Gynecomastia is the enlargement of breast tissue in males, typically caused by an imbalance in hormones estrogen and testosterone.  It is a benign condition, that is it is non-cancerous, and it can affect either both the breasts or one breast.  It can also be seen as a lump in the breast and could be tender to touch. It is common during puberty due to fluctuation of hormone levels, but it can also affect men of all ages.  Enlarged breasts during puberty usually resolves without treatment within 6 months to 2 years.

Obesity can also cause enlargement in breasts in men due to excess fat tissue getting deposited in the breasts.  This is termed as Pseudogynecomastia.

Treatment options

Circumareolar mastectomy is performed for removing the tissue lump. The breast tissue is removed surgically, but the nipple, areola and the overlying skin are preserved and is done through an incision circling the areola.

Liposuction is also performed for gynecomastia.  In liposuction, excess fat from the breast is removed through small incisions using a device for suctioning.

Talk by Dr. R. Padmakumar on Gynecomastia

What is the cause of Gynecomastia?

It is caused by an imbalance of estrogen and testosterone hormones, means the amount of testosterone drops compared to estrogen.  Testosterone is the hormone that is responsible for muscle mass and body hair, while estrogen results in the growth of breasts being a hormone of females.

Medical conditions such as thyroid disorders, liver failure or cirrhosis, or kidney failure can also contribute to fluctuating hormone levels.  It can also be caused by side effects of some medications or substance use. Excessive use of steroids in gym goers is leading to gynecomastia in young adults in recent times.

Can Gynecomastia go away on its own?

Gynecomastia during puberty usually resolves within 6 months to 12 years without treatment.

Is Gynecomastia a serious problem?

Not, it is not a serious problem, but it can be treated for cosmetic reasons as it can cause psychological distress and low self esteem especially in youngsters.

Can it be cancer?

Need to evaluate with USG breast to exclude cancer when it appears in more than 40 years age group.

Stages of Gynecomastia

It can be classified into four stages or grades depending on the severity.

• Grade 1:  Small growth of the breast without excess skin
• Grade 2:  Moderate growth of the breast without excess skin
• Grade 3:  Moderate growth of the breast with excess skin
• Grade 4:  Significant growth of the breast with excess skin

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Hanging abdomen with an apron is unsightly and uncomfortable for any woman. Not able to wear the dress of their choice is so depressing to anyone. The self esteem gets down with every morning seeing the self profile. But they can be happy that there is a sure way out.

Causes of hanging abdomen

Overweight or Obesity: General adiposity (excess fat) as part of increase in Body Mass Index can cause an increase in abdominal circumference. The ideal BMI is 18-23. Once it is above 23 till 27.5 it is overweight and 27.5 onwards is obesity. BMI is calculated as weight in Kg/Ht in M2 e.g. If a person has 100 kg weight and 2m height, BMI= 100kg/ 2m x 2m=25 Kg/M2

Truncal Obesity (Abdominal obesity): Increasing abdominal obesity is more dangerous than the overall increase in weight. Ideally, the abdominal circumference at umbilical level should be below 80 cm in women. The increase in BMI and abdominal circumference leads to various medical illness like Diabetes, hypertension (increase in blood pressure), dyslipedemia (increase in cholesterol), sleep apnea (breathing difficulty/ snoring with respiratory arrest), PCOS (Polycystic ovarian disease) and fatty liver. It also increase the risk of cancers of breast and ovary.

Divarication Recti (separation of muscles of abdominal wall) : This happens mainly and commonly following pregnancy when there is excessive stretch of abdominal wall muscles making it fall apart from the midline. This leads to bulging of abdomen and patient will have a state similar to pregnancy look. This is highly distressing to any woman. The abdominal bulge will be such that it projects out and comes anterior than breast level in a profile view.

Ventral Hernia : Ventral hernia muscle defect with herniation / projection of abdominal contents in to the sac formed at the muscle weakness. The intestines or omentum get trapped in this defect and can cause life threatening problems.

Sagging Fat and Skin : The lower abdominal wall fat and skin is redundant (extra) and hangs down in an unsightly manner. The skin sagging may be unrelated to the muscle weakness. The pulling down of the abdominal wall by the weight of this apron itself will be causing discomfort and muscle weakness. The disfigurement in these patients is unexplainable.

