eMedicine Specialties > Plastic Surgery > Breast

Gynecomastia

Jay M Pensler, MD, Aesthetic Plastic and Reconstructive Surgery, Private Practice; Clinical Associate Professor, Department of Surgery, Division of Plastic Surgery, Northwestern University Medical School
Merle J Yost, BA, MA, LMFT, Licensed Marriage and Family Therapist

Updated: Jul 1, 2009

Introduction

Gynecomastia is derived from the Greek terms gynec (feminine) and mastos (breast). The literal translation, male breasts, relates to any condition that results in excessive development of breast tissue in males. Males may rarely develop breast cancer, but this is often associated with testicular atrophy.

Male breast volume is composed of a combination of ductal and stromal tissue, commonly referred to as glandular tissue, and an increase in adipocytes, typically referred to as fatty tissue. Excess skin resulting in significant ptosis of the breast may be present in patients with severe gynecomastia.

Preoperative anteroposterior view of a patient with idiopathic gynecomastia.

Preoperative lateral view of a patient with gynecomastia.

History of the Procedure

Galen introduced the term gynecomastia in the second century AD. He defined gynecomastia as an unnatural increase in the breast fat of males. Although Galen was aware that glandular enlargement of the male breast occurred as a separate entity, he did not consider this gynecomastia.

The first recorded description of a reduction mammaplasty was by Paulas of Aegina in the seventh century AD, who referred to the condition as an "effeminacy of men." Several medical and surgical treatments of gynecomastia were described in the 1800s.

Treatment of gynecomastia has continued to evolve over the ages. Presently, a multifaceted surgical approach is used to optimize correction of the deformity. The fatty component is removed with one or a combination of the variants of liposuction, while the glandular component requires direct excision. The skin is redraped over the underlying structures or, in severe cases, resected. The patient's treatment plan should be crafted to correct the specific problems that are unique to his specific case.¹

Problem

Gynecomastia results in an increase in breast tissue in males that, when problematic, is readily detectable by other individuals. This results in significant functional and psychological limitations. The physical deformation may also be exquisitely painful. Situations like gym class may require children or adolescents to remove their shirts in the presence of other students. This can put a boy with gynecomastia in danger not only of embarrassment but also of physical harm.

Most patients have never heard of this condition until the family physician identifies it. The physician may be unaware of the possible causes of the condition and its psychological impact. After initial presentation, boys are frequently advised to ignore the gynecomastia and are told that it will go away. Fortunately, in most instances, cases of minimal subareolar pubertal-onset gynecomastia do regress as puberty progresses.

Individuals with no regression or even progression of the deformity often receive little or no understanding about the shame and humiliation they experience. Coaches, sergeants, physicians, parents, and peers (both boys and girls) can inflict damage out of ignorance, cruelty, or both. The author reports that a parent recently exclaimed during an initial evaluation, "I just don't understand why 'he' has to slouch around all the time." Postural and clothing modifications to mask the deformity are the norm in these patients from puberty through adulthood.

Awareness of gynecomastia needs to progress in order to inform the men and boys with gynecomastia and their physicians what can be done to improve the condition.

Frequency

Gynecomastia can occur in persons of any age. During adolescence, males develop firmness around the breast as the breast bud enlarges due to the hormonal fluxes of puberty. The subareolar firmness which normally develops regresses with time. Breast tissue is typically present on a microscopic level in male patients; a small amount of breast tissue is normal. The visible appearance of breast tissue in a male is abnormal.

The definition of clinically significant gynecomastia is subject to interpretation by any author; therefore, reports in the literature are often confusing, as the reader is forced to compare apples to oranges when examining different studies. Nydick et al reported 65% of boys "may have the problem" but cautioned that it typically resolves.² Webster noted the incidence of gynecomastia to be around 8% in a series of naval patients,³ while Williams noted that 40% of men examined in his series of autopsies had gynecomastia to some degree.⁴ Approximately 40% of healthy men and up to 70% of hospitalized men have palpable if not visible breast tissue. The incidence of some degree of palpable breast tissue in males increases to more than 60% in those in the seventh decade of life in one series.

Etiology

Gynecomastia can be classified based on etiology. Idiopathic gynecomastia accounts for over 85% of cases that require surgical intervention.

