Surgical Management of Gynecomastia—a 10-year Analysis

Gynecomastia Surgery in 4996 Male Patients Over 14 Years: A Retrospective Analysis of Surgical Trends, Predictive Risk Factors, and Short-Term Outcomes

BACKGROUND

The high prevalence of benign male breast tissue enlargement (gynecomastia) has resulted in a marked increase of gynecomastia cases. While about one third of male adults experience some form of gynecomastia, gynecomastia surgery (GS) outcome research is limited to small study populations and single-center/-surgeon databases. In this study, we aimed to access the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify preoperative risk factors for complications and investigate postoperative outcomes of GS.

METHODS

In this retrospective study, we queried the ACS-NSQIP database from 2008 to 2021 to identify male adult patients who underwent GS. Postoperative outcomes involved the occurrence of any, surgical and medical complications, as well as reoperation, readmission, and mortality within a 30-day postoperative time period. Univariable and multivariable assessment were performed to identify risk factors for complications while adjusting for possible confounders.

RESULTS

The study included 4,996 GS patients with a mean age of 33.7 ± 15 years and BMI of 28.2 ± 5.1 kg/m2. White patients constituted 54% (n = 2713) of the cohort, and 27% (n = 1346) were obese. Except for 2020, there was a steady increase in GS cases over the study period. Outpatient surgeries were most common at 95% (n = 4730), while general surgeons performed the majority of GS (n = 3580; 72%). Postoperatively, 91% (n = 4538) of patients were discharged home; 4.4% (n = 222) experienced any complications. Multivariable analysis identified inpatient setting (p < 0.001), BMI (p = 0.023), prior sepsis (p = 0.018), and bleeding disorders (p = 0.047) as independent risk factors for complications.

CONCLUSION

In this study, we analyzed 4996 male adult GS patients from the ACS-NSQIP database, revealing an increased caseload and significant general surgeon involvement. Risk factors like bleeding disorders, inpatient status, and prior sepsis were linked to postoperative complications, while BMI was crucial for predicting adverse events. Overall, our findings may aid in enhancing patient care through advanced preoperative screening and closer perioperative management.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Unraveling the Enigma: A Rare Case of Recurrent Idiopathic Gynecomastia in an Adolescent

Gynecomastia presents as abnormal hypertrophy of mammary tissue in males that is typically asymptomatic and usually does not require intervention. Gynecomastia responds well to medical and surgical treatment, when necessary, with low recurrence rates. The authors report an atypical case of recurrent idiopathic unilateral gynecomastia first presenting in an adolescent male. Physical examination, hormonal, and oncologic evaluations were normal. After subcutaneous mastectomy with liposuction and treatment with Tamoxifen at 19 years old, his unilateral gynecomastia recurred over the course of 3 years, requiring a second surgery. Furthermore, we review the literature for recurrent gynecomastia after surgical management to examine prevalence and risk factors.

Etiopathological Factors Associated with Gynecomastia Patients Seeking Surgical Correction in the South Indian Population

Background  Although several medical conditions are associated with gynecomastia, around 60% of cases are idiopathic. The role of endocrine testing in idiopathic gynecomastia is controversial. This study was done to determine the etiological and lifestyle factors associated with different grades of gynecomastia. Patients and Methods  This was a descriptive study conducted at the department of plastic surgery in a tertiary care hospital in South India between January 2014 and December 2016, among the patients seeking corrective surgery for gynecomastia. Results  A total of 73 patients were included in the study with a mean age of 22.56 years. The majority of the patients displayed Simon's Grade IIa gynecomastia (56.2%). The etiological factors identified in this study were hormonal abnormalities (47.95%), hypogonadism (2.7%), and drug intake (1.4%). The most common hormonal abnormality discovered was high estradiol values (15.1%) followed by decreased testosterone levels (13.7%). The chi-squared test revealed no statistically significant relationship between the hormonal values, type of food, body mass index (BMI), or physical activity and the grades of gynecomastia. Conclusion  Most of the patients (50.68%) in our study had idiopathic gynecomastia. The most common hormonal abnormality detected was high estradiol values. No correlation was found between the hormonal values, type of food, BMI, or physical activity and the grades of gynecomastia.

A Clinical, Etiological, and Therapeutic Profile of Gynecomastia

Background and objective

Gynecomastia is defined as a benign proliferation of male breast glandular tissue, either unilateral or bilateral, resulting from an imbalance of testosterone and estrogen. In this study, we aimed to describe the clinical, etiological, and therapeutic aspects of gynecomastia.

Materials and methods

A retrospective, descriptive study was conducted in the Department of Endocrinology, Diabetology, and Nutrition at the Hassan II University Hospital in Fez, Morocco, over a period of 10 years. We included all patients admitted for exploration and treatment of gynecomastia. The data were analyzed using Microsoft Excel 2016 and SPSS Statistics version 18 (IBM, Armonk, NY).

Results

A total of 86 patients were included in this study; the mean age of the patients was 33 years (range: 15-86 years). A family history of gynecomastia was found in 4.6%. Isolated gynecomastia was the most frequent symptom (60.4% of cases). It was bilateral in 54% of cases, stage II in 63% of patients, stage I in 17%, and stage III in 20%. The first-line assessment (renal insufficiency, hepatic insufficiency/cirrhosis, dysthyroidism) was normal in the majority of cases. The etiologies were dominated by hypogonadism in 32.6% of cases, pubertal gynecomastia in 21%, and senile gynecomastia in 8.1%. Regarding treatment, 42% of patients received an etiological treatment, while surgical treatment was provided in 28% of cases, observation in 15% of cases, and androgen therapy in 15%. Pathological examination of all surgical specimens was benign. The follow-up was marked by 30.3% of static gynecomastia, 29% of regression, 17.5% of good response after surgery, and 24.4% of treatment refusal.

