Gynaecomastia Treatment in Ukraine

Gynaecomastia is enlargement of the male breast caused by growth of glandular tissue. It is driven by a shift in the balance between oestrogens and androgens at the level of the gland itself, not by excess weight or lack of exercise. That is why the conversation with the patient starts not with choosing a surgical technique but with the question of why the gland started to grow.

There are two fundamentally different situations. In the true form, a firm, mobile disc of glandular tissue can be felt under the areola, often tender when pressed. In pseudogynaecomastia, or lipomastia, the gland is unchanged and the volume comes only from fatty tissue, spread evenly, with no firmness under the nipple. The operation depends directly on this: fat is removed by liposuction, but liposuction does not remove a firm gland, which has to be excised. Most men have both components; the only question is the proportion.

Some forms are physiological. Pubertal gynaecomastia appears at the age of 12–14 against the background of hormonal changes and occurs in more than half of teenage boys. In most cases it resolves on its own within 1–2 years, so a teenager should not be rushed into surgery: an operation is discussed only after a year or two of monitoring, when the picture is stable and the gland has stopped changing. The second physiological form is age-related: after 50–60 testosterone levels fall, the proportion of fatty tissue increases, and the gland responds to this change.

Surgery is considered when the condition has lasted more than a year or two, the tissue has become fibrous and no longer responds to medication, the cause has been found and dealt with, and your weight is stable. It is not appropriate with active pubertal gynaecomastia, with an uncontrolled condition that caused the enlargement, if you are still taking anabolic steroids or testosterone boosters, with obesity before weight has been corrected, or when you expect the procedure to give you a sculpted chest, because it does not.

Separately and plainly: a firm lump on one side with nipple retraction, nipple discharge or enlarged lymph nodes in the armpit is a reason to rule out male breast cancer, not an indication for cosmetic surgery. Breast cancer in men is rare, but it does occur, and if these signs are present the patient is first referred for mammography, ultrasound and, if needed, a biopsy. No cosmetic procedure is planned in this situation until the diagnosis is clear.

MediUkraine is a treatment search and coordination service, not a clinic. We select a medical centre and a plastic surgeon, arrange the dates of the tests and the operation and support patients, including those travelling from abroad. The indications, scope and technique of the procedure are determined by the surgeon after an in-person examination, together with an endocrinologist.

The technique is determined by the balance of three things: how much glandular tissue there is in the breast, how much fat, and whether there is excess skin. This is established before the operation, by palpation and ultrasound, not in the operating theatre. Surgeons use the Simon classification to describe the grade: I, small enlargement without excess skin; IIa, moderate enlargement without excess skin; IIb, moderate enlargement with excess skin; III, marked enlargement with significant excess skin and a lowered nipple.

Liposuction is the basic stage for the pseudo form, where the volume comes from fat. It is done under tumescent anaesthesia: the tissue is infiltrated with a solution containing adrenaline, then cannulas of 3–4 mm are inserted through 3–5 mm punctures in the fold beneath the chest and on the side of the chest wall. Power-assisted (PAL) and ultrasound-assisted (VASER) systems pass more easily through dense fibrous fat, which is more common in men than in women. Liposuction smooths the transition to the side of the chest wall well, but it does not remove the firm disc of gland under the areola: this is a fundamental limitation of the method.

Subareolar gland excision is the operation for the true form. An incision about half the circumference of the areola is made along its lower edge, at the border between the pigmented and lighter skin: in this position the scar usually becomes barely noticeable over time, although how it matures in a particular patient depends on skin type and tendency to scarring. Through this access the glandular tissue is freed and removed in one piece, together with the part behind the areola, which is what gives the firmness on palpation.

The key technical point of the operation is how much tissue to leave under the areola. A layer of 5–10 mm is deliberately preserved beneath the nipple-areola complex: it holds the shape, maintains the blood supply to the areola and prevents the skin from sticking to the chest muscle. If this layer is removed completely, a depression forms where the areola is, more noticeable than the original problem, and it has to be corrected with fat grafting.

