Introduction

As the times are changing, so are the views on inclusivity. Long gone are the days where dressing up was just a ‘girly’ thing to do. In today’s time and age, everybody wants to look good and feel great about themselves, without hiding behind baggy, ill-fitted clothes. This positive change in our society’s train of thought is what has brought men into reaching out for aesthetic assistance. Gynecomastia or enlarged male breasts is a growing concern in today’s world, where clinics are finding patients increasingly diagnosed with this condition. Enlarged male breasts also have a fragile impact that can cause a lack of confidence, bullying due to peer pressure and at times, unfortunately, it can also cause a feeling of shame and guilt. All of this mental stress is due to increased felinity to the silhouette of the male patient’s body that is caused by this condition. Gynecomastia is typically caused due to the increase of female hormone levels in the male body. Enlarged male breasts are characterized by augmented male breasts that are firm in the areolar region and can be painful to the touch. They become enlarged due to the accumulation of fat and the proliferation of glandular breast tissue.

Who does this condition affect?

Gynecomastia is prevalent in three age categories of the average male human, which can be divided into the following stages:

Neonatal gynecomastia

This is the first peek of glandular enlargement of the breast tissue noticed. It occurs to the male fetus within the womb due to the increased fluctuations of female hormones estrone and estradiol. However, this peek naturally goes away two to three weeks post-partum when the baby stops receiving these hormones via the placenta.

Adolescent gynecomastia

The second peek of gynecomastia is seen among 62% of adolescents and pre-pubescents. This happens due to the increase in estradiol levels during early puberty, beginning from the tender age of 10 to 12. Nevertheless, as these adolescents enter their teenage years, testosterone is meant to overtake the estrogen levels and the condition nullifies before the age of 18.

Senile gynecomastia

The final peek of male breast enlargement is noticed in men aged from 50 to 80. Gynecomastia in this age group occurs due to the effects of ageing like reduction in testosterone levels and due to medication.

What causes gynecomastia?

The major reason noted to be the cause of male breast enlargement is the altered imbalance between androgens (male hormones) and estrogens (female hormones). Nevertheless, the causes of gyno can be interlinked where two or more causes combine. The cause of this imbalance can be divided into three groups:

1. Physiological

As mentioned above, gynecomastia can occur naturally during the three peeks in the male human body as there may be inevitable hormonal fluctuations. The prevalence of male breast enlargement during infantile, pubertal and senile age groups is quite common.

2. Pathological

Another cause for enlarged male breasts could be due to pathological or underlying medical conditions that alter hormones and impact the balance. Some known causes are listed  below:

• Liver disease

Alcohol abuse alters the hormone balance by affecting the hypothalamic-pituitary-testicular axis, thereby decreasing the production of testosterone. Spironolactone, a medication used to treat cirrhosis is also noted to be a contributing source.

• Starvation

malnourishment leads to a decrease in androgen and the increase of estrogen precursors due to adrenal stress. Eventually, leading to breast enlargement in male patients.

• Hypogonadism

• Type 1 diabetes

When a patient has had type 1 diabetes for a long period, they can develop an uncommon condition called diabetic mastopathy. Wherein, the tough masses form in the breasts.

• True hermaphroditism

This rare condition is characterized by the patient having both ovaries as well as testicles. Excessive production of estrogens leads to decreased testosterone levels and might cause gynecomastia due to their inhibiting effect on intra-testicular chytochrome activity.

• Tumours

Renal carcinoma, gastric carcinoma, large-cell lung carcinoma, prolactin-secreting pituitary adenomas and other hormone balance altering cancers have been linked to gynecomastia.

• Renal failure

Male breast enlargement is noticed in up to 50% of patients on dialysis due to Leydig cell dysfunction.

Grave’s disease

Approximately 10 to 40% of patients diagnosed with hyperthyroidism can also develop gynecomastia

Ectopic HCG production

The prevalence of HCG in the male body is almost undetectable, however, when tumours/disease/medication interferes with these levels, it can lead to male breast enlargement.

Androgen insensitivity syndrome

Kennedy’s syndrome

Is a congenital neuromuscular disorder that leads to the testicular atrophy and, thus, can cause gynecomastia.

Stressful life events

stress has been linked to gynecomastia due to the excessive production of estrogen precursors from adrenal glands, in combination with high serum cortisol, estradiol and low amounts of testosterone.

