What Are the Causes of Gynecomastia?

The term gynecomastia originates from the Greek words gynec (feminine, woman-like) and mastos (breast); it refers to the excessive enlargement of male breast tissue for any reason.

Male breast tissue, like female breasts, consists of milk-producing glands and ducts (glandular tissue) as well as fatty tissue. In cases of gynecomastia, the glandular tissue, fatty tissue, and breast skin enlarge and expand in varying proportions. This growth can be visible to the eye, and on physical examination, firm breast tissue can be felt. Surgical treatment varies depending on the condition of the components that cause gynecomastia.

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Frequency of Gynecomastia

Gynecomastia can occur at any age. In newborns, it develops due to estrogen hormones passed from the mother and usually resolves within a few weeks. At the beginning of puberty (ages 13–15), approximately 60% of boys develop gynecomastia to varying degrees, which typically regresses over a few years; by age 17, the prevalence drops to 7.7%. In older age, the prevalence increases again due to decreased testosterone levels.

In 25–75% of cases, gynecomastia is observed in both breasts. In one-third of patients, the size of each breast differs. Pain and tenderness may also be present.

Causes of Gynecomastia

In 25% of all gynecomastia cases and approximately 85% of surgically treated cases, no specific cause is found (idiopathic gynecomastia). Gynecomastia can also result from various conditions that increase estrogen levels or decrease testosterone levels, including cancers (adrenal tumors, testicular tumors, lung cancer, liver cancer, etc.), endocrine disorders, metabolic diseases, trauma, psychological stress, obesity, hereditary factors, viral infections, and especially medications.

Before Consulting a Plastic Surgeon

Before surgical correction, it is essential to consult an endocrinologist to investigate the cause of gynecomastia. In adults, breast enlargement may signal a more serious underlying disease that can be easily overlooked. Ultrasound examination of the breast is important to evaluate both the structural condition of the breast and to rule out cancer.

Gynecomastia and Breast Cancer

The prevalence of breast cancer in men with gynecomastia is similar to that of the general male population. However, in patients with Klinefelter syndrome who develop unilateral gynecomastia, breast cancer should be particularly suspected, and a biopsy should be performed.

Gynecomastia and Testicular Tumors

Studies show that men who underwent surgery for gynecomastia have a higher prevalence of testicular tumors. Therefore, men with gynecomastia should be evaluated for testicular tumors.

Non-Surgical Treatment of Gynecomastia

For newborns and adolescents, observation is usually appropriate. During puberty, gynecomastia is expected to regress within 1–2 years. If gynecomastia that began at ages 13–15 persists around age 17 and causes significant psychological distress, surgery should be considered.

If an underlying cause is identified, treating that cause may reduce gynecomastia. For drug-induced gynecomastia, it is appropriate to wait one year after discontinuing the medication.

During the waiting period, chest exercises can be performed to develop chest muscles; however, increasing muscle mass may make gynecomastia more noticeable.

Types of Gynecomastia

Gynecomastia can be classified into three types based on breast tissue composition:

  1. Glandular Type: Predominantly firm glandular tissue; requires surgical removal.
  2. Mixed Type: Combination of glandular and fatty tissue; treated with surgery and liposuction.
  3. Fatty Type: Predominantly fatty tissue; treated with liposuction alone.

Simon (1973) classified gynecomastia based on breast size and excess skin:

  • Type I: Small, no excess skin. Small, firm tissue beneath the nipple; removed through a small incision under the nipple.
  • Type IIA: Moderately large, no excess skin.
  • Type IIB: Moderately large, excess skin present. Treatment depends on dominant tissue type—liposuction, surgery, or both. Excess skin usually retracts within 6 months; occasionally, extra skin removal is required.
  • Type III: Very large, excess skin, nipple may sag. Reducing very large breasts without visible scarring is difficult; excess skin is removed using various techniques, and the nipple is repositioned. Sometimes only the excess breast tissue is removed first, and residual skin is addressed 6–9 months later.

Surgical Treatment of Gynecomastia

Planning surgery considers:

  • Amount of excess skin
  • Degree of nipple sagging
  • Amount of firm glandular tissue
  • Amount of fatty tissue
  • Size of the areola

If excess skin is minimal, glandular tissue is removed through small incisions around the areola. If fatty tissue dominates, liposuction is performed. Often, both surgical excision and liposuction are combined for optimal contour.

Incisions may be adjusted to equalize nipple diameter if asymmetry exists. Nipple repositioning may require different incisions if sagging is present.

In cases with excess skin, elasticity and contraction ability are important. In young patients, after liposuction, a compressive bandage is applied for 4–6 weeks to allow skin retraction, avoiding additional incisions. In severe cases, extra skin is excised, leaving circular, lollipop, or inverted-T scars. Sometimes a staged approach is used: liposuction and small incision first, followed by 6–9 months of skin retraction before further skin removal.

There is no single standard treatment; the surgeon determines the most suitable method in consultation with the patient.

Anesthesia in Gynecomastia Surgery

Small, limited cases may be treated under intravenous sedation and local anesthesia. Larger or bilateral cases are more comfortably performed under general anesthesia.

Postoperative Care

Drains may be used for a few days to prevent fluid or blood accumulation. Sutures are usually hidden under the skin and removed after 5–7 days if necessary. A tubular bandage is applied for 4–6 weeks to ensure proper skin adhesion and contour. Active sports are restricted for 6 weeks to prevent hematoma, seroma, or wound disruption.

Complications of Gynecomastia Surgery

The most common aesthetic complications arise from surgeries performed by non-specialists, including nipple retraction (crater deformity) or irregular shapes.

Early postoperative complications include hematoma, seroma, infection, and partial or complete nipple circulation problems.

Late complications include overcorrection or undercorrection of breast tissue, asymmetry between breasts, mispositioned nipples, nipple numbness, color changes in the areola, and poor scar healing.

Assoc. Prof. Dr. M. Beşir Öztürk

Specialist in Aesthetic, Plastic, and Reconstructive Surgery