Male breast reduction

Three things can make a male chest look breasted. They are not the same problem, and they are not treated the same way.

• Volume that is mostly fat — softer, more peripheral, often also sitting on the sides of the chest below the armpit. This is the layer liposuction can reduce.

• Volume that is the breast gland itself — firmer, typically a disc under the nipple–areola. This tissue is often too firm to come out through a cannula. A direct reduction through an incision in the lower half of the nipple–areola is then required.

• Skin excess — the envelope that is left after the volume has gone, or that was already there after significant weight loss. Addressing volume without tightening skin that cannot retract leaves a smaller but still hanging chest.

In our practice the plan is built from that distinction. Many chests need liposuction and a direct gland reduction in the same sitting. A smaller group needs only liposuction. A more extreme group, particularly after substantial weight loss, needs volume reduction and skin tightening together.

3D imaging can help to show how much of the fullness is a surface layer and how much is a firmer central mound, and to discuss the scar that would come with a skin reduction if one is needed. A simulation is a planning tool. It is not a picture of the outcome.

Male breast reduction has its place when the chest contour is distorted by gland, fat or skin that will not settle with training or with time, and when the man wants that contour changed. It can be one-sided or both. Asymmetry is common and is planned for, not ignored.

It is less suitable as a first step when a hormonal driver is still active and untreated. Operating on a chest that is still being driven by an uncorrected endocrine problem invites partial recurrence. That is why an endocrinology assessment is generally a good approach before contemplating the surgery.

It is also the wrong operation if the complaint is simply a heavy torso from current weight that the man still intends to lose. Further weight loss after a reduction can leave skin that was not a problem on the day of surgery. Better to be close to a stable weight, or to plan the skin component honestly if a large loss has already happened.

Adolescent swelling of the breast is common and often settles. Surgery is not the first conversation in a chest that is still changing.

Some hormonal problems can continue after surgery and lead to at least partial recurrence of the volume. In those instances medical treatment is beneficial to stabilise the problem before proceeding to surgery. Treatment of an underlying cause does not always make the existing gland disappear — once the tissue has become firm it often stays — but it can reduce the chance that the same process rebuilds what has been taken out.

Lifestyle contributors are part of the same conversation: anabolic steroids, some prescribed medicines, significant alcohol use, and other substances that shift the oestrogen–androgen balance. We need a clear list of medicines and a truthful account of what else is in the picture. Surgery does not protect a chest that is put back under the same drive.

If you have not had an endocrinology examination before the surgical consultation, it is advisable to undertake one. The surgical plan sits on top of that, not instead of it.

When the volume is soft enough, liposuction alone can reduce it. In most mixed chests liposuction is the first part of the intervention. It treats the front of the chest and, frequently, the sides below the armpit, where fatty tissue tends to gather. Leaving that periphery untreated while flattening only the centre is how a chest ends up looking operated rather than simply flatter.

Energy-assisted methods have been used in this area to help extract fat and to give the skin a degree of tightening. They are an adjunct, not a substitute for a direct reduction when the gland is firm, and they do not replace a formal skin tightening when the envelope is truly excess.

In many instances the breast tissue itself is too firm to be removed with liposuction techniques, and a direct reduction is required. This is carried out through an incision in the lower half of the nipple–areola. The gland is shaped rather than emptied. Taking the centre down to nothing while the periphery still holds volume produces a saucer or “dinner-plate” contour that is harder to live with than the original mound. A conservative, even reduction is the safer aim.

Tissue that comes out is sent for histological examination. That is routine, not a suggestion that something sinister is expected.

In more extreme situations the breast volume excess is associated with excess skin. Significant weight loss is one of the more common causes of skin excess in the male chest that benefits from a combination of volume and skin reduction. The scars are then more than the lower-areola incision: around the nipple–areola, and sometimes a vertical limb and a scar in the crease under the breast. The areola itself may need to be reduced. In the most deflated chests after massive weight loss, repositioning of the nipple as a graft is sometimes part of the same conversation. That is a different magnitude of operation from a lower-areola disc excision, and the scar and nipple-sensation implications are correspondingly larger.

The operation is carried out under general anaesthetic or local anaesthetic with intravenous sedation. It takes, in general, 1.5 hours, and can be longer if the procedure involves more extensive skin tightening. It is commonly carried out as a day-case intervention.

