Gynaecomastia in teenage boys

Most teenage boys will have some breast enlargement during puberty. In the vast majority of boys this will resolve spontaneously. Surgery should not be considered until a boy has reached at least 18, and then only after careful assessment

Gynaecomastia in later life

There are causes for male breast enlargement that should be excluded: they include obesity (breast tissue production is stimulated by conversion of testosterone to estradiol by the enzyme aromatase - found in adipose tissue), certain drugs used for stomach ulceration or heart disease, excessive use of cannabis, or alcohol. 

Gynaecomastia can be caused by health-problems such as liver or kidney failure, rare genetic disorders, hormonal treatment for prostate cancer, or tumours and infections affecting the testicles. 

Assessment in primary care

Most patients visit their General Practitioner who will usually carry out an examination (which may include testicular examination). 

If a hard lump is detected, a distorted nipple, or an axillary (arm-pit) lump, the General Practitioner may request an urgent review in a breast cancer clinic. 

The General Practitioner may consider arranging some blood tests (blood tests are not routinely needed for gynaecomastia in puberty). Baseline tests would include thyroid function tests (TFTs), electrolytes (U&E’s) and liver function tests (LFTs). If these are normal she or he, will usually request a hormone blood screen: which might include testosterone, LH, FSH, estradiol, beta-hCG, alpha-fetoprotein, SHBG, prolactin and dehydroepiandrosterone. Very occasionally patients may be referred for blood tests to look for a chromosomal abnormality.

In many patients, no identifiable cause is found.

Surgery for gynaecomastia

If the tissue is very soft and fatty, it might be possible to remove the excess tissue using liposuction. In the majority of patients I have achieved the best result by an open excision of the breast tissue. I usually do this through an incision that runs along the inferior edge of the areolar. This usually heals to produce a thin scar that is not readily noticeable, and can be hidden by chest hair. This procedure is sometimes referred to as “Webster’s” technique.

Surgery is usually performed using a general anaesthetic. The procedure lasts about 90 minutes. Depending upon the amount of tissue removed, patients will either go home the same day or stay one night in hospital.

Aftercare 

Patients usually return for review at 1 week and 2 weeks after surgery. I usually encourage patients to wear a tight fitting chest garment (this is similar to a tight vest, we will fit you for this before your surgery) for 3-4 weeks after surgery. Patients can start to use an exercise bike at 3 weeks, and can run at 6 weeks. Most patients can return to clerical work at 2 weeks and manual work at 6 weeks.

Risks of surgery

Risks include bleeding and return to theatre (usually on the first night after the operation), inadequate removal of excess breast tissue, asymmetry, tethering of the nipple, and reduced nipple sensation.