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.
This incision may be enlarged by lateral and medial extensions, though this is rarely required.
The Webster intra-areolar incision may be enlarged by lateral and medial extensions.
The transverse nipple-areola incision may be used, but it may often be associated with limited exposure.
The transverse nipple-areola incision.
The triple-V incision is an additional approach that has been advocated.
The triple-V incision offers increased exposure. This approach is rarely used today.
The transaxillary incision has been recommended because of its advantage of scars on the chest wall; however, its disadvantage is that it causes glandular resection to be more difficult and incomplete. Obtaining adequate hemostasis is also very difficult through this approach.
In severe gynecomastia, skin resection and nipple transposition techniques may occasionally be necessary. The most common type is the Letterman technique. After the skin is resected, the nipple-areola complex is rotated superiorly and medially based on a single dermal pedicle.
The most common technique for skin resection and nipple transposition is the Letterman technique.
Sometimes, in massive gynecomastia, an en bloc resection of excessive skin and breast tissue and free nipple grafting can be performed, but such cases are extremely unusual.
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.
Preoperatively, the surgeon should outline the incision and estimate the thickness and depth of fat and breast tissue to be removed. Liposuction is performed after the infiltration of tumescent solution. The authors presently use a combination of ultrasonic-assisted liposuction (UAL), power-assisted liposuction (PAL), and traditional liposuction. The surgical dissection, which proceeds after the liposuction, entails a dissection that is extended to the pectoralis major fascia. The fat and breast tissue are excised en bloc from the pectoralis fascia. Hemostasis is achieved with a Bovie electrocautery instrument. A catheter may need to be inserted to prevent postoperative hematoma; however, with the use of tumescent solution that contains epinephrine, this is rarely required.
Liposuction-assisted mastectomy
Teimourian and Pearlman, first introduced liposuction with surgical resection in the 1980s.13 Recently, the advent of ultrasonic liposuction has improved the results of gynecomastia correction. In liposuction-assisted mastectomy, less compromise of the blood supply, nipple distortion, saucer deformity, and areola slough occur. In addition, the postoperative complications (eg, hemorrhage, infection, hematoma, seroma, necrosis) are fewer with this technique than with open surgical resection. However, liposuction-assisted mastectomy is not effective for correcting glandular gynecomastia. Therefore, the fatty and glandular components of the breast must be assessed prior to any surgical intervention. Few patients can be sufficiently treated with liposuction only.
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
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Further Reading
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
