Fat vs. Gland: the debate (long)

[Spleen]

Yeah,

There's always a lot of talk here about the type of gynecomastia a person has: is it fat or is it gland?  Distinguishing between the two types is considered important because the common opinion is that glandular gynecomastia can only be sorted out thru medical means (surgery or medication) while fatty gynecomastia may be resoved by diet and exercise.  Based on my very recent surgery experience I'm going to challenge this notion.  All of the following blather is my own opinion based on my experience.  Others may (and I'm sure, will) have differing opinions.

Here's my before pix:
http://www.gynecomastia.org/cgi-bin/gyne_yabb/YaBB.cgi?board=1;action=display;num=1115146713

The top pic is a view of my old right nip.  That was what I would have called my "bad" one since the pointiness of the areola was so pronounced from the natural contour of my chest.  The second pic is of the left side where the transition was less pronounced.  My nips have looked like this for better than 20 years with almost no change.  

Initially my doc planned just excision, but decided just before surgery to get ready for lipo too.  After surgery he told me that the gland he removed from the right side was small, maybe the size of a big grape.  The left side was more like a poached egg, considerably bigger.  But how could this be?  We all "know" puffy nipples are caused by gland, not fat.  Right?

Well, after loking at the pic again I noticed that my right breast was fuller in appearance.  Maybe that was because of the larger gland?  But what about those pointy nips?  Even when I was on a serious no carb diet for a couple years and doing lots of cardio I had 8-9% body fat and I still had puffy nipples.  But, I realized, I also had a little spare tire.  I could never shake that belly fat, just as I could never shake those puffy nipples.

So I got to thinking: maybe you could have gyne that is more fat based, even with a case of puffy nipples, and you won't necessarily be able to erase it by cutting fat.  It's a fact that most folks have stubborn areas on their bodies that won't cut up despite all the dieting and exercise.  

So here's the conclusions I've come to.  First, that the fat vs. gland debate might largely be irrelevant.  In the end what does it matter if your breasts are fat or gland when the real problem is that you have breasts?   It's like worrying if the guy who just punched you in the face studied boxing or Tang Soo Do.  What does it matter when you still have the same result: a black eye?  I had two docs feel my teats and comment that they thought the right side had more gland.  The results of surgery proved otherwise.  

Second, I think that it might be case that fatty gynecomastia could be resitant to dieting and exercise.  It was in my case.  If gland was the issue then when I had low body fat my right side should have diminished while the left side maintained its size.  That didn't happen.  Again, I don't think it will matter if it's fat or gland if it ain't going away when you start to cut body fat.

Lastly, I think it may be wise to only enter an operating room if your plastic surgeon is at least prepared to do both excision and lipo.  What if he cuts you and doesn't find much gland and isn't set up for lipo?  Or how about the many guys we've seen here complain that their doc said they'd fix it with lipo-only and they still had puffy nips because no excision was done?  For any one case a PS may not need to do both but it would be good to know that they're prepared for any eventuality.

Spleen

[toronto]

i completely agree with you..everything you said..

the thing is..with gland, it's not such an "indulgence" to get surgery...there's nothing u can do about it, it's there, not your fault..

more often than not, fat is seen as something u should work off, it's like the person who gets lipo to get rid of stomach fat..they're seen as too lazy to work it off the hard way...

i think that's the reason the fat vs gland debate exists...if it's fat in theory work it off, if it's gland, you have to get an op to get it out, so might as well get lipo while your under to complement the gland excision...

in my case it was a mix of gland and fat (with more gland than fat)...but let's say it was 100% fat with no gland..would i have gotten the op? or would i have worked out that much harder to get my body fat down..i don't know..

[DrBermant]

So here's the conclusions I've come to.  First, that the fat vs. gland debate might largely be irrelevant.  In the end what does it matter if your breasts are fat or gland when the real problem is that you have breasts?   It's like worrying if the guy who just punched you in the face studied boxing or Tang Soo Do.  What does it matter when you still have the same result: a black eye?  I had two docs feel my teats and comment that they thought the right side had more gland.  The results of surgery proved otherwise.  

Second, I think that it might be case that fatty gynecomastia could be resitant to dieting and exercise.  It was in my case.  If gland was the issue then when I had low body fat my right side should have diminished while the left side maintained its size.  That didn't happen.  Again, I don't think it will matter if it's fat or gland if it ain't going away when you start to cut body fat.

