Gynaecomastia

Clinical Characteristics of Asymmetric Bilateral Gynecomastia: Suggestion of Desirable Surgical Method Based on a Single-Institution Experience

BACKGROUND

Asymmetric bilateral gynecomastia (ABGM) is uncommon, and reports on its characteristics are rare. In the present study, we investigated the clinical characteristics and surgical treatment of ABGM.

METHODS

We conducted a retrospective study of 1159 patients with gynecomastia who underwent subcutaneous mastectomy with liposuction at Damsoyu Hospital from January 2014 to February 2016. We then analyzed differences in the characteristics and operative results between two groups of patients: those with asymmetric and symmetric gynecomastia. Asymmetric gynecomastia was defined as gynecomastia meeting both of the following criteria: (1) upon physical examination, the size of the palpable mass below the nipple-areolar complex was twice as large as the smaller one, and (2) upon ultrasonography, the depth of the glandular tissue under the nipple-areolar complex was twice as large as the smaller one.

RESULTS

Fifty-four patients were diagnosed with asymmetric gynecomastia. Among them, 51 had ABGM and three had unilateral gynecomastia. In the asymmetric group, more patients had a larger left than right breast (33 patients, 64.7%). The incidence of true-type (entirely glandular) breasts was significantly higher in the asymmetric group (84.3%) than in the symmetric group (p < 0.001). The asymmetry ratios in the asymmetric and symmetric groups were 1.87 ± 2.07 and 0.20 ± 0.16, respectively (p < 0.001).

CONCLUSION

Bilateral mastectomy provided an acceptable and symmetric cosmetic outcome in patients with ABGM.

LEVEL OF EVIDENCE IV

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Surgical management of gynecomastia: experience of a general surgery center

AIM

Gynecomastia is a common finding in male population of all ages. The aim of our study was to present our experience and goals in surgical treatment of gynecomastia.

PATIENTS AND METHODS

Clinical records of patients affected by gynecomastia referred to our Department of Surgery between September 2008 and January 2015 were analyzed. 50 patients were included in this study.

RESULTS

Gynecomastia was monolateral in 12 patients (24%) and bilateral in 38 (76%); idiopathic in 41 patients (82%) and secondary in 9 (18%). 39 patients (78%) underwent surgical operation under general anaesthesia, 11 (22%) under local anaesthesia. 3 patients (6%) presented recurrent disease. Webster technique was performed in 28 patients (56%), Davidson technique in 16 patients (32%); in 2 patients (4%) Pitanguy technique was performed and in 4 patients (8%) a mixed surgical technique was performed. Mean surgical time was 80.72±35.14 minutes, median postoperative stay was 1.46±0.88 days. 2 patients (4%) operated using Davidson technique developed a hematoma, 1 patient (2%) operated with the same technique developed hypertrophic scar.

CONCLUSIONS

Several surgical techniques are described for surgical correction of gynecomastia. If performed by skilled general surgeons surgical treatment of gynecomastia is safe and permits to reach satisfactory aesthetic results.

Autologous fat injection into the pectoralis major as an adjunct to surgical correction of gynecomastia

BACKGROUND

Correction of gynecomastia in males is a frequently performed aesthetic procedure. Various surgical options involving the removal of excess skin, fat, or glandular tissue have been described. However, poor aesthetic outcomes, including a flat or depressed pectoral area, limit the success of these techniques.

OBJECTIVES

The authors sought to determine patient satisfaction with the results of upper chest augmentation by direct intrapectoral fat injection in conjunction with surgical correction of gynecomastia.

METHODS

In this prospective study, 26 patients underwent liposuction and glandular excision, glandular excision alone, or Benelli-type skin excision. All patients received intramuscular fat injections in predetermined zones of the pectoralis major (PM). The mean volume of fat injected was 160 mL (range, 80-220 mL per breast) bilaterally. Patients were monitored for an average of 16 months (range, 8-24 months).

RESULTS

Hematoma formation and consequent infraareolar depression was noted in 1 patient and was corrected by secondary lipografting. Mean patient satisfaction was rated as 8.4 on a scale of 1 (unsatisfactory) to 10 (highly satisfactory).

CONCLUSIONS

Autologous intrapectoral fat injection performed simultaneously with gynecomastia correction can produce a masculine appearance. The long-term viability of fat cells injected into the PM needs to be determined.

LEVEL OF EVIDENCE

4 Therapeutic.

Gynecomastia in German soldiers: etiology and pathology

BACKGROUND

We found a high incidence of patients with gynecomastia in the German Ministry of Defense Guard Battalion in Berlin. For this reason, we conducted the present study to investigate etiological and pathological aspects of this condition.