Physiologic gynecomastia occurs primarily in newborns and in adolescents at puberty. In the newborn, the neonatal breast results from the action of maternal estrogens, placental estrogens, or both in concert. The increased breast tissue usually disappears in a few weeks. Neonatal gynecomastia is not a problem that requires surgical intervention.

Adolescent gynecomastia, by definition, is initiated during puberty. The median age of onset is 13 years. Breast tissue growth is often asymmetrical, and the breasts are frequently tender. Adolescent gynecomastia usually regresses by the latter teen years. Note that the normal course during puberty is for a palpable, often visible, mass below the areola that begins to resolve in the mid teen years. While continued visible enlargement in the size of the breast is not normal in a teenager, residual palpable gynecomastia may be present in one or both breasts through the mid teen years. The authors would stress that the norm would be progressive diminution of any visible or palpable deformity through this period. In each case, the clinician must evaluate the degree of tissue present, the clinical presentation, and the physical and psychological effects on the patient.

Pathologic gynecomastia may be due to testosterone deficiency, increased estrogen production, or increased conversion of androgens to estrogens. The pathological conditions associated with gynecomastia include congenital anorchia, Klinefelter syndrome, testicular feminization, hermaphroditism, adrenal tumors, liver disorders, pituitary tumors, and malnutrition.

Many pharmacological agents have been linked to gynecomastia.⁵ These drugs can be categorized by their mechanisms of action. The first type is drugs that act exactly like estrogens (eg, diethylstilbestrol, birth control pills, digitalis, estrogen-containing cosmetics). The second type is drugs that enhance endogenous estrogen formation (eg, gonadotropins, progesterone, clomiphene). The third type is drugs that inhibit testosterone synthesis and action (eg, ketoconazole, metronidazole, and cimetidine). The final type is drugs that act by unknown mechanisms (eg, isoniazid,⁶ methyldopa, captopril, tricyclic antidepressants, diazepam, marijuana, heroin). While heavy marijuana use has been linked to gynecomastia in rats, the relationship in humans is at best poorly documented. Chronic alcohol abuse may result in hepatocellular destruction and scarring which may result in gynecomastia. Adult patients should be routinely questioned about alcohol abuse or addiction.

A link between testicular atrophy, Klinefelter syndrome, and breast cancer has been noted. Longstanding, stable gynecomastia in an otherwise healthy male does not require an extensive medical workup.

Pathophysiology

In boys, the main sex hormone is testosterone, which is secreted by the testes. In girls, the main sex hormone is estrogen, which is secreted by the ovaries. However, both hormones are secreted in both sexes. Some production of estrogen occurs in the testes, and some production of testosterone occurs in the ovaries. Gynecomastia has long been considered the result of an imbalance between estrogens, which stimulate breast tissue, and androgens, which antagonize this effect. An alteration in the normal ratio of estrogen to androgen has been found in patients with gynecomastia in association with many different etiological factors.^7,8

Estradiol is the growth hormone of the breast in women, and an excess of estradiol leads to the proliferation of breast tissue. Under normal circumstances, most estradiol in men is derived from the peripheral conversion of testosterone and adrenal estrogen. The basic mechanisms of physiologic gynecomastia have been postulated to represent a decrease in androgen production, an absolute increase in estrogen production, and an increased availability of estrogen precursors for peripheral conversion to estradiol.

Pathophysiology of gynecomastia. Estradiol is the growth hormone of the breast, and an excess of estradiol leads to the proliferation of breast tissue. Under normal circumstances, most estradiol in men is derived from the peripheral conversion of testosterone and adrenal estrone. The basic mechanism of endocrine-related gynecomastia is a decrease in androgen production, an absolute increase in estrogen production, and an increased availability of estrogen precursors for peripheral conversion to estradiol.

Presentation

Patients present with an increase in breast tissue, which is asymmetric in one third of cases. The degree of asymmetry between the 2 sides varies widely. Some patients present with unilateral gynecomastia, while other individuals have a size discrepancy between the 2 sides that ranges from moderate to severe. Breast tenderness may also be noted in one third of patients. Enlargement is usually central and symmetric, although occasionally it is eccentric.

In 1934, Webster classified gynecomastia into 3 types.³ The first is glandular. Patients with a glandular component require surgical removal of the gland. The second is fatty glandular. With the fatty glandular form, surgery combined with liposuction allows good contouring. The third is simple fatty. In the cases that are primarily fatty in nature, liposuction alone provides good results.

