Gynecomastia is a benign proliferation of glandular breast tissue causing breast enlargement in males (1,2). There is a great deal of variation in the prevalence of gynecomastia reported in the literature. Prevalences ranging from 4% to 69% have been reported among adolescent males (3,4). Among adult males, prevalences between 32% and 65% have been reported (5,6). Comprehensive reviews of etiologic factors, including drugs that cause gynecomastia, have been published (1,2,7). Approximately 25% of patients experience idiopathic adult gynecomastia and 25% suffer from acute or persistent gynecomastia secondary to puberty (8). Other causes of gynecomastia include drugs (10% to 20%), cirrhosis or malnutrition (8%), primary hypogonadism (8%), testicular tumors (3%), secondary hypogonadism (2%), hyperthyroidism (1.5%), and renal disease (1%) (8). Gynecomastia results from an absolute or relative imbalance between estrogens, which stimulate development of breast tissue, and androgens, which antagonize this effect (9,10). During the initial period of gynecomastia development associated with puberty, ductal epithelium proliferates and stromal and connective tissue hyperplasia and edema occur (11,12,13). After this initial period of 1 to 2 years, less epithelial growth occurs, and there is deposition of dense, collagenous fibers causing periductal fibrosis and hyalinization (11,12,13). Once this occurs, surgical treatment is required to correct gynecomastia.

Surgical techniques using a variety of incisions, excisions, suction-assisted lipectomy, power-assisted liposuction, ultrasound-assisted liposuction, or some combination of these methods have been used to treat gynecomastia. Recently, several minimal-access excisional techniques have been described. In 1996, Morselli (14) first described the pull-through technique for treatment of gynecomastia. This technique involved the use of suction-assisted lipectomy to remove fatty breast tissue, followed by the use of a clamp to pull the remaining fibroglandular breast tissue through the two incisions used for liposuction. In 2003, Hammond et al. (15) reported consistently pleasing results obtained by combining ultrasound-assisted liposuction with the pull-through technique. In addition, Bracaglia et al. (16) reported their experience using suction-assisted lipectomy and the pull-through technique, and Ramon et al. (17) described the use of cross-chest power-assisted superficial liposuction with the pull-through technique under endoscopic visualization; both reported consistently good results. In 2008, we reported our initial experience combining power-assisted liposuction with the pull-through technique (18). We use several instruments that allow easier excision of fibroglandular breast tissue and make it possible to remove this tissue through a single incision located at the lateral aspect of the inframammary crease. Since first using this technique in January of 2003, we have successfully performed it in more than 200 patients. This technique has been used to treat patients with various degrees of gynecomastia and consistently produces a naturally contoured male breast while resulting in a single inconspicuous scar.

Rohrich et al. (19) provide a comprehensive review of the management of gynecomastia and present a straightforward algorithm for its evaluation and treatment. Treatment of gynecomastia should begin, if possible, with identification of the underlying cause. Given that the majority of patients presenting for evaluation of gynecomastia have idiopathic adult gynecomastia or acute or persistent gynecomastia due to puberty, a detailed history and physical examination usually suffice to rule out other causes that may require further workup. Positive findings in the history or abnormal physical findings may necessitate further diagnostic investigations such as hormonal levels, imaging studies, and karyotyping, depending on the suspected etiology for gynecomastia (19).

During preoperative evaluation, an important differentiation should be made between gynecomastia and male breast cancer. Breast cancer in men accounts for approximately 1% of all cases of breast cancer (20). The mean age for male breast cancer is 65 years, but it may occur at any age (20). A family history of breast cancer increases the risk of male breast cancer, and this has been linked to both BRCA1 and BRCA2 genes (20). Although the association of gynecomastia and male breast cancer is of uncertain significance, high risk for male breast cancer has been established in certain states of relative estrogen excess to androgen deficiency such as Klinefelter syndrome, exogenous estrogen use, cryptorchidism, orchitis, or postorchiectomy (20). Exposure to ionizing radiation may also increase the risk of male breast cancer (20). Physical examination of the breasts may reveal signs that are suspicious for male breast cancer. Breast tissue in gynecomastia is usually soft or elastic and tends to be located bilaterally around the nipple-areola complex (1). In contrast, male breast cancer is usually hard or firm, may not be associated with the nipple-areola complex, and is typically unilateral (1). In addition, other clinical signs may include skin dimpling, nipple retraction, and bloody nipple discharge (1). If male breast cancer is suspected, the patient should undergo diagnostic mammography, which is 90% sensitive and specific for differentiating malignant from benign breast masses in males (1,21).