Breasts have been considered as a sign of beauty, from time immemorial. Ancient paintings and sculptures, clearly prove that big and firm breasts have always been, considered as an integral parameter for evaluation of beauty of women, across cultures. This consideration is equally applicable for both the eastern civilizations as well as the western culture, as can be seen from statues obtained from archaeological sites from India to ancient Greece. But does big breast, always signify beauty and brings satisfaction to the concerned person ? The answer may not always be a yes; specially if the concerned person is not a female. Yes, we are talking about males with big breasts. Most men, would not be happy, to see a big breast on their chest. It literally causes increased burden in their chests.
Increased breast size in males, which is better known in medical parlance, as Gynaecomastia; and as man boobs for the normal people - causes serious mental and psychological disturbances for the affected individual. The reasons are pretty obvious. Breast are usually a sign of femininity and big breasts certainly makes a man look more effeminate. The term - Gynaecomastia was introduced by the great Greek physician and surgeon – Galen in second century AD and the surgical treatment was first described by Paul of Aegina, the famous surgeon in 7th century AD.
The increased size of male breast is due to increase in amount of it’s component tissues ie increase in glandular tissue, supportive tissue (stroma) and/or fat in the male breast (Although pure fat deposit in breast of obese men is more appropriately called pseudo gynaecomastia or lipomastia ). The changes may involve either one breast or on both breasts, and the involved breast may or may not be be tender or painful. The increased size of breast tissue is due to the imbalance between the sex hormone – Testosterone and Oestrogen. All individuals irrespective of their sex contain both female hormones (oestrogen) and male hormones (androgens/testosterone). Glandular tissue proliferation is stimulated by Oestrogen and inhibited by androgens or male hormones like Testosterone. For this reason Gynaecomastia is commonly seen in life stages, where hormonal changes are common resulting in a temporary state of relatively higher Oestrogen. These stages are – infancy, adolescence and old age, which being a normal part of growth can be termed as physiological Gynaecomastia.
The male breast size increases because of many reasons. An attempt has been made to explain them one by one.
As explained before the hormonal level fluctuates in an individual, in certain periods of life, such as – infancy, adolescence and old age. Soon after birth, the increased breast size is because of increased level of circulating maternal oestrogens in the new-born’s blood. With passage of time the level of oestrogen gradually decreases and the breast size slowly becomes normal.
Increased breast size is also seen in almost 66% of adolescent boys. This is due to hormonal imbalance that occurs in this period. In most of the cases the condition resolves spontaneously. Even in those where it remains afterwards – it is not of significance, to warrant treatment. The chances of developing Gynaecomastia again increases in old age, due to decrease of testosterone level and imbalance in testosterone to oestrogen ratio. This variety is also known as senile Gynaecomastia.
Increased weight than what is ideal for age & height, increases the chances of the Gynaecomastia. The reason for this are two. An overweight person has more fat in his body, which in turn is directly related to enlargement of breast due to excess fat deposition. This condition is called as pseudo gynaecomastia or false Gynaecomastia, as it is pure accumulation of fat and not proliferation of glandular tissue. Other than this very common understood mechanism, there is also another mechanism responsible. Being overweight also leads to hormonal imbalance, as oestrogen level increases in this condition. This causes breast tissue to grow.
Breast Enlargement or gynaecomastia can also occur as side effects of medications, being taken for some other health condition. Some of these are –
Chronic addiction to Alcohol, Heroin, Marijuana, Amphetamines and Methadone have been seen to cause Gynaecomastia.
Hormonal changes occur in this condition also, resulting in Gynaecomastia.
Tumours of Pituitary gland, adrenal gland, lung and testes have been seen to cause Gynaecomastia.
Any trauma or disease which affects Testis and decreases the secretion of male hormone testosterone can cause Gynaecomastia. The testis may be primarily involved or may be involved because of some secondary reasons. Insufficient function of pituitary gland and Klinefelter syndrome (a kind of genetic abnormality) causes Gynaecomastia, as testosterone production is impaired in this condition.
In conditions of starvation and malnutrition, testosterone levels drops causing Gynaecomastia.
In condition of chronic liver diseases, the level of sex hormone binding globulin is altered causing imbalance between level of testosterone and oestrogen and resulting in Gynaecomastia.
Unfortunately this is the most common cause of gynaecomastia. This denotes Gynaecomastia or Breast enlargement, in which no definite cause can be found.
Many people are confused, when they decide on seeking treatment for the mentioned conditions. Most of patient suffering from the said condition end up with a Physician, expecting a medicinal solution for the problem. Unfortunately that does not work out, most of the times. Patient suffering from this condition should realise, that it is the Plastic Surgeon, who can give a total satisfactory cure for this malady. Sometimes if Gynaecomastia is caused, as a result of a primary pathology or problem in some other organs of the body, then a secondary referral to a physician or a specialist Endocrinologists may be required. But the primary doctor, in charge of the case is always ideally a Plastic Surgeon.
Usually the cosmetic deformity makes the person suffering seek medical attention. The most common complain is that, the affected individual seeking medical advice, finds it embarrassing to wear tight fitting clothes or is embarrassed to change clothes in male’s changing room in front of other people, as his breasts look like a woman.