Another classification described by Simon in 1973 groups the patients into categories according to the size of the gynecomastia.¹⁰ Group 1 is minor but visible breast enlargement without skin redundancy. Group 2A is moderate breast enlargement without skin redundancy. Group 2B is moderate breast enlargement with minor skin redundancy. Group 3 is gross breast enlargement with skin redundancy that simulates a pendulous female breast. Patients in groups 1 and 2 require no skin excision, but the breast development associated with group 3 is so marked that excess skin must be removed.

Indications

Generally, gynecomastia is a benign condition. Longstanding cases do not require histologic examination of surgically removed tissue. Rapid changes in the size of the breast, especially when unilateral in nature, may represent a malignancy particularly when pharmacologic manipulation can be ruled out. Also, changes in breast size in a patient with Klinefelter syndrome should be viewed with caution.

Surgical intervention is indicated in patients for diagnostic purposes or, most commonly, for patients who request treatment for physical modification. Most patients who visit a plastic surgeon request treatment for improvement of the obvious physical deformity which enhances psychological and physical wellbeing. These patients seek treatment because they find that the condition, which is readily apparent in everyday life, adversely impacts day-to-day activities under various circumstances. The physical deformation necessitates behavioral modifications that have numerous implications in the lives of the patients who are affected. Patients wear loose clothing and often avoid exposure in showers and swimming pools. Patients in high school and college are reticent to participate in any athletic activity that may directly or inadvertently require removal of one's shirt, exposing the chest.

Patients with gynecomastia typically slouch forward and roll the shoulders toward the midline in an effort to camouflage the deformation. The aforementioned posturing has a submissive connotation to the public with whom they interact. Patients return for postoperative appointments standing tall. In cases involving teenagers, parents typically remark "I have been trying to have him stand up straight for years!" The postural changes alone, which result at all age levels both sitting and standing, have numerous positive implications in peer-to-peer interactions.

Relevant Anatomy

The plastic surgeon must know the anatomy of the breast and be able to differentiate between the fat tissue and the glandular tissue. In a liposuction-assisted mastectomy, the surgeon primarily targets the fatty component of the breast. The glandular tissue is quite dense and is extremely resistant to removal by any method other than direct excision. The requirement of direct surgical resection of tissue in some patients may explain the poor results obtained by some practitioners in specific cases. As previously mentioned, longstanding stable cases of gynecomastia do not routinely require histologic examination of the excised tissue.

Contraindications

Liposuction-assisted mastectomy with or without gland excision for gynecomastia patients can be performed under local anesthesia, intravenous conscious sedation, or general anesthesia. The choice of sedation should be determined preoperatively by the physician and patient. Any significant medical problems, such as heart disease, lung disease, or diabetes, must be excluded before the procedure is performed. Rapid or unusual progression or presentation of the disease may require endocrinologic evaluation, which is optimally preformed prior to any surgical intervention. If the etiology of the gynecomastia is related to an adrenal or pituitary tumor, the tumor should be addressed prior to any attempt to correct the gynecomastia. If the gynecomastia is related to drug use, the use of the offending agent should be stopped prior to surgery.

Males who are upset with the appearance of their chest may also have substantial psychological issues. A boy who is being abused or humiliated commonly focuses on some part of his external appearance to avoid dealing with internal pain that he feels unable to manage or control. What may have started as a minor physical condition can be a cover for much deeper emotional issues that no amount of surgery can resolve. While Yost has demonstrated that more than 91% of individuals who have had surgery are happy with the procedure and would recommend surgery to a friend, individuals who require multiple surgeries may need to be screened for body dysmorphic disorder (BDD) and referred for treatment.¹¹

Workup

Laboratory Studies

• History and physical examinations are key elements used when considering the diagnosis of gynecomastia.¹² Longstanding stable cases in an adult do not require blood tests other than those that would be required for an outpatient surgery. For routine outpatient surgery in healthy individuals aged less than 40 y, the authors do not require any laboratory testing prior to routine surgery.
• Blood work should include liver function tests and assays for follicle-stimulating hormone, luteinizing hormone, human chorionic gonadotropin, thyroid-stimulating hormone, thyroxine, estrogen, estradiol, and testosterone levels in children and in individuals with progressive disease.
  
  

  

  Flow chart of the workup to determine the etiology of gynecomastia.

