Plastic Surgery for Gynecomastia Workup

  • Author: Jay M Pensler, MD; Chief Editor: James Neal Long, MD, FACS   more...
 
Updated: Sep 20, 2011
 

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.

The coauthor requires a normal prothrombin time/partial thromboplastin time (PT/PTT) before surgery is performed. If a patient has a history of bleeding with wisdom tooth extraction or adenoid surgery, further investigation should be performed to rule out medical bleeding such as von Willebrand disease.

See the image below.

Flow chart of the workup to determine the etiologyFlow 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.

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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.

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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.

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Histologic Findings

Gynecomastia has 3 recognized pathological patterns, as follows:

  • 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.
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Staging

Idiopathic gynecomastia is a benign condition.

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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 Feinberg 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)

Miguel A Delgado Jr, MD, FACS  Private Practice

Miguel A Delgado Jr, MD, FACS is a member of the following medical societies: American Medical Association, American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and International Society of Hair Restoration Surgery

Disclosure: Nothing to disclose.

Merle J Yost, MA, LMFT  Licensed Marriage and Family Therapist

Disclosure: Gynecomastia.org founder and past owner Other

Specialty Editor Board

Pankaj Tiwari, MD  Assistant Professor, Division of Plastic Surgery, Ohio State University College of Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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 & 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.

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

James Neal Long, MD, FACS  Associate Professor of Plastic and Reconstructive Surgery, Division of Plastic Surgery, Children's Hospital and Kirklin Clinics, University of Alabama at Birmingham School of Medicine; Chief of Plastic, Reconstructive, Hand, and Microsurgery, Birmingham Veterans Affairs Medical Center

James Neal Long, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Society of Plastic Surgeons, Plastic Surgery Research Council, Sigma Xi, Southeastern Society of Plastic and Reconstructive Surgeons, and Southeastern Surgical Congress

Disclosure: Nothing to disclose.

References

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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.
Flow chart of the workup to determine the etiology of gynecomastia.
Incision for minimally invasive gynecomastia surgery.
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.
A periareola incision followed by another outer circle of skin. The skin in between is removed and the outer circle has a purse-string closure, which is approximated to the smaller circle. This completes the peiareola donut mastopexy.
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.
Stage 2 - Periareola skin excision with a purse-string closure.
Preoperative anteroposterior view of a patient with idiopathic gynecomastia.
Preoperative lateral view of a patient with gynecomastia.
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.
Postoperative view of patient after surgical glandular excision and combined ultrasonic-assisted liposuction (UAL) and power-assisted liposuction (PAL).
Preoperative gynecomastia patient. Note the enlarged breast size.
Post surgical correction of gynecomastia. Note the improved contour, which enables the patient to look better both in and out of clothes.
Resected tissue. Note that the white tissue, which is glandular breast tissue, has a higher density than the fat (adipose) tissue. The thick and dense glandular tissue in not ammenable to liposuction.
Preoperative gynecomastia patient. Courtesy of Miguel Delgado, MD.
Post surgical correction of gynecomastia. The patient underwent gland excision with liposuction. Courtesy of Miguel Delgado, MD.
Preoperative gynocomastia patient. Courtesy of Miguel Delgado, MD.
Post surgical correction of gynecomastia. Gland excision with liposuction. Note the large mole on the right chest that has flattened out. Courtesy of Miguel Delgado, MD.
Preoperative gynecomastia patient. Courtesy of Miguel Delgado, MD.
Post surgical correction of gynecomastia. Gland excision with liposuction. Note how the skin contracts. Courtesy of Miguel Delgado, MD.
Resected gynecomastia tissue. Courtesy of Miguel Delgado, MD.
Pull-through technique. Tissue seen pulled half way through the incision. Preoperative and postoperative photos of this patient. Courtesy of Miguel Delgado, MD.
Preoperative photo before the pull-through technique. Courtesy of Miguel Delgado, MD.
Glandular tissue being pulled through. Courtesy of Miguel Delgado, MD.
Breast gland pulled through from each side. Courtesy of Miguel Delgado, MD.
Postoperative photo after pull through technique. Courtesy of Miguel Delgado, MD.
Thirteen-year-old with adolescent gynecomatia. Gland excision with liposuction only, no skin excision. Note the degree of skin contraction. A secondary periareola-skin resection could remove the small fold. Courtesy of Miguel Delgado, MD.
Twenty-five-year-old with adolescent gynecomastia. Courtesy of Miguel Delgado, MD.
Postoperative photo after gland excision and liposuction. Patient is seen 6 month after surgery. Courtesy of Miguel Delgado, MD.
Forty-eight-year-old male gynecomastia patient with breast ptosis. Courtesy of Miguel Delgado, MD.
Three months postoperative after a superior cresant lift, triple-V incision. Note how the areola is elevated so the inframammary fold nearly eliminated. Courtesy of Miguel Delgado, MD.
Fifteen-year-old boy with severe gynecomastia. Courtesy of Miguel Delgado, MD.
Postoperative photo after stage 1 gland excision and liposuction through a Webster incision. Note the significant contraction of the skin, but laxity is still present. Courtesy of Miguel Delgado, MD.
Postoperatively, after periareola donut mastopexy. Patient seen 3 months after sugery. The skin laxity has been improved. Courtesy of Miguel Delgado, MD.
Forty-five-year-old man with adolescent gynecomastia. Courtesy of Miguel Delgado, MD.
Postoperative hematoma. The most common complication in the coauthor's practice. Courtesy of Miguel Delgado, MD.
Patient seen 2 months after evacuation of hematoma. If the hematoma is treated appropriately (ie, immediately removed), there will be no long-term ill effects. Courtesy of Miguel Delgado, MD.
Fifty-two-year-old man with adolescent gynecomastia. The skin is poor quality and the nipple-areola complex is very low. Courtesy of Miguel Delgado, MD.
Postoperative photo after gland excision, liposuction, nipple reposition, and lateral skin excision. Three months postoperatively. Courtesy of Miguel Delgado, MD.
Twenty-six-year-old man with adolescent gynecomastia. Courtesy of Miguel Delgado, MD.
Four months postoperatively after gland excision and liposuction. Note large, thick areola do not seem to contract or shrink as well. Courtesy of Miguel Delgado, MD.
Eighteen-year-old with adolescent gynecomastia. Courtesy of Miguel Delgado, MD.
Three months postoperatively after gland excision and liposuction. Courtesy of Miguel Delgado, MD.
 
 
 
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