Surgical Treatment of Gynecomastia: Complications and Outcomes

Pseudoangiomatous stromal hyperplasia: a rare cause of gynecomastia in men

A 17-year-old male with chest malformation and left breast enlargement underwent surgery for gynecomastia. Histological examination revealed mammary fibrous stroma with ductal hyperplasia and features of pseudoangiomatous stromal hyperplasia. Postoperative follow-up showed no complications, but 8 months later, the patient experienced a mild recurrence with enlargement of the nipple-areolar complex. Although recommended for secondary glandular resection, the patient declined further surgery.

Single Axillary Incision Reverse Sequence Endoscopic Nipple-Sparing Mastectomy in the Management of Gynecomastia: Short-Term Cosmetic Outcomes, Surgical Safety, and Learning Curve of the Preliminary 156 Consecutive Procedures from a Prospective Cohort Study

BACKGROUND

Currently, a standard, optimal surgical procedure is still lacking for gynecomastia. Despite the development of a variety of surgical interventions, these techniques were often limited to patients with Simon I and II. The present study aimed to introduce a novel technique for all types and grades of gynecomastia, and reported the preliminary results.

METHODS

Patients who received single axillary incision reverse sequence endoscopic nipple-sparing mastectomy (R-E-NSM) from March 2021 to March 2023 were enrolled at a single institution. The data from 3-month follow-up cut-off were collected prospectively and analyzed to determine the short-term esthetic and safety results of this technique, as well as the learning curve.

RESULTS

A total of 159 single axillary incision reverse sequence endoscopic nipple-sparing mastectomy procedures were performed in 81 gynecomastia patients. Among these 81 patients, 7 patients (8.6%) were classified as Simon grade I, 29 patients (35.8%) as grade IIa, 24 patients (29.6%) as grade IIb, and 21 patients (25.9%) as grade III. In the patient-reported cosmetic results, the overall satisfaction score was 8.4 ± 1.4. A total of 74.1% of patients were highly satisfied, and 25.9% were satisfied. The overall complication rate was 10.1%, and only 1 patient had a major complication. According to the cumulative sum plot analysis, approximately 12 cases were needed for surgeon B and 11 cases for surgeon C to decrease their operation time significantly.

CONCLUSIONS

R-E-NSM is safe and effective for all Simon grade gynecomastia patients, with excellent cosmetic results and a short learning curve. However, a long-term follow-up assessment is still needed.

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 .

Postoperative Psychological Impact on Teenagers after Gynecomastia Correction

Gynecomastia is common among teenagers. Most published research focused on how surgery is effective in enhancing the aesthetic appearance of the breast. Limited information is already known about the psychosocial benefits of surgical interventions. This study explores and assesses the surgical, cosmetic, and psychological outcome of gynecomastia correction in teenagers.

Methods

This prospective study included 20 teenagers with Simon grade IIA gynecomastia. The assessment included complications, patients' satisfaction, Manchester Scar Scale, and Li et al questionnaire at 12 months postoperative. Rosenberg Self-Esteem Scale, 36-Item Short Form Survey (SF-36) for quality of life, and school achievement level were evaluated 1 month preoperative and 12 months postoperative. Statistical analysis was done.

Results

Patients were aged 13-19 years old. The follow-up period was 12 ± 36 months. Postoperative complications included seroma formation (n = 1) and mild asymmetry (n = 3). Results were "uniformly good to excellent" on a satisfaction scale. The Manchester Scar Scale shows the lowest score, which denotes the highest outcomes. The Li et al questionnaire showed a positive overall change. Comparing Rosenberg Scale scores pre- and postoperatively revealed higher scores postoperatively, which indicate higher self esteem. Comparing SF-36 pre- and postoperatively showed a significant increase in postoperative quality of life. Comparing school achievement pre- and postoperatively showed marked improvement postoperatively. Results were highly statistically significant.

Conclusions

Surgical treatment of teenage gynecomastia is beneficial for different psychosocial domains. Pull-through of the mammary gland combined with liposuction provides satisfactory cosmetic results. Patients who underwent surgery reported a significant improvement in psychosocial load, better school achievement, higher quality of life, and better self-esteem.

