Gynecomastia



Gynecomastia


John T. Stranix

Alexes Hazen





ANATOMY



  • In gynecomastia, the excess glandular tissue is typically centered under the nipple-areola complex (NAC), with a predominantly fibrous component (FIG 1).



    • Pseudogynecomastia refers to diffuse fatty enlargement of the male breast related to obesity and demonstrates a predominance of adipose vs fibrous tissue.


  • Normal male breasts are flat in appearance with mild fullness around the NAC.


  • The male NAC diameter is normally 2 to 4 cm (mean 2.8 cm) and centered on the midclavicular line over the fourth intercostal space. Mean sternal notch to nipple distance is 20 cm.


  • The pectoralis muscle provides superior fullness to the anterior male chest that transitions inferiorly to flat tissue over the lower chest at the level of the inframammary fold (IMF).



    • A well-defined IMF results in a more feminine breast appearance.






FIG 1 • Cross-sectional depiction of normal male chest anatomy compared to gynecomastia.


PATHOGENESIS



  • Benign proliferation of male breast parenchyma occurs due to a relative increase in the ratio of free estrogen to androgen locally in the breast.2


  • Physiologic gynecomastia occurs in newborns (circulating maternal estrogens), adolescents (excess plasma estradiol during early stages of puberty), and men after age 65 (decreased testosterone production).



    • Neonatal and pubertal gynecomastia are typically selflimiting and usually resolve over several months to years.


  • Pathologic gynecomastia can result from various metabolic (cirrhosis, renal failure), endocrine (hypogonadal state, hyperthyroidism), oncologic (adrenal or testicular tumors), or congenital (Klinefelter syndrome) disorders.


  • Pharmacologic gynecomastia has been linked to a number of medications and occurs by several known mechanisms; however, direct mechanisms have not been identified for all associated medications.3


  • Gynecomastia does not increase the risk of male breast cancer development compared to the normal male population.



    • Patients with Klinefelter syndrome, however, have up to a 50 times increased risk of developing breast cancer.4 Due to the elevated oncologic risk in this population, an excisional technique should be used to provide a specimen for pathology analysis.



PATIENT HISTORY AND PHYSICAL FINDINGS



  • Clinical evaluation of enlarged male breasts begins with a detailed history and review of symptoms, focusing on elucidating known causes of gynecomastia and differentiation from pseudogynecomastia and tumor.



    • History should include age, onset and duration of enlargement, breast symptoms (pain, tenderness, discharge), medications, alcohol or recreational drug use, and social/psychological effects of breast enlargement. Past medical, surgical, family, and reproductive history should also be obtained.


    • Signs/symptoms of liver disease, malnutrition, kidney failure, hyper- or hypothyroidism, weight changes, adrenal disease, and malignancy.


  • Physical examination



    • Breasts should be assessed for symmetry, nipple abnormalities, glandular or fat predominance, skin excess, degree of ptosis, and nodules or masses. Approximately 50% of gynecomastia is bilateral.1 Axillary and supraclavicular lymph node basins should be examined in the setting of a suspicious mass.


    • Glandular tissue in gynecomastia is characterized by mobile, rubbery subareolar breast tissue.


    • Masses or nodules with abnormal firmness, overlying skin changes, eccentric location, or associated nipple discharge should raise concern for breast carcinoma.


    • Secondary sexual characteristics should be examined: body hair distribution, muscle mass, penile development, and testicular size, consistency, and symmetry.


    • Signs of systemic disease should also be evaluated: thyromegaly, exophthalmos, hepato- or splenomegaly, abdominal masses, ascites or cirrhotic stigmata, visual fields, cranial nerves, and fundoscopy.


IMAGING AND OTHER DIAGNOSTIC STUDIES



  • Laboratory or radiographic studies are not necessary in most cases of gynecomastia.


  • Mammography, and possibly biopsy, is indicated if findings on physical examination are consistent with a breast neoplasm.


  • Testicular ultrasound should be obtained in the setting of prepubertal bilateral gynecomastia, evidence of undervirilization, and/or a testicular mass.5 Endocrine labs are also appropriate in this situation; consider karyotype if Klinefelter syndrome is possible.


  • Laboratory testing should be directed by abnormalities identified on history and physical exam.




NONOPERATIVE MANAGEMENT



  • The majority of patients with new-onset gynecomastia are best managed with reassurance and observation for 12 to 18 months.1,6



    • No detectable abnormality is found in up to 60% of patients on initial evaluation.5


  • Correction of underlying causes should be performed: discontinue offending medications, correct hormonal imbalances, address metabolic or endocrine disorders.


  • Medical therapy with testosterone and aromatase inhibitors has had limited success. Treatment with tamoxifen, however, has been shown to result in gynecomastia regression in recent randomized trials.1


SURGICAL MANAGEMENT



  • Surgical intervention should be considered for patients with a diagnosis of symptomatic gynecomastia of duration greater than 12 months.



    • Due to irreversible fibrosis of hypertrophic breast tissue that develops 6 to 12 months after the onset of gynecomastia, medical treatments beyond that stage are unlikely to result in significant regression.1,7


  • Surgical treatment of gynecomastia has evolved to become increasingly less invasive through the use of liposuction and endoscopy; however, more severe cases often require open techniques with a higher scar burden.


  • Multiple classification systems have been developed to guide surgical management. The system devised by Rohrich et al.7 classified gynecomastia based on breast size and degree of ptosis.


Preoperative Planning



  • In addition to standard components of informed consent, the preoperative consultation must include a discussion of scar burden/location, possible need for direct excision of residual subareolar fibrous tissue, as well as the potential for undercorrection requiring a second-stage procedure.



    • Even patients with only mild gynecomastia may have a residual fibrous component that is not amenable to liposuction and requires excision.


  • Preoperative markings are performed with the patients in the upright sitting or standing position.


  • Prophylactic antibiotics covering skin flora are administered prior to skin incision.


Positioning



  • Surgery is performed under general anesthesia as an outpatient procedure.


  • Patients are positioned supine with arms abducted and secured to padded, adjustable arm boards. The hips are centered over the bed break, and the patient is secured with a safety strap.



    • Intraoperative assessment of adequate/symmetric resection requires sitting the patients fully upright in the operating room and they should be secured in a manner that enables this to be safely accomplished.


  • Sequential compression devices are applied to the lower extremities.


  • The entire anterior chest is prepped into the field to allow intraoperative symmetry assessment. Chest hair is removed with electric clippers as needed.


Approach

Dec 6, 2019 | Posted by in Reconstructive microsurgery | Comments Off on Gynecomastia

Full access? Get Clinical Tree

Get Clinical Tree app for offline access