolar incision, and will surgically excise most of the glandular, fibrous and fatty tissue. It is very important to leave a certain amount of tissue beneath the NAC, otherwise, the breast under the NAC will look sunken. Dr. Berman always places a drain on each side which will remain for 4-6 days and is easily removed by Dr. Berman in the office. It is sutured in place so that the drain will not fall out when they take a shower. Patients can shower the day following surgery. After surgery, a special surgical vest is worn for about 12-14 days. Patients can usually return to work in about 5 days (if they work from home, even sooner) and are permitted to do unrestricted exercising in about 2 weeks. The scar usually heals with a very hard to see scar that continues to improve with time. Dr. Berman always gives his surgical patients his cell phone number so he can be easily reached after surgery.
PUFFY OR PROMINENT NAC:
The main complaint for men in this category is that they feel that their NAC are too puffy, , especially in tight fitting shirts and specifically in warmer weather. The treatment for this is in-office surgery. It is done under local anesthetic with oral sedation. The patient will need someone to drive him to and from the office because of the oral sedation. The same periareolar incision discussed in the type of procedure explained above is used. In this scenario, though, Dr. Berman also elevates the NAC superiorly, freeing it with very little tissue underneath it. Using a headlight and loop magnification, Dr. Berman then determines how much breast and other tissue should be removed that is located directly beneath the NAC. The incision is closed with dissolving sutures, steristrips and a Coflex (like an ace wrap). The patient is able to go home immediately following the procedure. The patient will simply need to wear an ace wrap for 5 days post procedure, but can return to work the very next day. There should be little discomfort post surgery.
NIPPLE STICKS OUT TOO FAR:
The procedure to rectify this problem is performed in the office as well. Dr. Berman reduces the prominence of the nipples by reducing the actual size of the nipples. Desired outcome and size of the nipples is based on a discussion with the patient and Dr. Berman prior to the procedure. The scar is usually very hard to see and the procedure is quick. The patient can return to work the next day.
OZEMPIC AND WEIGHT LOSS
Any weight loss, especially if sudden, whether aided by Ozempic or other medication, can lead to droopiness. Most surgeons will treat this will extensive skin resections which works but does lead to a lot of obvious scarring. In many cases (but not all), Dr. Berman is able to confine the scarring to just around the areola. However it is important to note, that this will often require more than one surgery (almost always done in the office under local anesthetic with oral sedation), where with each surgery, Dr. Berman is able to tighten the skin significantly but leaves all of the scarring around the areola, which is much less conspicuous than scarring elsewhere on the chest. Dr. Berman has employed this technique numerous times with excellent results. The recovery from this surgery is very quick and the patients can return to work the very next day.
PRACTICAL ADVICE FROM DR. BERMAN
Whenever you have 2 of anything, they will never be identical. They should be very similar, but there will always be some differences from side to side both before and after surgery.
As with any cosmetic surgery, you need to give it 6-12 months to get your final shape. There can be a bit of unevenness or waviness that occurs during the healing phase.
Lastly, Dr. Berman always tells all of his patients, regardless of procedures, to please aim for an improvement and never perfection.