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.

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.

Concentric mastopexy for pubertal gynaecomastia in an African child

Gynaecomastia refers to the enlargement of the male breast. It can be psychologically disturbing for children and adolescents as well as adults. While in children watchful waiting is advised as the gynaecomastia could resolve, surgical intervention becomes necessary where there is significant psychosocial disturbance. We present a case of an African child whose quality of life improved after correcting the gynaecomastia. We highlight the concentric mastopexy method in the surgical management of gynaecomastia.

Prospective Analysis and Comparison of Periareolar Excision (Delivery) Technique and Pull-Through Technique for the Treatment of Gynecomastia

BACKGROUND

Gynecomastia is one of the most common disorders affecting adolescent and adult males. It is a benign disorder but has severe psychological manifestations like low self-confidence, depression, anxiety and social phobia in patients suffering from gynecomastia. Different surgical techniques have been described utilizing a variety of incisions, excisions, lipectomy and liposuction methods. Very frequently, these methods are combined for the gynecomastia treatment with variable reported results. However, there is a lack of studies comparing these techniques. The present study was planned to compare cases of gynecomastia treated by liposuction with periareolar excision (delivery technique) and liposuction with a pull-through technique.

METHOD

A prospective randomized control study was conducted at a tertiary care hospital on 20 patients with gynecomastia. The patients were assigned to either liposuction with periareolar excision (delivery technique) or liposuction with pull-through technique. Anthropometric analysis and breast evaluation questionnaire (BEQ) scores were analyzed and compared before and after the surgery.

RESULTS

The majority of the study subjects were between 21 and 30 years of age. Low self-confidence was the main reason for surgery in most of the cases. Twelve patients had gynecomastia grade IIa and eight had grade IIb. Both groups had similar responses to BEQ scores before and after the surgery with no statistically significant difference. A statistically insignificant difference was observed between the groups on comparison of anthropometric analysis preoperatively and postoperatively. The mean lipoaspirate volume was 280 ml for the pull-through technique and 367 ml for the periareolar excision technique. No complications were observed in cases operated on by the pull-through technique, while two cases (10%) operated on by the periareolar excision had hematomas.

CONCLUSION

Both techniques provide excellent cosmetic results with low risk of complications in both small and moderate breast enlargement with skin excess. The pull-through technique combines the benefits of direct excision of glandular tissues along with the minimally invasive nature of liposuction. Thus, performing the procedure via a single incision without the use of drains is a safer alternative to traditional liposuction with the periareolar excision technique.

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.

[Concomitant breast surgery with a vertical latero-thoracic incision in continuity with a brachioplasty incision: About twelve (12) cases after massive weight loss]

INTRODUCTION

The need of iterative surgeries, the proximity of two anatomical areas, the combination of an aesthetic surgery with a surgery covered by health insurance are the reasons which motivated the authors to provide a simultaneous procedure on arms and breast in patients achieving massive weight loss. We propose a vertical continuation of the lateral mastopexy incision superiorly, in continuity with a simultaneous brachioplasty incision to treat the excess skin and subcutaneous tissue of the lateral chest wall, either by resection, or by increasing the breast with the patients own autologous tissue.

METHODS

Between 2010 and 2017, twelve patients aged between 31 and 56 years, with 42 being the average, have undergone a technique that utilises a vertical continuation of the lateral mastopexy incision superiorly, in continuity with a simultaneous brachioplasty incision: transverse skin incisions and free nipple transplantation for correction of extreme gynaecomastia (2 cases), mastopexy with resection of the excess tissue of the lateral chest wall (8 cases), autologous breast augmentation by the use of intercostal artery perforator flaps (2 cases). Mean body mass index (BMI) was 24kg/m² [23; 32] after average weight loss of 56kg [14; 112] following diet (3 cases) or bariatric surgery (9 cases).

RESULTS

Mean operative time was 4hours [3: 6], mean length of hospital stay was 4 days [2; 9]. We observed one major complication (hematoma) and one minor complication (wound dehiscence). At a mean follow-up of 21 months (ranged from 15 days to 84 months), the lateral flank scarring was well tolerated, with the additional benefit of reducing flank fullness.

