Male chest enlargement comes in two main forms, and from the outside they can look identical. One is extra fat. The other is overgrown breast gland, often packed into a firm disc behind the nipple. Plenty of men have some of each, and that mix shapes how a surgeon plans the operation.

Doctors often use the term pseudogynecomastia for chest fullness made mostly of fat, and keep the word gynecomastia for growth of the glandular tissue itself. The distinction sounds academic until you sit in a consultation room. A Houston practice’s guide to gynecomastia surgery shows how Leo Lapuerta, MD, FACS, a triple board-certified plastic surgeon with more than 30 years of experience, approaches each version.

Two tissues with different habits

Fat tends to feel soft and spreads across the chest. Gland tissue tends to feel firmer and sits centered under the areola. A man can’t always tell which one he has from the mirror, and a hands-on exam in the office is the starting point.

The practice lists the usual causes of gynecomastia as hormonal imbalance, steroid use, weight gain and certain medications that contain estrogen. It notes that the tissue can appear during adolescence or with weight gain. Men who first notice the change after putting on pounds face a muddier picture, because fat and gland can grow at the same time.

The two tissues also respond to effort in different ways. Body fat shrinks with weight loss. Gland tissue does not follow the same rule, and the practice says many men who try diet and exercise find their gynecomastia persists. For a man who has trained hard and still sees the same shape under his shirt, that pattern is a clue.

The two conditions, side by side

• Main tissue: Pseudogynecomastia is mostly fat. True gynecomastia involves breast gland, often with fat around it.
• Feel: Fat is soft and diffuse. Gland is often a firm, central area under the areola.
• Response to weight loss: Fat can shrink with diet and training. Gland tissue tends to stay put.
• Surgical approach: Fat comes out with liposuction. Firm gland under the areola has to be cut out, in addition to liposuction.

Step one: liposuction through a small opening

For men with mild gynecomastia, the practice describes liposuction of the chest tissue mound as the main treatment. Dr. Lapuerta makes a small incision at the areola and first injects a fluid that contains local anesthetic and a medication to limit bleeding. He leaves the fluid in place for a period of time before he begins.

He then passes a narrow cannula, a thin suction tube, through the same opening to remove the excess tissue and taper the area so the contour of the pectoral muscles shows through. The practice says liposuction is part of most cases, and that some techniques can help the chest skin tighten. Those choices come up during the consultation.

Step two: removing the firm tissue

Suction does not clear a dense knot of gland. For patients with firm, central breast tissue under the areola, Dr. Lapuerta adds a second step in the same operation: an incision along the lower border of the areola, through which he excises the tissue. He closes it with sutures, and the practice says the scar is well hidden along the lower border of the areola.

Men with moderate to severe gynecomastia fall into a different group. The practice describes them as better candidates for a full male breast reduction, a larger operation than the one or two-step approach.

The exam that comes first

The consultation includes a manual breast exam to check for cysts or masses that may need a biopsy or ultrasound before surgery. Men can develop breast cancer, though it is rare, and the practice states that Dr. Lapuerta sends any suspicious tissue found during surgery to pathology. Based on the exam, he tells the patient whether a one or two-part procedure fits, or whether a full reduction makes more sense.

The practice also outlines the recovery. The surgery usually takes one or two hours in an outpatient setting, and the patient needs a driver home. Swelling follows, and men wear a compression garment for six weeks. Sutures come out at a follow-up visit two weeks after surgery. Many patients return to work within a few days and resume exercise after six weeks, while final results can take up to six months to show. Like any operation, it carries risks, which belong in the consultation conversation.

Dr. Lapuerta holds certification from the American Board of Plastic Surgery and the American Board of Surgery, plus certification in Surgery of the Hand. In his view, a surgeon’s experience with a specific procedure, measured in cases and years, together with board certification, is the best determinant of an outcome patients are happy with.

Once the excess tissue is gone, the practice points out, a man who wants more definition can build on the result with strength training, because the pectoral muscles are no longer hidden.

This article is for general information only and is not medical advice. Results vary from patient to patient. Consult a board-certified plastic surgeon or your physician about your own situation. Written in partnership with Joseph Lambert, a publicist working with Leo Lapuerta, MD Plastic Surgery.