METHODS

Within six years, a total of 211 patients underwent surgery for gynecomastia. We compared this group of patients with a control group of healthy males without signs or symptoms of gynecomastia. The two groups were matched for median age.

RESULTS

The groups showed significant differences (p<0.05) in serum testosterone, free triiodothyronine (fT3), LH (luteinizing hormone) and prolactin levels and in body mass index (BMI). In addition, there was a highly significant correlation between left-sided gynecomastia and membership in the Guard Battalion.

CONCLUSIONS

We found differences in hormone blood levels between gynecomastia patients and a control group. Moreover, gynecomastia was predominantly seen on the left side in guard soldiers. A possible explanation is the mechanical impact of the carbine against the left side of the body during rifle drills.

Quality of life in the surgical treatment of gynecomastia

BACKGROUND

Gynecomastia has an incidence of up to 60% of adolescents, causing pain and self-image disorders for the patient, leading to emotional and physical problems that can be reversed with treatment. This prospective case control study assessed the surgical treatment of gynecomastia and its impact on quality of life.

METHODS

Thirty-three patients aged 18-50 years and with 2-21 years of gynecomastia progression were included in the study. Adenectomy was performed. Preoperatively and 6 months postoperatively, patients completed the Brazilian version of the Short-Form 36 (SF-36) quality of life questionnaire.

RESULTS

There was improvement in the SF-36 domains of General Health, Functional Capacity, Social Aspects, Vitality, and Mental Health.

CONCLUSION

The Short-Form 36 questionnaire demonstrated that surgical treatment of gynecomastia afforded positive changes in quality of life.

Gynecomastia associated with fenofibrate

OBJECTIVE

To report a case of probable fenofibrate-induced gynecomastia.

CASE SUMMARY

A 56-year-old white hypercholesterolemic man was treated with fenofibrate 160 mg/day for 1 year. During the course of treatment, he developed gynecomastia on the left side, which resolved after the drug was stopped and replaced with alpha tocopherol acetate. Sixteen months after fenofibrate discontinuation, the patient was rechallenged and subsequently developed gynecomastia symptoms on the right side. The usual etiologies of gynecomastia were excluded by careful assessment of the patient's medical history, physical examination, and results of diagnostic tests such as chest X-ray, mammography, scrotal ultrasonography, routine blood chemistry, and extensive hormonal panel. Gynecomastia again resolved after discontinuation of fenofibrate.

DISCUSSION

In this case, the resolution of gynecomastia on discontinuation of fenofibrate and recurrence after rechallenge highly suggest the role of fenofibrate. Use of the Naranjo probability scale registered causality as probable. Case reports of gynecomastia caused by different drugs have been previously published, but, to our knowledge, this is the first report linking gynecomastia to the use of fenofibrate. The pathogenesis of this adverse drug reaction remains unclear.

CONCLUSIONS

Although fenofibrate-induced gynecomastia appears to be uncommon, patients receiving this medication should be monitored for this adverse drug reaction.

Golf-inhibiting gynecomastia associated with atorvastatin therapy

Gynecomastia can have a significant emotional and social impact on men. Although numerous drug therapies may cause this condition, we found no documented cases of gynecomastia associated with atorvastatin. We describe the development of breast enlargement and tenderness in a 52-year-old Caucasian man 6 months after his simvastatin therapy had been switched to atorvastatin. His symptoms ultimately interfered with his ability to play golf and participate in other activities. These problems resolved after atorvastatin discontinuation and did not recur despite resumption of simvastatin therapy. The gynecomastia in this patient represented a possible adverse effect of atorvastatin according to the Naranjo adverse drug reaction probability scale. The mechanism may be atorvastatin's theoretical suppression of adrenal or gonadal steroid production through effects on cholesterol synthesis. Based on this and other case reports, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) should be considered as a potential cause when evaluating otherwise unexplainable cases of gynecomastia in patients taking these drugs.

Pediatric Breast Deformity

Congenital breast anomalies represent a relatively common set of disorders encountered by pediatric plastic surgeons with a spectrum of severity that ranges widely from the relatively benign polythelia to the very complex disorders such as Poland's syndrome and tuberous breast deformities. While the former can be treated in a single surgical setting with minimal morbidity, the more complicated disorders often require a staged reconstructive algorithm. Some disorders also require a multidisciplinary management for both workup and management. Although rarely a source of functional morbidity, these physical deformities are often a significant source of psychological stress for the adolescent male or female who feels alienated from their peers. The purpose of this article is to review the most common congenital breast disorders including the diagnosis, workup, and management especially the timing of surgical intervention as guided by normal developmental milestones.

