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Breast Surgery

Gynecomastia procedure

Authors Mia Demant, MD, Christian Kaare Paaskesen med. student, Hasan Gökcer Tekin, MD, Magnus Balslev Avnstorp, MD, Mia Steffensen, MD

Definition

Benign enlargement of the male breast, caused by an increase in ductal tissue, stroma, and/or fat. The condition is most frequent due to hormonal changes.

Background

Gynecomastia was first introduced by Galen of Pergamon during the 2nd century AD, the surgical resection was first described by Paulis of Aegina in the 7th century AD. Suction-assisted lipectomy was first performed in the 1980s, and more recently ultrasound-assisted liposuction has been used.

Incidence

The incidence of gynecomastia (GM) is between 25 to 65 percent, depending on selection criteria. It is most commonly seen in hormonal transition phases such as neonatal age, puberty, and the age after 50 years.

Etiology

GM in adult men can be the first symptom of an underlying disease, and a thorough investigation is recommended. Treatment of an underlying cause of GM is the first-line treatment. Besides the physiological causes, the pathological or induced changes can be multiple, including:

  • Medical drugs, e.g. antiandrogens (i.e. finasteride), antihypertensive (spironolactone), exogenous hormones (i.e. prednisone), marijuana, and gastrointestinal drugs (H2 histamine receptor blockers)
  • Pathological hormonal changes, i.e. pituitary tumors (prolactinomas) and testis tumors (Leydig and Sertoli cell tumors)
  • Alcohol abuse or overuse via adverse effects on the liver
  • Klinefelter’s syndrome
  • Kidney disease
  • HIV
  • Cannabis abuse

Pathophysiology

GM is most often caused by increased estrogen activity, decreased testosterone activity, or the use of numerous medications. The hormonal imbalance between estrogen and androgen eventually leads to ductal hyperplasia, i.e. glandular tissue proliferation. This can be caused by estrogen-secreting neoplasms, but more commonly are the conversion of androgens to estrogens by tissue aromatase (as occurs in obesity). In Klinefelter’s syndrome, levels of free testosterone are low because of gonadal failure, and conditions like chronic liver disease result in alterations of serum levels of sex hormone-binding globulin, which again disturbs the balance between free testosterone and estrogen. Androgen receptors can also be blocked by certain medications, while estrogen receptors can be activated by others, together with environmental exposures.

Many obese people have so-called ‘pseudo-GM’, where adipose tissue is illusory glandular tissue and can even give ptotic breasts.

Breast cancer as a differential diagnosis

It is of great importance to distinguish benign GM from potential breast cancer. Breast cancer in men is a rare disease with approximately 30 cases annually in Denmark. The median age of onset is 70 years (10 years later than women’s) and patients, who meet the criteria below should be referred to a breast surgery center in a cancer patient pathway:

  • A suspicious lump in one breast
  • Inverted nipple (new)
  • Indentation of skin (new)
  • Nipple-areola eczema or ulceration (Morbus Paget)
  • Clinically suspicious axillary lymph nodes

Relevant Anatomy

In the case of GM, the male breast poses a pyramidal shape with feminine features. Different from the female breast, male breast tissue contains no lobules and is rather dense. It is placed above the pectoralis major muscle and under the nipple-areolar complex (NAC) in close relation to the adipose tissue.

Pre-operative planning and considerations

Physical examination and patient history are crucial in ruling out pseudo-gynecomastia and other causes than primary gynecomastia (see causes in pathophysiology). The prevalence of asymptomatic gynecomastia is 70% in men aged 50-69 years, whereas symptomatic gynecomastia is marked lower. Pre-operative examination includes: 

Patient history

  • Note the age of onset and duration
  • Ask about recent changes in nipple size, pain or discharge
  • Inquire if the patient has any history of testicular trauma or mumps
  • Ask about any alcohol- or drug use (both prescription- and over-the-counter medications together with recreational drugs)
  • Catch up if there is a history of GM in the family
  • Finally, evaluate if the patient has any sexual dysfunction, infertility or hypogonadism

Physical examination

Most commonly, GM presents bilaterally, but unilateral is may be seen as well. When palpating the affected breast(s), you feel an elastic, rounded and discoid process, located centrally beneath the NAC. The glandular tissue is tender and only in 2 percent, nipple discharge occurs. 

When assessing the level of GM, the Tanner Scale (grade 1-5)  is often used.

Tanner Scale

Figure 1. Tanner Scale.
Grade 1: No glandular tissue. Grade 2: Forming breast buds. Small area of surrounding, glandular tissue. Widening of areola. Grade 3: Breast more elevated, extending around the areola area, but remains following the skin contour. Grade 4: Increased breast size and elevation. NAC elevated from the skin. Grade 5: Final breast development. NAC again in contour of the breast with a central projection.

Additional physical examination

  • Breast ptosis and residual skin
  • Breast gland or adipose tissue? Isolated masses and tenderness
  • Palpation of thyroid gland and testes
  • Palpation of lymph nodes (breast cancer?)

