When the nation’s top reporters researched gynecomastia for the Washington Post, their research naturally led them to Dr. Khalifeh, one of the nation’s leading experts on the matter. We invited them into our suite to first hand report on a live surgery. Read here the article about Gynecomastia and Dr. Khalifeh.
Dual Board Certified Plastic Surgeon
Dr. Khalifeh is passionate about Gynecomastia Surgery, and passion is what drives his excellence. After treating over one thousand men with gynecomastia, he is now considered one of the top gynecomastia doctors on the east coast and has patients flying in to seek his expertise. Patients find Dr. Khalifeh to be an approachable, genuine, and straightforward communicator. A consummate perfectionist, Dr. Khalifeh combines over 14 years of experience and artistic touch to bring out the best results in his patients’ results. As a gynecomastia specialist, Dr. Khalifeh performs hundreds of gynecomastia cases every year Dr. Khalifeh cherishes the huge difference that he makes in each and every man’s life with this procedure.
Dr. Khalifeh came to the United States when he was eleven, settling in Baltimore. He graduated Summa Cum Laude and Phi Beta Kappa from the University of Pennsylvania, and earned his medical degree from the Vanderbilt University School of Medicine, where he earned the top spear award in physiology and graduated Alpha Omega Alpha. He then completed his training in Plastic Surgery at the prestigious Johns Hopkins Hospital. He has been recognized as a top plastic surgeon by realself.com, Northern Virginia Magazine, Arlington Magazine, amongst other publications. In addition to his private practice, he serves in the Navy Reserves as a plastic surgeon, and was deployed in 2019 to help with the Navy’s Covid-19 efforts.
In his personal life, Dr. Khalifeh enjoys being a dad to his young daughters and outdoor activities including hiking and skiing.
Real Patient Results
Your Gynecomastia Guide
What is Gynecomastia?
What Causes Gynecomastia?
Men and women share many common embryological features, and every man is born with breast tissue and nipples. The breast tissue, while present, typically does not develop significantly. When it does develop, causing gynecomastia, it is usually triggered by hormonal changes and imbalances. The major hormonal players, no surprise, are testosterone, which inhibits the breast from growing, and estrogen, which stimulates the breasts to grow. In reality the body’s hormonal milieu is more complicated than just these two hormones, but for simplicity’s sake, any condition that blocks or reduces the effect of testosterone or augments the amount or effect of estrogen can lead to breast growth.
In the vast majority of the cases that present, no single or identifying cause can be found. We then call this idiopathic gynecomastia.
Other times, the changes in hormones can be caused by some prescription medications such as finasteride (Propecia) and spironolactone, and of course, anabolic steroids, sometimes prescribed but often used by bodybuilders to enhance muscle build up. The list is long as many other agents can also trigger hormonal imbalances, but these are some of the main ones.
Illicit drugs, especially marajiuana is often blamed for gynecomastia development, although the amounts smoked have to be substantial. Medical conditions such as Klinefelter syndrome or pituitary insufficiency sometimes have too be also ruled out.
Whatever the root cause of gynecomastia is, the mainstay of treatment remains surgical. By the time the patient seeks treatment, the condition has been long enough that a medical treatment is no longer effective. Plus, many feel that the risk of surgery is less than the risk of lifelong medical treatment with hormones.
Gynecomastia vs. Pseudogynecomastia
Commonly asked question, but I personally feel that there is too much emphasis on this question. There is no absolutely absolutely true pseudogynecomastia as all men naturally have some breast glandular tissue. I want you to think of the breast as a container full of both fat and gland, but there is a continuum of the proportion between gland tissue and fat tissue. During surgery, I see that surgically when I bisect the specimen at the end of the removal. Before surgery, I can palpate the difference, and notice that pseudogynecomastia is softer and more uniform in feeling, whereas truer gynecomastia is harder and the hardness varies, being greatest right under the nipple.
On one end of the continuum is a hard glandular blob of tissue that I feel gets close to being 100% glandular. When I divide it in half, all I see is white hard tissue, with very little fat interspersed. On the other hand is a chest area filled with fat and fibrous stroma much ackin to other areas of the body, except for a small collection of glandular tissue the areola, and we call that pseudogynecomastia.
