Congenital Breast

Describe breast development.

During the sixth week of gestation, ectodermal cells form a primordium along the primitive mammary ridges (“milk lines” that extend from the axilla to the groin). By the 10th week of gestation, the upper and lower aspects of these ridges atrophy; the middle portion of the ridges, located at the level of the fourth interspace, persist and eventually develop into breast tissue. In the fifth month of gestation, the areola develops, and shortly after birth, the nipple appears.

After birth, residual circulating maternal estrogens may cause neonatal gynecomastia which typically involutes as these hormones are metabolized. Thelarche precedes puberty by approximately 1 year and marks the beginning of breast growth. At puberty, estrogens cause ductal and stromal tissue proliferation and progesterones cause alveolar budding and lobular growth. Breast growth is generally completed by 16 to 18 years of age.

Describe chest wall development.

During the fourth week of gestation, ectodermal cells from the neural crest and somatic cells from the paraxial and lateral plate join and differentiate into forty somites caudal to the head region. These further differentiate into the dermomyotome (dorsal) and sclerotome (ventral), which become the trunk musculature and skeleton, respectively. The sclerotome also differentiates into the vertebral bodies. The sternum develops during the sixth week of gestation separately from the ribs, arising from longitudinal pairings of mesenchymal tissues. Failure of fusion leads to a cleft sternum.

How can congenital breast disorders be generally classified?

Hypoplastic (athelia, amazia, amastia, unilateral/bilateral hypoplasia, tuberous breast, and Poland syndrome).

Hyperplastic (gynecomastia, hyperplasia, symmastia, polythelia, polymastia, and giant fibroadenoma).

What organ system should always be included in the initial preoperative evaluation of patients with gynecomastia?

Genitalia may reveal an underlying cause such as testicular tumors, nonpalpable and/or undescended testes. These findings should prompt genetic and/or endocrine evaluation prior to surgery.

What pharmaceutical agents are linked to the development of gynecomastia?

Cimetidine, digitalis, minocycline, spironolactone, anabolic steroids, haloperidol, opiates, marijuana, phenothiazines, tricyclic antidepressants, progestins, amphetamines, isoniazid, methyldopa, estrogens, diazepam, reserpine, and theophylline.

How is gynecomastia classified?

There are three grades:

Grade I: small enlargement, no skin redundancy.

Grade IIA: moderate enlargement, no skin redundancy.

Grade IIB: moderate enlargement with skin redundancy.

Grade III: marked enlargement with skin redundancy.

What is the modification of gynecomastia classification for surgical planning?

Simplify to the three grades:

Grade I: Localized button of tissue localized to areola. Chest not fatty, no skin excess. Simple excision.

Grade II: Diffuse gynecomastia on fatty chest, indistinct tissue edges. Suction lipectomy adjunct to excision.

Grade III: Diffuse gynecomastia with excessive skin, requires skin excision outside areola and/or nipple repositioning.

What are the options for surgical management of gynecomastia?

Suction-assisted lipectomy or ultrasound-assisted lipectomy only.

Glandular resection through periareolar incision +/− suction-assisted lipectomy.

Skin and glandular resection.

Concentric circle resection.

Pedicled relocation of nipple with skin resection.

Breast amputation with free nipple grafting.

Wise-pattern mastopexy should NOT be performed in gynecomastia.

What is the role of liposuction in gynecomastia?

Suction-assisted lipectomy is primarily used to improve chest contour by lateral feathering as an adjunct to surgical excision. Although, it can be used as a primary treatment modality in breast tissue that is primarily fatty. Ultrasound-assisted liposuction (UAL) can be used as a primary modality in most patients and is primarily applicable to dense, fibrous tissue. It offers the advantage of minimal external scarring. With the use of UAL, the use of excisional techniques may be reserved for patients with severe gynecomastia with significant skin excess AFTER attempted UAL.

What is the timing of surgical intervention in patients with gynecomastia?

Surgery should not be offered to patients with gynecomastia for duration of less than 1 year. If gynecomastia persists for more than 1 year, the likelihood of spontaneous resolution is low and surgery may be offered anytime after 1 year. Correctable medical causes such as endocrine imbalance, medications, or tumors preclude surgical intervention.

What is the incidence of gynecomastia in males at puberty?