Management strategies for gynecomastia

Introduction

Gynecomastia, a term commonly used to refer to male breast enlargement, affects roughly one-third to two-thirds of the male population at some point in their lives. The condition can negatively impact quality of life and patient satisfaction, and this has been recognized for many decades. The term itself encompasses a variety of histopathological variations, and etiologies range from benign to sinister. Management options include medical and surgical considerations. A multidisciplinary approach to workup is often beneficial. Wide practice variation exists, particularly with regard to surgical approaches. Financial considerations related to third party payment may also be challenging. Therefore, precise attention to detail is required in the perioperative, as well as operative, care.

Presentation

Males develop gynecomastia most commonly at three lifetime points, corresponding to physiologic hormone fluctuations. It is estimated that 60–90% of neonates develop transient, palpable breast tissue resulting from transplacental estrogen effects. This condition commonly resolves within 1 year. Pubertal gynecomastia (usually in patients aged 10–17 years old) has a reported incidence of one-third to two-thirds of adolescent males. It is thought that 90% of these cases spontaneously resolve within 2 years of onset. These may be related to relative estradiol excesses in comparison to testosterone. Another peak of gynecomastia occurs in aging men (50–80 years old), often as a consequence of hypogonadism (decreasing testosterone) or pharmaceutical drug therapies. Underlying causes are identified in roughly 50% of these cases.

The degree of enlargement and the anatomical changes associated with the enlargement can be quite variable. Bilateral cases are roughly as common as unilateral cases. Components of the physical examination, pertinent most particularly to treatment planning, include: Breast size, skin redundancy, skin elasticity, breast ptosis, nipple position, and tissue predominance (glandular, fibrous, fatty, or connective tissue). Anatomical considerations also include factors beyond the breast itself, such as upper abdominal laxity, breast tuberosity, chest shape, BMI, and history of weight loss.

In fact, many classification systems exist to attempt to classify the variable presentations of gynecomastia and to assist in surgical treatment planning. Two of the most cited are by Simon et al ., focusing on breast size and skin excess, and Rohrich et al ., characterizing breast size, skin excess, and tissue composition. Waltho et al . performed a systematic review of the available classification schemes and propose a newer scheme, relating it to surgical indications, synthesizing practical components of 11 prior classification systems that the authors reviewed (see Table 15.1 ). ^6,8,10,20 The Waltho scheme, labeled the McMaster Classification, emphasizes breast weight, breast composition, essentially firm or fatty, and presence or absence of skin excess, emphasizing the primacy of breast size as the determinant of severity of disease. These criteria impact surgical decision-making as discussed below.

Patients may variably present initially to the plastic surgeon, or as referrals from primary care providers or specialists like endocrinologists. Understanding potential etiologies and the diagnostic workup that has occurred allows the plastic surgeon to determine the remaining workup as needed. It is recommended that plastic surgeons document presence of an etiological workup, whether led by themselves or those in other medical fields.

Etiology and diagnostic evaluation

As previously mentioned, gynecomastia occurs frequently at various points during the male life span. Most commonly, cases are considered idiopathic. However, careful evaluation is necessary to assess both for sinister etiologies and also for causes that may be more beneficially managed with observation, reversal of inciting agents, or medical treatments, rather than surgery.

Box 15.1 demonstrates the wide variety of etiological factors that might lead to gynecomastia. Overall, many causes relate to relative or absolute excess of estrogens, decrease in circulating androgens, and defects in androgen receptors. While the dangerous etiologies are uncommon, they do exist. This leads to difficult decision-making regarding intensity of workup for any individual patient. Andrology consensus guidelines recommend involvement of specialist care beyond initial screening for lipomastia (fatty infiltration rather than true gynecomastia of glandular origin), breast cancer, or testicular cancer.