Conclusions

It is important to adopt a step-by-step approach in treating gynecomastia, starting with detailed questioning and clinical examination. The surgical treatment is currently the treatment of choice, the final goal of which is good aesthetic as well as psychological outcomes.

Complications and Quality of Life following Gynecomastia Correction in Adolescents and Young Men

BACKGROUND

Persistent adolescent gynecomastia negatively affects health-related quality of life. Surgery results in psychosocial improvements, but the effects of postoperative complications on health-related quality of life are unknown. The authors examined whether complications following adolescent gynecomastia surgery impact postoperative health-related quality of life.

METHODS

Patients aged 12 to 21 years who underwent surgical correction of unilateral/bilateral gynecomastia between 2007 and 2019 were enrolled (n = 145). Relevant demographic and clinical data were obtained from medical records. Fifty-one patients completed the following surveys preoperatively, and at 6 months and 1, 3, 5, 7, 9, and 11 years postoperatively: 36-Item Short-Form Health Survey (Version 2), Rosenberg Self-Esteem Scale, and the 26-item Eating Attitudes Test.

RESULTS

Within a median period of 8.6 months, 36 percent of breasts experienced at least one complication. The most common were residual tissue (12.6 percent), contour irregularities (9.2 percent), and hematomas (7.8 percent). Patients reported significant postoperative improvements in self-esteem and in seven health-related quality-of-life domains (Physical Functioning, Role-Physical, Bodily Pain, Vitality, Social Functioning, Role-Emotional, and Mental Health) at a median of 33.3 months. Postoperative survey scores did not vary by grade or procedure, or largely by body mass index category or complication status. However, patients aged younger than 17 years at surgery scored significantly higher than older patients in the Short-Form Health Survey Vitality and Mental Health domains postoperatively.

CONCLUSIONS

Health-related quality-of-life improvements are achievable in adolescents through surgical correction of persistent gynecomastia. Postoperatively, patients largely experienced similar health-related quality-of-life gains irrespective of complication status, grade, surgical technique, or body mass index category. Minor postcorrection complications are but do not appear to limit postoperative health-related quality-of-life benefits.

Clinical features, presentation and hormonal parameters in patients with pubertal gynecomastia

Objective:

Gynecomastia is benign enlargement of breast in male. It is postulated that its development is primarily due to a mismatch in ratio of oestrogen and androgen at breast tissue. The aim of this study was to highlight the clinical features, presentation and hormonal parameters at the time of consultation.

Methods:

All adolescent patients who attended endocrinology department with the complaint of breast enlargement were taken into study. We analysed their thyroid function test, oestrogen, testosterone, prolactin, alpha-fetoprotein, follicle-stimulating hormone, luteinizing hormone, beta HCG (human chorionic gonadotropin) and liver function. Clinical features and anthropometry were recorded.

Results:

Out of 50 patients enrolled, 34 (68%) had bilateral gynaecomastia while 16 patients (32%) had unilateral disease. Mastalgia was seen in 44 patients (88%). Psychological disturbance in the form of depression was seen in 60% of adolescent boys with gynecomastia. Tanner stage B had positive correlation with oestrogen to testosterone (E2/TTE) ratio (r = 0.47; P = 0.034). All other hormonal parameters were normal.

Conclusion:

Mastalgia was one of the presenting complaints in majority of patients and many had bilateral enlargement. Altered oestrogen to testosterone ratio is altered in majority of patients thus may be reason for pubertal gynecomastia.

Surgical Management of Gynecomastia: A Comprehensive Review of the Literature

Gynecomastia is a graded condition characterized by enlargement of the male breast that affects a significant proportion of the male population. A plethora of varying surgical approaches currently exists in the literature; thus this comprehensive review sought to analyze surgical practice patterns and trends as they pertain to gynecomastia grade and severity. The current literature was queried utilizing the PubMed and MEDLINE databases—based on predefined parameters and individual review, 17 studies were ultimately included. Key data points included gynecomastia grade, surgical intervention, rate of complication, including hematoma, seroma, infection, and necrosis, and drain use. Two-sample t test was utilized for further analysis. A total of 1112 patients underwent surgical treatment for gynecomastia. Skin-sparing mastectomy with or without liposuction was the most frequently used procedure followed by mastectomy with skin reduction. Major complication rates ranged from 0% to 33%, with hematoma formation being most common (5.8%) followed seroma (2.4%). There was a higher rate of hematoma/seroma formation among authors who routinely utilized drain placement (9.78% versus 8.36%; P = 0.0051); however, this is likely attributable to the large discrepancy in percentage of grade III patients found in each group (50.23% versus 4.36%; P = 0.0000). As a wide variety of surgical techniques exist for the treatment of gynecomastia, an individualized approach based upon gynecomastia grade and patient preference may assist the surgeon in providing optimal outcomes. This senior author’s preferred method for treatment of gynecomastia is illustrated in the included algorithm.

Clinical and Biochemical Phenotype of Adolescent Males with Gynecomastia

OBJECTIVE

Gynecomastia is defined as a benign proliferation of male breast glandular tissue. Its prevalence during puberty varies between 50-60% and is also common in neonatal and elderly males. It develops mainly due to the disequilibrium between estrogen and androgen activity in breast tissue, where estradiol (E2) binds to estrogen receptors and stimulates ductal and glandular cells. The aim of this work was to investigate the relationship between sex hormone alterations and the natural history of gynecomastia.

METHODS

Participants in this study were young males referred to an outpatient clinic, between January 2011 and February 2016, with breast enlargement. Thyroid function, liver function, hormone concentrations and tumor markers were measured and anthropometric assessment was conducted.

