Laboratory Studies
History and physical examinations are key elements used when considering the diagnosis of gynecomastia. [18] 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.
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 ultrasonographic examination of the testes and breasts, computed tomography scan of adrenal glands, magnetic resonance imaging of sella turcica, and mammography when appropriate.
A study by Athwal et al of 53 males with new-onset gynecomastia indicated that a combination of clinical examination and ultrasonography is highly sensitive and specific for the detection of breast cancer in these patients. [19] It should be noted, however, that all males going through puberty have enlargement of the breast bud, which is typically accompanied by pain in the bud. This normal process in male growth and development does not require any type of testing. Breast cancer in males most often presents with rapid growth of the adult breast, which is usually unilateral in nature over a period of months.
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, as follows [20] :
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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.
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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.
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The third type, the intermediate type, is an overlapping pattern of both the florid and the fibrous types.
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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.
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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.
