Gynecomastia is a deformity that usually manifests in teenage boys where there is massive hormone stimulation of the nascent breast tissue causing enlargement associated with pain and a very disturbing physical deformity. Gynecomastia tends to run in families therefor there is some genetic component and usually becomes manifest in the early teenage years when male hormones are active. It is usually associated with mild to moderate torso obesity. The deformity is worsened by weight as there usually an aspect of the deformity that is fat tissue in addition to tender breast tissue. It is that fat portion of the deformity that has caused insurance carriers to demand weight loss as well as hormonal studies to document and treat the disease. There are insurance carriers who specify in their contracts that they explicitly do not cover gynecomastia resection under any circumstance.
The treatment of gynecomastia in adolescents should include, if necessary, an attempt at weight loss followed by surgical resection, usually tumescent liposuction technology. Unfortunately, if surgery is performed in the early to mid-teenage years there is a possibility of recurrence, usually beneath the nipple/areolar complex, as it is virtually impossible to remove the breast tissue in its entirely. Additionally, any upper fluctuation in weight will also give the appearance of a recurrence.
Gynecomastia in adult males is usually due to excessive marijuana smoking and/or abuse of anabolic steroids or large doses of testosterone. Most men who fit this profile are body builders with a reasonable low body fat. Those with higher body fat percentages also have a fatty component to the deformity. Most body builders who “stack” their anabolics also take an anti-estrogen drug trying to prevent the painful breast enlargement. Surgical removal for pain relief and cosmetic chest improvement usually requires direct excision. These men usually have hypertrophic and highly vascular chests causing common hematoma formation post-operatively. Again, recurrence can be common if the patient continues to use steroids.
Gynecomastia, especially the teenage version, occurs at a very unsettled age when there may be extreme body dysmorphism. Children this age can be unpleasantly negative at a time when undressing for the gym or going to the swimming pool can be a traumatic event. These psychological issues are reason enough to operate early even if a re-do becomes necessary.
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Men pay for approximately 80% of the cosmetic surgery performed while becoming a patient only 20% of the time. It is hard to know if this is indicative of the social taboo regarding men and cosmetic surgery or is it a result of the idea that men are much less stoic than women and are basically averse to the minimal discomfort involved. Regardless of the cause, men are more frequently having plastic surgery and generally have the same reasons for having cosmetic improvement as our women patients: improved self esteem, being competitive with younger people in the work place, and to appear more youthful and attractive to the opposite sex.
Men age somewhat differently than women and require surgeries that are tailored for their specific facial aging issues. For instance, men are more likely to complain about their necks while women focus on the midface/cheek area. Both men and women have upper and lower blepharoplasty but men rarely want the browlift procedure so as to not look like “Kenny Rogers.” Kenny Rogers is a well known celebrity, singer, actor and country music star who was the unfortunate victim of an overdone browlift – forehead too tight, too smooth, too high, thus totally changing his appearance for the worse. In addition to eyelid and neck rejuvenation men are likely to inquire about liposuction of the waist and abdomen area. Men desire a nice tight, jaw line and neck with a youthful profile, a sculpted waist and bright, open, uncluttered, youthful eyes. Post-operatively, men tend to go back to work too quickly, tend to bruise worse than women, and are less likely to follow post-operative instructions. Men and women both require a full dose of positive reinforcement throughout the healing process. Early and often post-operative photos to document healing and cosmetic improvement are helpful during the early stages of healing where bruising and some swelling is to be anticipated. Men are less likely to keep all of their post-operative appointments and tend to be more secretive regarding their surgery than women. Men are uniformly less patient while healing but more appreciative of the good results and more youthful appearance over time. Men are less likely to have researched the procedures they want and tend to be referred mostly by other patients and thus are less affected by marketing schemes than women. Terminology is also important to men who shy away from the term “facelift” but respond well to being offered a “necklift.” Even with their idiosyncrasies, men are generally some of our most appreciative patients.
Dr. Paul Howard
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