RESULTS

Subjects comprised 93 males, aged 9 to 18 (mean±standard deviation age 13.8±2.6) years. In 63 of 93 (67.7%) the gynecomastia was confirmed and 28 were followed-up for a median period of three months. None of the boys showed any reduction in breast size during follow-up. There was no correlation between body mass index Z-score and breast size. Breast enlargement progressed in nine boys (32.1%). A positive correlation between estrogen to testosterone (E2/TTE) ratio and Tanner B stage (r=0.47; p=0.034) was observed.

CONCLUSION

The E2/TTE ratio may be a helpful tool in diagnosing gynecomastia. Altered E2/TTE ratio might be responsible for a proportion of cases described previously as idiopathic. Additionally, weight loss does not imply reduction of breast size in boys. Nonetheless it should be the first step in the management of prolonged gynecomastia.

Mastectomy in Transgender and Cisgender Patients: A Comparative Analysis of Epidemiology and Postoperative Outcomes

Background:

Mastectomy is a commonly requested procedure in the transmasculine population and has been shown to improve quality of life, although there is limited research on safety. The aim of this study was to provide a nationwide assessment of epidemiology and postoperative outcomes following masculinizing mastectomy and compare them with outcomes following mastectomy for cancer prophylaxis and gynecomastia correction in cisgender patients.

Methods:

The American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2017 was queried using International Classification of Diseases and Current Procedural Terminology codes to create cohorts of mastectomies for 3 indications: transmasculine chest reconstruction, cancer risk-reduction (CRRM), and gynecomastia treatment (GM). Demographic characteristics, comorbidities, and postoperative complications were compared between the 3 cohorts. Multivariable regression analysis was used to control for confounders.

Results:

A total of 4,170 mastectomies were identified, of which 14.8% (n = 591) were transmasculine, 17.6% (n = 701) were CRRM, and 67.6% (n = 2,692) were GM. Plastic surgeons performed the majority of transmasculine cases (85.3%), compared with the general surgeons in the CRRM (97.9%) and GM (73.7%) cohorts. All-cause complication rates in the transmasculine, CRRM, and GM cohorts were 4.7%, 10.4%, and 3.7%, respectively. After controlling for confounding variables, transgender males were not at an increased risk for all-cause or wound complications. Multivariable regression identified BMI as a predictor of all-cause and wound complications.

Conclusion:

Mastectomy is a safe and efficacious procedure for treating gender dysphoria in the transgender male, with an acceptable and reassuring complication profile similar to that seen in cisgender patients who approximate either the natal sex characteristics or the new hormonal environment.

The round-the-clock technique for correction of gynecomastia

Background

Gynecomastia is a common condition that can cause severe emotional and physical distress in both young and older men. Patients in whom symptomatic recalcitrant gynecomastia persists for a long time are potential candidates for surgery.

Methods

From January 2014 to January 2016, 15 patients underwent correction of gynecomastia through a single 3-mm incision at our institution. Only patients with true gynecomastia underwent surgery with this new technique. Through the small incision, sharp dissection was performed in a clockwise and counterclockwise direction describing two half-circles. Health-related quality of life and aesthetic outcomes were evaluated using a modified version of the Breast Evaluation Questionnaire (BEQ).

Results

The patients’ average age was 23.5 years (range, 18–28 years), and their average body mass index was 23.2 kg/m² (range, 19.2–25.3 kg/m²). One case was unilateral and 14 cases were bilateral. The weight of glandular tissue resected from each breast ranged from 80 to 170 g. No excess skin was excised. Bleeding was minimal. The mean operating time was 25 minutes (range, 21–40 minutes). No complications were recorded. All lesions were histologically benign. The patients’ average score was 3.5 (on a 5-point Likert scale) in all domains of the BEQ for themselves and their partners.

Conclusions

In this study, we demonstrated the safety and reliability of a new technique that allows mastectomy through an imperceptible 3-mm incision. We obtained high patient satisfaction scores using our surgical technique, and patients reported considerable improvement in their social, physical, and psychological well-being after surgery.

Atypical ductal hyperplasia in men with gynecomastia: what is their breast cancer risk?

PURPOSE

Atypical ductal hyperplasia (ADH) significantly increases the risk of breast cancer in women. However, little is known about the implications of ADH in men.

METHODS

Review of 932 males with breast pathology was performed to identify cases of ADH. Patients were excluded if ADH was upgraded to cancer on excision, or if they had contralateral breast cancer. Cases were reviewed to determine whether any male with ADH developed breast cancer.

RESULTS

Nineteen males were diagnosed with ADH from June 2003 to September 2018. All had gynecomastia. Surgical procedure was mastectomy in 8 patients and excision/reduction in 11. One patient had their nipple areola complex removed, and 1 required a free nipple graft. Median patient age at ADH diagnosis was 25 years (range 18-72 years). Of the 14 patients with bilateral gynecomastia, 10 had bilateral ADH and 4 had unilateral. Five cases of ADH were described as severe, bordering on ductal carcinoma in situ. No patient reported a family history of breast cancer. No patient took tamoxifen. At a mean follow-up of 75 months (range 4-185 months), no patient developed breast cancer.

CONCLUSION

Our study is the first to provide follow-up information for males with ADH. With 6 years of mean follow-up, no male in our series has developed breast cancer. This suggests that either ADH in men does not pose the same risk as ADH in women or that surgical excision of symptomatic gynecomastia in men effectively reduces the risk of breast cancer.

The Characteristics and Short-Term Surgical Outcomes of Adolescent Gynecomastia

BACKGROUND

Most adolescent gynecomastia is resolved spontaneously in 3 years. But, persistent gynecomastia could have a negative influence on psychoemotional development on adolescence. The purpose of this study is to report the characteristics of adolescent gynecomastia patients who received the surgeries, and discuss the short-term surgical outcomes.

METHODS

Of the 1454 patients who underwent gynecomastia surgery at Damsoyu hospital from January 2014 to May 2016, 71 were adolescents. Subcutaneous mastectomy with liposuction was performed for adolescent patients who had gynecomastia for more than 3 years and showed psychosocial distress. Demographic and outcome variables were retrospectively analyzed.