CONCLUSION

The extended lateral flank scar allows reducing the excess skin and subcutaneous tissue of the lateral chest wall, while being easily concealable. This technique offers an elegant solution to this excess that used to persist after multistage surgeries.

Modified Benelli procedure for subcutaneous mastectomy in gynecomastia: A randomised controlled trial

Background

Gynecomastia is defined as a benign glandular proliferation of the male breast tissue causing enlargement of the breast and a feminine appearance. Gynecomastia is usually treated surgically in some patients by different techniques.

Aim of the study

is to allow ample excess during excision and to remove excess skin to allow for better cosmetic results using "modified Benelli technique" and to obtain good breast shape with better nipple areola complex position without any breast tension.

Type of the study

Randomised controlled trial study.

Patients and methods

The study included 150 patients with gynecomastia (Grade II and III) for the period between January 2010 and January 2016 who attended private hospitals and Al-Kindy Teaching Hospital. The patients were divided into two groups according to the operative techniques used. Group A included 75 patients treated surgically with subcutaneous mastectomy using periareolar incision. Group B; included the other 75 patients who were managed by "modified Benelli technique".

Results

The subcutaneous mastectomy using "modified Benelli technique" showed a significantly lower operating time due to ample access for excision of breast tissue. Excision of excess skin allowed the areola to retain a cosmetically more acceptable position. There was a lot of pleating of the skin compared to the other technique using the periareolar incision.

Conclusions

This technique namely the "modified Benilli technique" provides a relatively simple method with an aesthetically good outcome to treat gynecomastia with a low rate of complications and recurrences.

Barriers to the Effective Management of Gynecomastia in Adolescents

BACKGROUND

The aim of this study was to explore the impacts of gynecomastia on adolescents, explore the surgical and psychological success of mastectomy, and evaluate the adequacy of insurance guidelines and coverage.

METHODS

American College of Surgeons National Surgical Quality Improvement Program (NSQIP) surgical database from 2010 to 2014 was evaluated for current procedural terminology codes 19300 and 19303, representing mastectomies for gynecomastia and complete mastectomies respectively to compare surgical site complications.

RESULTS

Of 1132 procedures for mastectomy for gynecomastia 1.5% of patients (n = 17) were associated with postoperative superficial surgical site complications. In the same timeframe, a total of 33,124 procedures for simple, complete mastectomy performed with a postoperative surgical complication rate of 2.2% (n = 721). Results of a Chi-squared goodness of fit χ (1, N = 34,997) = 2.10, P > 0.05 suggests no statistically significant difference between incidence of surgical site complications for a mastectomy for gynecomastia versus typical mastectomy.

DISCUSSION

High surgical success rate, coupled with significant improvements in psychosocial functioning suggests that mastectomy is a highly effective intervention for adolescents with gynecomastia. However, due to vague and inadequate coverage and evaluation criteria surgery is often not performed. This paper offers a framework for developing a quantitative system by which to evaluate surgical candidates by adopting well-established guidelines currently in use for reduction mammoplasties and suggests further analysis into a cost/benefit analysis for coverage of the procedure.

Management of gynecomastia-changes in psychological aspects after surgery-a systematic review

Gynecomastia affects up to two-thirds of the male population. For many patients the psychological impact of the disease is substantial. Surgical treatment is indicated when medical treatments fail. Until now, most published research on the subject has focused on how effective surgical treatment is on correcting the cosmetic appearance of the breast. Little is known about the effect of surgical treatment on the psychological aspects of the disease. The aim of this review was to identify the psychological domains affected by the disease and the effect of surgical treatment on these. A systematic search of the published literature was performed. All studies on the subject were evaluated for inclusion and six studies were included in the review. Several of the included studies reported improvement in quality of life and several psychological domains after surgical treatment for gynecomastia. Among these domains, are; vitality, emotional discomfort, limitations due to physical aspects and limitations due to pain. Impact of surgical treatment for gynecomastia seems to be beneficial for several psychological domains. The current level of evidence on this subject is very low and future studies, examining the impact of the surgical intervention for gynecomastia on psychological domains, are greatly needed. More data on this subject could improve the pre-operative evaluation of these patients and help identify the patients that will benefit from treatment.

