A firm disc under the nipple, with a soft fullness around it that has not gone with training or weight loss. That chest has both gland and fat in it, so it takes both operations in the same sitting: VASER liposuction (ultrasound assisted lipectomy) of the fat through small ports, then removal of the glandular disc through an incision at the edge of the areola. This is BB grade 3, the most common gynaecomastia operation I perform.
It takes about 2 hours under general anaesthetic, as a day stay or with 1 night on the ward. There is a drain on each side. A pressure dressing and a compression garment go on in theatre. The main risk is a haematoma, bleeding into the space left after the gland is removed.
Whether this is the right operation depends on examination. Where there is gland with no fat, fat with no gland, or the nipple has dropped, the operation is different, and each has its own page below.
Is this the operation for you?
BB grade 3 is a specific pattern, and the men who have it describe the same things:
- A firm or rubbery disc directly under the nipple that feels different from the softer tissue around it.
- A soft fullness that spreads beyond the areola across the chest.
- The nipple areola stands out from the chest.
- The skin is tight and the nipple has not dropped.
Each side is graded separately, and the sides can be treated differently in the same operation. With your arms raised, the fullness flattens and the disc stays put. That is how I confirm both are there.
Where a different operation applies
- A firm disc, little or no fat: BB grade 1: gland excision only.
- Fat only, no firm disc (pseudogynaecomastia): BB grade 2: VASER liposuction (ultrasound assisted lipectomy) only.
- The nipple has dropped, skin still elastic: BB grade 4: crescent lift.
- Skin that will not tighten, or a nipple well below the chest muscle: BB grade 5: mastectomy with free nipple-areola graft.
Nipple position is measured against the lower border of the pectoralis major, not the fold under the chest, which moves down with the skin. How the grades fit together is on the gynaecomastia treatment options page.
Gynaecomastia in puberty is common and usually settles on its own over 1 to 2 years, so surgery is not the first consideration in a teenager. This page is written for adults. Long-standing gynaecomastia on both sides that has not changed, including since puberty, 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 both operations, not one
Liposuction (suction assisted lipectomy) alone removes the fat and leaves the disc, so the nipple areola still stands out. Gland excision alone removes the disc and leaves the fullness around it, with a step in the contour at the areolar edge where the disc was. A BB grade 3 chest needs both, done together: VASER liposuction (ultrasound assisted lipectomy) to reduce the fat and blend the edges, then the disc out through the areolar incision.
The operation
The fat is treated first: a dilute solution of local anaesthetic and adrenaline goes in to limit bleeding, the VASER liposuction (ultrasound assisted lipectomy) probe breaks the fat up with ultrasound energy, and it is suctioned out through small ports. The ports only pass the cannula.
The disc then comes out through an incision along the lower edge of the areola, where the change in skin colour hides the scar. I remove it under direct vision, follow any extensions, and leave a measured layer under the nipple, because taking everything is what leaves a dished nipple. Bleeding is controlled before closing, a drain goes in on each side through one of the ports, and all excised gland is sent for histopathology.
The operation is designed to leave the disc gone, the fullness reduced, the areola level with the chest, and scars only at the areolar edge and the port sites; the skin tightens over the following months according to its elasticity.
The anaesthetic consultation is usually by phone, with the physical assessment, including your airway, on the day. Men paying for the hospital themselves usually go home the same day; most men with health fund cover stay 1 night. You need someone to take you home.
Recovery
Recovery is longer than after gland excision alone because a wider area of the chest is treated. The timings below are a guide; healing differs from man to man.
The first 2 weeks
- You leave theatre in a pressure dressing with the compression garment over it. The dressing comes off in my rooms the next day, and the garment stays on for about 4 weeks full time, then 2 weeks half time.
- The drains usually come out the next day, once each side is draining less than 20 mL.
- Bruising, swelling and numbness spread across the chest, not just around the areola.
- Walk early and often. No straining or heavy lifting, because that pushes blood into the healing cavity.
- Desk work usually within about a week; a physical job takes longer.
- After hours, you call Maitland Private Hospital, where a nurse triages by phone.
When you can train again
Return to the gym is staged: lower body and cardio first, upper body next, chest last. Pushing this early is the most common way a haematoma happens after the first few days.
The scar and follow-up
The scars at the areola and the port sites are pink and firm for months and keep maturing for a year or more. Silicone strips from 4 weeks, about 12 hours a day for 3 months; massage of the scar line and the treated chest from 1 to 3 months, 15 minutes morning and night; SPF 30 or higher for the first year. I see you the next day, through the first 2 weeks as needed, then at 4 weeks, 3, 6 and 12 months, included in my fee, and your GP takes over your general care at the 4-week review.
Risks
The risk specific to this operation is a haematoma: blood collecting in the cavity left after the disc is removed, with the areolar incision a narrow window to control bleeding through. In one published series of this combined operation, a haematoma occurred in about 1 in 10 men, and most settled without a return to theatre. Seroma, fluid rather than blood, comes second, because the VASER liposuction (ultrasound assisted lipectomy) leaves a wider raw area under the skin. The drains are there for both.
The other risks are those of any chest surgery: changed nipple sensation, a hollow under the nipple if too much is taken, a dip or ridge where the fat was removed, asymmetry between the sides, permanent scars that can thicken, infection, residual tissue at the edges, and the risks of anaesthesia and blood clots. I go through each in the complications of VASER liposuction (ultrasound assisted lipectomy) with gland excision for BB grade 3 gynaecomastia article. Excised gland does not grow back, but fat can return with weight gain, and where a driver such as continued anabolic androgenic steroid use is still active, new tissue can form.
Book a consultation online
I examine both sides, grade each one, and tell you which operation applies.
Cost and Medicare
There are 2 Medicare item numbers, 31525 for one side and 31526 for both, covering mastectomy for gynaecomastia with or without liposuction (suction assisted lipectomy), so the combined operation sits within them. 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 disc with fat around it can qualify on the glandular component. A chest that is mostly fat in a man whose weight explains it generally does not.
Where an item applies, Medicare pays a set benefit towards the surgeon and anaesthetist fees, leaving a gap, and a health fund with the right hospital cover may pay the hospital fee. Where none applies, the operation is cosmetic and neither contributes. Fees and out-of-pocket amounts for a day stay and an overnight stay are on the VASER liposuction (ultrasound assisted lipectomy) with gland excision cost page.
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. It covers:
- Your history, including how long it has been there, whether it has changed, your medications and any anabolic androgenic steroid use.
- Examination of both sides, arms down and arms raised, to separate gland from fat and grade each side.
- Clinical photographs, which are also the evidence the Medicare item numbers require.
- Which operation applies to each side, the risks and the recovery.
You then receive an itemised written quote. A second consultation, at no charge and available remotely, goes through your blood results and any remaining questions, and surgery is booked at Maitland Private Hospital.
Book your first consultation online
Bring your referral and a list of your medications.
About Dr Bernard Beldholm
I developed the BB grading system because the published classifications did not map onto the operations I actually perform. A BB grade 3 chest is where matching the operation to the tissue matters most, because it needs both.
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.
