Gynecomastia

gynecomastia

1. Gynecomastia DR SAMIK SHARMA

2. Definition Gynecomastia refers to the enlargement of the male breast due to a proliferation of ductal, stromal, and/or fatty tissue . Pseudogynecomastia ( lipomastia ): Excessive development of the male breast from subareolar fat deposition without glandular proliferation.

3. Anatomy of the Gynecomastia Tissue and Its Clinical Significance Unlike the female breast, male glandular tissue contains no lobules . Healthy men typically have predominantly fatty tissue with few ducts and stroma , which is distinctly different from women’s breasts where ducts, stroma , and glandular tissue predominant Gynecomastia is the benign enlargement of this glandular tissue . Transient gynecomastia presents as a florid pattern with an increase in budding ducts and cellular stroma .

4. Demographics It is the most common breast problem in men. Most males experience some degree of gynecomastia during their lives, but definition and reporting are inconsistent. Overall incidence is 32%-36% (up to 40% in autopsy series). Up to 65% of adolescent boys are affected. Up to 75% of cases are bilateral.

5. Clinical Classification Idiopathic (most common) Physiologic Neonatal: Circulating maternal estrogens via placenta Pubertal: Relative excess of plasma estradiol versus testosterone Elderly: Decreased circulating testosterone, peripheral aromatization of testosterone to estrogen

6. Pathologic Classification of Gynecomastia

7. Pharmacologic

8. Histologic Classification Degrees of stromal and ductal proliferation • Florid: Increased budding ducts and cellular stroma ; seen in gynecomastia that is present for approximately 4 months • Intermediate: Overlapping florid and fibrous patterns • Fibrous: Extensive stromal fibrosis, minimal ductal proliferation; seen in gynecomastia thatis present for 1 year

9. The duration of gynecomastia is the most important factor in determining the pathologic picture. Florid pattern response well to medical treatment, while fibrous type needs surgical management.

10. Risk of Malignant Transformation No increased cancer risk for patients without Klinefelter’s syndrome Klinefelter’s syndrome: Risk increases 60-fold (1:1000 increases to 1:400)

11. Preoperative Workup History Age of onset Duration Symptoms Medications Recreational drug

12. Physical Examination Fat versus glandular predominance, laterality, ptosis, skin excess, masses Differentiate true gynecomastia from pseudogynecomastia . Rule out breast cancer . Testicular examination Thyroid , liver, or other abdominal masses Lack of male hair distribution Feminizing characteristics

13. Clinical manifestation Gynecomastia usually manifests as a palpable, discrete button of tissue radiating from beneath the nipple and areola. Gynecomastia feels “ gritty ” when the breast is pinched between the thumb and forefinger. Fatty tissue ( Pseudogynecomastia ), unlike gynecomastia , will not cause resistance until the nipple is reached. (Difference in clinical examination).

14. Additional diagnostic tests General labs : Blood testosterone, TSH/free thyroxine , luteinizing hormone (LH), human chorionic gonadotropin ( hCG ) Small, firm testes : Karyotyping, because hallmark finding in cases of 47,XXY Abnormal testicular examination results or mass : Testicular ultrasound, b-human chorionic gonadotropin (b- hCG ), follicle-stimulating hormone (FSH), LH, serum testosterone, orestradiol

15. Classification Webster : Based on tissue type Type I: Glandular Type II: Fatty and glandular mix Type III: Simple fatty

16. Simon et al: Based on degree of tissue and skin excess Type I: Minor breast enlargement without skin excess Type II: Moderate breast enlargement IIa : Without skin excess IIb : With minor skin redundancy Type III : Gross breast enlargement with skin excess creating a pendulous breast

17. Staging ( Rohrich et al) Grade I: Minimal hypertrophy (250 g) with no ptosis Ia : Primarily glandular Ib : Primarily fibrous Grade II: Moderate hypertrophy (250-500 g) with no ptosis Ia : Primarily glandular Ib : Primarily fibrous Grade III: Severe hypertrophy (500 g) with grade I ptosis Grade IV: Severe hypertrophy with grade II or III ptosis

18. Management Idiopathic Observation Gynecomastia often regresses after 3-18 months of enlargement. Gynecomastia that is present for 12 months rarely regresses because of tissue fibrosis. Weight reduction if obese Surgery

19. Physiologic Tamoxifen ( Nolvadex ) is particularly useful for “lump”-type gynecomastia . Clomiphene citrate is used with limited success. Aromatase inhibitors ( letrozole , testolactone ) show therapeutic potential in early trials but efficacy is not confirmed. Testosterone has limited ability to induce regression once gynecomastia is established. Danazol , a synthetic testosterone derivative, has been used with some success in pubertal gynecomastia ; however, side-effect potential is high.

20. Pathologic Removal of testicular tumors Correction of underlying causes or disease Remove offending drug in pharmalogical causes

21. Radiation Prophylactic breast irradiation may have some benefit in reducing the incidence of gynecomastia in patients on long-term antiandrogen therapy (e.g., prostate cancer). Risk of malignancy with this type of exposure is not defined. There is no indication for use in cases of idiopathic gynecomastia .