Pharmaceutical

The final cause for gynecomastia can be grouped under the medicinal or drug-induced category. Certain medicines can have effects that lead to hormone imbalance and further leads to gynecomastia. Apart from hormonal changes, drugs can also leave an impact on the liver and kidneys, creating a new pathological pathway to male breast enlargement. Unmonitored use of steroids has been a commonly noted connection with enlarged male breasts. This occurs because the unregulated use of anabolic steroids, tend to throw off the balance between androgens and estrogens, causing an enhancement of the breast gland. This is also a common misconception where the enlarged gland is mistaken for hardened muscle by bodybuilders and fitness freaks. Digitoxin and herbal products can have estrogen-like effects that can eventually lead to male breast enlargement due to the proliferation of the breast glands. Intensive chemotherapy and antiretroviral therapy have also been connected with regards to gynecomastia. Recreational drug marijuana is beginning to become legal in many countries and is slowly being recognized for some medicinal properties. However, excessive use of marijuana and its products whether it is for recreational or medicinal purposes can be an androgen receptor blocker that can, in turn, lead to gynecomastia. According to the Rohrich classification, the severity of gynecomastia can be put into four grades:

Grade 1

Mild hypertrophy, lesser than 250g of breast tissue, showing no ptosis or excess skin.

Grade 1A

Minimal hypertrophy, mainly glandular

Grade 1B

Minimal hypertrophy, usually fibrous

Grade 2A

Moderate hypertrophy, about 250 to 500g of breast tissue, showing no ptosis or excess skin

Grade 2

Moderate hypertrophy, typically glandular

Grade 2B

Moderate hypertrophy, primarily fibrous

Grade 3

Severe hypertrophy, more than 500g of breast tissue, shows grade 1 ptosis, extra skin and can be glandular or fibrous.

Grade 4

severe hypertrophy, showing grade 2 or 3 ptosis, excess skin and can be glandular or fibrous

How can gynecomastia be treated?

Gynecomastia can only be definitively treated with gynecomastia surgery treatment, also known as male breast reduction. This aesthetic procedure can be split into two parts namely; liposuction and excision. Liposuction may be sufficient on its own if the patient does not have much glandular enlargement or fibrous tissue. In some cases, patients may require both procedures involved in Gyno Treatment to reach desired results. Nevertheless, if the patient presents with very mild grade enlargement, medication may be sufficient after finding the root cause. At Tamira, you can find experts who are well-versed in treating gynecomastia in Chennai.

How is the procedure performed?

Part 1: Liposuction

Since enlarged male breasts present accumulation of fat, the said fat is extracted using liposuction. The treatment begins with making small incisions to insert the cannula. The cannula is a thin, long tube that extracts the fat from the treatment site assisted by gentle suction.

Part 2: Excision

In case the patient presents with excessive glandular hypertrophy or fibrous tissue, it is optimal to remove it surgically. The excision technique involves the surgeon snipping off the excess breast tissue and skin. The incision is sutured and if need be, the nipple is repositioned.

Who is eligible for this procedure?

The ideal patient would be within the adult bracket, who has been diagnosed with the condition for a minimum of a few months and preferably with no circulatory ailments. It would be beneficial if the patient is a non-smoker as nicotine can interfere with recovery and may cause necrosis. However, if the patient is a smoker, they would be required to quit smoking a few weeks before and after the treatment. Nevertheless, this procedure can also be performed on adolescents if the situation calls for it.

Are there any risks of leaving gynecomastia untreated?

From a scientific point of view, there are little to no risks of leaving gynecomastia untreated since it is benign. However, there is a rare chance of the patient developing breast cancer due to the condition. Nevertheless, the patient can also suffer from a psychological standpoint.

How do you prevent gynecomastia?

Gynecomastia can be prevented by leading a healthy lifestyle, following a good diet and enough exercise. Here are a few tips to prevent any avoidable causes of male breast enlargement:

• Keeping track of alcohol consumption and reducing it to the minimum can also help curb the situation if the underlying cause is the liver.
• Terminating the usage of anabolic steroids and recreational drugs like marijuana are highly advisable.
• All medication should be consumed under the discretion of a physician and should not be consumed over the counter.
• Avoiding too much stress by taking breaks and relaxing can also be helpful.

Nevertheless, some causes can be genetic or idiopathic that cannot be prevented or foreseen.

Are there any potential treatment risks?

Similar to any invasive procedure, gynecomastia also comes along with its set of risks. The general risks include; bleeding, scarring, tenderness, necrosis and infection. As the treatment calls for the use of general anaesthesia, it also comes along with the rare risks associated with its use. The other risks include dissatisfaction and excessive gland removal can also cause saucer deformity. These risks can be prevented by choosing a skilled and well-experienced surgeon. In conclusion, the main blame would be on the frivolous urban lifestyle that causes the underlying medical conditions eventually leading to gynecomastia. It is easy to say that this ailment is growing as common as cold due to its relevance to current times and limitless hobbies.