A firm disc under the nipple that does not flatten however lean you get. If that is your chest, and the rest of it is lean with tight skin, this is the operation that removes it: gland excision on its own, also called subcutaneous mastectomy, for BB grade 1 gynaecomastia. The disc comes out through an incision at the lower edge of the areola. No liposuction (suction assisted lipectomy), no skin removal.
It is a day procedure under general anaesthetic at Maitland Private Hospital, about 1 hour, with no drain and no garment: a compression bandage overnight, off in my rooms the next day. The main risk is a haematoma, bleeding into the space left after the gland is removed, and the plan is built around preventing it.
Is this the operation for you?
Men with BB grade 1 describe the same things:
- A firm or rubbery disc directly under the nipple.
- The disc sits within the areola and does not spread across the chest.
- The nipple areola stands out and does not flatten with training or weight loss. Losing fat often makes the disc more obvious.
- The rest of the chest is lean and the skin is tight.
I grade each side separately, and the two sides can differ. At examination I have you raise your arms: fat flattens, a glandular disc becomes more prominent. It is one of the more reliable ways of separating the two.
Where a different operation applies
- Fat with no firm disc, which is pseudogynaecomastia: BB grade 2: VASER liposuction (ultrasound assisted lipectomy) only.
- A firm disc plus a fatty component: BB grade 3: VASER liposuction (ultrasound assisted lipectomy) with gland excision.
- The nipple has dropped but the skin still has good elasticity: BB grade 4: crescent lift.
- Loose skin that will not tighten, or a nipple well below the lower border of the chest muscle: BB grade 5: mastectomy with free nipple-areola graft.
The overview of all five grades is on the gynaecomastia treatment options page.
Gynaecomastia during puberty is common and usually settles on its own within 1 to 2 years, so surgery is not the first consideration in a teenager. This page is written for adults. Long-standing gynaecomastia that has not changed does not need 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 excision, not liposuction (suction assisted lipectomy)
Suction removes fat. The glandular disc is firm and fibrous, and suction leaves it where it is, so the areola stands out exactly as before once the swelling settles. The opposite mistake, taking too much from under the nipple, leaves a dished contour. In BB grade 1 the disc is the only thing to remove, so it is cut out under direct vision and the layer beneath the nipple is kept.
The operation
- The incision runs along the lower edge of the areola, on the line where the darker areolar skin meets the chest skin. The colour change is what hides the scar.
- The disc is lifted out under direct vision, including the extensions that run out beyond the areola, so nothing is left to feel later.
- A measured layer of tissue stays under the nipple. Take it and the nipple sinks into a hollow. Leave too much and the disc is still there.
- Bleeding is controlled as I go through a narrow window, which is why the whole plan is built around the haematoma risk.
- Everything removed goes to histopathology.
- No drain. A compression bandage goes on in theatre and comes off the next day.
- General anaesthetic, home the same day. The anaesthetic consultation is usually by phone. You need someone to take you home.
What the operation is designed to leave: the disc gone, the areola no longer standing proud, the nipple in place with an even contour, and a scar on the areolar line that fades over a year or more. A step-by-step account, including why I prefer direct excision under vision, is in the article on gland excision for BB grade 1 gynaecomastia.
Recovery
- Day 1: bandage off in my rooms, a Comfeel dressing on, no garment.
- First 2 weeks: swelling, bruising and some discomfort. Numbness around the nipple is common early and usually settles. Walk early. No straining or heavy lifting, because that pushes blood into the healing cavity. Desk work in about a week.
- Training: staged. Lower body and cardio first, upper body next, chest last. I tell you when at each review.
- Scar: silicone strips from 4 weeks, about 12 hours a day for 3 months; massage from 1 to 3 months; SPF 30 or higher for the first year.
- Follow-up: the next day, through the first 2 weeks as needed, then 4 weeks, 3, 6 and 12 months, included in my fee. Your GP takes over general care at 4 weeks. After hours, you call Maitland Private Hospital.
Book a consultation online
I examine both sides, grade each one, and tell you which operation applies.
Risks
Gland excision is surgery and it carries risk. The one specific to this operation is a haematoma: blood collecting in the cavity left after the disc is removed, reported in around 5% of cases in published series. It shows in the first day or two as swelling, firmness or pain on one side. A small one settles; a significant one means a return to theatre. The other risks are those of any chest surgery: changed nipple sensation, seroma, a hollow under the nipple, asymmetry, a permanent scar that can thicken, infection, residual tissue, and anaesthetic and clot risk. Excised gland does not grow back, but where a driver such as continued anabolic androgenic steroid use is still active, new tissue can form. Each is covered, with the published rates, in the full article.
Cost and Medicare
Medicare items 31525 (one side) and 31526 (both sides) cover mastectomy for gynaecomastia. They apply where the enlargement is glandular, not caused by obesity and out of proportion to your build, with photographic evidence in your notes. A firm glandular disc is the presentation most likely to qualify. Where an item applies, Medicare pays a set benefit towards the surgeon and anaesthetist fees, and a fund with hospital cover at the right level may pay the hospital fee. Fees and out-of-pocket amounts are on the gland excision cost page. You receive an itemised written quote after consultation.
Your next step
A GP referral is needed before the first consultation, which is in person at my rooms in Lorn because the grade is decided by examination: your history, both sides examined arms down and arms raised, clinical photographs, and which operation applies to each side. You then receive a written quote, and a second consultation at no charge, which can be remote, goes through your blood results and any questions. Surgery is booked at Maitland Private Hospital as a day procedure.
Book your first consultation online
Bring your referral and a list of your medications.
About Dr Bernard Beldholm
The BB grade 1 patient is a familiar one in my rooms: a fit man, often someone who trains seriously, with a firm disc under the areola that has not moved however lean he gets.
I have been performing gynaecomastia surgery for more than 15 years, and male chest surgery is a significant part of my practice. The two ways this surgery goes wrong both come from defaulting to one operation: liposuction (suction assisted lipectomy) alone leaves the disc, and over-resection leaves a dished contour. I developed the BB grading system so that the operation matches what is in the chest, side by side, from VASER liposuction (ultrasound assisted lipectomy) for fat to mastectomy with free nipple-areola graft at the far end. I 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.