RESULTS

The mean age was 17.5 ± 0.77 years old. All gynecomastia cases were bilateral. Simon's grade IIa (35 patients, 49.3%) was the most common, and grade III was not observed. Fifty-one patients (71.8%) were classified as having a glandular-type breast component. Fourteen patients (19.7%) had complications, but only 3 cases (4.2%) required revision. Most of the patients (70 patients, 98.6%) were satisfied with the esthetic results, and the average 5-point Likert score was 4.85 ± 0.40. Recurrence was not observed. As the Simon's grade increased from I to IIA, a higher BMI, larger amounts of breast tissue, and longer operation times were observed.

CONCLUSIONS

Gynecomastia that did not regress spontaneously was mostly the glandular type, so not only liposuction but also surgical removal of glandular tissue is necessary. Surgical treatment, selectively performed in patients who have had gynecomastia for 3 years, and have experienced psychosocial distress, could be an acceptable treatment for adolescent gynecomastia.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the table of contents or the online instructions to authors www.springer.com/00266 .

Gynecomastia: histological appearance in different age groups

OBJECTIVE

Gynecomastia is a common finding in the male population which is mostly idiopathic. The aim of our study was to analyze the histological differences in young and old patient groups and its association with recurrence rates.

METHODS

Three hundred and five gynecomastia patients (555 breasts) undergoing surgical treatment from 1997 to 2015 were divided into four groups: Group 1: 13-17 years, Group 2: 18-30 years, Group 3: 31-49 years and Group 4: 50-83 years. They were evaluated concerning clinical classification, histological differences and association with antiandrogen or steroids/immunosuppressive therapy.

RESULTS

We found that the rate of florid gynecomastia was higher in older patient groups, while fibrous gynecomastia was more common in adolescents and young adults (p = .0180). Glandular gynecomastia was more frequent in younger patients, while in the older patient groups, lipomatous gynecomastia was more common (p = .0006). Patients presenting with florid gynecomastia showed a higher rate of recurrence than patients with the fibrous type of gynecomastia (12.5 and 4.7%, respectively). Of note, 18.75% of florid gynecomastia was associated with antiandrogen agents or steroid/immunosuppressive therapy, while only 4.69% of fibrous gynecomastia was associated with antiandrogenic or immunosuppressive therapy. However, there was no increase of recurrence rates in patients using antiandrogen agents or undergoing steroid/immunosuppressive therapy.

CONCLUSIONS

Fibrous gynecomastia was found to be more common in adolescents and young adults, while the florid type was more frequent in older patients. Patients presenting with florid gynecomastia showed a higher rate of recurrence than patients with the fibrous type of gynecomastia.

Closed-Suction Drains After Subcutaneous Mastectomy for Gynecomastia: Do They Reduce Complications?

BACKGROUND

In cases of refractory gynecomastia, surgical excision of excess glandular breast tissue is often warranted. Closed-suction drain placement is commonplace; however, the effect of drains on preventing complications after male breast surgery has not been fully elucidated in the literature.

OBJECTIVE

To investigate the effect of drains on reducing seroma and hematoma after subcutaneous mastectomy for gynecomastia.

METHODS

Retrospective chart review of patients undergoing subcutaneous mastectomy for gynecomastia over a 10-year period. Charts were reviewed for demographics, BMI, comorbidities, type of local anesthesia, specimen weight, use of liposuction, and placement of drains. Outcomes were determined by seroma or hematoma in the 30-day postoperative period.

RESULTS

A total of 163 breasts were studied (group I = no-drain, n = 46; group II = drain, n = 117). Group I had a higher rate of clinically significant seromas requiring needle aspiration than group II (6.5 vs 0%, p = 0.0214). There was no difference in rates of hematoma (group I vs II, 2.2 vs 6.0%, p = 0.443) and total fluid collections (group I vs II, 19.6 vs 16.2%, p = 0.647). BMI, use of local anesthesia, specimen weight, and use of liposuction were not significantly associated with postoperative complications.

CONCLUSIONS

Closed-suction drains may reduce rates of clinically significant seromas requiring needle aspiration. Though drains carry their own pertinent adverse effects (e.g., patient discomfort and anxiety, cost, and additional clinic visits), there remains no universal standard of care and surgeon practices vary widely. Given the potential to reduce seroma rates, we recommend that surgeons consider placing drains and discuss with patients the benefits and risks of drains after surgical treatment of gynecomastia.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Severe Gynecomastia: New Technique Using Superior Pedicle NAC Flap Through a Circumareolar Approach

: Gynecomastia is defined as benign proliferation of glandular breast tissue in men. Gynecomastia causes considerable emotional discomfort because of limitation of everyday activity especially in young men. Surgical treatment of gynecomastia significantly contributes to an increase in social activity and an improvement of social acceptance and emotional comfort, and thus significantly improves satisfaction from personal life in men who underwent this intervention. Various surgical techniques were suggested to treat gynecomastia, but most of them end with visible scars especially in severe degree gynecomastia. The aim of many plastic surgeons is to advocate new techniques treating severe gynecomastia (grade II B and III according to Simon et al) with less visible scars.

OBJECTIVE

The author proposed a new technique combining both surgery and liposuction for treating grade II B and III gynecomastia using only circumareolar approach.

AIM

This study evaluates aesthetic results after surgery and assessment of the incidence of early and late postoperative complications.

METHOD

The patient was marked preoperatively while standing. Under general anesthesia, ultrasound-assisted liposuction of the periglandular area and de-epithelialization of excess skin were performed. A superiorly based nipple areola complex flap was created based on the subdermal plexus. The excess glandular tissue was resected through the lower half of the circle of the de-epithelialized area. Closure of the wound was done after insertion of 14-French redivac.