The consultation is where the three layers — fat, gland, skin — are separated, and where the medical history is taken seriously. Conditions and medicines matter. Blood thinners raise the bleeding risk and need a specific plan. Raised blood pressure also increases the bleeding risk and should be controlled before a chest reduction, particularly if an open reduction is part of the operation.

Previous chest surgery, including an earlier liposuction or an earlier gland excision elsewhere, changes what the tissues will do and where the scars already sit. Bring that history.

No operation is without risk. The list below is the one we discuss; it is not exhaustive. Individual risk depends on the technique, the medicines, the blood pressure, and whether the driver of the original volume is still active.

• Anaesthetic. A risk with any operation. In a healthy adult it is low; it is not zero. Local anaesthetic with intravenous sedation is an alternative to a general anaesthetic for many of these chests, and carries its own discussion with the anaesthetist.

• Bleeding. Common to all surgery. It is more relevant with an open reduction than with liposuction alone, and may prompt a return to the operating theatre. After liposuction the bruising is usually more limited.

• Infection. In the region of 1 to 2 per cent with gynaecomastia correction, and it can happen despite the antibiotics we prescribe. Increasing redness, swelling or temperature needs to be discussed without delay.

• Pain. Usually limited after this type of surgery. A small percentage of patients are prone to more prolonged or neuropathic pain, which may need specialist input.

• Scars. Small and relatively discreet when the work is liposuction, often placed at the front of the armpit crease, or when the gland is taken through the lower half of the areola. More extensive skin reduction makes the scar more visible — around the nipple, and sometimes vertical and in the crease — and occasionally needs treatment to improve its quality.

• Deep vein thrombosis. The increased tendency to clot after surgery under anaesthetic. Early mobilisation, compression stockings and, when indicated, medicine that thins the blood are the usual precautions.

• Reduced sensation. On the front or the side of the chest after liposuction, and around the nipple–areola after a direct reduction. It is more typically temporary.

• Seroma. Clear fluid collecting in the treated area, sometimes needing drainage. Relatively uncommon after male breast reduction.

• Asymmetry. The two sides of the chest are not the same to start with. Surgery can aim for a closer match. Perfect symmetry is not achievable.

• Under-correction and over-correction. Possible with both liposuction and open reduction. Over-correction is the harder of the two to repair, because scar tethers the tissues. That is why a conservative reduction is preferred to an aggressive one.

• Recurrence of breast volume. More likely if an untreated hormonal or lifestyle driver remains. Residual gland can also respond later. This is one of the reasons an endocrinology assessment before surgery is worth doing.

• Further surgery. To improve contour, to treat a fluid collection, to revise a scar, or to take more tissue if the first reduction was deliberately conservative.

Supporting dressings for the breast stay for the first week. A supporting garment is worn for three weeks. The garment is there to control swelling and to help the skin settle on the new volume; it is not optional window-dressing.

If drains are used — typically after an open reduction rather than after liposuction alone — they usually come out within a day or two.

Antibiotics are routinely prescribed for the first five to seven days. Pain medicine is supplied; many men need little of it. If pain is sharp, one-sided or increasing, that is a reason to get in touch rather than to take more tablets and wait.

Recovery from surgery is usually a week for return to office work, and ideally close to three weeks for return to stronger physical activities or exercise. The chest wall is a moving part of every press-up, swim and weights session. Coming back earlier because the scars look quiet is how a collection or a contour irregularity is invited.

• It does not treat an active hormonal problem. That work belongs with endocrinology, and often has to happen first.

• It does not substitute for weight loss that is still intended. A chest reduced at a high weight and then deflated by a further two stone is a different chest.

• Liposuction alone does not reliably remove a firm subareolar disc. If the pinch is soft at the periphery and rubbery under the nipple, plan for a direct reduction.

• It does not produce a bodybuilder’s dry pectoral if the skin is already thin and loose. Skin quality sets a ceiling.

• It is not female-to-male chest reconstruction, which is a different operation with a different scar pattern and a different brief.

A consultation-led fee, once the mix of liposuction, direct gland reduction and any skin tightening is defined. The same word — male breast reduction — covers a 90-minute day-case through the lower areola and a longer skin-tightening operation after weight loss. Those are not the same fee.