A systematic approach to the surgical treatment of gynaecomastia

Numerous techniques have been described for the correction of gynaecomastia, and the surgeon is faced with a wide range of excisional and liposuction procedures. There is a paucity of literature describing an integrated approach to the management of this condition and the roles of the different treatment modalities. A review of all gynaecomastia patients operated on by one surgeon over a 2-year period was undertaken. Patient satisfaction was assessed using a linear analogue scale with a maximum score of 10. In total, 48 breasts in 29 patients were treated--31 breasts by liposuction alone (19 by conventional liposuction, 12 by ultrasound-assisted liposuction), eight breasts by liposuction and open excision, and nine breasts by liposuction, open excision and skin reduction (concentric or Lejour mastopexy). There were no early postoperative complications, such as haematoma, seroma or infection, and 91% of patients were very satisfied (score: 8-10) with their cosmetic outcome. The most frequently encountered complication was a residual subareolar lump (five breasts), all in patients treated by conventional liposuction alone. In order to avoid the common complication of an uncomfortable residual subareolar nodule, the threshold for open excision in patients undergoing conventional liposuction should be low. Ultrasound-assisted liposuction extends the role of liposuction in gynaecomastia patients. Although skin excess remains a challenge, it can be satisfactorily managed without excessive scarring. A practical approach to the surgical management of gynaecomastia, which takes into account breast size, consistency, skin excess and skin quality, is proposed.

How should gynaecomastia be managed?

BACKGROUND

The purpose of the present paper was to review the management of men referred to a breast clinic with presumed gynaecomastia.

METHODS

A retrospective analysis was carried out of 175 men over the age of 16 years who presented with breast enlargement and/or 'lumps', during a 7-year period to a single-surgeon. All patients had complete biochemical assessment (liver function tests, gamma-glutamyl transferase, prolactin, alpha-fetoprotein, beta-human chorionic gonadotropin), and mammography and/or ultrasound with fine-needle biopsy if indicated.

RESULTS

One hundred and seventy-five men, median age 44 years (range: 18-89 years), were assessed. Thirty-nine had bilateral true gynaecomastia and 88 had unilateral gynaecomastia (53% left). Carcinoma of the breast was diagnosed in eight, pseudo-gynaecomastia in 18, 13 had physiological pubertal changes only and nine had other diagnoses. Adverse drug reactions were possibly implicated in the aetiology of 47 patients, alcohol in seven patients, cannabis in one patient, testicular malignancy in four patients and hepatocellular carcinoma in one patient. Five patients were found to have hyperprolactinaemia. Twenty-four per cent of patients were reassured without intervention; 18% failed to attend follow up. Sixteen per cent were treated with danazol, 15% underwent surgery and 28 were referred for management of their cause. Danazol was effective in 81%, and three patients required surgery when danazol was ineffective. One further patient developed testicular cancer 9 months after presentation.

CONCLUSION

Men presenting to a breast clinic require clinical assessment to exclude diagnoses other than gynaecomastia. True gynaecomastia can be managed with exclusion of causative factors by non-invasive investigation and examination. Many patients can be reassured as to the idiopathic nature of the condition and many will fail to attend follow up. Danazol is successful in some patients and surgery should be reserved for resistant cases.

The tuberous male breast

Whilst tuberous female breasts are well described, the tuberous male breast is a very unusual variant of gynaecomastia. Two cases are presented, the development of the condition is considered and the surgical management is discussed.

Clonal karyotypic abnormalities in gynecomastia

Gynecomastia is a benign condition that frequently occurs in the male breast gland; however, the cytogenetic data on this entity are very limited. To our knowledge, three cases have been reported in the literature, and the only one with an abnormal karyotype had a concomitant breast carcinoma. In this study we report clonal chromosomal alterations in a gynecomastia sample without any signs of adjacent malignant tissue. The nonrandom abnormalities observed were a deletion of 12p, monosomies of chromosomes 9, 17, 19, and 20, and the presence of a marker chromosome. Most of these alterations have been previously described in the literature in other breast lesions, including benign and malignant (male and female) tumors, indicating their recurrence and nonrandomness in abnormal processes of the mammary gland.