RESULTS

This treatment protocol was applied to 27 patients, 18 to 53 years of age, from February 2008 till now. Among these patients, 4 were classified as type IIB and 23 as type III. Follow-up ranged from 3 months to 4 years. Complications were the following: 1 hematoma, 1 wound dehiscence, 1 loss of nipple areola complex, 2 cases of hypertrophied scars, and 3 minor aesthetic problems near areolae.

CONCLUSIONS

A new periareolar approach for correction of severe-grade gynecomastia permits broad resection of excess skin and submammary tissue while avoiding unattractive scars on the patient's chest.

Complications and Outcomes After Gynecomastia Surgery: Analysis of 204 Pediatric and 1583 Adult Cases from a National Multi-center Database

BACKGROUND

Gynecomastia is a common disease that is prevalent across all age groups of boys and men. Although benign in nature, it can lead to psychological and social distress, prompting affected patients to seek medical attention. Management strategies include observation and drug therapy, yet surgical procedures remain the hallmark of treatment. The goal of this study was to analyze patient demographics, outcomes, and complication rates of gynecomastia surgery in a large multi-institutional cohort.

METHODS

We performed a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program adult and pediatric databases to produce two cohorts that underwent gynecomastia surgical repair. The two populations were compared for comorbidities, perioperative details, and complication rates. Multivariate analyses helped detect risk factors associated with adverse events.

RESULTS

A total of 204 pediatric and 1583 adult male patients were identified in our analysis. Mean ages were 15.8 and 39.6 years, respectively. A BMI of 28.2 in the latter cohort revealed an overweight adult population. Preoperative comorbidities (0.0-4.9% in children, 0.0-6.4% in adults) and American Society of Anesthesiologists scores (ASA 1 + 2: 98.5 and 82.7%) symbolized a healthy population. Procedures were subsequently performed mostly as outpatient (84.3 and 93.9%) and with short hospitalization durations (0.27 and 0.06 days). Our results demonstrated low surgical (3.9 and 1.9%) and medical (0.0 and 0.3%) complications within the standardized 30-day postoperative period. Children and adolescents, however, required double mean operative times compared to adults (111.3 vs 56.7 min).

CONCLUSION

Operative gynecomastia treatment remains a safe treatment modality across all age groups. Patients with known preoperative medical or surgical comorbidities necessitate more extensive perioperative assessment and monitoring.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Is the transposition of the nipple-areolar complex necessary in Simon grade 2b gynecomastia operations using suction-assisted liposuction?

OBJECTIVE

The aim of this study was to assess the efficacy of suction-assisted liposuction (SAL) in Simon grade 2b gynecomastia and its effect on sternal notch to nipple areola (SNN) distance.

METHODS

A retrospective analysis was performed on 21 patients with grade 2b gynecomastia who underwent SAL. Preoperative and postoperative SNN distances of the patients were measured, the results were analysed using a Mann-Whitney U test and a p-value <.05 was accepted as statistically significant. Aesthetic results were evaluated by the surgical team considering five criteria: breast size, breast shape, nipple-areolar complex positioning, scarring, and skin tightness of the breast envelope. A 10-point Likert scale was used to assess patient satisfaction with SAL surgery.

RESULTS

All of the patients were followed up for an average period of 17.8 months (range = 12-28 months). The mean amount of lipoaspirate was 232 mL per breast (range = 190-310 mL). The mean preoperative SNN distance was 22.3 cm (range = 20-23.5 cm), whereas postoperative was 21.3 cm (range = 19.2-22.8 cm); the difference was statistically significant (p < .05). There was one case of nipple areola necrosis, three hypoesthesia, five persistent pains, and four slight buttonhole deformities. The aesthetic result was evaluated as very good by the surgical team, and the overall patient satisfaction rate in terms of breast shape and volume was 92%.

CONCLUSIONS

It was concluded that SAL provides a good aesthetic outcome in patients with Simon grade 2b gynecomastia and shortens the SNN distance by 1 cm, but further clinical studies are required to support this conclusion.

The surgical management of male breast cancer: Time for an easy access national reporting database?

INTRODUCTION

Male breast cancer is extremely rare with an incidence of less than 1% of all breast cancers. Literature reports a peak of incidence at roughly 71 years of age. Management currently follows the same clinical pathways as female breast cancer as a general rule.

METHODS

A retrospective search for all patients who were referred and diagnosed with male breast cancer at our centre was undertaken. Patients notes were then explored for demographics, histological staging, multidisciplinary team meeting outcome and treatment. A literature search including the search terms 'Male Breast Cancer AND Surgery' or 'Male Breast Cancer AND Experience' were used. Non English language articles, or those without abstracts were excluded.

RESULTS

Seven patients were reviewed over 3 years (2006-2009). Mean agea was 69 years and mean lesion size was 15 mm. Histology was invasive ductal carcinoma for all patients. All patients were ER receptor positive. Two patients were HER2 positive. Five patients were offered mastectomy. One patient refused treatment. In follow up at 36 months there were 3 recurrences. 1 patient was lost to follow up. There were 3 mortalities. The literature search identified 72 articles. Articles were subdivided into those that discussed the surgical management of male breast cancer (n = 8), articles that discussed male breast cancer as podium presentations or posters with no full text article publication (n = 13) and finally full text publications of case experience of male breast cancer (n = 21).

DISCUSSION

We report a series of seven cases of male breast cancer encountered over three years, evaluating patient demographics as well as treatment and outcomes. In our series patients were managed with mastectomy. New evidence is questioning the role of mastectomy against breast conserving surgery in male patients. Furthermore there is a lack of reporting infrastructure for national data capture of the benefits of surgical modalities. Literature review highlights the varied clinical experience between units that remains reported as podium presentation but not published. The establishment of an online international reporting registry would allow for efficient analysis of surgical outcomes to improve patient care from smaller single centres. This would facilitate large scale meta analysis by larger academic surgical centres.