Both spectrum of the conditions bother patients, and the treatment is still surgical but in terms of treatment and response to nonsurgical options, here are some observations, which may or may not be self-evident:
a) Pseudogynecomastia equals more fat, almost exclusively found in overweight men, and much more responsive to diet and exercise and weight loss since those target the fat cells all over the body
b) Pseudogynecomastia treated with a lot of lipo, but I do recommend a small incision to extract that small 10% of gland tissue
c) Pseudogynecomastia develops later in life with weight gain, or remains afte weight loss in someone that was previously obese
Either way, even in cases of “pseudogynecomastia” I still recommend both lipo and excision, since excision takes a few minutes only. Otherwise the 90% soft tissue is removed, and it will leave a small hard ball under the nipple that I could have removed with a 30 more minutes of work and only a slightly larger incision.
I hope this answers your question. If you are closer on the spectrum of true gynecomastia, then surgery is your best option. If you are overweight and your breast tissue is composed of a lot of fat, you can certainly get rid of that tissue if you lose weight, plus you will look great in other portions of your body too.
Grades Of Gynecomastia
As you do your research, you will note many classification systems for gynecomastia, and I will include one here that is commonly used. The grading system is “academic” in nature, and does not necessarily reflect how you feel about your chest. As a surgeon, I am not looking at grade, but at what aspects of the chest that I need to address. How much tissue is there? Is the tissue soft (fatty) or hard (glandular). Where are the nipples, and do they need reduction or lifting? What is the nature of the skin quality and excess, and do I need to resect any?
Small hardnodule of tissue that is located right below the areola. I often refer to this as a “puffy nipple”. The nipple often “puffs” out in heat, and retracts in cold or when touched/pinched.
Tissue is spread all over the chest, although not surpassing the chest borders. The skin tone is acceptable, although there may be some descent of the breast. The treatment consists of a combination of liposuction and gland excision.
Tissue exceeds the borders of the chest to also go into the axilla and lateral chest. There is increasing skin excess.
There is enlargement of breast with significant excess of skin and increasing feminization. Skin excision via a double incision technique is often necessary.
Remember, the grading system is simplistic, and remember that not everyone falls into these categories.
Are There Any Gynecomastia Exercises That Work?
A well developed attractive chest is a hallmark of a man that works out regularly. So it’s not surprising that the reverse question is asked often: are there any exercises that reverse gynecomastia?
I always encourage working out. When it comes to physique, developing stamina and muscles always adds to attractiveness. However as far as gyno is concerned, the answer to this inquiry often depends on the fat content of the underlying tissue.
Exercise is an effective treatment option for many individuals with gynecomastia containing fat tissue (even those with a mixed fat-gland component). The fat will shrink. Pushups, bench press, swimming, etc. can all reduce fat in the breasts while augmenting and sharpening the pecs.
What is not treatable via exercise is the glandular component. That tissue, once solidified, is usually resistant to all treatment modalities except a surgeon’s scalpel.
Can Liposuction Alone Be Used To Treat Gynecomastia?
The short answer to the question above is no. Liposuction alone is not recommended. Remember every man (including pseudo gynecomastia) has glandular tissue form during embryology, which may develop further during puberty and complete regression is not likely. Now as I always say, if you have glandular tissue, it doesn’t mean you need it removed. However if you do choose to be flatter, I do recommend you get both excision and lipo. This is borne out of several observations over the years.
- A) Patient satisfaction is much higher when you get glands excised compared to those that have glands removed.
- B) Leaving the gland, which is normally cushioned by the fat, creates a harder lump underneath the nipple which you will feel and may be bothersome.
- c) Finally, we’re already doing surgery if we are doing lipo! Yes The additional surgery time, risk, and small scar is definitely worth it for you to get an excision as well.
Real Patient Results
What Is Recovery After Gynecomastia Surgery Like?
Healing varies between patients, of course, but a timeline of what to expect in your recovery is helpful in deciding whether to do the surgery or when to do surgery. Below is what a typical gynecomastia patient experiences day by day after surgery.