A split-body study evaluating the efficacy of a conformable surface cryolipolysis applicator for the treatment of male pseudogynecomastia

BACKGROUND

Cryolipolysis is a non-invasive method of body shaping that has been used for male pseudogynecomastia. However, traditional vacuum suction cryolipolysis requires a minimum pinchable fat layer which may not always be present in this area.

OBJECTIVE

To evaluate the efficacy and safety of a conformable surface cryolipolysis applicator for the reduction of male pseudogynecomastia.

MATERIALS AND METHODS

Ten male subjects with pseudogynecomastia received two cycles of cryolipolysis to the breast 6 weeks apart. Ultrasound was used to measure the thickness of adipose tissue.

RESULTS

Seven of 10 patients completed the study. Compared to baseline, the mean ± SD change in adipose tissue thickness was 8.12 ± 6.94 mm for the treated versus 1.03 ± 6.03 mm for the control breast at week 6 (p = 0.014), and 8.71 ± 7.04 mm for the treated vs. 2.66 ± 7.04 mm for the control breast at week 12 (P = 0.16). Four (4) of seven (57%) patients were at least slightly satisfied with the treated breast, and although subject satisfaction was higher in the treated breast, this did not reach significance (0.085). Adverse events were mild and transient.

CONCLUSION

A conformable surface cryolipolysis applicator was effective in reducing the mean adipose tissue thickness in subjects with male pseudogynecomastia. Lasers Surg. Med. © 2018 Wiley Periodicals, Inc.

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 .

No-Drain Single Incision Liposuction Pull-Through Technique for Gynecomastia

BACKGROUND

Several different methods have been proposed for treatment of gynecomastia, depending on the amount of breast enlargement and skin redundancy. The liposuction pull-through technique has been proposed as an efficacious treatment for many gynecomastia cases. This work aims to study the outcome of this technique when applied as an outpatient procedure, without the use of drains and through a single incision.

METHODS

Fifty-two patients with bilateral gynecomastia without significant skin excess were included in this study. The liposuction pull-through technique was performed through a single incision just above the inframammary fold and without the use of drains. Patients were followed up for 6 months.

RESULTS

The proposed technique was able to treat the gynecomastia in all patients, with a revision rate of 1.9% to remove residual glandular tissues. There were no seromas, hematomas, nipple distortion, permanent affection of nipple sensation or wound healing problems.

CONCLUSION

The liposuction pull-through technique is an effective treatment for gynecomastia without significant skin redundancy. It combines the benefits of the direct excision of glandular tissues, with the minimally invasive nature of liposuction. Performing the procedure through a single incision without the use of drains and without general anesthesia is a safe alternative.

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 http://www.springer.com/00266 .

Trends in the Surgical Correction of Gynecomastia

Gynecomastia refers to the enlargement of the male breast due to a proliferation of ductal, stromal, and/or fatty tissue. Although it is a common condition affecting up to 65% of men, not all cases require surgical intervention. Contemporary surgical techniques in the treatment of gynecomastia have become increasingly less invasive with the advent of liposuction and its variants, including power-assisted and ultrasound-assisted liposuction. These techniques, however, have been largely limited in their inability to address significant skin excess and ptosis. For mild to moderate gynecomastia, newer techniques using arthroscopic morcellation and endoscopic techniques promise to address the fibrous component, while minimizing scar burden by utilizing liposuction incisions. Nevertheless, direct excision through periareolar incisions remains a mainstay in treatment algorithms for its simplicity and avoidance of additional instrumentation. This is particularly true for more severe cases of gynecomastia requiring skin resection. In the most severe cases with significant skin redundancy and ptosis, breast amputation with free nipple grafting remains an effective option. Surgical treatment should be individualized to each patient, combining techniques to provide adequate resection and optimize aesthetic results.