Incidental unilateral and bilateral ductal carcinoma in situ encountered in the surgical management of young male gynecomastia

BACKGROUND

The increased risk for malignant tumors associated with male gynecomastia has been well established and many authors have reported cases of concurrent gynecomastia and ductal carcinoma in situ (DCIS) in the same breast. Synchronous bilateral breast cancer in association with gynecomastia is exceptionally rare. We aim to report and evaluate the management outcome of 5 cases of gynecomastia associated with DCIS (1 bilateral and 4 unilateral).

METHODS

A retrospective database analysis of the surgical treatment outcome of 74 male patients who had gynecomastia was done. A bilateral subcutaneous nipple-preserving mastectomy approach was done to all. Histopathology reports were reviewed.

RESULTS

74 patients diagnosed and treated for gynecomastia were included. The incidence rate of gynecomastia in our hospital male patients was 0.17%. The mean age was 22 years, range 17-29 years. Five (6.76%) patients were found in histopathology specimens to have DCIS, 1 patient (23 years old) had bilateral DCIS of low grade, 4 patients had unilateral positive involvement, 3 had right breast DCIS, and 1 had left breast DCIS, and all were of low-grade papillary subtype. The incidence of ductal carcinoma in situ among our series gynecomastia patients was 6.76%.

CONCLUSION

We conclude that gynecomastia is a benign breast disease but recent reports had described malignant variants, mostly DCIS, including 5 young males in our series. Therefore, regardless of the age group, histopathological examination of the resected gynecomastia tissue should be carefully done in all patients. Further evidence-based studies are needed to investigate the optimum management of incidental DCIS in gynecomastia specimens.

An Ameliorated Approach for Sharp Resection in Gynecomastia Surgery

Surgery has become the accepted standard for the majority of patients with gynecomastia to get rid of feminine-looking breast enlargement. Many surgical techniques have been proposed according to grade of gynecomastia. The sharp resection of glandular tissues is a keystone for most of them. However, technical difficulties in application and inexperience in mastectomy often lead to poor cosmetic outcomes. Over excision and saucer-like deformity, under resection, and asymmetries are most common ones among them. The author presents an ameliorated subcutaneous mastectomy method to facilitate the learning curve and to improve the esthetic results avoiding saucer-like deformity and other breast contour deformities. This method consists of an en bloc tissue dissection via superior periareolar incision and excision of fatty glandular tissue in suprafascial plan, with slicing and trimming procedure. It is possible to adjust the degree of tissue reduction during surgery; hence, it may be labeled as a "cut-as-you-go" technique. Between 2008 and 2012, 23 male patients were operated with this technique. Medical photographs and drawings were used to describe the technique. The operation resulted in smooth, symmetric breasts befitting to men in all 23 patients. No major complications were observed in any of the cases. None of the patients reported a discomfort in sensation of nipple-areolar complex. The presented technique provides high degree of patient satisfaction and excellent esthetic outcomes and is a promising choice in gynecomastia surgery with extremely low recurrence rates and easy learning curve.

Clinical and surgical management of unilateral prepubertal gynecomastia

INTRODUCTION

Gynecomastia is the benign proliferation of the glandular tissue in the male breast. This condition is thought to be caused by the imbalance between estrogen action relative to androgen action at the breast tissue level. Bilateral gynecomastia is frequently found in the neonatal period, early in puberty, and with increasing age. Prepubertal unilateral gynecomastia in the absence of endocrine abnormalities is extremely rare, with only a few cases in literature.

PRESENTATION OF CASE

We present an otherwise healthy boy of 12 years old with unilateral breast masses. No abnormalities were found on ultrasonography and on all endocrine parameters. Treatment consisted in a new "modified" Webster technique.

DISCUSSION

The results confirmed validity of this technique in terms of esthetic and functional results, and patient satisfaction. Atypical presentations of gynecomastia are often not recognized. The main pathophysiology of gynecomastia is alteration in the balance between the stimulatory effect of estrogen and the inhibitory effects of androgens on the development of the breast. If there is no causal treatment, surgical resection is the therapy of first choice.

CONCLUSION

The exact mechanism of unilateral gynecomastia formation in our case is unclear. The evaluation of unilateral gynecomastia can therefore be complex. In conclusion, the surgical treatment of unilateral gynecomastia requires an individual approach, based on an appropriate diagnostic algorithm.

Gynecomastia: Clinical evaluation and management

Gynecomastia is the benign enlargement of male breast glandular tissue and is the most common breast condition in males. At least 30% of males will be affected during their life. Since it causes anxiety, psychosocial discomfort and fear of breast cancer, early diagnostic evaluation is important and patients usually seek medical attention. Gynecomastia was reported to cause an imbalance between estrogen and androgen action or an increased estrogen to androgen ratio, due to increased estrogen production, decreased androgen production or both. Evaluation of gynecomastia must include a detailed medical history, clinical examination, specific blood tests, imaging and tissue sampling. Individual treatment requirements can range from simple reassurance to medical treatment or even surgery. The main aim of any intervention is to relieve the symptoms and exclude other etiological factors.

Gynecomastia: physiopathology, evaluation and treatment

Gynecomastia (GM) is characterized by enlargement of the male breast, caused by glandular proliferation and fat deposition. GM is common and occurs in adolescents, adults and in old age. The aim of this review is to discuss the pathophysiology, etiology, evaluation and therapy of GM. A hormonal imbalance between estrogens and androgens is the key hallmark of GM generation. The etiology of GM is attributable to physiological factors, endocrine tumors or dysfunctions, non-endocrine diseases, drug use or idiopathic causes. Clinical evaluation must address diagnostic confirmation, search for an etiological factor and classify GM into severity grades to guide the treatment. A proposal for tailored therapy is presented. Weight loss, reassurance, pharmacotherapy with tamoxifen and surgical correction are the therapeutic options. For long-standing GM, the best results are generally achieved through surgery, combining liposuction and mammary adenectomy.