22. Surgical Options Techniques Periareolar or intraareolar incisions Offer direct access for tissue resection Transaxillary incisions For select cases; limited operative exposure All types of dermal and glandular pedicles for nipple relocation Free-nipple grafting Allows en bloc resection of skin and breast tissue

23. Traditional and ultrasound-assisted liposuction (UAL) Basic tenets of UAL treatment Superwet infiltration Stab incisions at inferolateral aspects of intramuscular fat Radial pattern across entire chest Disruption of intramuscular fat Avoid upper lateral pectoral region Dressing: Two layers of Topifoam compression vest for 4 weeks continuously, then 4 more weeks at night

24. Arthroscopic shaver Allows precise resection of fibrous tissue after liposuction or en bloc resection

25. Mild to Moderate Gynecomastia (Simon Grades I and IIa , and Rohrich Grades I and II) Milder forms of gynecomastia are quite common and 65% of men are thought to have some degree of gynecomastia , the proportion seeking surgical treatment is much lower p atients with minimal glandular hypertrophy typically have little skin excess and are treated readily with liposuction, frequently as the definitive treatment some patients present with small amounts of fibrous gynecomastia well localized under the nipple and may be effectively treated with direct excision using a small periareolar incision

26. Power-assisted (PAL) and ultrasound-assisted liposuction (UAL) technologies have increased the extent of tissue removal capable by liposuction The improved skin retraction often associated with UAL has allowed it to be used as a definitive treatment modality in many cases. Relatively high energy levels are used, with higher levels focused under the nipple to assist with removing the fibrous glandular tissue. Access ports are generally made at the lateral inframammary fold (IMF) combined with a periareolar or upper anterior axillary incision to allow for cross-hatching

27. Vibration amplification of sound energy at resonance- ( VASER) assisted liposuction is a newer form of UAL technology utilizing the application of alternating ultrasonic energy which is considered by many practitioners to be a safer modality when treating fibrous areas close to the skin surface

28. Even in mild forms of gynecomastia , there may be a residual glandular component that needs to be addressed after liposuction. A low threshold for direct excision should be maintained, as residual firm, subareolar glandular tissue can be a great source of patient dissatisfaction. In patients for whom liposuction is not entirely sufficient, glandular tissue requires direct excision either primarily, or in a staged fashion, accompanying skin excision . “Pull through” technique described by Morselli , which describes blindly dissecting the breast parenchymal tissue from the skin and pectoral fascia then grasping and pulling the tissue out through the liposuction incision for piecemeal excision through liposuction incision

29. reinforced or laser-sharpened cannulas, have been explored to allow for removal of this fibrous component as well . Most recently, the use of orthopedic arthroscopic shavers has gained popularity, patients were treated with liposuction followed by arthroscopic shaver morcellation to address any residual glandular component

30. Severe Gynecomastia (Simon Grade IIB and Rohrich Grade III) Patients with severe gynecomastia will usually require some form of skin resection Many techniques utilizing various skin excision patterns and pedicles similar to those used in female mastopexy and reduction mammoplasty have been used Letterman described the use of an oblique Dufourmentel-Mouly procedure based on an elliptical incision with a bipedicled dermal areolar flap. however , has large oblique extra-areolar scar extending laterally , much like a traditional mastectomy.

31. Wise-pattern scars and glandular pedicles similar to those in traditional reduction mammoplasty . These techniques present many drawbacks for male patients . Not only do these procedures often leave excess glandular tissue behind, but the Wise pattern frequently causes coning of the breast and unacceptable scarring.

32. C ircumareolar excision allow for skin excision without extra-areolar scarring. This technique relies on a central mound with an intercostal blood supply through the prepectoral fascia. Similar techniques, as described by Botta , recognize nipple–areolar complex (NAC) viability on the subdermal plexus alone and utilize superiorly based dermo -glandular flaps, allowing for a more uniform excision of breast tissue

33. Severe Gynecomastia with Grade II or III Ptosis (Simon Grade III and Rohrich Grade IV)

34. In cases of severe gynecomastia with marked ptosis and extreme skin excess, other incisions which cause extra-areolar scarring may be required. For these cases, the most reliable and simple technique is breast amputation using an IMF incision with free nipple grafting These procedures have become increasingly necessary as the population of massive-weight-loss patients grows.

35. The new NAC is drawn as a horizontal oval ∼3 cm in diameter at the fourth intercostal space; however, the size varies depending on the patient's overall body habitus . Again, initial liposuction is performed. The incision is made in the IMF and carried down to the level of the pectoral fascia. The glandular tissue is then dissected off the fascia to the level of the second intercostal space. The nipple is removed as a full-thickness graft. The superior flap is then pulled inferiorly to estimate and mark the excision of excess skin and soft tissue. The IMF incision is closed in layers over a drain. Finally, the nipple is placed onto a de-epithelialized bed and secured with a bolster dressing.

36. Complications/Outcomes Potential complications from gynecomastia surgery include hematoma , seroma , infection, inadequate resection , poor scarring , contour deformity , breast asymmetry , sensory changes , pain.

37. Overall complication rate has been reported between 14.5 to 53%, with hematoma being the most common . The most common late complication is inadequate resection of glandular tissue or skin.

38. Summary Many patients will obtain adequate correction with less invasive techniques such as ultrasound-assisted liposuction . In patients with significant skin excess or poor skin elasticity, excellent results can be achieved with a single-stage procedure using a combination of UAL, direct excision, and periareolar skin excision to flatten the breast and remove the excess skin and volume. Only patients with the most severe excess skin redundancy require techniques involving an elliptical skin excision or breast amputation with free nipple grafting.