1. What exactly is gynecomastia and how do I know if I have it?
Gynecomastia is the presence of breast tissue in a male and it is often mixed with fatty tissue. It can occur in a newborn but frequently disappears. It often occurs during puberty and disappears in most young men, although it may persist forever in some of them. It can also occur later in life due to a variety of factors, which include use of bodybuilding steroids, marijuana, various medications, etc. Oftentimes it is due to hereditary factors. There are rarely severe hormonal irregularities. Gynecomastia is not related to obesity but may coincide with it. It may be as small as a firm area of tissue just under the nipple or as large as a DD cup pendulous breast.

Sometimes one can feel firm breast tissue under the nipple or in the surrounding chest area when the arm is stretched over the head. However, most often a doctor will be able to determine if you have gynecomastia.




2. How is your procedure performed?
During my surgical training, I was disappointed in the usual surgical treatment for this problem, for many people were left with large scars or deformities which in some cases was worse than the original problem. As an answer, I designed my own set of surgical instruments specifically for this problem. In my hands, it is performed on an outpatient basis in my office operating room. The average case takes 90 to 120 minutes and is performed under "twilight sleep" sedation. Routinely there will be some swelling, bruising and temporary diminished feeling in the chest and the nipples. All of these symptoms subside within several weeks. The extra skin tightens by itself and the areola often shrinks in size. The pain after surgery has been described as " I feel like I just did 300 pushups." Most men are able to return to sedentary-type work within four to seven days after the surgery. A compression dressing is placed on the chest and worn under the clothing for approximately three weeks. Strenuous exercise and sports may begin three weeks after surgery. Complete healing may take up to three or four months.




3. At what age can surgery be done? Can a youngster or a teenager qualify for surgery? Is there an upper age limit for surgery?
There is no right or wrong age for surgery to be performed. In my view, if gynecomastia has been present for two or more years and is stable and not increasing in size, then surgery may be considered. Obviously, this is on an individual basis. All too often, teenagers with this problem are given a pat on the shoulder by their doctor and told to wait it out until it disappears by itself. Unfortunately, many teenagers spend their entire teenage years waiting for this to occur and are subject to ridicule and embarrassment during this critical time in their lives. On the other hand, one should give it adequate time to resolve by itself. The vast majority of gynecomastia is not due to hormonal imbalance and frequently a complete hormonal work up will be negative. Older men suffering with this condition are also candidates, but must understand that the skin may not totally tighten after the surgery in performed. Again, decisions must be made on an individual basis.




4. Does insurance cover the cost of gynecomastia surgery? Are payment plans available?
Unfortunately, insurance companies over the past few years have adopted a position that this is a cosmetic procedure and therefore refuse to pay for it. In my experience, at the present time, very few, if any insurance companies will provide coverage for this surgery unless it is an extreme condition. The insurance companies remain immune and uncaring as to the emotional damage that this condition engenders. For my patients, credit cards are accepted and a payment plan is available by application.




5. How can I locate a doctor who does this procedure in my area?
I would strongly recommend that you consult a board-certified plastic surgeon. You may call the American Society of Plastic Surgeon's referral line (800) 635-0635. Make sure that you visit at least three surgeons for their opinions and ask to see their personal photographs of before and after gynecomastia patients.




6. Do I have an increased risk of cancer if I have gynecomastia?
The presence of gynecomastia does not make you more prone to breast cancer. Several studies have concluded that there is no increased risk of male breast cancer in those men with gynecomastia. It is important to note that one percent of all breast cancers occur in men so that any new lump or one-sided growth (asymmetry of the breast) should be investigated by a physician.




7. Is there a relationship between gynecomastia and drugs or medications?
Many drugs and medications produce gynecomastia as a side effect. Some illegal drugs such as marijuana, heroin and bodybuilding steroids can also produce gynecomastia. In some cases, stopping the medication may result in a diminishment of gynecomastia but in my experience, once the gynecomastia is present it usually will remain unless corrective surgery is performed.




8. Am I more prone to develop gynecomastia if I am overweight?
Patients who are overweight may have a flat chest and thin patients may have gynecomastia. Oftentimes, the two conditions coincide and treatment for the gynecomastia will also be addressed towards treatment for the enlarged fatty breast. Occasionally, additional liposuction of the chest area under the armpit is necessary in order to achieve an improved overall contour of the chest.




9. Will exercise and or weight loss diminish my gynecomastia?
Weight loss may diminish the fat (and hence the size) of an enlarged breast slightly, but breast tissue does not respond to weight loss because it is a different type of tissue. Exercise will not diminish gynecomastia because it will build up muscle and the chest muscle will still be camouflaged by the overlying excessive breast tissue.




10. Are there any other methods of treatment of gynecomastia?
Surgery for established gynecomastia is the only known and recognized treatment. Creams, lotions, massage, injections, exercise, "magic pills" all will do nothing for established gynecomastia.