Hanging Abdomen can be Treated

Patients need to consult a surgeon who is well-versed with the problem and its corrective measures. Detailed physical examination with abdominal girth, height, weight, BMI, BP, Pulse, oxygen saturation to be checked. The co-existing problems like diabetes, hypertension, snoring, respiratory difficulty with walking, menstrual irregularities, stress incontinence and psychological problem (mainly depression).

Those who have increased BMI should be advised for weight reduction. To a good extend it is possible by diet regulations and exercise. There are some drugs available to reduce weight but it helps in reducing weight around 4-5 kg only. Those with higher BMI will be benefitted by intragastric balloon placement or by bariatric surgery of which sleeve gastrectomy is the best. Abdominal obesity also gets controlled to a great extent by these procedures.

Divarication of recti (the separation of muscle in the central abdomen), the ventral hernia and sagging skin with fat (the abdominal apron) needs tummy tuck (abdominoplasty). The exercises to tone the abdominal wall, weight reduction or application of any kind of solutions or application of slim devices like vibrators are not going to give any kind of benefit to these patients.

Abdominoplasty Procedure

Pre-hospitalization

The procedure of tummy tuck involves a pre-hospitalization checkup including blood tests. Ultrasound abdomen is performed to rule out any other surgical problem in abdomen like an ovarian cyst or gallbladder stones which can be talked at the same time. The necessary consultations will also be done with other specialists as needed.

Operation

The operation is done under anesthesia, either general or regional, so that patient will be comfortable. The incision will be made at the lowest skin crease of abdomen to give excellent cosmetic outcome. The skin and subcutaneous fat will be mobilized. The muscles which are far apart will be brought together. In case of hernia a net like material (mesh) will be used to give additional strength. The excess fat and skin will be removed and wound closed. The wound closure is also done in a careful manner with no stitches outside. This also will add to the perfect healing with very minimal scar. The scar will be completely hidden by the smallest of dress.

Post Surgery

Patient needs to be in hospital for 2-3 days and can resume normal activities after that. All kinds of job can be started within two weeks time. Wearing an abdominal binder during this period will give additional comfort.

Methods of Abdominoplasty

Tummy Tuck Before and After

Procedure Outcome

The outcomes are such great that patients get immediate results and regain self esteem. The profile changes and any modern dress will suit the person. The medical issues related to the divarication like dragging pain in abdomen and backache due to the abnormal posture and weight of ventral hernia will also get resolved. In those with higher BMI and sagging abdomen the procedure to reduce weight (sleeve gastrectomy) is done along with the tummy tuck thereby avoiding scars of the bariatric surgery and unnecessary second hospitalization. Combination of these procedures is an innovative method developed at our center to give maximal benefit for patient with superior quality of life.

Tummy Tuck for women

Women who have had several pregnancies find their muscles and skin stretched. They find this procedure useful to tighten those muscles and remove the excess belly fat. Divarication Recti (separation of muscles of the abdominal wall) commonly happens following pregnancy when the abdominal wall muscles are excessively stretched leading to a bulging of the abdomen. This can be rectified by tummy tuck surgery.

Tummy Tuck for men

Tummy Tuck can also be performed in men who has hanging abdomen.

Assessment

The psychological impact of these illness on the patient is very significant. They will be always worried about and other is depression seeing the bad body contour every day. Being not able to wear the dress they like and not able to move around comfortably also keeps them introverts and less sociable. Many jobs also demand people with normal BMI and body shapes. Even promotions are jeopardized by these abnormalities. The associated medical problems and the need for medication for the same will also be making patients uncomfortable and dissatisfied in life.

Tummy Tuck Surgery Cost in Kerala

Tummy Tuck Surgery cost in Kerala is cheap compared to Tummy Tuck Surgery cost in other parts of India. For an enquiry about the cost contact:

Tummy Tuck Surgery in India

Tummy Tuck Surgery in India is performed regularly by Dr. R. Padmakumar, one of the best Tummy Tuck Surgeon in India. He is also Dr. Padmakumar is hailed as one of the Best Bariatric Surgeon in India & UAE. He is renowned for new and improved treatment techniques and the first in the World to perform SCARLESS BARIATRIC SURGERY with Abdominoplasty.

