Plastic Surgery for Gynecomastia Treatment & Management
- Author: Jay M Pensler, MD; Chief Editor: James Neal Long, MD, FACS more...
Medical management has been shown to produce variable results. Reports of successful medical treatment have been most consistently linked to instances when the gynecomastia is of recent onset and is caused by testosterone deficiency. (However, many reports of "successful" medical treatment of gynecomastia are simply misconstrued attempts to treat adolescent individuals with normal findings during puberty that would have resolved spontaneously. It must be stressed that minimal development of the breast bud during puberty is a normal finding in males that resolves in time with no treatment.)
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 tamoxifen and clomiphene, the aromatase inhibitor testolactone, and danazol (a weak androgen that inhibits gonadotropin secretion and causes a decrease in plasma testosterone). A study by Akgül et al indicated that tamoxifen administered for pubertal gynecomastia will not adversely affect skeletal maturation in adolescent boys, impacting neither bone mineralization nor growth potential.
Pensler et al looked at the number of estrogen receptors in gynecomastia and the binding capacity of the receptors and found not only that there was no increase in the number of receptors in patients with gynecomastia but that the receptors exhibited normal binding; these results would question the rationale for antiestrogen use.
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.
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. Radiation in cases of idiopathetic gynecomastia is not indicated at this time.
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. It should be stressed that the glandular tissue of the breast is very thick and is often virtually impossible to remove without direct excision.
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 and is the preferred approach used by the author. The length of the incision varies according to the specific anatomy of the patient. The glandular breast tissue has a greater density than adipose tissue. The glandular tissue is not amenable to liposuction.
The Webster intra-areolar incision is placed in the inferior hemisphere. See the image below.
This incision may be enlarged by lateral and medial extensions, though this is rarely required. See the image below.
The transverse nipple-areola incision may be used, but it may often be associated with limited exposure and nipple distortion may result. See the image below.
The triple-V incision is an additional approach that has been advocated. See the images below.
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. See the image below.
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. See the image below.
In patients with an abnormal inframammary crease, wide undermining into the abdominal skin may be required to optimize the result.
Two-stage breast reduction for moderate-to-severe gynecomastia
For moderate-severe gynecomastia, a 2-stage surgical procedure may be an option. The first stage is liposuction followed by a Webster-type periareola incision and removal of gland, fat, and fibrous tissue to obtain a nice contour. The second stage is performed 4-6 months later, after the blood supply has reestablished itself from below and allows for a periareola donut mastopexy. The advantage of this technique is the limited incision around the nipple-areola complex. It should be stressed that in the majority of cases, adequate skin contraction occurs to obviate the need for skin resection.
Minimally invasive gynecomastia surgery
See the image below.
Minimally invasive gynecomastia surgical procedures have been proposed. The so-called "pull-through technique" described by Moreslli in 1996 has been further refined by Hammond et al, Bracaglia et al, and Lista and Ahmad. A very small (approximately 5 mm) incision is made at the areolar edge, and liposuction is followed by releasing the glandular tissue from the overlying areola and pulling it through the incision, thus the pull-through technique. The major advantage is the smaller incision, although the periareola incision that is typically used is very difficult to see. This technique is only used in well-selected patients with minimal impact on the final result.
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.
Teimourian and Pearlman, first introduced liposuction with surgical resection in the 1980s. 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.
A standard preoperative workup that is age-appropriate should be performed. Long-standing cases of idiopathic gynecomastia that are stable do not require routine endocrine evaluation. Avoiding aspirin or other blood thinners is critical since postoperative hematomas are common.
The technique used depends on the degree of gynecomastia and the skin elasticity. The percentage of patients that benefit from open surgical resection to optimize the final results has continued to increase. The authors have found that surgical open resection is required in most cases. If the gynecomastia requires surgical resection, the Webster intra-areolar incision is 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. Some surgeons rarely use drains, while others almost always use them.
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 the overwhelming majority of patients, liposuction is performed in conjunction with excision.
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. Drains may or may not be used, depending on the experience of the surgeon and the patient presentation.
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. See the images below.
Complications of mastectomy for gynecomastia include the following:
Hematoma (most common; see images below)
Nipple or areola necrosis
Nipple or areola inversion
A postoperative hematoma is shown below.
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 some regression in 60% of patients; however, this is typically inadequate and requires surgical intervention. If the gynecomastia is of long duration, it is exceeding rare to find any instances of spontaneous regression.
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.
The enhanced awareness of gynecomastia in men appears to parallel the interest in cosmetic procedure for men in general. Plastic surgical procedures in men continue to show a steady rise in the United States. Americans spent almost $11 billion on cosmetic procedures in 2012. Of that total, $6.7 billion was spent on surgical procedures. Men had approximately 10% of the procedures performed, which amounted to just under 1,000,000 procedures. The percentage of cosmetic procedures for men has increased over 106% from 1997.
In general, the management of gynecomastia is not controversial; its typically benign nature and the indications for medical and surgical management are well established.
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