  
  
• A sex chromatin study should be performed to exclude Klinefelter syndrome when appropriate.
• Elevated estrogen and 17-ketosteroid levels in urine indicate the presence of a feminizing adrenal tumor.

Imaging Studies

• If indicated by the patient's history, physical examination, and laboratory results, preoperative workup may include an ultrasound examination of the testes and breasts, computed tomography scan of adrenal glands, magnetic resonance imaging of sella turcica, and mammography when appropriate.

Other Tests

• Excisional biopsy or fine-needle aspiration of breast tissue should be performed if a breast tumor is suspected.
• Excised tissue should be sent for histological examination to exclude malignancy in appropriate cases. Approximately 1% of all primary breast tumors are reportedly found in men, and breast cancer accounts for 0.7% of all male cancers. As previously mentioned, unilateral cases with rapid progression should be viewed with suspicion.

Histologic Findings

• Gynecomastia has 3 recognized pathological patterns.
  • The first type, the florid type, is characterized by an increase in the number and length of ducts, proliferation of ductal epithelium, periductal edema, a highly cellular fibroblastic stroma and hypervascularity, and the formation of pseudolobules. The florid type is the most common in patients with gynecomastia of less than 4 months' duration.
  • The second type, the fibrous type, is characterized by dilated ducts with minimal proliferation of epithelium, an absence of periductal edema, and an almost acellular fibrous stroma without adipose tissue. The fibrous type is the most common in patients with gynecomastia that lasts for 4-12 months.
  • The third type, the intermediate type, is an overlapping pattern of both the florid and the fibrous types.

Staging

• Idiopathic gynecomastia is a benign condition.

Treatment

Medical Therapy

Medical management is most successful when the gynecomastia is of recent onset and is caused by testosterone deficiency. Testosterone administration has inconsistent effects in persons with Klinefelter syndrome, but it can cause dramatic improvement in those with other forms of testicular failure (eg, anorchia, viral orchitis). Testosterone therapy involves an element of uncertainty because testosterone can serve as substrate for extraglandular estrogen formation. Under some circumstances (eg, patient with liver disease), androgen therapy can cause a disproportionate increase in plasma estrogen levels.

Various drug regimens have been tried for the treatment of gynecomastia. These drugs include the antiestrogens tamoxifen⁷ and clomiphene, the aromatase inhibitor testolactone, and danazol (a weak androgen that inhibits gonadotropin secretion and causes a decrease in plasma testosterone). Treatment with dihydrotestosterone, which cannot be aromatized to estrogen, has also been reported to cause significant symptomatic improvement in uncontrolled studies of persons with gynecomastia. However, to the authors' knowledge, no controlled studies have been conducted to test the clinical effectiveness of any of these regimens and, in the authors’ hands, none of the aforementioned treatments have been even minimally successful in patients with idiopathic gynecomastia.

Without an increase in receptor number or binding capacity of the receptors, exogenous medical treatment is not likely to be effective; therefore, medical treatment is not likely to be effective for patients with idiopathic gynecomastia, since they do not exhibit an altered number of such receptors.

Radiation

Several studies have shown that prophylactic breast irradiation reduces the risk of gynecomastia in patients with prostate cancer who are undergoing long-term estrogen or anti-androgen therapy. The risks of long-term malignancies, however, have not been clearly defined.

Surgical Therapy

The objectives of surgical management for breast gynecomastia are (1) to restore the normal male breast contour and (2) to correct deformity of the breast, nipple, or areola. The surgical options for the patient with gynecomastia are mastectomy, liposuction-assisted mastectomy, or a combination of the 2 approaches. Most patients receive maximal benefit from a combined approach.

Surgical resection (subcutaneous mastectomy)

The choice of surgical technique depends on the likelihood of skin redundancy after surgery. Generally, skin shrinkage is greater in younger individuals than in older individuals. Many different incisions have been described for the excision of male breasts. The most common approach is the intra-areolar incision, or Webster incision. The Webster incision extends along the circumference of the areola in the pigmented portion. The length of the incision varies according to the specific anatomy of the patient.

The Webster intra-areolar incision is placed in the inferior hemisphere.

The Webster intra-areolar incision is placed in the inferior hemisphere.

The Webster intra-areolar incision may be enlarged by lateral and medial extensions.

The transverse nipple-areola incision.

The triple-V incision offers increased exposure. This approach is rarely used today.

