Medical Therapy
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 [11] 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. [21]
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; [13] 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.
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. Radiation in cases of idiopathetic gynecomastia is not indicated at this time.
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. 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 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 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.
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.
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.
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.
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. See the image below.
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.
In patients with an abnormal inframammary crease, wide undermining into the abdominal skin may be required to optimize the result.
Decreased skin elasticity
As the number of patients seeking surgical correction for gynecomastia increases, more individuals are presenting with below-average skin elasticity. Patients with deficient elasticity require a much wider dissection and redraping of the thoracic skin envelope after removal of the glandular component. Persons who have experienced significant weight loss and the resultant loss of skin elasticity may, in the worst cases, require skin resection in addition to redraping. [22]
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, [23] Bracaglia et al, [24] and Lista and Ahmad. [25] 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.
Liposuction-assisted mastectomy
Teimourian and Pearlman, first introduced liposuction with surgical resection in the 1980s. [26] 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. 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.
Intraoperative Details
Surgical resection
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.
In order to further refine and improve the postoperative results in surgical resection, the author has extended the area of skin undermining in patients with poor skin elasticity.
Preoperative view of a male aged 32 years with bilateral gynecomastia. Note the excess skin present prior to surgery.
Postoperative view of the patient from the previous image. Extensive skin undermining and redraping were needed to achieve the demonstrated result.
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 the overwhelming majority of patients, liposuction is performed 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. Drains may or may not be used, depending on the experience of the surgeon and the patient presentation.
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. See the images below.
Postoperative view of patient after surgical glandular excision and combined ultrasonic-assisted liposuction (UAL) and power-assisted liposuction (PAL). Courtesy of Jay Pensler, MD.
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 the adolescent gynecomastia patient at 8 months after surgery. Note the improved profile and the contraction of the skin envelope as a result of the glandular tissue removal. Courtesy of Jay Pensler, MD.
Complications
A retrospective study by Zavlin et al found the prevalence of gynecomastia surgery complications in pediatric and adult patients to be low, with 30-day surgical complication rates of 3.9% and 1.9%, respectively, and 30-day medical complication rates of 0.0% and 0.3%, respectively. The investigators also found that the mean operative time for pediatric patients (111.3 minutes) was almost double that for adults (56.7 minutes). [27]
Complications of mastectomy for gynecomastia include the following:
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Hematoma (most common; see images below)
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Breast asymmetry
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Nipple or areola necrosis
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Nipple or areola inversion
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Infection
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Sensory changes
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Painful scar
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Contour deformity
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Conspicuous scar
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Skin redundancy
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Seroma
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Hyperinflammatory pigmentation
A postoperative hematoma is shown below.
Postoperative hematoma. The most common complication in the coauthor's practice. Courtesy of Miguel Delgado, MD.
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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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.
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Flow chart of the workup to determine the etiology of gynecomastia.
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Incision for minimally invasive gynecomastia surgery.
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The Webster intra-areolar incision is placed in the inferior hemisphere.
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The Webster intra-areolar incision may be enlarged by lateral and medial extensions.
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The transverse nipple-areola incision.
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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.
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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.
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Stage 2 - Periareola skin excision with a purse-string closure.
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Preoperative anteroposterior view of a patient with idiopathic gynecomastia.
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Preoperative lateral view of a patient with gynecomastia.
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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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Postoperative view of patient after surgical glandular excision and combined ultrasonic-assisted liposuction (UAL) and power-assisted liposuction (PAL). Courtesy of Jay Pensler, MD.
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Preoperative gynecomastia patient. Note the enlarged breast size. Courtesy of Jay Pensler, MD.
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Postsurgical correction of gynecomastia. Note the improved contour, which enables the patient to look better both in and out of clothes. Courtesy of Jay Pensler, MD.
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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 is not amenable to liposuction.
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Preoperative view. Note the excess tissue in the axillary region in addition to the tissue in the breast. Treatment in addition to correction of the gynecomastia requires aggressive liposuction of the axilla. Courtesy of Jay Pensler, MD.
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Postoperative view of above patient. Note the correction not only of the gynecomastia but the improved transition into the axilla (armpit). Courtesy of Jay Pensler, MD.
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Preoperative gynocomastia patient. Courtesy of Jay Pensler, MD.
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Postsurgical correction of gynecomastia. Gland excision with liposuction. Note the large mole on the right chest that has flattened out. Courtesy of Miguel Delgado, MD.
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Preoperative gynecomastia patient. Courtesy of Miguel Delgado, MD.
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Postsurgical correction of gynecomastia. Gland excision with liposuction. Note how the skin contracts. Courtesy of Miguel Delgado, MD.
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Resected gynecomastia tissue. Courtesy of Miguel Delgado, MD.
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Pull-through technique. Tissue seen pulled half way through the incision. Preoperative and postoperative photos of this patient. Courtesy of Miguel Delgado, MD.
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Preoperative photo before the pull-through technique. Courtesy of Miguel Delgado, MD.
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Glandular tissue being pulled through. Courtesy of Miguel Delgado, MD.
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Breast gland pulled through from each side. Courtesy of Miguel Delgado, MD.
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Postoperative photo after pull through technique. Courtesy of Miguel Delgado, MD.
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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.
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Twenty-five-year-old with adolescent gynecomastia. Courtesy of Miguel Delgado, MD.
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Postoperative photo after gland excision and liposuction. Patient is seen 6 month after surgery. Courtesy of Miguel Delgado, MD.
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Forty-eight-year-old male gynecomastia patient with breast ptosis. Courtesy of Miguel Delgado, MD.
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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.
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Fifteen-year-old boy with severe gynecomastia. Courtesy of Miguel Delgado, MD.
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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.
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Postoperatively, after periareola donut mastopexy. Patient seen 3 months after sugery. The skin laxity has been improved. Courtesy of Miguel Delgado, MD.
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Forty-five-year-old man with adolescent gynecomastia. Courtesy of Miguel Delgado, MD.
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Postoperative hematoma. The most common complication in the coauthor's practice. Courtesy of Miguel Delgado, MD.
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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.
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A 16-year-old patient with adolescent gynecomastia. Courtesy of Jay Pensler, MD.
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Postoperative view of the adolescent gynecomastia patient at 8 months after surgery. Note the improved profile and the contraction of the skin envelope as a result of the glandular tissue removal. Courtesy of Jay Pensler, MD.
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Preoperative view of a male aged 32 years with bilateral gynecomastia. Note the excess skin present prior to surgery.
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Postoperative view of the patient from the previous image. Extensive skin undermining and redraping were needed to achieve the demonstrated result.