Tummy Tuck Surgery Cost in India

Tummy Tuck Surgery cost in India is also cheap compared to other parts of the world. For an enquiry about the cost contact:

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Diet and exercise, behavior therapy, and anti-obesity drugs are the first-line treatments for obesity and overweight. But for severe obesity this has limited success and long term success is very poor. Weight loss surgery or bariatric surgery results in greater weight loss than these conventional treatments. Weight loss surgery aids in improving the quality of life and brings improvement in obesity related diseases such as diabetes mellitus, hypertension, etc.

When is Weight Loss Surgery indicated?

Weight loss surgeries have proved effective and long term studies show that these procedures cause long term weight reduction, resolution of diabetes, improvement in cardiovascular risk factors and obstructive sleep apnea, etc.

According to a medical guideline published by the American College of Physicians, Weight Loss Surgery should be considered as an option for treatment in patients with BMI of 40 kg/m2 or above, who instituted an adequate exercise and diet regimen, but failed, and also in patients presenting with obesity-related comorbid conditions.

Obesity increases the risk of many diseases and health conditions. These include: Type 2 diabetes (Diabetes Mellitus), Coronary heart disease, Hypertension (High blood pressure), Cancers (endometrial, breast, and colon), Dyslipidemia (for example, high cholesterol), Stroke, Liver and Gallbladder disease, Obstructive Sleep Apnea and respiratory problems, Osteoarthritis, Infertility, Asthma

Frequently Asked Questions on Bariatric Surgery

What are the 4 Types of Bariatric Surgery?

Types of Weight loss Surgeries include:

•  Laparoscopic Sleeve Gastrectomy (LSG)
• Laparoscopic Gastroplasty
•  Roux-en-Y Gastric Bypass
•  Mini Gastric Bypass (MGB)

Laparoscopic Sleeve Gastrectomy – Laparoscopic Sleeve Gastrectomy is a surgical procedure for weight loss. Sleeve gastrectomy is also known as a vertical sleeve gastrectomy or gastric sleeve procedure. In this procedure, the outer margin of the stomach is removed to restrict the amount of intake of food leaving the size of the stomach to about 15% of the original size of the stomach.

Roux-en-Y Gastric Bypass – Gastric Bypass is a surgical weight loss procedure for treatment of morbid obesity. In this procedure the stomach is divided into a small upper pouch and a large lower pouch. The small intestine is then reattached to the pouch that creates a bypass for food, which results in absorption of less calories and nutrients.

Intragastric Balloon Placement for Weight Loss – Intragastric Balloon Placement involves using an endoscope to place a deflated balloon in the stomach. The balloon is then inflated to decrease the amount of intragastric space. The balloon is then left in the stomach for a period upto 6 months. Due to the restricted amount of food intake there is an average weight loss of 10-15 kg. This is highly effective in overweight people not classified as obese.

Which Bariatric Surgery is the safest?

Sleeve Gastrectomy is considered to be safer than Roux-en-Y Gastric Bypass and Mini Gastric Bypass as the anatomy is not altered in Sleeve Gastrectomy.

In Roux-en-Y Gastric Bypass, there is alteration in the anatomy as the stomach is divided into small upper pouch and large lower pouch and the small intestine is attached to the pouch (anastomosis) to create a bypass for food.  In Mini Gastric Bypass, the small intestine is connected by a single anastomosis, and thus there is an alteration in the anatomy.  Whereas in Sleeve Gastrectomy such anastomosis is not created and thus there is no alteration in the anatomy.

Gastroplasty on the other hand has the advantage of having no gastric leak.  There is less than 1% risk of Gastric leak that is possible in other bariatric procedures like Sleeve Gastrectomy or Gastric Bypass procedures and people could be afraid of such risks.    Gastric leak happens when digestive fluids leak through the staple line or incisions or anastomosis. Though Gastroplasty is considered safer than Sleeve Gastrectomy, Sleeve Gastrectomy is recommended is patients with high BMI as there is signification reduction of weight compared to Gastroplasty.  In Gastroplasty, 10 – 15 kg reduction is expected, where as in Gastrectomy or Bypass procedures there is much more significant loss of weight.

