Correction of Gynecomastia

Introduction

Gynecomastia is defined as benign glandular enlargement of the male breast, its hallmark location being a concentric mass directly beneath the nipple. ^, It can consist of various proportions of excess subareolar fibrous breast and adipose tissue peripherally, and its extent depends on the individual’s body habitus. By contrast, pseudogynecomastia is enlargement of adipose tissue of the male breast. Gynecomastia is by far the most common breast problem in men, with an overall incidence of 32%–36% with up to 75% of cases being bilateral.

Physiologic temporary overgrowth of the adolescent breast also can be responsible for gynecomastia. With onset at approximately age 14 in more than 65% of healthy boys, gynecomastia typically resolves within 2 years. Persistent adolescent-onset gynecomastia beyond age 21 is unlikely to resolve with conservative management.

Gynecomastia also can manifest in men of advanced years. In middle-aged and older men, it is most commonly due to the excessive aromatization of androgens to estrogens, resulting in a decreased overall level of circulating testosterone. It may manifest in 40%–50% of men over 40 years of age.

Although most patients with gynecomastia present with cosmetic concerns, symptomatic gynecomastia can be characterized by breast pain and tenderness. In this chapter, the authors describe their preferred techniques for surgical treatment of gynecomastia to ensure an optimal outcome but with minimal scarring. In addition, patient selection and preoperative evaluation are also described.

Indications and Contraindications

Most patients present with cosmetic concerns about their breast appearance or chest contour. Some patients may complain about breast pain and tenderness. Therefore, surgery is usually indicated to correct gynecomastia related to a breast or chest contour problem.

Contraindications for surgical correction of gynecomastia include any medical conditions that cause such a condition. Therefore, a complete endocrine workup and certain imaging studies are required for all patients to identify endocrine disorders or tumors related to the testicles, adrenal gland, or pituitary gland. In addition, thyroid, renal, or liver function and medications taken by patients should be evaluated.

Preoperative Evaluations and Special Considerations

Initial evaluation requires a detailed history and physical examination to differentiate among fatty tissue, parenchymal enlargement, and a tumor. Age of onset, duration, symptoms, medications, recreational drug use, and medical history are key components to the initial evaluation. The breast examination assesses for fatty versus glandular predominance, excess breast skin, breast ptosis, and palpable masses. In addition, male breast cancer also should be ruled out.

Classification schemes exist to better define the extent of gynecomastia and dictate surgical treatment. The Simon classification has traditionally been employed (types I–III), as follows :

• I.

  Small but visible breast development, without skin redundancy

  • a.

    Moderate breast development without skin redundancy

  • b.

    Moderate breast development, with skin redundancy

• II.

  Severe breast development with large skin redundancy

The normal average areolar diameter in the male nipple–areola complex is 25–30 mm, and these dimensions may be affected in cases of gynecomastia. The areola circle must also be addressed and may require a reduction in size or correction in the case of nipple herniation. Finally, mammography or even biopsy may be indicated in certain patients.

Complications are generally rare and well tolerated, but risks of overresection or underresection should be disclosed to patients preoperatively to manage expectations, facilitate informed consent, and provide anticipatory guidance for secondary revisions.

Surgical Techniques