Loose skin, a nipple that sits well below the muscle, and tissue that no amount of weight loss has shifted. That is the BB grade 5 chest, and the operation for it is a mastectomy with free nipple-areola graft.
The breast tissue and the loose skin are removed through an incision across each side of the chest, and the nipple and areola are put back as a free graft in a higher position. Of all the gynaecomastia treatment options I offer, it is the largest operation, and it comes with a trade I put to every man at this grade: a flat chest in exchange for permanent scars across the chest.
It is 1 night in hospital, with a drain on each side. A firm dressing called a bolster holds each graft in place until day 10, and a compression vest is worn for 4 weeks full time, then 2 weeks in the daytime.
The 2 risks that matter most are loss of part or all of the graft, and a haematoma, which is bleeding under the skin.
Is this the operation for you?
It applies where:
- The skin has lost its spring: stretch marks, slow or no springback when pinched and released, and a loose envelope at rest.
- The nipple sits well below the lower border of the pectoralis major muscle.
- The chest has been through major weight loss, or has been large and unchanged for years.
What I measure at examination
2 readings put a chest at BB grade 5. The first is nipple position: standing, I measure the nipple centre against the inferior border of the pectoralis major. I use the muscle border, not the fold under the chest, because the fold drops with the skin and the muscle border does not. The second is skin elasticity, a five-point BB elasticity grade scored from stretch marks, recoil on pinch and release, and looseness at rest.
A nipple more than 2 cm below the muscle border is BB grade 5 whatever the skin does. So is BB elasticity grade 4 or 5: skin that will not tighten however much is removed from under it.
If the readings are different
- BB elasticity grade 1 or 2 with the nipple within 2 cm of the border is a BB grade 4: crescent lift.
- BB elasticity grade 3 is the uncertain skin. I do the BB grade 4 operation first and reassess at 6 to 12 months. It becomes a BB grade 5 operation only if the skin has not retracted.
- Where the nipple has not dropped, one of the smaller operations applies: BB grade 1: gland excision only, BB grade 2: VASER liposuction (ultrasound assisted lipectomy) only or BB grade 3: VASER liposuction (ultrasound assisted lipectomy) with gland excision.
Gynaecomastia around puberty is common and usually settles on its own, so this operation is not for adolescents. Long-standing bilateral gynaecomastia that has not changed needs no hormone investigation before surgery.
Not sure which grade you are?
Download the five grades guide: what each BB grade looks like and the operation that matches it.
Why a free graft, not a lift and not a pedicle
A crescent lift moves the nipple up by 2 cm, sometimes 2.5 cm, and no more. Loose skin cannot be lifted. It has to be cut out, and once that much skin is gone the nipple has to travel a long way.
There are 2 ways to move it. One keeps the nipple and areola on a stalk of their own tissue, called a pedicle, so they arrive with their blood supply intact. The other takes them off as a free graft and sets them onto the flat chest. The problem with the pedicle is what it leaves behind: a mound of tissue under the nipple that can still read as gynaecomastia.
I use the free graft at this grade because it gives the flattest chest. It also has costs that do not change from man to man: permanent scars across the chest, a nipple with no sensation, and some change in its colour and how far it stands out.
The operation
Where the incisions go
The incision runs across each side of the chest, just below the lower border of the pectoralis major, on the line the muscle makes. It extends inwards towards the sternum and outwards around the side of the chest, and in a large chest the 2 sides can meet in the middle. The nipple and areola are removed as a full-thickness graft, trimmed to a male size, and set into their new, higher position. I mark all of it with you standing, before surgery.
What comes out and what stays
The loose skin between the incision lines and substantially all of the gland come out. Where there is a fatty component, VASER liposuction (ultrasound assisted lipectomy) removes it. The graft is laid on its new bed and held there by the bolster. A drain goes in on each side. All excised tissue goes to pathology.