Which Bariatric Surgery is best long term?

Sleeve Gastrectomy is best long term because the portions of stomach which secretes Ghrelin and acid  in excess is removed.  Ghrelin is the hormone which is responsible for increasing appetite and cholesterol and the acid in the stomach is responsible for digesting the food.    As the part of the stomach responsible for secreting Ghrelin and acid is removed, appetite is reduced leading to less food intake.

Sleeve Gastrectomy is also considered best long term, because since there is no bypass created unlike Gastric Bypass procedures, the patient will not suffer from micronutrient deficiency.  No additional diet or vitamin supplements will be required and weight loss attained will be almost as equal to complex bypass procedures. Sleeve Gastrectomy is also best long term compared to Gastroplasty as the weight loss expected in Gastroplasty is around 10 – 15 kg, where as in Sleeve Gastrectomy there is a significant loss of weight.

Complications of Obesity

Obesity is a medical condition. Obesity occurs due to excess body fat accumulated in the body and is considered a serious medical condition due to the adverse health effect obesity has on the body. People with BMI (Body Mass Index) exceeding the normal range has much greater risk of medical issues. Medical issues include cardiovascular diseases, diabetes mellitus, OSA or obstructive sleep apnea, asthma, etc..

Obesity is a serious medical condition.  People who suffer with obesity and overweight, compared to people with normal or healthy weight, are more likely to develop a number of potentially serious health conditions.  These include:

Hypertension, also called high blood pressure. 

High Cholesterol (Dyslipidemia).

Heart disease:   High blood pressure, abnormal cholesterol levels and high sugar are risk factors for heart disease.  Obesity gives stress to the heart to send blood to all the cells of the body.

Stroke:   Stroke is a condition where the blood flow to a part of the brain stops, which causes the brain cells to die.  High Blood pressure and abnormal cholesterol levels increases the risk for stroke. 

Type 2 diabetes.   It is believed that obesity accounts for 80-85% of the risk of developing type 2 diabetes.  Obese people are 40 times more likely to develop type 2 diabetes than people with normal weight.

Gynecological and sexual problems. Obesity may lead to infertility and irregular periods in women and may cause erectile dysfunction in men.

Sleep apnea and breathing problems are more likely to develop in obese people.  Sleep apnea is a condition in which a person has one or more pauses in breathing during sleep.

Osteoarthritis.  Obesity increases the stress placed on weight-bearing joints.  This may cause damage to the cartilages.

Cancers.  Obesity might increase the risk of cancer of the cervix, uterus, endometrium, ovary, breast, rectum, colon, esophagus, liver, pancreas, gallbladder, kidney and prostate.

Digestive problems.  Obesity increases the likelihood that you’ll develop heartburn, gallbladder disease.

Fatty Liver disease.  This occurs when fat builds up in the liver.   This disease often affects people who are overweight or obese and/or diabetic patients and also in middle aged people.

Polycystic ovarian disease or PCOD.

Pregnancy:  Obese women who are pregnant is at increased risk for developing gestational diabetes, high blood pressure during pregnancy that causes problems for both mother and child.

Depression and anxiety.

Low quality of life.

Bariatric Surgery may help in lowering the risk of Stroke and Heart attack. Bariatric Surgery helps in lowering the risk of stroke and myocardial infarction (heart attack) in patients suffering with type 2 diabetes and severe obesity according to a study published in the Journal of the American Medical Association (JAMA). The study was conducted to investigate the relationship between bariatric surgery and incident macrovascular (coronary artery disease and cerebrovascular diseases) events in patients with severe obesity and type 2 diabetes. This observational study concluded that patients with type 2 diabetes and severe obesity who underwent bariatric surgery, compared to those who did not undergo surgery, bariatric surgery was associated with a lower risk of macrovascular outcomes.

Related Links

• Bariatric Surgery Gallery – Before and After
• Video Gallery
• About Bariatric Surgeon – Dr. R. Padmakumar

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