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n/a
Document type
Clinical policy
Place
Hertfordshire and West Essex ICB
Output type
Clinical Policies & Evidence-based Interventions
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Gynaecomastia Surgery

v1.1

Gynaecomastia is a common condition that causes male breasts to swell and become larger than normal.

Surgery to remove male breast tissue is not usually carried out by the NHS. It can be done in very specific situations if the reasons for surgery meet certain criteria. 

Studies looking at those individuals that have and have not had surgery showed a variation in the criteria applied, impacting on the ability of a patient to access this surgery. 

The EBI programme proposes clear, evidence-based criteria for use across England. The expected outcome from the use of these criteria is consistent and fair access for male patients to funding for gynaecomastia reduction surgery across England through individual funding requests (IFRs).

Clinical overview

True gynaecomastia is the enlargement of the male breast due to hyperplasia of the glandular tissue. Pseudo gynaecomastia is bilateral breast enlargement entirely due to adipose tissue.

Gynaecomastia is common, occurring in 33-41% of men aged 25-45. It is strongly associated with obesity. Gynaecomastia can be due to hormonal imbalances (e.g., liver cirrhosis, renal insufficiency, gonadal failures), drug induced or physiological (such as in newborns, during puberty or old age). Medical or surgical treatments may be considered to manage pain or for cosmetic improvement, but resolution is not always possible. 

Surgery for gynaecomastia should not be routinely funded by the NHS. However, there may be some circumstances, for example when gynaecomastia is due to rare congenital or endocrine causes, where surgery may be considered via the Individual Funding Requests (IFR) process. Patients who have or are receiving treatment for prostate cancer may benefit from surgery where first line medical treatment has been unsuccessful, however, this does not fall within the remit or scope of this guidance. Given the limited evidence base, psychological distress alone will not be routinely accepted as a reason to fund surgery

Psychological screening of all individuals seeking aesthetic surgery should be performed by the consulting clinician and onward referral for formal appearance psychology assessment and intervention made as appropriate.

Criteria: In cases where an IFR is being considered the following criteria must be met:

  • The reduction in breast tissue will be significant i.e., 250g or more or Simon Grade 3 or more.
  • The weight of the resection and pre and postoperative photographs MUST be recorded for       audit purposes AND
  • Have a body mass index (BMI) of <27 AND
  • Endocrinological causes have been investigated — Those patients with significant gynaecomastia secondary to underlying endocrinological conditions should have been adequately treated for that primary condition and their application for surgery be supported by their treating doctor AND
  • In drug-induced gynaecomastia, the offending agent should be withdrawn, where possible for at least one year to allow resolution.

Patients may present in adolescence or early adulthood. This should not preclude patients from being considered if the above criteria have been met. However, the patient should be monitored for at least one year to allow for natural resolution if aged 25 or younger.

This recommendation does not cover the following, where separate guidance is available:

  • Gender reassignment surgery 
  • Surgery for breast cancer 
  • Gynaecomastia caused by medical treatments for prostate cancer. 

Given the limited evidence base, psychological distress alone will not be routinely accepted as a reason to fund surgery. 

Expected Outcome 

The implementation of this proposed guidance would result in a reduction in unwarranted variation to access across England for male gynaecomastia surgery by standardising the criteria for the consideration of funding.

Rationale for recommendation

The Get It Right First Time (GIRFT) Breast Surgery report identified significant variability in ICB’s approach to funding surgery for gynaecomastia. Surgery for gynaecomastia should not be routinely funded on the NHS except for in exceptional circumstances. However, findings from the GIRFT report emphasise the need for a standard set of criteria that commissioners must consider when reviewing IFRs for gynaecomastia surgery. 

Medical treatment of gynaecomastia is associated with a high success rate and avoids surgical intervention. However, the clinical course of gynaecomastia is proliferation of glandular tissue followed by fibrosis. Once fibrosis has occurred, treating the cause may stop further growth but is unlikely to reduce breast tissue already present and surgical treatment is the only definitive treatment. A systematic review found surgical excision of glandular tissue combined with liposuction provides the most consistent results and a low rate of complications. 

