56. Gynecomastia
Ronald E. Hoxworth, Kuylhee Kim, Dennis C. Hammond
INDICATIONS AND CONTRAINDICATIONS
■ Typically, neonatal and pubertal cases resolve with expectant management.1
• Neonatal cases: Resolved within several weeks
• Pubertal cases: 75% of cases resolved within 2 years without treatment2
■ Drug-related cases can resolve with removal of the offending agent before the development of breast tissue fibrosis.
■ Pathological causes necessitate formal medical evaluation with special attention to the associated comorbidities.
• Patients with Klinefelter syndrome (karyotype 47, XXY) have a 50× higher incidence of male breast cancer. (The prevalence of Klinefelter syndrome in males with breast cancer is 7.5%.)3,4
■ The presence of hypertrophic breast tissue for >12 months typically warrants surgical treatment because of fibrotic transformation.5,6
DEMOGRAPHICS
■ Reported incidence: Up to 36% in general population7
■ 65% of pubertal boys affected (up to 75% bilateral)8
ETIOLOGIC FACTORS
■ Often multifactorial, involving excess estrogens, decreased androgens, and/or androgen receptor defects.
CLINICAL CLASSES
■ Idiopathic: Most common (25%)
■ Physiologic
• Neonatal: Influence of maternal estrogens
• Pubertal: Elevated estradiol/estrogen ratio
• Senile: Peripheral conversion of testosterone to estrogen by aromatase
■ Pathological: Cirrhosis, kidney failure, testicular/adrenocortical/pituitary tumors, hypogonadism, hyperthyroid, adrenal hyperplasia, and bronchogenic carcinoma
■ Pharmacologic: Estrogens, gonadotropins, androgens, antiandrogens, chemotherapy agents, calcium channel blockers, ACE inhibitors, digitalis, CNS agents, antituberculosis medications, and drugs of abuse
HISTOLOGY5
■ Represents the cellular changes seen with prolonged gynecomastia
■ Florid: Symptoms <4 months; cellular stroma and ducts increased
■ Intermediate: Symptoms present 4-12 months; mix of florid and fibrous patterns
■ Fibrous: Gynecomastia present >1 year; minimal ducts but extensive stromal fibrosis
PREOPERATIVE EVALUATION
HISTORY
■ Age of onset
■ Duration
■ Additional symptoms
■ Current/recent medications
■ Illicit drug use
■ Past medical history
■ Family history (breast cancer)
SENIOR AUTHOR TIP: Be certain to note whether or not the presence of the excess breast tissue causes pain. This can be an important symptom that may determine whether or not insurance coverage will be extended for treatment.
PHYSICAL EXAMINATION
■ Breast: Fatty versus fibrosis, ptosis grade, masses, skin excess, unilateral versus bilateral, milky discharge (prolactin-secreting tumor)
■ Testicular examination: Size, masses, firmness
• Ultrasound examination for abnormal findings (i.e., masses)
■ Organomegaly: Liver, thyroid, abdominal viscera
■ Feminine features
■ Absence of masculine attributes (i.e., hair pattern)
LABORATORY TESTS
■ Beta-human TSH/free thyroxine, chorionic gonadotropin, follicle-stimulating hormone, luteinizing hormone, serum testosterone, and estradiol levels to correlate abnormal physical findings
■ Consider liver function tests for hepatomegaly.
• Endocrine consult and chromosomal analysis when indicated
IMAGING
■ Breast imaging through mammography or ultrasonography: May be controversial, because gynecomastia is much more common than male breast cancer
■ Mammography: When breast cancer is suspected.9 Helpful for assessing the quality of breast tissue (fatty versus fibrous)
TIP: Completion of a testicular exam needs to be documented in the medical record. If there is any concern for potential scrotal mass or inconsistency in testicular exam, ultrasound imaging of the scrotum/testicles is indicated.
STAGING10
■ Grade I: Minimal hypertrophy (<250 g) and no ptosis
■ Grade II: Moderate hypertrophy (250-500 g) and no ptosis
■ Grade III: Severe hypertrophy (>500 g) and grade I ptosis
■ Grade IV: Severe hypertrophy (>500 g) and grade II or III ptosis
INFORMED CONSENT
■ If surgery is indicated, the planned incisions and appearance are discussed.
• Pictures/diagrams are used to reinforce the discussion.
■ Both the general and the most relevant potential complications (see preceding section) are included.
■ Asymmetry, contour irregularities, and the need for further procedures are discussed, especially when liposuction is used alone or staged excision is planned.
TECHNIQUE
NONOPERATIVE
■ Expectant management is recommended for neonatal (weeks to months), pubertal (up to 2 years), and idiopathic cases.
■ Offending agents (medications, drugs) are removed or changed if pharmacologic source suspected.
■ Hormonal therapy is considered where appropriate.
• Testosterone, antiestrogens (tamoxifen), and danazol show limited efficacy.
■ For pathological causes, the underlying disease or source (i.e., testicular tumor; liver, pituitary, or thyroid disease) is treated.
■ Gynecomastia present for >12 months typically will not spontaneously regress because of dense fibrosis and hyalinization.
OPERATIVE
SENIOR AUTHOR TIP: If at any time the condition begins to adversely affect the normal social development of the patient resulting in social withdrawal, avoidance of normal sports activities, or embarrassment in situations where the chest is exposed as in swimming, a low threshold for operative treatment should be instituted.
■ Markings are made while patients are standing.
• Boundaries for treatment are outlined.
• A topographic technique is employed involving concentric circles extending outward from areola.
■ The breast is palpated to identify parenchyma (fibrous) versus fat deposits.
■ The IMF is identified and may need to be undermined and redraped after liposuction.
• Zones of adherence along the periphery are noted and undermined and released as needed.
■ The procedure is performed with the patient under general anesthesia or local anesthesia with IV sedation in the operating room or a licensed surgery center.
■ A standard instrument tray is used for surgical excision and includes lighted breast retractors or a headlight.
TIP: Disruption of the IMF is a key technical consideration in redraping of the soft tissue for cosmesis. This is a distinguishing feature between female breast surgery where obliteration of the IMF would be considered technically improper.
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