The cause is usually idiopathic [1]. Gynecomastia can start with puberty, resolving on its own in most cases [1], or develop in older men as the balance of circulating testosterone and estrogens shifts toward the latter [1, 3].

Pathologic gynecomastia may be caused by medications such as antiandrogens, exogenous hormones, cardiovascular medications such as digoxin and spironolactone, and antiulcer medications such as cimetidine and ranitidine [3]. Chronic alcoholics and men who use anabolic steroids as part of a bodybuilding program are more likely to develop this condition. Certain hormonal abnormalities, inherited or acquired, usually involving either a deficiency of testosterone or an excess of estrogen, can cause breast enlargement. Other causes include thyroid abnormalities, renal failure, liver disorders such as alcoholic cirrhosis. In rare cases gynecomastia may be cause by an estrogen-producing tumor [1].

Surgical treatment addresses excess volume and, when needed, excess skin [4]. Ideally, surgical correction should allow a man to expose his chest without feeling self-conscious. Scars need to be kept to a minimum so as not to exchange one cosmetic flaw for another. Even if the skin is not optimally tight, this is a normal consequence of aging, and preferable to an operated-on appearance.

Ultrasound-assisted or power-assisted liposuction is advantageous in removing dense adipose tissue from within the fibrous parenchymal framework of the breast [4, 5]. Many men having liposuction of the abdomen and flanks will also have the chest treated simultaneously if it is offered to them and the price increment is not prohibitive. These patients may be satisfied with an improvement, if not correction of their gynecomastia. Because gynecomastia is not their presenting concern, an improvement without necessarily a correction is welcome (Fig. 9.1). I tell patients to expect about a 30–40% reduction from liposuction alone. If they desire a “flat” chest, liposuction alone may not suffice.

Liposuction is performed under total intravenous anesthesia, laryngeal mask, airway, and no paralysis. The chest is first infiltrated with a wetting solution of normal saline with 0.05% lidocaine and 1:500,000 epinephrine. Typically, 200–300 cc of solution is infused per side through inframammary incisions. Both sides are infused along with the abdomen and flanks if treated simultaneously. After infusion of all areas to be treated, ultrasonic liposuction (Lysonix 3000, Mentor Corp.) is performed using the same incisions in the same sequence to allow time for the local anesthesia and epinephrine to take effect. In many cases the patient is turned onto each side during surgery and the axilla and lateral breast are treated from the same axillary incision (simultaneously with the flanks in many men). Patients are never turned prone.