The most common technique for skin resection and nipple transposition is the Letterman technique.

In massive gynecomastia, an en bloc resection of excessive skin and breast tissue and free nipple grafting can be performed using an elliptical incision with a nipple-areola graft.

Preoperative Details

A standard preoperative workup that is age-appropriate should be performed. Longstanding cases of idiopathic gynecomastia that are stable do not require routine endocrine evaluation.

Intraoperative Details

Surgical resection

The technique used depends on the degree of gynecomastia. If the gynecomastia requires surgical resection, the Webster intra-areolar incision is the typically the most appropriate. Prior to surgical resection, the breast is infiltrated with tumescent solution and liposuction is performed. For massive breast gynecomastia, more skin removal and deeper excision are necessary. With an accurate estimation of the extent of the hypertrophied tissue and the thickness of the fat on the chest wall, the dissection should reach the pectoralis major muscle fascia very near to the preoperatively estimated breast limits. The hypertrophied tissue is then excised from pectoralis major fascia. Hemostasis is secured, and a surgical drain may, rarely, be placed. Subcutaneous tissues are reapproximated, and the skin is closed subcuticularly. The authors use a compression vest postoperatively, which has made drains unnecessary in the overwhelming majority of patients.

Liposuction-assisted mastectomy

Liposuction-assisted mastectomy is the most popular method used for pseudogynecomastia. The liposuction cannulas are inserted through a 3-mm areolar incision or an incision in the anterior axilla along the pectoralis major tendon. The surgeon the removes fatty and minimal glandular tissues. For small and moderate gynecomastia, suction lipectomy is extended to the clavicle, to the sternum, to 2 cm below the inframammary crease, and to the axilla. For moderate to large gynecomastia, suction lipectomy is extended to the postaxillary fold in conjunction with excision.

Postoperative Details

Compression garments are applied for at least 4 weeks. A small amount of blood, injection fluid, and liquified fat may leak from the incision sites for approximately 24 hours. The patient may resume his physical activities within few days. Exercise is resumed a few days after surgery and is gradually increased over time. Patients return to work typically after 1-2 days.

Follow-up

Patients are usually seen 1 week postoperatively and once a month for the first 6 months. The final results are not fully appreciated for up to a year.

Postoperative view of patient after surgical glandular excision and combined ultrasonic-assisted liposuction (UAL) and power-assisted liposuction (PAL).

Postoperative view of above patient. Note that while the glandular and fatty tissue have been removed, the nipples remain in the preoperative position relative to each other. Also note the significant skin retraction postoperatively.

Complications

Complications of mastectomy for gynecomastia include the following:

• Hematoma (most common)
• Breast asymmetry
• Nipple or areola necrosis
• Nipple or areola inversion
• Infection
• Sensory changes
• Painful scar
• Contour deformity
• Conspicuous scar
• Skin redundancy

Outcome and Prognosis

Regardless of the etiology of gynecomastia, the prognosis is excellent when surgery is performed by a surgeon experienced with the disorder. In pathological-induced gynecomastia, medical and surgical treatment of the cause is required. In drug-induced gynecomastia, withdrawal of the medication leads to regression in 60% of patients. If the gynecomastia is of long duration, it is unlikely to spontaneously regress.

Future and Controversies

Drug-induced gynecomastia and gynecomastia due to long-term exposure to estrogen are believed by some to increase a patient's risk for breast cancer. However, numerous clinical studies have failed to show the relationship between breast cancer and gynecomastia. The only study which shows clear association between gynecomastia and male breast cancer is with Klinefelter syndrome; patients who have gynecomastia and Klinefelter syndrome are at about 50% increased risk of male breast cancer. Drug-induced gynecomastia is the second most common cause of gynecomastia. Significant studies have been conducted to research the effects of the drugs that cause gynecomastia; however, much additional work is required.

If the gynecomastia patient is not satisfied with an otherwise excellent surgical result or a clear history of abuse from having the condition is noted, therapy may be required, and the appropriate referral should be recommended. Resolving any severe overlying emotional issues produces a much higher satisfaction rate with the surgical outcome in these individuals.

In general, the management of gynecomastia is not controversial; its typically benign nature and the indications for medical and surgical management are well established.

