Chapter 55: Gynecomastia

Two-thirds of males have gynecomastia during puberty and most often this is self-limiting, requiring no intervention. Gynecomastia may be classified as idiopathic, physiologic, pathologic, or pharmacologic, and most males have it to some degree during their lives. Approximately half of cases are bilateral. No evidence suggests an increased risk of breast cancer in association with gynecomastia in the general population.1,2

2. Braunstein GD. Clinical practice. Gynecomastia. N Engl J Med 2007;357(12):1229–1237 All the options presented are potential causes of gynecomastia, but most cases have no obvious precipitating cause. A thorough history should be obtained and an examination performed to exclude a potentially treatable cause before surgical management begins. Once this has been established, decisions can be made regarding the choice of surgical intervention for each individual patient. Many obese patients will display gynecomastia which tends to be bilateral and of fatty origin. In these circumstances, weight reduction can be beneficial.1,2

Numerous medications are known to cause gynecomastia (see Box 55.1). This highlights the importance of obtaining a thorough medical history during assessment of these patients. Reversible causes can be established and managed accordingly. Whether or not statins can cause gynecomastia has been debated. This was discussed in the New England Journal of Medicine in 2007.1,2 The available evidence linking statins to gynecomastia was based on case reports only and involved pravastatin and atorvastatin rather than simvastatin. Overall, the evidence was weak. Simvastatin is unlikely to be a significant factor in gynecomastia. BOX 55.1 PATHOLOGIC CLASSIFICATION OF GYNECOMASTIA Increased Serum Estrogen Increased Endogenous Production Leydig or Sertoli cell tumors Eutopic or ectopic human chorionic gonadotropin–secreting tumors Adrenocortical tumors Higher Aromatization Aging Obesity Hyperthyroidism Liver disease Familial or sporadic aromatase excess syndrome Klinefelter’s syndrome Testicular tumors Adrenal tumors Refeeding after starvation Exogenous Sources Topical estrogen creams Oral estrogen ingestion Displacement of Estrogen from Sex Hormone- Binding Globulin Medications such as spironolactone and ketoconazole Decreased Estrogen Metabolism Cirrhosis Decreased Testosterone Synthesis Primary Gonadal Failure Trauma Radiation Drugs Klinefelter’s syndrome Congenital anorchia Secondary Hypogonadism Hypothalamic diseases Pituitary failure Kallmann’s syndrome Decreased Androgen Action Androgen receptor defect Antiandrogen drugs MISCELLANEOUS Chronic Renal Failure Liver Disease Human immunodeficiency virus (HIV) Chronic Illness Enhanced Breast Tissue Sensitivity Environmental Agents Embalming agents Lavender and tea tree oils Phenothrin in delousing agents

There are a number of key differences in the male and female breast and understanding these is important when managing patients with gynecomastia. The male breast has a far smaller volume of glandular tissue that tends to be located close to and beneath the nipple-areola complex (NAC). In gynecomastia, the excess glandular tissue is also centered around the nipple with a predominantly fibrous component. The breast base width and NAC are smaller than in the female breast. The NAC diameter is usually around 2.8 cm and ranges from 2 to 4 cm. It is located approximately 20 cm from the sternal notch most commonly. The inframammary fold is less well defined in males but sits at the same level in both sexes.1–3

Young, lanky patients with gynecomastia and abnormal testicular development may have the chromosomal abnormality 47,XXY. This condition is known as Klinefelter’s syndrome1 following its description in 1942. It is also associated with other feminizing features such as a lack of male hair distribution. Patients are likely to be infertile and have an increased risk of developing breast cancer (greater than 60 times). Further confirmation of the diagnosis is required. A thorough breast examination can help to differentiate between glandular and adipose tissue and is important as it can affect the surgical options available for treatment. It also helps to identify or exclude the presence of potential breast malignancy. A routine assessment should also continue with examination of the neck and abdomen to identify thyroid, liver, or other abdominal masses. Examination of the testes is routine but further imaging, such as ultrasound, is only required if pathology is suspected. It is standard practice to obtain a set of baseline blood tests to assess the hormone profile in cases of gynecomastia, if this has not already been completed by the referring physician.2,3

glandular gynecomastia, with no evidence of testicular abnormality or axillary lymphadenopathy. He takes Male breast cancer accounts for only 1% of all breast cancer (not 5%). Therefore, the risk for a male is usually only one-hundredth that of a female patient. The risk increases if a female family member is diagnosed with breast cancer. The most common age at diagnosis in males is around 65 years of age. Although nifedipine may be a cause of gynecomastia, new-onset unilateral disease requires exclusion of malignancy. Mammography is the best modality, with a 94% sensitivity and specificity for distinguishing between benign and malignant lesions. It has a negative predictive value very near to 100 in this setting because of the low overall prevalence of male breast cancer.1–3