Surgical treatment of gynecomastia by vacuum-assisted biopsy device

BACKGROUND

Gynecomastia is a benign clinical condition that is the unilateral or bilateral enlargement of the male breast, but sometimes it causes serious psychological and physical stress in young men and brings about phobia of malignancy in elderly men. Minimally invasive and functional therapy represents an inevitable trend in breast surgery. We investigated the feasibility and safety of vacuum-assisted biopsy device in treating gynecomastia.

METHODS

From January 2006 to January 2010, 20 male patients with gynecomastia were treated by an 8-gauge vacuum-assisted biopsy device. The average age was 24.7 years (range, 18-47 years).

RESULTS

The operation was successfully performed in all 20 patients with a mean operating time of 51 minutes and a hospital stay of 4 days. Postoperative complications included 1 case of hematoma, but no nipple necrosis, local skin necrosis, or skin buttonhole occurred. No other operation-related complications were observed. Satisfactory chest contour was gained in all cases without any abnormality, skin redundancy, or recurrence during the follow-up of 6-48 months.

CONCLUSIONS

Treatment of gynecomastia by the Mammotome device is distinctive, practicable in manipulation, safe, and can achieve excellent cosmetic results. The Mammotome procedure simply represents another novel treatment option for gynecomastia.

Gynecomastia - evaluation and current treatment options

CLINICAL QUESTION

What is the best management approach for gynecomastia?

RESULTS

In most patients, surgical correction usually leads to immediate cosmetic and symptomatic improvement and is considered the best approach. In men who are being treated with antiandrogen therapies, pharmacological intervention with tamoxifen is the most effective approach, followed by radiotherapy.

IMPLEMENTATION

Pitfalls to avoid when treating gynecomastia Failure to detect the very rare male breast cancerOverly aggressive early intervention or evaluationAppropriate medical interventionWhen to refer to specialist treatment.

Bilateral Pulmonary Emboli After Bilateral Mastectomy in a 15-Year-Old Boy with Hypogonadism: A Case Report

Pulmonary emboli are rare, yet serious, complications of body contouring surgery. When they occur, they more often follow as complications of long, invasive procedures in adults. The present report details a case of bilateral pulmonary emboli in an obese 15-year-old boy with hypogonadism undergoing bilateral mastectomy for gynecomastia. The diagnosis of bilateral pulmonary emboli was made on the basis of clinical presentation and positive ventilation/perfusion scan. The patient responded well to heparin anticoagulation treatment. The relevance of pediatric obesity, pediatric body contouring surgery and the risk of thromboembolic events in pediatric patients are discussed.

Evidence-based patient safety advisory: liposuction

Liposuction is considered to be one of the most frequently performed plastic surgery procedures in the United States, yet despite the popularity of liposuction, there is relatively little scientific evidence available on patient safety issues. This practice advisory provides an overview of various techniques, practices, and management strategies that pertain to individuals undergoing liposuction, and recommendations are offered for each issue to ensure and enhance patient safety.

Treatment of adolescent gynecomastia

PURPOSE

Adolescent gynecomastia is common but variable in severity. The disease may be self-limited. Although antiestrogen therapy can be used in persistent gynecomastia, results are mixed. Subcutaneous mastectomy via a circumareloar incision is familiar to most pediatric surgeons and provides excellent cosmetic results in most cases. Severe gynecomastia may require alternative procedures. There is little information in the pediatric surgical literature to provide the pediatric surgeon with treatment options for these children. A variety of techniques have been used by plastic surgeons for female patients requiring breast reduction and are sometimes a useful addition to the surgical repertoire for the management of very large breasts in adolescent gynecomastia. We reviewed our experience with the use of inferior pedicle reduction mammaplasty and subcutaneous mastectomy in adolescents with gynecomastia and describe the techniques used.

METHODS

After obtaining institutional review board approval, a retrospective review was conducted on all patients operated on for gynecomastia from January 1999 to March 2009. Data recorded included patient demographics, diagnostic evaluation, medical and surgical treatment, complications, and outcome.

RESULTS

Twenty patients underwent an operation for gynecomastia. Eight patients had bilateral inferior pedicle reduction mammaplasty, and 12 patients underwent either unilateral or bilateral subcutaneous mastectomy. The mean age at operation was 15.5 years (range, 14-18 years). In all cases, the histopathologic feature was consistent with gynecomastia. There were no postoperative wound infections. One patient developed a seroma after subcutaneous mastectomy requiring drainage. The mean amount of tissue removed after bilateral reduction mammaplasty was 275.1 g. No patients had devascularization of the nipple-areolar complex or nipple loss. One patient had mild subcutaneous asymmetry after a reduction mammaplasty that required no further intervention. Seven patients (87%) had an excellent cosmetic outcome after reduction mammaplasty. Mean length of follow-up was 18.8 months.

CONCLUSIONS

Although many adolescents with true gynecomastia have mild or self-limited disease, operative treatment may provide significant benefit to the remainder. Milder grades of gynecomastia can be managed with subcutaneous mastectomy. Selected severe cases can be safely and effectively treated with reduction mammaplasty.

Gynecomastia: pathophysiology, evaluation, and management

Gynecomastia, defined as benign proliferation of male breast glandular tissue, is usually caused by increased estrogen activity, decreased testosterone activity, or the use of numerous medications. Although a fairly common presentation in the primary care setting and mostly of benign etiology, it can cause patients considerable anxiety. The initial step is to rule out pseudogynecomastia by careful history taking and physical examination. A stepwise approach that includes imaging and laboratory testing to exclude neoplasms and endocrinopathies may facilitate cost-effective diagnosis. If results of all studies are normal, idiopathic gynecomastia is diagnosed. The evidence in this area is mainly of observational nature and lower quality.