Lastly, I think it may be wise to only enter an operating room if your plastic surgeon is at least prepared to do both excision and lipo.  What if he cuts you and doesn't find much gland and isn't set up for lipo?  Or how about the many guys we've seen here complain that their doc said they'd fix it with lipo-only and they still had puffy nips because no excision was done?  For any one case a PS may not need to do both but it would be good to know that they're prepared for any eventuality.

Spleen

Dieting is good for losing weight in general.  However, you cannot pick where the fat comes from.  Men tend to put weight on their chest and stomach first and lose these region's fat last.

Yes, it can be difficult to determine gland, fat, skin contributions for gynecomastia.  All can contribute to a female like chest contour.  My Dynamic Technique evolved years ago to manage the large variations of problems I have seen that present as gynecomastia.  This permits me to bring an artist's collection of surgical techniques to the operating room.  Which subset I need can vary from one patient to the next.  Sometimes liposuction alone is needed.  More often a combination of methods including excision are essential to contour the chest.

I do not need to wait until the tissues are removed to determine what is there and have never said so, although I have been misquoted.  My clinical exam is very good however, I have found cases where fat felt like gland and gland felt like fat.  As soon as I am placing the anesthesia with needle and cannula, gland reacts differently than fat.  This helps in what needs to be done next.  As I make my incision near the areola chest junction, the gland is often easily seen.  Gland tends to be white while fat is yellow.  Gland tissue removed can be seen on the many examples of my website.

Hope this helps,

Michael Bermant, MD
Learn More About Gynecomastia and Chest Sculpture

[Spleen]

I'm gonna pat myself on the back for getting Doc B. to post something other than his usual "canned" response.  Good post Doc, and to the point.  You are a great resource for info.  Thanks.

What I think Doc B confirms is that resolving the problem surgically requires being prepared for two approaches: excision and lipo.  If a doc tells you he's gonna go with one approach *only* IMO get another opinion.

[Paa_Paw]

I too think that you merit a pat on the back and applaud Dr B. For his response.

Because Gynecomastia runs in my family,  I regard it as physiologically normal but with sometimes severe emotional effects.

The issue of Fat vs Gland becomes of no importance when the emotional effects are the primary criteria for evaluation.  Emotionally, there is no difference.  Most often, there is at least some glandular tissue surrounded by fat and again the arguement becomes a waste of time.

As to whether surgery is justified, the emotional issues are more important than the volume of tissue.  Patient education and realistic expectations of the surgical outcome are also very important.  Hopefully, the person had a good endocrinological work-up prior to being considered for surgery.

[SW_ON_Huge_Moobs]

Seeing we have a doctor on here I will ask about some of the criteria used to determine how much is fat and how much is gland in an exam setting (ie before going in).

I won't be going for an assessment until the fall (I want to do the surgery over the fall and winter) and I know I can't get a diagnosis over a internet forum but I still am curious.

I have very LARGE moobs and they seem to be made up of very hard fibreous matter when I squeeze.  I have lost about 50 lbs and need to lose another 100 lbs and what remains is all round the middle and butt and thighs.

I have lost enough that there seems to be NO fat left on my upper chest and I can see all the blue viens on my upper chest AND even on my moobs RIGHT down to the nipples.  There is a inch and a half roll of fat on my sides at moob level and that is obviously all fat but I cant pinch any fat on my moobs (BTW the solid fibre mass seems to go E-W side to side as opposed to N-S and my moobs droop)

So I guess my question to the doc is how much of it can be fat when you can all ready can see the veins on the moobs right down to the mipple - hey maybe that typo I just made applies, so I wont change it.   If gyne-dudes have moobs we have mipples!

[Paa_Paw]

In a response to a post some time ago, Dr Bermant said that it is often difficult to tell in the pre-operative exam.

He went on to boast a bit about his own methods etc.

The boasting is justified,  This kind of surgery has not been around for a very long time and each Surgeon has essentially his own methods.  Even though they usually come down to Excision and Liposuction They differ in how they employ these methods.  Concurrently, The Surgeon is a sculptor.   It is sometimes difficult to distinguish where the transition takes place from Doctor to Artist.  Perhaps, there is not a transition at all but that both the Doctor and the Artist co-exist at all times.

Back to the original question, The only way to know for sure is to Operate and see what is there.

Either way, the emotional impact is the same so the question is moot.