A review of 18 cases of gynecomastia where liposuction was performed suggests that insufficient treatment was obtained by suction lipectomy alone as the primary method. When these patients subsequently underwent excisional surgery, removal of the gland resulted in a "dished-out" appearance. The patients ranged in age between 24 and 46 years. All were treated for aesthetic complaints. All patients were initially treated by other surgeons, and the method of breast gland suction was unknown. However, eight patients underwent some type of partial glandular resection by scalpel, whereas the others only underwent liposuction. At secondary surgery, all specimens removed demonstrated a sizable amount of mammary gland extending to the limits of dissection. The glands did not exhibit any anatomic alterations resulting from the first surgical procedure. Bodybuilders (n=9) had no adipose tissue on the excised specimen or any fat under the chest flap. The remaining patients had some adipose tissue present under the chest wall and some fat retained over the excised specimen, although in small amounts. Of the 18 patients treated, four had central mammary depression, and six had lateral depressions resulting from the absence of fatty tissue from the first procedure. All patients had a marked change in the shape of the chest wall, which, before the secondary surgery (performed by the author), had exhibited some abnormality. Performance of liposuction alone for gynecomastia unmasks underlying mammary tissue, which when treated secondarily has a tendency to result in a contour deformity, because of the earlier removal of central or peripheral adipose tissue. Consequently, in situations where the fat contributes to the appearance of gynecomastia, it is important to combine liposuction with glandular excision during the primary operation. In conclusion, I believe certain cases of gynecomastia require glandular excision in conjunction with liposuction, particularly in obese patients.