Why May Some Athletes get Gynecomastia?
While the presence of gynecomastia is generally frowned upon by society, it is can be rather vilified for bodybuilders with gynecomastia. Dedicated bodybuilders put themselves in high testosterone states, either through rigorous dieting/exercise and pro-testosterone supplementation, or through exogenous use of anabolic steroids, or most commonly, a combination of both. When the male system is confronted with more testosterone than it can handle, a specific enzyme known as “aromatase” converts excess androstenedione into estrogen and estrone, which are very potent estrogens. This estrogen level in turn stimulates the male gland to hypertrophy, resulting in an asymmetric appearance to the male chest. In men that dedicate themselves to incredibly high standards of muscle aesthetic, this appearance can seem unsightly, leading male bodybuilders to commonly seek out treatment for gynecomastia.
Treatment Options for Bodybuilders
For bodybuilders with gynecomastia, treatment starts with avoiding anabolic steroids with higher levels of aromaticity. Specifically, these include Sustanon®, Dianabol®, Winstrol®, and Anadrol®. Further therapy is designed to reduce the conversion of androgens into estrogens. These include aromatase inhibitors such as anastrozole. Other therapies act to block estrogen receptor binding, such as Tamoxifen, but this approach is associated with greater side effects.
For bodybuilders with gynecomastia seeking the best possible outcome, a combination of liposuction with surgical excision offers the most comprehensive outcome. Liposuction is used to generally reduce the glandular component, and blend the surrounding soft tissue into the soon-to-be-removed gland.
The procedure can be done under local anesthesia, but most of our patients opt for a “twilight” anesthesia. Surgery is done through an incision of less than 2.5 centimeters, with the incision strategically placed at the juncture of the male areola with the breast skin to reduce outward signs of scarring.
Example of Bodybuilder with Gynecomastia
This is an example of how gynecomastia presents in high level athletes. This young man found our practice while living in Tampa, Florida. He has a classic presentation of excess glandular tissue that cannot be worked off or removed via increased physical activity. On the anterior photos, you can see a curve of tissue beneath the areola that obscures the inferior border of the pectoralis major muscle insertion. His left side has a greater degree of descent than his right.
Oblique and lateral views also show the lower lateral fullness that is obscuring a well developed pectoralis major muscle. Lastly, on lateral view, there is a downward angle to the areolar complex as a whole.
On the right side, there is a cone shape to the breast, and again, the nipple areolar complex is angled downwards.
This is the typical presentation we see with bodybuilders or high octane athletes. Regardless of whether exogenous steroid use is present or absent, the high testosterone levels present in these male athletes always lead to increased production of estrogens, which in turn leads to a feminization of the male chest. To the public at large, this may not seem like a significant issue, but to men that work this hard on their muscularity, development of gynecomastia with bodybuilders is at the least demoralizing, and at the most, devastating.
Left Side Done
In this instance, we employed a combination of liposuction and mimimal incision mastectomy to achieve an outstanding result. Again, liposuction was used to contour the overall pectoralis muscle area and axilla. The excess fat that is hormonally sensitive in the chest area was appropriately removed using power assist liposculpture. Next, a 2.5 centimeter incision was made in the lower axilla, and the entire gland itself was removed atraumatically. No surgical drains were used. Bruising was present for 2-3 days. Sutures were removed eight days following surgery. The patient was able to start light cardio workouts the day after surgery, and gradually increased his workouts over 14 days to his normal training regimen. This particular patient competed in an International Federation of Bodybuilding and Fitness (IFBB) show 23 days following his procedure!!
This photograph is shown immediately after surgery. Patients are dressed with a specific type of dressing allowing them to shower and participate in athletic activity.
As you can see, there is minimal scarring. The gland has been removed in its entirety, and power assist liposculpture has been used to reduce the fat pockets that were previously obscuring the muscle projection.