A chest that is soft all over, moves with your weight and flattens when you raise your arms, with no firm disc under the nipple. That is BB grade 2, which is pseudogynaecomastia: chest fat with no breast gland. The operation is VASER liposuction (ultrasound assisted lipectomy) of the chest wall on its own. Nothing is cut out, no skin is removed, and the only scars are the ports.
It is a day procedure under general anaesthetic at Maitland Private Hospital and takes about 1 hour. No drain is used. A compression vest goes on in theatre and is worn for 4 weeks.
The main risk is an uneven contour, and the technique is built around spreading the fat removal evenly.
Each side is graded on its own, and where there is a firm disc, or the nipple has dropped, a different operation applies. Each has its own page, linked below.
Is this the operation for you?
The men who have a BB grade 2 chest describe the same things:
- Soft fullness across the chest, with no firm lump under the nipple.
- It goes down with weight loss and comes back with weight gain.
- The tissue behind the nipple pinches like the fat elsewhere on the chest.
- The skin has not stretched, and the nipple sits at or above the lower border of the chest muscle.
- Your weight is stable. A chest that is still changing is reassessed, not operated on.
I grade each side separately, and one side can have a disc while the other does not.
At examination I have you raise your arms. Fat flattens out when you do that. A glandular disc does the opposite and becomes more prominent. It is one of the more reliable ways of separating gland from fat before anything is planned. If the whole chest flattens, there is no disc.
Where a different operation applies
If any of the following describes your chest, a different operation applies:
- A firm disc on a lean chest: BB grade 1: gland excision only.
- A firm disc plus fat: BB grade 3: VASER liposuction (ultrasound assisted lipectomy) with gland excision.
- Fat with the nipple dropped, but skin that still springs back: BB grade 4: crescent lift.
- 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.
Nipple drop is measured against the lower border of the pectoralis major muscle, not the fold under the chest, because the fold moves down with the skin. How the grades fit together is on the gynaecomastia treatment options page.
Whether the skin tightens once the fat is gone depends on its elasticity, graded on a five-point BB elasticity grade. BB elasticity grades 1 and 2 tighten on their own, BB elasticity grade 3 is uncertain, and BB elasticity grades 4 and 5 will not, which makes the operation BB grade 5.
Gynaecomastia during puberty is common and in most boys it 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. A chest that is fat only, with no disc, needs no hormone tests.
Not sure which grade you are?
Download the five grades guide: what each BB grade looks like and the operation that matches it.
Why VASER liposuction (ultrasound assisted lipectomy) on its own, and not gland excision
With no disc there is nothing to cut out. An incision at the areola on a fat-only chest adds a scar for no gain, and tissue taken from under the nipple where there is no gland leaves a hollow.
The failure runs the other way too. Suction on a chest that does have a disc leaves the disc standing, and the areola stands out as before once the swelling settles. That man needs a second operation. Examination separates the two, which is what the arms-raised sign above is for.
The operation
Where the ports go
The cannula goes in through ports of a few millimetres on the chest, and those are the only scars.
What comes out and what stays
A fluid containing local anaesthetic and adrenaline goes in first: it limits bleeding, eases pain afterwards, and the ultrasound probe needs it to work in the tissue. The probe loosens the fat, which on the male chest is firmer and more fibrous than fat elsewhere, and the cannula removes it. Fat is taken evenly across the chest wall and feathered into the surrounding chest so there is no step, and a layer is kept under the skin and under the nipple so the contour stays even. There is no gland to remove and no drain. Liposuction (suction assisted lipectomy) aspirate is not sent for histopathology.
The operation is designed to leave a flat chest wall with the areola sitting flat on it, and skin that tightens over the following months according to its BB elasticity grade. Swelling hides the shape for the first weeks, and I judge the contour at 3 to 6 months, sometimes longer.
Anaesthetic and the day
The operation is done under general anaesthetic. Most anaesthetic consultations are by phone before the day. The physical assessment, including your airway, is done on the day of surgery. You will need someone to take you home afterwards.