11. If surgery is performed, will the results be permanent? What if I gain weight after the surgery?
Surgery will remove virtually all of the breast tissue and it will not regrow (much as a woman's breast will not regrow after a mastectomy for cancer). Should you gain substantial weight after surgery, then some amount of fat will find itself on the chest but it will also be distributed over other parts of the body so that you will not regain the specific enlargement on the chest that you had prior to surgery. Conversely, if you lose weight after gynecomastia surgery, the results of the surgery will be enhanced.




12. How can I contact Dr. Jacobs? What if I am not in the NY metropolitan area?
You may contact Dr. Jacobs at 815 Park Avenue New York, NY 10021 or call him at (212) 570-6080. You may also write to Dr. Jacobs about your personal situation and enclose photographs as well. Dr. Jacobs will make every effort to reply.




13. Can liposuction be performed on other areas of the body (for example, abdomen or love handles) at the same time as the gynecomastia surgery?
Yes, but the decision must be based upon your doctor's best surgical judgement.




14. Is gynecomastia more common in any particular race or ethnic group?
No. Gynecomastia can affect anyone — it is an "equal opportunity" condition.




15. I have had prior surgery for gynecomastia and I am not pleased with the results. Can anything be done?
Scars from prior surgery are permanent, although they may be improved by scar revision surgery. Contour irregularities can be improved on occasion. Each of these problems must be decided upon on an individual basis. Consult a plastic surgeon for an evaluation.




16. I have an underlying medical condition (HIV positive, prostate cancer, heart disease, etc.). Can surgery for gynecomastia still be done?
Oftentimes successful gynecomastia surgery can be performed despite an underlying medical condition. A thorough evaluation by your physician is most important to clear you for elective gynecomastia surgery.




17. I have very large areolas -- what can be done to reduce the size?
In the majority of cases, the chest skin will tighten after the excessive tissue beneath (breast and/or fat) has been removed in the course of surgery. Since the nipple/areola is a skin structure, it too will tighten and diminish in size. In fact, the average shrinkage is about 15-20%. The areola will also darken somewhat in color after surgery. Hard to imagine this? Just think of a balloon with a circle drawn on it. Then let some of the air out -- the circle (think of the areola) will be smaller. One added bonus: if an incision has been made in the areola to help remove glandular tissue, the resultant scar will also shrink in size.




18. What can be done for "puffy nipples?"
"Puffy nipples" is a common complaint and one for which treatment can be difficult. It refers to a "dome-like" appearance of the areola. As you know, your nipples will change and tighten in response to temperature changes or physical/emotional stimulation. This ability to change has to do with tiny muscle cells within the areola (pigmented skin). No surgery, injection, pill, cream, etc can substantially alter this normal bodily physiologic change. What must be evaluated is whether you have any firm breast tissue beneath the areola which is causing projection of the areolas and how much is possible to be removed. Surgery to remove this breast tissue must be done carefully, for if overdone, it can result in a depression (like a saucer) which is difficult to correct.




19. What can be done for very large, female-type nipples (not the areolas)?
Surgery can be performed which will reduce the actual projection of the nipple itself. Dissolving sutures are used which will fall out during the healing process. The scars resulting from this procedure are virtually invisible. Surgery can also reduce the diameter of an enlarged nipple. These procedures can be performed alone or in conjunction with gynecomastia surgery.




20. I was formerly very heavy. I have lost weight but still have enlarged breasts and lots of loose skin. What can be done?
I see this often in patients who have lost some weight on their own or in extreme forms on patients who have had gastric bypass surgery and lost huge amounts of weight. Every case is different and must be evaluated independently. There is no question that I can successfully remove the underlying excess breast and/or fat tissue. The culprit here is that the skin has lost much of its elasticity and is unable to tighten by itself. Therefore, some amount of surgical skin removal and tightening will be necessary and this will result in permanent scars. The exact placement of the scars will vary with the individual. It then becomes a trade-off of scars for a better, tighter, trimmer shape

In many cases, there is only a little skin laxity to be anticipated after surgery. In these cases, I will recommend my usual liposuction procedure (with or without glandular removal as needed) as a first stage. Then I wait and observe for a minimum of 6-8 months to give optimum time for skin tightening to occur by itself. Then the patient and I will evaluate the results and decide whether further skin tightening (admittedly with scars) will be necessary or desired. If surgery is to be done, then the scars will be far less extensive than had it been done at the first stage and it would be a much smaller operation. On the other hand, sometimes the patient is quite satisfied simply with the results of the first procedure -- maybe not perfect but perfectly acceptable -- and then no further surgery would be done.




21. I have only one enlarged breast -- what can be done?
Gynecomastia usually occurs on both breasts but it can also appear just on one side. Care must be taken to evaluate the condition to make sure there are no other diagnoses possible, such as a tumor, etc. Surgery can be performed just on the affected side. However, often there is some smaller amount of breast tissue on the other side which was not noticed when compared to the larger side. If this smaller amount of gynecomastia is not addressed at surgery, then the end result may be that the operated side will look completely normal and the un-operated side may then be objectionable. Careful examination of both breasts independently is therefore very important and surgery on both breasts considered if need be.