Unilateral Male Breast Masses: Cancer Risk and Their Evaluation and Management

Breast cancer is an uncommon cause of breast enlargement in the adult male. Overall, it accounts for <1 per cent of all male cancers. Although most male breast carcinomas are clinically apparent, distinguishing early breast cancer from gynecomastia, the most common cause of male breast enlargement, is considered a difficult task. To overcome this difficulty, many surgeons proceed directly to surgery as their initial diagnostic test. Although appropriate in some cases, the infrequent occurrence of male breast cancer and the diagnostic accuracy of mammography and fine-needle aspiration cytology suggest a modification of our present management. The aim of this study was to assess the incidence of breast cancer in men with unilateral breast masses and to propose a treatment algorithm for unilateral male breast masses. The medical records of 36 male patients who underwent subcutaneous mastectomy for a unilateral breast mass at the Buffalo Veterans Administration Medical Center between 1989 and 1996 were retrospectively reviewed. Data was collected on a standard data form. The median age was 63-years-old (range, 22–82). Gynecomastia was diagnosed in 30 patients (83%), lipoma in 4 patients (11%), invasive breast cancer in 1 patient (3%), and melanoma in situ in 1 patient (3%). Of the 30 patients with gynecomastia, 60% (18 patients) gave a history of a medical condition or use of medications known to cause gynecomastia, compared with 16 per cent (1 of 6) of the patients without gynecomastia (P = 0.08). Half of the patients with gynecomastia presented with an asymptomatic mass compared with 67 per cent of the patients without gynecomastia (P = not significant). The median duration of symptoms for patients with gynecomastia was 3 months. Men with unilateral breast masses have a low incidence of breast cancer. A male patient with a palpable unilateral breast mass consistent with gynecomastia on the basis of historical, physical and mammographic findings does not require surgical biopsy unless other clinical indications prevail. Lack of symptoms (pain) related to the mass is probably not helpful in deciphering gynecomastia from breast cancer.

Cost-effective management of gynecomastia

BACKGROUND

Routine endocrine screening of idiopathic gynecomastia has been advocated, but may not be cost effective. We carried out a cost-benefit analysis of this approach.

METHODS

A retrospective study (1992 to 1997) of 87 adult males with symptomatic gynecomastia was performed.

RESULTS

Thirty-four (39%) patients had extrinsic causes; 53 (61%) were considered idiopathic. Forty-five idiopathic cases underwent endocrine testing: beta human chorionic gonadotropin alone, 16; and beta human chorionic gonadotropin, LH, estradiol, testosterone+/-testicular ultrasound, 29. One (2%) occult Leydig cell testicular tumor was detected. Forty-four patients had normal studies and remain well after local excision.

CONCLUSION

Routine endocrine evaluation of idiopathic gynecomastia is rarely productive; such testing is best done selectively.

Chromosome banding analysis of gynecomastias and breast carcinomas in men

Male breast cancer is 100 times less frequent than its female counterpart and accounts for less than 1% of all cancers in men. Although men with breast cancer also often have gynecomastia, it is still unknown whether gynecomastia per se predisposes the male breast to malignant disease. We describe the cytogenetic analysis of three gynecomastias and four breast cancers in men. No chromosome abnormalities were detected in two cases of gynecomastia, with no other concomitant breast disease. The third gynecomastia sample, taken from a site where a breast carcinoma had previously been removed, had a t(2;11)(p24;p13) as the sole chromosome change; this is the first time that an abnormal karyotype has been described in gynecomastia. All four cancers had clonal chromosome abnormalities. Several cytogenetically unrelated clones were found in the breast tumor and in a metastasis from case 1. In the carcinoma of case 2, a single abnormal clone was found, characterized by loss of the Y chromosome, monosomy 17, and a deletion of the long arm of chromosome 18. In the carcinoma of case 3, a clone with loss of the Y chromosome as the sole change dominated, accompanied by the gain of an X chromosome in a subclone. In the lymph node metastasis examined from case 4, a single clone carrying trisomies for chromosomes 5 and 16 was detected. Our findings, especially when collated with data on the six karyotypically abnormal breast carcinomas in men described previously, indicate that gain of the X chromosome, gain of chromosome 5, loss of the Y chromosome, loss of chromosome 17, and del(18)(q21) are nonrandom abnormalities in male breast carcinomas.

Surgical treatment of gynaecomastia. Five years' experience with liposuction

Since liposuction became part of our surgical regimen in 1988, we have operated on 67 patients for gynaecomastia during the five year period 1988-1992. Sixty two of the patients were seen at an extra follow up 4-59 months (means 29 months) postoperatively. Compared to studies that did not include liposuction as part of the operation, we found a lower incidence of postoperative complications and a higher degree of patient satisfaction. Preoperative distinction between adipose and glandular tissue is difficult, and we therefore consider that liposuction should be used during the first part of the operation in nearly all cases of gynaecomastia. Regardless the amount of fat, tunnelling and suction are beneficial, because they help to refine the peripheral contour and define the glandular tissue. Liposuction seems to help the skin to contract, and skin resections are rarely indicated.