A firm disc under a nipple that has dropped, on skin that still springs back when you pinch it. That is BB grade 4 in my grading system, and this page covers the operation for it.
A crescent of skin is removed above the areola, which lifts the nipple by up to 2 cm. The glandular disc comes out through the same incision, and VASER liposuction (ultrasound assisted lipectomy) reduces the fat around it. About 1.5 hours under general anaesthetic at Maitland Private Hospital, a drain on each side, and home the same day without private health insurance or after 1 night with it.
The main risk is a haematoma, bleeding into the space left after the gland is removed. The risk that belongs to the lift is distortion of the areola.
Each side is graded on its own, and the two sides can differ.
Is this the operation for you?
The BB grade 4 chest has 3 features:
- The nipple sits low or points downward.
- A firm disc behind the areola, with or without fat around it.
- Skin that springs back when pinched, with few or no stretch marks.
The grade comes down to 2 measurements at examination. The first is where the nipple centre sits against the lower border of the pectoralis major muscle, with you standing: within 2 cm below it is BB grade 4. I measure from the muscle border, not the fold under the chest, because the fold moves down with loose skin. The second is a 5-point BB elasticity grade, read from stretch marks, how fast the skin recoils after a pinch, and how loose it sits at rest. BB elasticity grade 1 or 2 with the nipple inside that 2 cm band means BB grade 4.
Where the nipple has not dropped, the operation is 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. Where the skin is loose (BB elasticity grade 4 or 5), or the nipple sits more than 2 cm below the border, the lift cannot reach and the operation is BB grade 5: mastectomy with free nipple-areola graft. All 5 are compared on the gynaecomastia treatment options page.
BB elasticity grade 3 is the decision point, and I perform this operation first. If the skin has not retracted at 6 to 12 months, a second stage removes the loose skin and repositions the nipple as a free graft.
Raising the arms flattens fat and makes a disc stand out. This page is written for adult men; breast tissue that appears during puberty usually settles on its own and is not a reason for early surgery.
Not sure which grade you are?
Download the five grades guide: what each BB grade looks like and the operation that matches it.
Download the guideThe operation
The lift is never done on its own. Moving skin does nothing about the disc that holds the areola forward or the fat around it, and liposuction (suction assisted lipectomy) alone leaves the disc and the drop. The skin, the disc and the fat are treated together, and the lift has a ceiling: forcing more out of it widens the scar and pulls the areola out of shape.
Where the incisions go
A crescent of skin is marked above the areola while you are standing. There are 2 versions. In the first, the incision stays at the junction between the areola and the chest skin and gives 1 to 1.5 cm of lift. In the second, it extends horizontally past each edge of the areola, gives 2 to 2.5 cm of lift, and leaves a 2 to 3 cm scar on the chest skin at each side. Which one I use is decided at examination, on how much loose skin there is and the BB elasticity grade. There are also small ports for the cannula.
What comes out and what stays
The crescent is removed fully, or its outer layer only with the deeper layer kept for the nipple’s blood supply. The disc comes out through the same incision, with a measured layer of tissue kept under the nipple so the areola does not sink. VASER liposuction (ultrasound assisted lipectomy) reduces the fat around the disc. All excised gland goes to histopathology. The operation is designed to leave the nipple up to 2 cm higher, the areola level with the chest, and a scar along the upper areolar edge, extended horizontally in the second version.
The day
General anaesthetic at Maitland Private Hospital, about 1.5 hours. The anaesthetist consults you by phone beforehand. A compression garment goes on in theatre. A drain on each side exits through one of the ports, so there is no extra incision. Without private health insurance you go home the same day with both drains in; with insurance you stay 1 night. Someone needs to take you home.
Recovery
- Day 0: surgery.
- First 2 weeks: rooms visits 2 to 3 times a week for wound checks and dressing changes, and the drains come out once output is below 20 mL. Walking from day 1, no lifting or straining.
- Weeks 1 to 6: compression garment, 4 weeks full time then 2 weeks in the daytime.
- Week 4: review, silicone strips start on the scar, and your GP takes over your general care again.
- Months 1 to 3: 2 types of massage, on the scar line and on the treated tissue. Training is staged: lower body and cardio first, upper body next, chest last.
- Months 3, 6 and 12: reviews. The skin is reassessed at 6 to 12 months.
Bruising and numbness spread wider than after gland excision alone, because the fat has been treated as well, and both settle over months. Desk work within 1 to 2 weeks; a physical job takes longer.
Risks
The main risk is a haematoma. Blood collecting in the space left by the disc shows in the first day or 2 as one side becoming swollen, tight and painful. It means a return to theatre.
The lift adds 2 risks of its own. Closing the crescent pulls on the top of the areola, which can leave it oval or teardrop shaped, or the 2 nipples at different heights; some of this settles with the swelling, and any revision waits until 12 months. The other is skin that does not retract as expected, which is where the second stage comes in.
The rest of the list:
- Nipple numbness, which mostly recovers over months but can be permanent.
- Seroma, fluid that may need drawing off with a needle.
- A hollow under the nipple, or a difference between the sides.
- A permanent scar that can thicken, along the upper areola and on the chest skin in the extended version.
- Rarely, loss of part of the areola from a thinned flap.
- Infection, residual tissue, and the anaesthetic and clot risks of any operation.
Gland that has been removed does not grow back; fat can return with weight gain. The full list is in the BB grade 4 complications article.
Book a consultation online
I examine both sides, grade each one, and tell you which operation applies.
Book OnlineCost and Medicare
Medicare item 31525 (1 side) or 31526 (both sides) covers this operation: removal of the gland for gynaecomastia, with or without fat reduction. The item applies where the enlargement is glandular and out of proportion to your build, with photographs kept as evidence. The crescent of skin does not carry a separate item, and the nipple-areola graft item does not apply because the nipple is not grafted. A written quote follows the consultation. Full detail, including what changes with private health insurance, is on the crescent lift cost page.
Your next step
A GP referral is needed before the consultation. Bring it, along with any blood results or imaging and a list of your medications.
The consultation is in person, because the grade is decided by examination. At that visit I:
- Take the history, including how long the tissue has been present and any weight change.
- Examine both sides with your arms down and raised, measure the nipple against the muscle border, and grade the skin’s elasticity.
- Take photographs, for your record and for Medicare.
- Give you a written quote if the operation suits you, followed by a second consultation to go through consent.
About Dr Bernard Beldholm
I have been performing gynaecomastia surgery for more than 15 years, and male chest surgery is a significant part of my practice.
I publish in the peer-reviewed literature and teach other surgeons. I am a Specialist Surgeon in the Hunter Valley, with rooms in Lorn, and I operate at Maitland Private Hospital, which has an intensive care unit.
