While most gynecomastia patients are looking for a "flat" chest what they really mean is they want a masculine chest. There is a difference. Overall, a masculine chest is flat with a defined pec. major muscle. The upper chest should remain full and powerful. The goal is to create a sculpted look by getting the nipple to lay flat against the pec. major muscle and by getting the the skin to wrap around the border of the muscle into a sculpted axilla.

The areola is the dark, pigmented skin around the nipple. Areola size is proportionate to chest size. Ideally, it should 25-35 mm and lay flush with the surrounding skin. However, slight elevation is common. Most people do not consciously realize it but areolas are usually wider than they are tall. A perfectly round areola is not ideal and an areola that is taller than it is wide may even appear unusual or “surgical”. This is particularly relevant with Types 4, 5 and 6 which usually require reducing and re-positioning the nipple with a free nipple graft. A protruding nipple is common with puffy nipple due to the pressure from the swollen breast tissue below. However, there are situations where the nipple is simply enlarged. Fortunately, reducing the nipple by excision is straight forward, low cost, little down time and very effective.

Overall, a masculine chest is full and powerful above the nipple but ripped and defined below. The key is to create muscle definition, flatten the nipple, yet keep the chest area above the areola normal thickness. Thinning too much will create a "fragile" appearance and worse, may create contour irregularities. The goal is to flatten the chest so that you can confidently wear tight white T-shirts and to create a V shape from both the back and front view. 

Ideally, the pectoralis major muscle should be defined and straight with the skin wrapping around it into a well defined chest fold and then into a defined arm pit hollow. Excess breast tissue, fat and/or saggy skin will blur this border and create a round, feminine appearance.

Should have sculpted appearance with a well define hollow at its apex. The borders of the pec. major in front and the latissimus dorsi in back should be well defined giving a V shape to the upper body. Excess fat/saggy skin can fill the arm pit creating an uncomfortable fullness in armpit and a saggy breast roll just below. For types 5 and 6’s, this is often as big of a concern as the chest. Creating a sculpted axilla and a V shape appearance to the upper body is one of the most rewarding parts of gynecomastia surgery yet it is usually overlooked as not being part of the gynecomastia. It is important for your surgeon to understand that the goal of surgery is to create a V shaped, masculine chest and not just to remove breast tissue. While this is true for all types it is particularly relevant for types 4,5 and 6. I can not tell you have powerful the results are when you create a sculpted pec., lat. and arm pit. It is truly life changing.

Ideally, there should not be any fat pockets. There are three common fat pockets that need to be evaluated and removed if present:

1. Pre-axillary fat – located just in front of the armpit.
2. Axillary fat – located within the arm pit itself and
3. Breast roll fat – located just below the arm pit and creates a fullness or breast roll. It blurs pec., arm pit and lateral definition and disrupts V shape and the upper body that defines masculinity.

Should not be present. Lateral chest/arm pit skin should be tight enough to prevent breast rolls, create a defined pec. border and lat. border with a sculpted arm pit in between. Breast rolls represent saggy skin under the arm pit. Flattening the chest and not correcting breast rolls actually makes the breast rolls more noticeable and creates a disproportionate look to the upper body.

Should not be present. They represent saggy skin that goes all the way around to the back. Optimal surgical treatment requires removing all the excess skin in a 360 degree fashion. Often seen with massive weight loss patients.