Significance of phosphatase and tensin homologue (PTEN), O(6)-methylguanine-DNA methyltransferase (MGMT), and DNA-dependent protein kinase catalytic subunit (DNA-PKcs) protein expression in gynaecomastia

This study was designed to investigate the pathogenesis of gynaecomastia by measuring phosphatase and tensin homologue (PTEN), O(6)-methylguanine-DNA methyltransferase (MGMT) and DNA-dependent protein kinase catalytic subunit (DNA-PKcs) protein in breast tissue specimens from 68 patients with gynaecomastia and 24 normal male controls using immunohistochemical staining. The gynaecomastia cases were divided into three different histological types: florid, intermediate and fibrous. The PTEN, MGMT and DNA-PKcs proteins were detected in both gynaecomastia and normal breast tissue, but the levels of immunohistochemical staining of each protein were significantly lower in gynaecomastia breast tissue than in normal breast tissue. There were also significant differences in the levels of immunohistochemical staining for the three proteins according to gynaecomastia histological type. These results suggest that abnormally low levels of PTEN, MGMT and DNA-PKcs protein in gynaecomastia breast tissue may play a role in the development of gynaecomastia. Further research is required to elucidate fully their individual roles in the pathophysiology of gynaecomastia.

The social context for psychological distress from iatrogenic gynecomastia with suggestions for its management

INTRODUCTION

Gynecomastia (breast development in males) is a side effect of androgen deprivation therapy (ADT) for prostate cancer (PCa). Medical interventions to prevent or treat gynecomastia carry risk of additional detrimental side effects. However, untreated gynecomastia can be physically uncomfortable and psychologically distressing. Shame from gynecomastia can lead patients to stop otherwise beneficial exercise.

AIMS

Our first aim is to explore the social context for gynecomastia and how it is interpreted by men with the condition, as well as by others, both male and female. Subsequently, we use our understanding of why gynecomastia is psychologically distressing to propose psychosocial interventions that could help men accept this side effect of ADT.

METHODS

We draw on academic literature, media accounts, and web-based testimonials from men with gynecomastia, to understand how gynecomastia is perceived by both patients and the medical community. We examine these resources in light of gynecomastia's impact on sex roles, sexuality, and gender identity issues.

MAIN OUTCOME MEASURES

By exploring what breasts in a male mean to the individual, we produce an understanding of the social context for distress from gynecomastia. From this understanding, we derive hypotheses about who might be most distressed from gynecomastia and strategies for alleviating this distress.

RESULTS

The shame and stigma of gynecomastia is linked to the objectification of women. We suggest that men fear that their breasts will marginalize and subordinate them within gender hierarchies. There is little evidence that breasts on a male erotically attract either men or women. Novel options for living with gynecomastia are contrasted with medicalized strategies including mastectomy.

CONCLUSION

Assessment instruments need to be developed to identify patients most likely to experience distress from gynecomastia and seek out medical interventions. Surgical, radiological, or pharmacological interventions may not be universally necessary if greater acceptance of gynecomastia is made available through psychosocial support programs. For example, PCa patients may learn to accept gynecomastia through reconceptualizing their breasts as autoerotic. Support programs modeled on those of the breast cancer community, including Encore and dragon boat racing, may also help to build communities to serve patients with gynecomastia while defending individuals against shame, isolation, and loss of self-esteem.

Gynecomastia: the horizontal ellipse method for its correction

BACKGROUND

Gynecomastia is an extremely disturbing deformity affecting males, especially when it occurs in young subjects. Such subjects generally have no hormonal anomalies and thus either liposuction or surgical intervention, depending on the type and consistency of the breast, is required for treatment. If there is slight hypertrophy alone with no ptosis, then subcutaneous mastectomy is usually sufficient. However, when hypertrophy and/or ptosis are present, then corrective surgery on the skin and breast is mandatory to obtain a good cosmetic result.

METHODS

Most of the procedures suggested for reduction of the male breast are usually derived from reduction mammaplasty methods used for females. They have some disadvantages, mainly the multiple scars, which remain apparent in males, unusual shape, and the lack of symmetry with regard to the size of both breasts and/or the nipple position. The author presents a new, simple method that has proven superior to any previous method described so far. It consists of a horizontal excision ellipse of the breast's redundant skin and deep excess tissue and a superior pedicle flap carrying the areola-nipple complex to its new site on the chest wall.

RESULTS

The method described yields excellent shape, symmetry, and minimal scars.

CONCLUSION

A new method for treating gynecomastis is described in detail, its early and late operative results are shown, and its advantages are discussed.

Gynecomastia in prepubertal and pubertal men

PURPOSE OF REVIEW

Gynecomastia is often benign, but it can be the sign of serious endocrine disease and the source of significant embarrassment and psychological stress. Understanding its pathogenesis is crucial to distinguish a normal developmental variant from pathological causes.

RECENT FINDINGS

There is a growing list of potential causes of gynecomastia. Rare and unique case reports continue to supplement the literature to augment our understanding of this common physical finding. However, the exact basis for the pathogenesis of gynecomastia remains unknown. There appears to be a local imbalance between estrogen stimulation and the inhibitory action of androgens on breast tissue proliferation. Gynecomastia in a prepubertal boy is rare and should prompt an immediate evaluation for possible endocrine disorder. Pubertal gynecomastia, on the contrary, is common and usually physiological, with sympathetic reassurance and watchful waiting the mainstays of treatment. There is some evidence that early pharmacological intervention with antiestrogens may diminish persistent pubertal gynecomastia, but treatment with an aromatase inhibitor has not been shown to be more effective than placebo.

SUMMARY

Treatment of gynecomastia is geared toward its specific cause. Currently, there are insufficient data to recommend medical therapy in children with idiopathic gynecomastia.