Recovery
The whole chest wall has been treated, so bruising and swelling spread across the chest and often track downwards over the first 1 to 2 weeks before they fade. There is no cavity and no drain. The timings below are a guide.
The first 4 weeks
- You go home the same day in the compression vest, with a hydrocolloid dressing (Comfeel) over each port. The next day you come to my rooms and I check the chest.
- The vest is worn full time for 2 weeks, then half time for a further 2 weeks.
- Expect bruising, swelling and a tight, firm chest, managed with the pain relief you are given. Numbness across the chest is common early and usually improves over the following months.
- Walk from day 1. Avoid straining and heavy lifting.
- Desk-based work is usually possible within about a week. A physical job takes longer.
- If something is not right after hours, you call Maitland Private Hospital, where a nurse triages by phone.
When you can train again
Return to the gym is staged, and I tell you when to step up at each review:
- Walking from day 1.
- Lower body and cardio first.
- Upper body next.
- Chest work last, because the chest needs to heal before it is loaded.
The scar
The port scars are small. Massage of the treated area starts between 1 and 3 months, 15 minutes morning and night, and the ports are covered with SPF 30 or higher for the first year.
Follow-up
I see you the next day, then through the first 2 weeks as needed, then at 4 weeks, 3 months, 6 months and 12 months. Those reviews are included in my fee. Your GP takes over your general care at the 4-week review and is kept informed throughout.
Risks
VASER liposuction (ultrasound assisted lipectomy) is surgery and it carries risk. The one specific to this operation is an uneven contour: fat removed unevenly, or too much in one place, leaving a dip or a hollow under the nipple. Too much is harder to put right than too little. Some unevenness settles as the swelling goes over the first year; where it does not, revision is considered, and not before 12 months.
The other risks are those of any chest surgery: seroma, changed nipple sensation, asymmetry between the sides, fullness left behind, skin that does not tighten, port scars, a burn from the heat of the probe, infection, haematoma (less likely than after gland excision but not zero), and the risks of anaesthesia and blood clots. I go through each of these, with the published rates, in the complications of VASER liposuction (ultrasound assisted lipectomy) for BB grade 2 gynaecomastia article.
Recurrence comes down to weight. The fat removed does not come back, but the fat cells that remain enlarge with weight gain.
Book a consultation online
I examine both sides, grade each one, and tell you which operation applies.
Cost and Medicare
The 2 Medicare item numbers for gynaecomastia surgery, 31525 for one side and 31526 for both, cover mastectomy where the enlargement is glandular, is not caused by obesity and is out of proportion to your build. A chest that is fat only, with no gland, does not meet that description, so VASER liposuction (ultrasound assisted lipectomy) on its own is cosmetic: Medicare pays no benefit and a health fund does not contribute to the hospital fee. Where examination finds a disc after all, the operation becomes BB grade 3 and the items may apply.
Fees and the out-of-pocket amount for a day stay are set out on the VASER liposuction (ultrasound assisted lipectomy) cost page. You are given an itemised written quote after consultation.
Your next step
A GP referral is needed before the first consultation. The consultation is in person at my rooms in Lorn, because the grade is decided by examination. It covers:
- Your history, including how long the fullness has been there, whether it changes with your weight, any medications, and anabolic androgenic steroid use.
- Examination of both sides, arms down and arms raised, to confirm there is no disc, and the skin pinched and released for its BB elasticity grade.
- Clinical photographs, which form part of your record.
You then receive an itemised written quote. A second consultation at no charge, which can be remote, goes through your blood results and any remaining 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
I am a Specialist Surgeon with specialist registration in general surgery. I have been performing gynaecomastia surgery for more than 15 years, and male chest surgery is a significant part of my practice, alongside body contouring after weight loss.
I developed the BB grading system because the published classifications did not map cleanly onto the operations I actually perform. I publish in the peer-reviewed literature, teach other surgeons, and host the Body Contouring Podcast.
My rooms are in Lorn, in the Hunter Valley, and I operate at Maitland Private Hospital, which has an intensive care unit. More about my training and practice is on the Dr Bernard Beldholm page.