Anaesthetic and the night
It is a general anaesthetic, both sides in the one operation. Most of the anaesthetic assessment happens by phone beforehand, and the airway is examined on the day. I assess your risk of clots and decide the precautions, and any aspirin or blood thinner is planned well before surgery, never stopped on your own. It is 1 night at Maitland Private Hospital, home the next day with someone to take you.
Recovery
- Day 0: surgery, 1 night in hospital.
- Day 1: home. Each drain comes out once its output falls below 20 mL.
- Day 10: the bolsters come off in the rooms. Until then they stay undisturbed, and you are shown at discharge how to wash around them.
- Weeks 1 to 4: compression vest full time, with wound checks in the rooms through the first 2 weeks.
- Week 4: review, silicone strips on the scars, and handover to your GP for ongoing care.
- Weeks 5 to 6: vest in the daytime only.
- Months 1 to 3: scar massage, 15 minutes morning and night.
- Months 3, 6 and 12: reviews. Sunscreen on the scars for the first year. Any revision waits until 12 months.
The graft looks worse before it looks better. Early on it is dark and then crusted, and it settles over the following weeks as it takes up its new blood supply.
Desk work is about 2 weeks off, manual work 4 to 6 weeks. Training is staged: walking from the first days, then the lower body and cardio, then the upper body, with chest work last. I clear each stage at review rather than by the calendar.
The recovery page for this operation sets out each stage in detail.
Risks
The risk that sets this operation apart is graft loss. Part of the grafted nipple and areola, or occasionally all of it, may not take. If that happens the area is managed with dressings while it heals over, and a further graft can be done later if needed.
The other main risk is a haematoma, bleeding under the skin after surgery. A small one settles on its own. A larger one means a return to theatre to drain it.
Some changes are part of the operation rather than complications, and I say so before surgery: the nipple loses its sensation permanently, the areola can heal paler or with uneven colour, and the nipple stands out less than it did.
The remaining risks are those of any large chest wound: the wound edges opening in places, dog ears at the ends of the scars, a difference between the 2 sides, scars that thicken or become keloid (a corticosteroid injection into the scar is available), a seroma, infection, an uneven contour, and the risks of a general anaesthetic and of clots.
Substantially all of the gland is removed, so the tissue does not grow back. What changes the result over the years is a large swing in weight.
The complications page for this operation goes through each of these in detail.
Book a consultation online
I examine both sides, grade each one, and tell you which operation applies.
Cost and Medicare
Medicare items 31525 and 31526 apply to mastectomy for gynaecomastia where the enlargement is not due to obesity and is out of proportion to your build, with photographs in your notes to show the clinical need. Item 45545 applies to the nipple-areola graft where Medicare accepts it in this setting. I assess eligibility at consultation. Your health fund’s contribution depends on your policy, and where no item applies, GST is added to the fee. The figures, and which item combinations apply, are on the mastectomy with free nipple-areola graft cost page. The gynaecomastia surgery cost guide covers the wider picture.
Your next step
You need a GP referral before the first consultation. At my rooms in Lorn, near Maitland, I examine the chest, grade each side on its own, and give you an itemised written quote. A second consultation, at no charge, goes through your blood results and can be done remotely. Telehealth is available for regional patients.
Where you have lost a lot of weight, surgery is planned once your weight is stable, and the pre-operative bloods include a nutritional panel. Current Australian guidance does not recommend stopping weight loss medications before surgery and I follow it, though a temporary dose reduction may be discussed if you cannot meet your protein targets. Do not change the dose on your own.
Book your first consultation online
Bring your referral and a list of your medications.
About Dr Bernard Beldholm
I am a Specialist General Surgeon and a Fellow of the Royal Australasian College of Surgeons (FRACS). I have performed gynaecomastia and body contouring surgery for more than 15 years, and men who have lost a large amount of weight make up much of my practice.
I publish in the peer-reviewed literature, teach other surgeons, and host the Body Contouring Podcast. My rooms are in Lorn, near Maitland in the Hunter Valley, and I operate at Maitland Private Hospital, which has an intensive care unit.