The first few hours: Immediately after the procedure is finished, Dr. Khalifeh’s team will place a male compression vest to compress the procedure site. There may be minor fluid leaking, most of which is the original tumescent fluid that was placed for the numbing, but for the most part, the dressings will stay dry. For any discomfort, you will typically have a mild pain medication, and you will feel your chest muscles sore, as if you had a very intense workout. You will also take antibiotics. On very rare occasions, Dr. Khalifeh will use a drain to collect the fluid, but most cases are done drainless. You will leave the office 30-45 minutes after your procedure is complete. A ride home or ride service is needed.
Your diet will be your regular diet. You will be able to move about and take care of yourself at home. After surgery, you will have to limit the range of motion of the arms, with care not to lift arms upward and stretch the incisions too much.
Day 2The day after: By day 2, your soreness and movement about the home will be more fluid. You may require a few pills of your pain medication. You will want to take the day off of work to help with the recovery. Dr. Khalifeh recommends leaving the garment on until 72 hours post-surgery, but you can sponge bathe and wash yourself around the garment to feel refreshed.
Day 3Most people who do not have an intensely physical job return to work on day 3. You will still be wearing your compression garment, fitted under your work clothes. You will be off of narcotics at that point.
Day 5-7By day 5-7, you will be able to do some minor non-impact aerobic exercises such as walking or stationary bicycle. Dr. Khalifeh will see you for follow up around that time to check out your recovery. You will start seeing some of the results, but you will also have some swelling and bruising still at this point.
Day 14At this point, the garment becomes optional, and many people stop wearing it. Most people return to their usual exercise regimen for the lower body. Upper body exercise will take another week or so. Sexual activity can also be resumed at this point. You will start appreciating and seeing your results, although there will still be swelling. The small incisions will have been sealed by then.
Day 30Your one month follow up with Dr. Khalifeh will ensure you are continuing to heal well. The incisions have healed, but may still be a little red. You may resume a full upper body workout.
Day 90Your three month follow up with Dr. Khalifeh. At 90 days, you will see 90% of the results. Typically, we take pictures at 90 days. There is still some minor swelling that will continue to improve over the next several months.
Day 360The incisions are fading and become harder to see. All the swelling is gone.
Will I Have Scars After Gynecomastia Surgery?
Any gynecomastia surgery will require an entry point. About 80 percent of cases can be performed thru an almost invisible, minimal incision on the lower aspect of the areolar-nipple circle. This incision allows excellent healing with a small scar that is very difficult to see or discern. The other 15% more severe gynecomastia cases (with a lot of redundant skin or very enlarged areolas ) require different surgical approaches. In those cases the scars are more visible and will be discussed thoroughly with the patient, but the more masculine chest obtained after the surgery makes the patients more confident despite the scar needed to achieve the results.
Example of almost invisible scar:
What Is The Cost Of Gynecomastia Surgery?
Whenever I get a teenager whose parents are bringing him in for his gynecomastia surgery, I make it a point to tell the kid how lucky he is to have parents that are taking his concerns seriously. This is because cost is the one of the impediments to gyno surgery for many young men. We attempt to make our fees accessible to many, while still maintaining our ability to specialize and excel at this procedure. We are happy to share our prices online, in one of two ways. The first way is to fill out a price request form, and we will send you our current pricing “menu” that describes pricing based on the generalized appearance of a patient.
The second and most accurate way to get your own quote is to submit a photo evaluation/quote request, where you will upload some photos and Dr. Khalifeh will evaluate and propose a treatment plan with your exact quote.
“Dr. Khalifeh and his staff were wonderful to work with throughout the gynecomastia surgery process and the results, even years later, have held up really well. He was very helpful and courteous throughout and I could tell he took a genuine interest in his clients. I highly recommend his practice.”
Additional Frequently Asked Gynecomastia Questions
How old do you have to be to undergo gynecomastia treatment?We recommend waiting until you are at least 18 if possible.
If puberty is done, and the psychological cost of waiting is high, in some cases it may make sense to undergo this procedure at a younger age.
Does health insurance cover gynecomastia treatment?Typically gynecomastia treatment is not covered, but calling your insurance company to ask them is the only way to know for sure. As a practice, we do not accept insurance directly but can provide patients with insurance codes when needed.