Multimedia

Media file 1: Pathophysiology of gynecomastia. Estradiol is the growth hormone of the breast, and an excess of estradiol leads to the proliferation of breast tissue. Under normal circumstances, most estradiol in men is derived from the peripheral conversion of testosterone and adrenal estrone. The basic mechanism of endocrine-related gynecomastia is a decrease in androgen production, an absolute increase in estrogen production, and an increased availability of estrogen precursors for peripheral conversion to estradiol.

Media file 2: Flow chart of the workup to determine the etiology of gynecomastia.

Media file 3: The Webster intra-areolar incision is placed in the inferior hemisphere.

Media file 4: The Webster intra-areolar incision may be enlarged by lateral and medial extensions.

Media file 5: The transverse nipple-areola incision.

Media file 6: The triple-V incision offers increased exposure. This approach is rarely used today.

Media file 7: The most common technique for skin resection and nipple transposition is the Letterman technique.

Media file 8: In massive gynecomastia, an en bloc resection of excessive skin and breast tissue and free nipple grafting can be performed using an elliptical incision with a nipple-areola graft.

Media file 9: Preoperative anteroposterior view of a patient with idiopathic gynecomastia.

Media file 10: Preoperative lateral view of a patient with gynecomastia.

Media file 11: Postoperative view of patient after surgical glandular excision and combined ultrasonic-assisted liposuction (UAL) and power-assisted liposuction (PAL).

Media file 12: Postoperative view of above patient. Note that while the glandular and fatty tissue have been removed, the nipples remain in the preoperative position relative to each other. Also note the significant skin retraction postoperatively.

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Keywords

male breast enlargement, female-like breasts, feminization, male feminization, mastectomy, liposuction-assisted mastectomy, reduction mammaplasty, male breast lesion, male breast abnormality, male breast anomaly, feminized male breast, breast mass, male breast mass, congenital anorchia, Klinefelter syndrome, Klinefelter's syndrome, testicular feminization, hermaphroditism, hermaphrodite, adrenal carcinoma, adrenal cancer, liver disorder, hepatic disorder, liver disease, hepatic disease, malnutrition, testosterone deficiency, gynecomastia, ideopathic gynecomastia, surgical gynecomastia, glandular gynecomastia

Contributor Information and Disclosures

Author

Jay M Pensler, MD, Aesthetic Plastic and Reconstructive Surgery, Private Practice; Clinical Associate Professor, Department of Surgery, Division of Plastic Surgery, Northwestern University Medical School
Jay M Pensler, MD is a member of the following medical societies: American Academy of Pediatrics, American Burn Association, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Medical Association, American Society for Aesthetic Plastic Surgery, American Society for Laser Medicine and Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Chicago Medical Society, Illinois State Medical Society, International College of Surgeons, and Sigma Xi
Disclosure: Nothing to disclose.

Coauthor(s)

Merle J Yost, BA, MA, LMFT, Licensed Marriage and Family Therapist
Disclosure: Gynecomastia.org Ownership interest Sole owner

Medical Editor

Pankaj Tiwari, MD, Assistant Professor, Division of Plastic Surgery, Ohio State University
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Saleh M Shenaq, MD†, Former Director and Founder, The International Brachial Plexus Institute; Former Chief, Section of Plastic Surgery, Methodist Hospital, Houston
Saleh M Shenaq, MD† is a member of the following medical societies: American Academy of Anti-Aging Medicine, American Academy of Pediatrics, American Association for Hand Surgery, American Association for the Advancement of Science, American Association of Plastic Surgeons, American Burn Association, American College of Physician Executives, American College of Surgeons, American Congress of Rehabilitation Medicine, American Medical Association, American Society for Aesthetic Plastic Surgery, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, American Society of Gene Therapy, American Society of Law Medicine and Ethics, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Trauma Society, Association for Academic Surgery, International College of Surgeons, Lipoplasty Society of North America, Plastic Surgery Research Council, Society for Neuroscience, Society of Surgical Oncology, Southern Medical Association, Texas Medical Association, and Texas Society of Plastic Surgeons
Disclosure: Nothing to disclose.

CME Editor

Nicolas (Nick) G Slenkovich, MD, Director, Colorado Plastic Surgery Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Al Aly, MD, FACS, Consulting Surgeon, Iowa City Plastic Surgery
Disclosure: Ethicon  Consulting fee Consulting; QMP Royalty Book royalty; Insorb Stapler Consulting fee Consulting; Insorb Stapler Ownership interest None; Medicis Intellectual property rights None

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