The key purpose of each of the classification systems for gynecomastia is that they help to guide the surgical decision-making process. This is true for the UTSW, Simon,and McMaster classifications as they focus on the composition and volume of the glandular/fatty breast constituents and the quality and volume of the skin. Of the three systems, the McMaster example includes a proposed treatment within it. Higher grades in all classifications correlate to more severe gynecomastia which often involves skin excess. Where there is an isolated volume excess or where the skin excess is mild, no skin resection is required. Conversely where there is a significant excess of skin and breast tissue then both will have to be removed. In general, having classification systems also helps clinicians communicate with one another and can be useful for research and forecasting outcomes, but these are less important in clinical practice within gynecomastia.1-4

Idiopathic gynecomastia often regresses between 3 and 18 months. Once it has been present for longer than a year, it is unlikely to completely regress because of tissue fibrosis, so progression along a surgical pathway would be indicated at this stage. Although tamoxifen is useful for lump-type gynecomastia, testosterone appears to have a limited benefit. Aromatase inhibitors have also been shown to help regression in pubertal gynecomastia without side effects. Danazol and clomiphene citrate have had only limited success and are not currently recommended for gynecomastia treatment.1,2 Surgical treatments may involve liposuction or gland/skin resection and may be combined in a single procedure. However, most patients tend to be treated with one or the other modality. In general, liposuction is the best treatment for mild to moderate glandular hypertrophy with no skin excess, whereas more dense glandular tissue, or those with skin excess, may need resectional techniques involving either gland only or skin and gland. The key benefit of liposuction is reduced scarring and shorter down times, but if the density of the glandular tissue is firm then it alone will not be successful.3–5

This patient has a moderate excess of both fatty and glandular tissue in the breast with a mild skin excess. His condition is ideally suited to ultrasound-assisted liposuction (UAL), rather than suction-assisted liposuction, as this has shown good results in treating gynecomastia. Given his age, skin and gland quality, he should not require skin excision or concurrent glandular tissue excision. UAL is associated with reduced bleeding and bruising, and radiographic dye studies have shown significantly less vascular disruption with UAL than with traditional techniques. The incision sites should be placed away from the inframammary fold in order to achieve adequate cross-hatching across the fold and into the glandular tissue. Compression garments are uniformly recommended following this procedure. Duration for compression is usually 4–6 weeks.1,2

Liposuction for gynecomastia can be highly effective in certain cases where there is good quality skin and no or mild excess, combined with fatty tissue present. The process has many similarities to liposuction in the female breast and other body areas; however, the key difference is that the IMF would be preserved in the female whereas in the male, it is should be intentionally disrupted with multiple passes across it. This is because the IMF gives female characteristics to the breast and its disruption can help masculinize the chest appearance. In all cases tumescent liposuction is generally preferred in order to reduce bleeding, improve pain control, and help to separate the fat. The choice of cannula will be personal preference and relate to the tissues being targeted rather than a difference due to male or female gender. Ultrasound-assisted liposuction can be particularly useful in cases where a degree of skin tightening is required. However, this technique is equally applicable to the male or female breast. In traditional liposuction techniques the deeper layers are targeted with the aim of preserving the superficial fat layer beneath the dermis. In gynecomastia, this approach is different because the intermediate and immediate subdermal adipose layers are also targeted. When using ultrasound-assisted liposuction it is important to keep the probe tip moving constantly to avoid thermal injury.1–3

This man has a combination of significant skin and glandular excess giving a feminine appearance to the breasts. This condition cannot be treated adequately with liposuction alone as this will leave a significant skin excess and ongoing ptosis. Proceeding with liposuction first as part of a two-stage process is beneficial because it can reduce the breast volume significantly and allow for skin shrinkage prior to surgical excision. The subsequent scarring incurred during the second stage should be reduced by adopting this approach. In a large study by Rohrich et al,1 most patients with a similar degree of gynecomastia to the patient described were initially treated with ultrasound-assisted liposuction and went on to have a second-stage excision at 6–9 months, once skin retraction had taken place.

There are a number of key risks involved with surgery for gynecomastia and these can be classified as early (perioperative) or late (long term). The most common early complication is hematoma and this is most prevalent following open resection techniques (approximately 10–15%). The combination of highly vascular tissue being resected via small access incisions probably explains this. Hematoma risks can be minimized during open surgery by careful and meticulous hemostasis throughout and checking again at the end of the procedure, ensuring the anesthetized patient has a normal systolic blood pressure. Hematoma rates tend to be far lower in liposuction-only cases (approximately 1%). Infection and poor wound healing are low risk early complications. Inadequate resection needing revision surgery is the most common long-term complication.1–3