The doctor before taking any final decision, goes through the entire history of the patient. The time of onset gives an idea about the probable cause. Any intake of medicines for underlying pathology or any drug addictions are asked about. A systematic clinical examination from head to downwards is performed, examining – status of Pituitary gland, Thyroid function, Pulmonary (Lungs) function, Breast examination, Liver / Kidney /Adrenal gland function and finally followed by testicular examination. Testicular tumours can cause Gynaecomastia, but is often overlooked by most patients and many Doctors. All the mentioned organ’s function are ascertained properly by the medical practitioner. Liver, Thyroid and Kidney function tests are also done, if in doubt. Presence of any tumour in Pituitary gland, Lungs, Adrenal gland and Testis, has to be also ruled out.
Sometimes if the doctor is suspicious, of any underlying pathology he/she may advise further examinations. These may include – Blood tests, Mammograms (for breast examination), Testicular ultrasound & Biopsy. In very rare cases even CT scan or MRI scan may be needed.
The most important decision for treatment of gynaecomastia, is to decide if at all a treatment is required ? Many of the cases occur in the previously mentioned adolescence period and in people approaching old age. Most of the cases improve on their own, without any intervention. All these things being said, it is always important to ascertain if the gynaecomastia is just an ordinary phase of a person’s ageing process or there is some sinister problem lurking in some other part of body, in some other organ. Before taking a final judgement, and assuring the person suffering that everything is normal, a good doctor always examines the whole body to exclude a secondary pathology.
If any secondary disease is found, it should be treated before undertaking treatment for Gynaecomastia. If some medicines appears to be problematic agent, a way to find another substitute should be tried. If the problem is because of some substance abuse, it should be discontinued and professional or expert help should be taken, including care from a deaddiction centre.
If no other secondary pathology or cause is found, the doctor ascertains the duration of the problem and age of the patient. The definite treatment is a surgical correction by a Plastic Surgeon. This course should be proceeded with if the patient’s age is over 18 years and the problem has been present for more than 1 year. If these criteria’s are not fulfilled and there is no other disease in the body, the best course is to wait.
The surgical choice for Gynaecomastia, is decided by the Plastic Surgeon depending on examination of the breast. If the glandular component is in larger proportion the operation of choice is – SUBCUTANEOUS MASTECTOMY. In this the patient is taken to operation theatre, where after administration of anaesthesia (usually general anaesthesia), the surgeon makes a small incision in the skin areola junction and removes the breast glandular tissue. The incision on areola – skin interface, ensures that the post operative scar formed is imperceptible and minimum.
If the breast size is increased, due to increased amount of fat; then the ideal surgery would be LIPOSUCTION . This surgery is also done in the operation theatre, usually under general anaesthesia, although Local anaesthesia can also be used. A infiltration cannula is used for infiltrating haemostatic and anaesthetic liquid in the breast area . This minimises the bleeding and also minimises the amount of pain, during and after surgery. After the surgery, by using a liposuction cannula, all the fat content is sucked out under negative pressure.
In majority of the cases, the combination of Mastectomy and Liposuction (along with excision of surplus skin ) is used, as in most cases of Gynaecomastia, the increase of Breast size is caused because of increase of both glandular component, as well as, some amount of fat. After surgery the patient is usually advised analgesics/painkillers and medications to decrease swelling. If chances of Infection is anticipated, then patient is also put in a course of antibiotics. Heavy exercises is forbidden for couple of weeks, to avoid bleeding in the surgical area. Compression garments, which applies uniform pressure in the operated areas are also advised for use up to 2 to 3 months, as these minimises the chance of post operative bleeding and gives the operated area, a regular post operative contour.
Breast swelling in males is usually ignored by the person concerned and his family members. An attempt to seek medical opinion is quite often met with ridicule and disdain. This attitude unfortunately causes serious problems in many cases . The reason for this is that the breast swelling may not be always be a simple case of Gynaecomastia, giving just a cosmetic ugly look, but sometimes may be associated with serious underlying pathology. In the worst case, an early stage of Breast cancer may be missed, when a breast swelling is ignored. Also studies have shown that Gynaecomastia patients have a five times greater risk of developing cancer. The reason for this is that both of these conditions are caused due to same hormonal imbalance – lower level of androgens & relative increase in Oestrogens.
The chances of Breast cancer in males is much lesser than females . It is believed that breast cancer in males just account for only 1 % of all breast cancer cases. But neglect in most cases gives rise to ominous results later on. Depending on the ethnicity; the chances of development is highest in men of African descent, followed by Caucasians and Asians & the probability is least in Hispanic men. This cancer can occur in any age, but commonly presents in males over the age of 60 years. Family history also increases the chances of a man developing Breast cancer later in life.
Breast cancer usually presents as palpable mass, present unilaterally, not necessarily centred around the nipple & feels firm or hard and fixed to surrounding structure, and maybe associated with nipple discharge or nipple inversion and may have associated skin changes in the breast area. Sometimes swelling in the underarm may be noticed due to enlargement of axillary lymph nodes. Mammography can help in this situation, to distinguish between breast cancer and benign breast disease. Sometimes ultrasound and biopsy studies may also be required, to establish the diagnosis and decide on the future course of action.
Breast swelling, which is rather a very common feature in males approaching puberty and old age. Most people consider it very innocuous looking cosmetic problem. But in some cases, ignoring this simple problem may cause a serious disease to present in a grossly aggravated condition later on . So even if a person is not looking forward to surgery, he should opt for a counselling with a qualified plastic surgeon to avert a possible tragedy later on.
(Disclaimer – Although this article has been written by a medical professional, it is not a substitute for a personalized face to face counselling with a doctor. This article is for general awareness and people suffering from above condition should seek a direct consultation, with a registered medical practitioner, without delay.)