Indications for endocrinologic and surgical assessment

No indications for assessment:

  • Lower grades of GM/pseudo-GM (Tanner scale 1-2)

Indications for endocrinologic assessment:

  • Pronounced discomfort
  • Persistent GM (more than a year)

Indications for plastic surgery (at public hospitals in Denmark):

  • Tanner Scale 3-5 (see above),
  • BMI ≤ 25 kg/m2, and
  • Unbearable tenderness and social embarrassment
  • Normal hormonal status
  • Non-smoker
  • To be a candidate for surgery, any underlying disease have to be excluded by an endocrinologic assessment.

Surgical options

The surgical technique depends on the size of the breast, skin elasticity and the skin envelope/residual skin. Different surgical approaches can be used depending on the patient’s anatomy:

Figure 2. Surgical techniques for gynecomastia.

Depending on the chosen technique, certain risks must be taken into consideration:

Semicircular incision

  • Low visibility, higher rate of hematoma
  • Chest discrepancy because of remaining tissue in the upper chest
Figure 3. Semicircular incision.

Periareolar approach

Scaring around the areola

Figure 4. Periareolar approach.

Subcutaneous mastectomy

Wide and distinct scar, especially if there is no chest hair. 

Figure 5. Subcutaneous mastectomy and liposuction.

Preoperative information

Pre-operative expectation alignment is essential, and information includes the risk of bleeding, seroma, loss of sensation, scarring, indented nipple and necrosis of nipple and skin. 

Step by step procedure

The traditional surgical treatment of GM in Denmark is liposuction combined with a subcutaneous mastectomy ad modum Webster.

The patient is marked while standing, where areas of excess glandular tissue is visualized. Access is created through a semicircular incision, from where excess glandular tissue is removed.

The breast ducts are divided while retracting the areolar flap
Breast tissue excision while traction is maintained outwards aided by a Kocher clam

Prior to the liposuction procedure, Klein’s solution is introduced into the fat. Klein’s solution contains lignocaine, epinephrine, and large amounts of saline. The saline balloons the fat tissue, epinephrine causes vasoconstriction, thus, decreasing bleeding, and lignocaine induces local anaesthesia.  

Alternative techniques includes liposuction through smaller, peripheral incisions, and the glandular tissue can hereafter be removed through these small incisions.

In severe cases with a large skin excess, it is often necessary with skin removal by either a concentric of vertical mastopexy.  

Postoperative care

Vitality of NAC is controlled with capillary response. Compression garments has to be worn for 2-4 weeks. No lifting of more than 5 kilograms and no sports/physical activities for 3-4 weeks after surgery. 

Follow-up

Clinical control 3 months after surgery. 

Pearls and pitfalls

Pearls

  • The physical appearance determines the choice of surgical technique:
    • Breast size
    • Skin elasticity
    • Excess skin
  • Leave more tissue under the nipple and areola than less
  • To define the desired periareolar diameter, use a purse-suture
  • The patient’s opinion about scarring should always be taken into consideration
  • Consider a minimal-scarring technique (liposuction or semicircular) following a second stage procedure after 6-9 months to allow maximum skin-retraction.

Pitfalls

  • Be careful with under/over-resection when performing liposuction alone
  • Drug-induced gynecomastia takes several months to recover from

References

12. Thorne, Charles Hm et al, Grabb and Smith’s Plastic Surgery (Wolters Kluwer, 7th ed, 2013;2014;)

13. Sansone A, Romanelli F, Sansone M, Lenzi A, Di Luigi L. Gynecomastia and hormones. Endocrine. 2017 Jan 1;55(1):37–44.

14. Swerdloff RS, Ng CM. Gynecomastia: Etiology, Diagnosis, and Treatment. In: Feingold KR, Anawalt B, Boyce A, Chrousos G, de Herder WW, Dungan K, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000 [cited 2020 Oct 22]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK279105/

15. Kjems E, Tranberg Kejs AM. Statistik om brystkræft hos mænd. 2019;

16. Blau M, Hazani R, Hekmat D. Anatomy of the Gynecomastia Tissue and Its Clinical Significance. Plast Reconstr Surg Glob Open [Internet]. 2016 Aug 30 [cited 2020 Jun 9];4(8). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5010345/

17.  Johnson RE, Murad MH. Gynecomastia: Pathophysiology, Evaluation, and Management. Mayo Clin Proc. 2009 Nov;84(11):1010–5.

18. Paulsen JF, Berg JO, Kroman N, Mieritz M, Jørgensen N. [Gynaecomastia]. Ugeskr Laeger. 2018 22;180(4).

19. Rohrich RJ, Ha RY, Kenkel JM, Adams WP Jr. Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction. Plast Reconstr Surg. 2003 Feb;111(2):909-23; discussion 924-5. doi: 10.1097/01.PRS.0000042146.40379.25. PMID: 12560721.

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