Male Gynecomastia and Female Breast Enlargement (hypertrophy)
I have had the good fortune to participate in the reimbursement decision making process for BCBS and other medical insurance companies in the past.
In particular, cosmetic or medically non-necessary vs elective reconstructive or medical necessary reimbursement for women and men’s breast enlargements has criteria which have not changed in many years. Not all insurers follow the same criteria, so you will have to communicate with your agent regarding your specific contract.
Breast size whether in men or women is determined by many factors such as genetics, age, weight and personal or environmental exposure to hormones. It is felt that today’s society is heavier producing more estrogen from fat and therefore affecting breast tissue by increasing its size. The exposure to plastics produces feminizing chemicals in our bodies. Hormones are used and passed through animals we feed upon. Plant hormones such as soy may also further enhance the feminizing size of male and female breasts.
When the size of the breast becomes functionally disabling to the individual is when medical insurers like Blue Cross and Medicare provide insurance funds for their reduction in size.
From a medical perspective, reduction in weight or reduced exposure to hormones may (but not necessarily will) reduce breast size.
Surgery is required when the volume and therefore weight of the breast creates other medical problems such as chafing and infection in the fold, neck and back strain, nerve impingement and others.
Since this can happen in many female teens through their 70’s, women will seek a breast reduction. Both the volume of the breast tissue which contains fat and parenchyma (the solid portion of mammary ducts and glands) and the skin envelope will be reduced using various incisions and leaving scars.
In men, weight loss will reduce breast size primarily in their teens and 20’s. Occasionally during this age and thereafter, the breast itself will not respond as well to weight loss or female hormone exposure. It seems the hormone receptors in the breast glands themselves are no longer available or working to be blocked. A combination of liposuction and excisional removal of breast tissue are useful.
A man with a small to medium primarily fatty mound can expect a reduction in the volume and tightening of the skin. Once the breast has expanded to a female appearance with a underlying crease and breast fold, a surgical reduction will be required and this, of course, will create scars.
Following massive weight loss from obesity generally leaves residual draping breasts empty of fat and breast tissue. This is generally not covered by insurance.
Publish date: Feb 1, 2012
By: Rochelle Nataloni
The popularity of gynecomastia surgery has skyrocketed in recent years. One estimate indicates that the procedure has experienced a 48 percent increase, with 16,500 men having had the procedure in 2001 (compared to a prior estimate taken in 1997).
This isn’t surprising, considering the incidence of benign enlargement of male breast tissue — at least a third of males are affected at some time during their life.1 Surgical treatment includes liposuction for primarily fatty cases or direct excision when glandular tissue is predominant.
Fair Oaks, Calif., surgeon Sydney E. Garfinkle, M.D., who specializes in gynecomastia, says he sees three categories of males affected by the condition. “Most commonly, the gynecomastia patients I see are young men between the ages of 19 and 30 who are bodybuilders, and the gynecomastia is a result of taking anabolic steroids. The next group comprises overweight men, usually aged 50 and above who have mostly excessive fatty tissue that is responsible for breast development.
“The third group is represented by young boys who have enlarged breasts because they are either overweight or simply have excessive breast tissue,” he says.
BODY BUILDERS The development of gynecomastia among bodybuilders comes as a result of the body making estrogen, Dr. Garfinkle says. “These men take anabolic steroids and when they are broken down, some of it changes to the female hormone estradiol, and the result is breast enlargement,” he says.
“Oftentimes, these men will attempt to reverse the breast development by taking an antiestrogen drug such as Nolvadex (tamoxifen, AstraZeneca). If they take it early enough, it can reverse their gynecomastia, but when that doesn’t work, they come to me,” Dr. Garfinkle says.
In these cases, Dr. Garfinkle performs a straightforward excision. “I make a periareolar cut right around the edge of the nipple, usually inferiorly in the lower part of the nipple, and from there I remove the excess breast tissue,” he says, adding that in these cases, no liposuction is necessary. “It’s a straightforward operation.”
One of the potential complications during the postoperative follow-up period is bleeding, because these patients tend to return to the gym sooner then recommended, he explains. “They are not the most compliant patients, and they’ll often return to lifting weights quite soon afterwards, and this can result in bleeding. I have had a few patients who developed a little fluid or a little blood in the operative area afterwards, and I have them come back to the office for a needle aspiration, which has been effective each time.”
“Typically, you can’t see those incisions afterwards,” he says. “I usually have three points where I approach the fatty tissue, and I aim to leave it relatively flat. I tend to leave approximately 4 mm of thickness of residual tissue because if you leave it too thin, it is possible that the skin will adhere to the underlying muscle or fascia and the patient will end up with a dimple.”
In older, formerly obese patients, rather than removing the excessive skin that is inevitable after fat and/or breast tissue removal, Dr. Garfinkle says it’s important for patients to have realistic expectations. “I tell them that there may be some residual sagging skin and that they shouldn’t expect an A-plus result. They understand that our aim is to shrink things down or reduce the size, and that that is the best we can do.”
THE YOUNGER CROWD While the literature suggests that gynecomastia resolves on its own in 80 percent of males who develop it in puberty, the patients who present in Dr. Garfinkle’s practice are not so lucky. “I see a skewed population; I see the failures,” he says. “By the time they get to me, if it’s substantial gynecomastia, in my experience, it’s not going to go away without intervention. In this young population, almost all of them require removal of the breast tissue. Many of them are overweight, and typically I do some liposuction as well as excision.”
It is important to evaluate patients in this age group for other pharmacologic or endocrine influences, Dr. Garfinkle says. “These factors tend to be operative in a very small percentage of patients, but it’s still important to consider. If you can discern that they have adequate testosterone, then you know that there isn’t something else responsible for the gynecomastia. If there is any question of causation, I recommend an endocrinologic evaluation.”
SKIN AND MUSCLE FACTORS In young patients, the skin bounces back into place immediately after removal of fat and/or breast tissue. In older patients, and especially in those who have lost a significant amount of weight, “You can’t count on the skin to shrink back into place in postoperative male patients who have pendulous breasts,” Dr. Garfinkle says.
Throughout the years, Dr. Garfinkle has changed his approach to postoperative compression. “For gynecomastia, a lot of surgeons rely on garments that are manufactured for liposuction patients. In a few of my early patients, I found that when I used those garments the patients had abnormal contours afterwards because the garments are fairly rigid,” he says, adding that he has since switched to a nylon spandex shirt for compression. “I have them buy one size too small so that it’s tight over the chest and holds things in place, and I have them wear that for about three weeks.”
The chest looks like it should in about one month, according to Dr. Garfinkle. “If you feel the breast tissue, it’s firm under the area of the nipple, and that’ll stay that way for three to six months postoperatively, so they continue to improve for up to six months.”
In some patients, especially young boys, the nipple becomes enlarged, Dr. Garfinkle says. “It’s stretched out and almost looks like a female nipple. If you take the tissue out, the nipple shrinks because it is erectile tissue, and when it shrinks, it gets folds in it and in some cases the result is a wrinkly nipple.”
If the nipple doesn’t shrink as much as the patient would like it to, Dr. Garfinkle remedies the situation by using a dermal punch to take two to four punches out of the periphery of the nipple. “I put a stitch in each one of those and in a week it looks normal,” he says.
1. Rahmani S, Turton P, Shaaban A, Dall B. Breast J. 2011;17(3):246-255.