22. I have very long, narrow, pendulous breasts. What can be done for this?
This is a rare condition called "tuberous gynecomastia" in which the excess breast tissue is concentrated only behind the nipple/areola instead of spreading out over the entire chest. This is akin to the "tuberous breast" problem (breast shaped like a zucchini) that is seen rarely in women. There is a difference, however, between how this is treated in men and women. In women we wish to preserve the breast tissue but make the breast rounder and oftentimes larger. This is achieved through an incision around half of the edge of the areola and then the addition of a breast implant. In your case, the opposite is desired. You want to be flat, masculine and with much smaller areolas.

My usual surgical approach involves minimal scars: aggressive liposuction and then glandular excision through a small incision. The skin will usually contract by and tighten by itself. That technique will not work for you unfortunately. In this situation, there is a very wide areola with dense glandular breast tissue directly beneath it and excess skin that has nowhere to go. This will call for a different approach and technique which will, unfortunately, leave a few more scars on the chest -- but would be a welcome trade-off I am sure. You will certainly feel comfortable wearing a snug t-shirt, for example.

In essence, the operation would consist of temporary removal of the nipple/areolas, which would be made smaller in the process. Then the breast tissue and excessive skin would be removed, leaving a horizontal incision on the chest. Then, the nipple/areolas would be placed back on the chest as a skin graft. The anticipated net result would be a smooth, contoured flat chest but with a horizontal scar (hopefully not too long) on each side. The new nipple/areola would be in the middle of each horizontal scar. The nipple/areola skin graft would be "ornamental" in that it would be insensate -- ie it would have no feeling. This operation is similar to a double mastectomy which would be performed on a woman.




23. Is a complete hormonal workup by an endocrinologist required prior to surgery?
No -- in the vast majority of gynecomastia patients hormonal tests reveal normal levels of testosterone and estrogen. That being said, the patient's history of the problem may indicate that abnormal hormone levels may be present (eg sudden development of gynecomastia in a healthy 20-something male) and that hormonal evaluation is necessary. The other possible causes such as illegal drugs (marijuana, body-building steroids), side effects of prescribed medications, adrenal tumor, pituitary tumor, testicular tumor, etc must also be evaluated. I will never refuse to have complete hormonal testing performed prior to surgery if the patient requests it. However, in most instances, all the tests will come back as normal.




24. What should I know about male breast cancer?
Male breast cancer (MBC) tends to be diagnosed at a more advanced stage than female breast cancer.  Some of this is thought to be due to men’s frequent disregard of any lumps or changes in their bodies.

MBC usually occurs in older men, the median age is 67 years old.  Jewish men have a slightly increased risk, which is thought to be due to hereditary factors.  Risk factors for MBC include a positive family history (another relative with the disease), lifestyle, occupation, etc.  Some genetic mutations have been linked to hereditary forms of MBC, including BRCA-1 and BRCA-2 genes.

There are some conditions which may predispose to MBC.  These include Klinefelter’s Syndrome, Cowden’s Syndrome and liver disease or dysfunction.  Occupational hazards include exposure to hot environments (ie steel mill, blast furnace), work in the soap or perfume industry and work exposure to petroleum and exhaust fumes.

The diagnosis of MBC usually involves the discovery (by the patient or his physician) of a one-sided, painless lump or mass under the nipple/areola.  Skin changes (orange peel-like skin) and/or bloody nipple discharge can also be a tip-off.  If any of these symptoms are found, one should consult a breast surgeon immediately.  As in many diseases, early diagnosis and treatment can save your life!




25. What are "bitch tits" in body builders?
Body builders are a unique sub-set of patients with gynecomastia.  For the most part, they have very low percentages of body fat and are in excellent physical and nutritional shape.  Many of them have taken anabolic steroids without proper physician supervision.  The obvious goal of these steroids is to help bulk up muscles but the frequent side effect is the development of excess breast tissue (commonly called "bitch tits").  This is due to the conversion in the body of some of the testosterone they have taken into estrogen.  The estrogen then promotes the growth of breast tissue.  They complain mostly about very localized gynecomastia (just under or around the areola) and/or puffy nipples.  In these patients, a peri-areolar incision (incision around the edge of the areola) is done 100% of the time.  The operation is on a small area only -- it is fast -- the healing is very quick and the results are excellent. The results will be permanent providing that additional illegal drugs are not used in the future.




26. What is Dr. Jacobs' policy on revision surgery?
is Dr. Jacobs' policy to stand behind his work.  No effort is spared in the operating room to provide the patient with a smooth, flat and contoured chest.  Recurrence or re-growth of breast tissue is extraordinarily rare.  However, much more common (though still rare) is the unpredictable development of scar tissue on the chest or directly beneath the nipple/areolar complex as a result of the patient's unique and individual healing processes.  This may require one injection or a series of injections of medication to "melt away" the scar tissue.  If these are done at all, they will not begin until at least three to four months or longer after surgery.  There is no charge for these injections.

If revision surgery is recommended by Dr Jacobs, then there will be no charge for the surgery but there will be a minimal charge for sedation anesthesia provided by the anesthesiologist.

It is policy of this office to offer these free services for up to one year after surgery.