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