A review of the literature and systematic review found that many young men suffer emotional distress due to gynaecomastia. A recent case-control study suggested surgical treatment improves the quality of life of adolescents, with improvements in physical and psychosocial functioning. A cohort study found that younger patients experienced better patient satisfaction and improvement in self-esteem after surgery. A systematic review on psychological changes after surgery for gynaecomastia found surgical treatment improved psychological functioning but the amount of published data was limited and of low quality, with further research required.

It should be noted that surgical intervention is highly unlikely to alleviate disproportionate psychological distress. In these cases, ideally an NHS psychologist with expertise in body image or an NHS Mental Health Professional (depending on locally available services) should detail all treatment(s) previously used to alleviate/improve the patient’s psychological wellbeing, their duration and impact.

References

1.  NHS. What is gynaecomastia? 2021 Available at: https://www.nhs.uk/common-health-questions/mens-health/whatis-gynaecomastia  

2.  NHS. Cosmetic procedures - Breast reduction in males. 2019 Available at: https://www.nhs.uk/conditions/cosmetic-procedures/breastreduction-male/  

3.  Thiruchelvam P, Walker J, Rose K, Lewis J, Al-Mufti R. Gynaecomastia. BMJ .2016;i4833 Available at: https://www.bmj.com/content/354/bmj.i4833 

4.  BMJ best practice. Gynaecomastia. BMJ; 2021 Available at: https://bestpractice.bmj.com/topics/en-gb/869/epidemiology 

5.  NHS. Gender Identity Services for Adults (Surgical Interventions. 2019 Available at: https://www.england.nhs.uk/wp-content/uploads/2019/12/nhsengland-service-specification-gender-identity-surgical-services.pdf  

6.  Association of Breast Surgery, British Association of Plastic, Reconstructive & Aesthetic Surgeons. Oncoplastic Breast Reconstruction Guidelines for Best Practice. Breast Cancer Now. 2018 

7.  NICE. Prostate cancer: diagnosis and management. [NG131]. 2019 Available at: https://www.nice.org.uk/guidance/ng131 

8.  Getting it right the first time. Draft GIRFT national report for breast surgery. GIRFT.2021 Available at: https://www.gettingitrightfirsttime.co.uk/bpl/ 

9.  Rew L, Young C, Harrison T, Caridi R. A systematic review of literature on psychosocial aspects of gynecomastia in adolescents and young men. Journal of Adolescence. 2015;43:206-212 

10.  Ordaz D, Thompson J. Gynecomastia and psychological functioning: A review of the literature. Body Image. 2015;15:141-148 

11.  Nuzzi L, Firriolo J, Pike C, Cerrato F, DiVasta A, Labow B. The Effect of Surgical Treatment for Gynecomastia on Quality of Life in Adolescents. Journal of Adolescent Health. 2018;63(6):759-765

12.  Sollie M. Management of gynecomastia — changes in psychological aspects after surgery — a systematic review. Gland Surgery. 2018;7(S1):S70-S7

13.  Fagerlund A, Lewin R, Rufolo G, Elander A, Santanelli di Pompeo F, Selvaggi G. Gynecomastia: A systematic review. Journal of Plastic Surgery and Hand Surgery. 2015;49(6):311-318 

14. Simon B, Hoffman S, Khan S. Classification and Surgical Correction of Gynecomastia. Plastic and Reconstructive Surgery. 1973;51(1):48-52 

15.  Kanakis G, Nordkap L, Bang A, Calogero A, Bártfai G, Corona G et al. EAA clinical practice guidelines—gynecomastia evaluation and management. Andrology. 2019;7(6):778-793 

16. Gupta V, Yeslev M, Winocour J, Bamba R, Rodriguez-Feo C, Grotting J et al. Aesthetic Breast Surgery and Concomitant Procedures: Incidence and Risk Factors for Major Complications in 73,608 Cases. Aesthetic Surgery Journal. 2017;37(5):515-527 

17. Honigman R, Phillips K, Castle D. A Review of Psychosocial Outcomes for Patients Seeking Cosmetic Surgery. Plastic and Reconstructive Surgery. 2004;113(4):1229-1237 

18. Fricke A, Lehner G, Stark G, Penna V. Long-Term Follow-up of Recurrence and Patient Satisfaction After Surgical Treatment of Gynecomastia. Aesthetic Plastic Surgery. 2017;41(3):491-498


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