Liposuction combined with excision is performed in most cases, because pure forms are rare. The order is as follows: first liposuction over the whole area, including the sides, then the remaining firm disc is removed through a subareolar incision. This gives an even transition between areas and reduces the area that has to be excised; an additional effect of liposuction is that the mobilised skin contracts better after the operation.

With small amounts of glandular tissue, a pull-through technique is used: after liposuction the remaining gland is grasped with a clamp and removed through the same puncture, without an incision around the areola. The method does not suit everyone: with a dense fibrous gland and with large volumes control is poorer, so surgeons go back to open access.

Skin excision is needed when the skin is stretched and will not contract on its own. With moderate excess, a periareolar lift (round-block) is done: skin is excised in a ring around the areola, the scar lies along its border, and a stretched areola can be reduced at the same time. With marked excess, particularly after significant weight loss or bariatric surgery, a vertical scar or a scar in the fold beneath the chest is used, and in the most severe grades the nipple-areola complex is transferred as a free graft. This last option is the most invasive: nipple sensation usually does not return afterwards, and pigmentation may become uneven.

Sometimes it is wiser to split the work into two stages. First the gland and fat are removed, the skin is given 6–12 months to contract, and only then, if excess remains, is it excised. This way the scars often turn out shorter than if the skin had been cut straight away; for young patients with elastic skin this is a common approach.

Asymmetry is prevented by a series of small details: the markings are made before the operation with you standing, because the contours shift when you lie down; the tissue removed from each side is weighed and compared; and at the end you are moved into a semi-sitting position and symmetry is assessed while still on the table. If needed, drains are placed for a day; they reduce the risk of blood and fluid collecting.

The removed tissue is always sent for histology. This is not bureaucracy: isolated cases of malignancy are found precisely in tissue that was removed as a benign enlargement of the gland, and the clinic must be prepared to change the treatment plan based on the pathologist's report. It is also worth understanding the limits of the procedure: the operation removes the gland and fat in the chest area, but it does not treat the cause, does not replace weight loss and does not create a sculpted chest. If your body mass index is high, the result will be different from the photos of athletic patients, and it is more honest to agree on this before the operation than to be disappointed after it.

You spend the first day in hospital under observation. Pain after this procedure is moderate and is usually controlled with ordinary painkiller tablets; the feeling of tightness from the compression garment is more bothersome. If drains were placed, they are removed on the first or second day, before discharge.

The compression garment is not a recommendation but part of the treatment. It is worn around the clock for the first 3–4 weeks, removed only for showering, and then for another 2–4 weeks during the day. It presses the skin against the chest wall, reduces swelling and lowers the risk of fluid collecting in the space left after tissue removal.

Stitches are removed on days 7–10 if they are not dissolvable. Showering is allowed from about the third day, once the wounds have closed; baths, swimming pools, saunas and the sea no earlier than after 4 weeks. In the first months the scar should be protected from the sun, otherwise it may stay darker for a long time.

Swelling and firmness under the areola are an expected phase, not a complication. Firm scar tissue in the excised area lasts from 1 to 3 months and gradually softens. Nipple sensation in the first weeks may be reduced or, conversely, heightened; in most patients it returns within a few months.

People return to office work after 5–7 days, provided it does not involve physical exertion. Light cardio is allowed after 3–4 weeks, and strength training and any load on the chest muscles after 6 weeks. Lifting more than 5 kg in the first month is not advisable: it is a common cause of a haematoma after discharge.

The shape is assessed no earlier than 3 months later, and the final shape at about 6 months, once the swelling has gone and the tissues have settled. The scar takes longer to mature: for the first months it is red and firm, and it fades over 6–12 months. In roughly one patient in ten, residual unevenness or asymmetry is found at the assessment stage and corrected with a minor procedure, and the surgeon warns you of this possibility in advance.