Sunday, April 25, 2010

Gynecomastia

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Gynecomastia means enlargement of the male breast. The definition has nothing to do with what causes the enlargement or what tissue it is composed of. It is most common around puberty & can involve one or both sides of the chest. Most commonly the enlargement is centralized in the breast but occasionally it is not. It is present to some degree in about a third of male population. It appears either early in adolescence or later in the adult years of life and can be very disruptive in the life of a teenager or adult. Working out in the gym, going to the beach and changing in the locker room can become unpleasant ordeals.



The causes can be classified as:

    • Physiological
    • Newborn-caused by placental hormones & resolves within a few weeks
      by itself
    • Adolescence-caused by alterations in estrogen:testosterone ratio & usually resolves after puberty (usually within 1 to 2 years only 7% of patients still have it after 3 years and 65% of adolescent boys have a temporary breast bud), 25% of all cases
    • Aging (involutional)-caused by testicular failure & treated by testosterone
      replacement
    • Obesity-caused by the conversion of androgens to estrogen in peripheral fat & treated first by diet/exercise/weight loss
    • Pathological
    • Deficient production or action of testosterone
    • Congenital defects
    • Testicular infection
    • After testicular trauma
    • Increased estrogen production as occurs with obesity or certain tumors
    • Tumors within the breast or other organs
    • Liver, adrenal or thyroid disease including alcohol induced liver disease, 10% of all cases
    • Decreased serum testosterone from kidney failure & hemodialysis, 1% of all cases
    • Drug Induced - 10 to 20% of all cases
    • Steroids including anabolic steroids used by body builders
    • A wide variety of prescribed medicines such blood pressure medication
    • Heroin
    • Marijuana
  1. Familial-inborn error of metabolism

The majority of cases are physiological or drug induced. Evaluation
by a qualified physician is required to see which category you fall into.
The treatment of the physiological category is straightforward while the
pathological is more complicated. Drug induced gynecomastia just requires
stopping use of the drug. If the gynecomastia is resistant to treatment
or is the adolescent type but persistent surgery is required. Gynecomastia arising before the onset of puberty requires a vigorous diagnostic workup because of the possibility of life threatening or shortening pathology.

Grades of Gynecomastia
The specific surgery required for treatment depends on the type of tissue contributing to the breast enlargement and the severity of gynecomastia i.e. the amount of extra skin present. Gynecomastia is graded as follows:
  • Grade I =Small breast enlargement with localized button of tissue that is concentrated around the areola. This is usually glandular with minimal fat contribution and only requires surgical removal of the glandular tissue. I prefer to do this through an incision around the lower half border of the areola so it is less visible after surgery.Grade I Gynecomastia
    Grade I Gynecomastia
  • Grade II =Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. These are fatty-glandular and require surgical removal of glandular tissue with or without removal of adjacent fat to give the best overall shape. I prefer to remove this fat using liposuction because that gives the best skin surface contour afterward. Usually these patients do not require any skin removal.Grade II Gynecomastia
    Grade II Gynecomastia
  • Grade III =Moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy present. This patients require skin removal and the pattern of removal/incision is based on the amount of skin that needs to be removed. Smaller skin removals can just be ellipses or half moon shaped sections right next to the areola.Grade IIIa Gynecomastia
    Grade III Gynecomastia-moderate severity

    Grade IIIb Gynecomastia
    Grade III Gynecomastia-more severe
  • Grade IV =Marked breast enlargement with skin redundancy and feminization of the breast. These require removal of breast tissue under the skin and the breast skin as well.Grade IV Gynecomastia
    Grade IV Gynecomastia
The American Society of Plastic Surgeons has recommended health insurance coverage for grade III and IV adult gynecomastia. Surgery for grade I and II is not considered medically necessary, it is cosmetic and therefore insurance coverage is not recommended. Individual health plans however differ in their written policies for coverage of gynecomastia. At least in California coverage of Grade IV is mandated by state laws regarding insurance coverage of reconstructive surgery.

Dealing with Extra Skin
gynecomastiaThe way to assess the amount of excess skin is to take the measurements depicted above. The sternal notch to nipple distance should be 18 to 20cm, the midline to nipple distance should be 11cm, areola diameter should be 3cm and the nipple to chest abdomen junction should be 5 to 6 cm apart. Deviations from these measurements should be taken into account when planning the pattern of skin removal that needs to be removed at surgery. In most patients with extra skin the breast tissue has stretched the overlying skin, gravity pulls it downward and the treatment is simple removal of a crescent of skin above the areola. Some surgeons believe that the skin will shrink after removal of the underlying breast tissue and therefore never remove any skin. Although this may be true for patients in their early teens I do not believe that is the case for adult patients past that age. In my experience these patients are very unhappy if excess skin when present is not addressed at the same surgery. The common failure to deal with skin excess accounts for reported dissatisfaction rates of 50%. In grade IV cases the surgeon is not left with much choice so larger skin excisions with more visible skin scar are the unfortunate trade off. In grade III cases more superficial liposuction can result in more skin shrinkage and disruption of the inframammary fold is essential in that it allows the skin to drape more naturally onto the abdomen. These 2 maneuvers allow the surgeon to deal with the excess skin while leaving less skin scars.

After liposuction and rhinoplasty, gynecomastia surgery is the third most common cosmetic surgery procedure performed on men in the United States.

CASES

gynecomastiagynecomastiaThis is a 29 year old, 5' 11" tall, 186 pound indvidual with sternal notch to nipple distances of 23cm and nipples 11cm from the midline. These measurements indicate that there was excess skin before surgery. I performed liposuction to remove the fat portions, directly cut out the glandular portions behind the nipples and then cut out 2cm high crescents of skin from just above the areola. I chose that method to get the most results with the smallest amount of skin incisions.


gynecomastiaThis is a 29 year old, 5'10" 220 pound individual who had lost 130 pounds by dieting. This left him with a lot of excess skin over large areas of the body. In this case I cut out the excess fat and removed a 1cm crescent of skin from the upper edge of the areola. He had an abdominoplasty - tummy tuck at the same time and I was able to pull some chest skin down towards the abdomen in the process which gave him more chest skin tightening with less chest skin scarring.

gynecomastia
gynecomastia mastectomyThis is a 33 year old individual with feminizing features. The sternal notch to nipple distance was 21.5cm on the right and 22cm on the left, midline to nipple distance was 8cm and areola diameter was 4cm. This case is clearly more severe than the others and in order to achieve a male appearance the nipples have to be shortened, the areola diameter decreased and extra skin and breast tissue removed. I did so by removing an ellipse of skin with underlying breast tissue. The upper edge of the ellipse lied above the areola while the lower edge was at the chest-abdomen junction. I then sutured the edges together and created a new smaller hole for nipple and areola in a better position on the chest wall.
video

January, 25, 2012 Addendum:
The Wachbataillon unit of the German army performs precision military drills at official ceremonial functions. Many of these drills involve smacking rifles against the left side of the soldiers' chests. In a study of the German soldiers a significant difference was found between the guards in this unit with gynecomastia and a control group of healthy males without signs of gynecomastia. Over 70 percent of the German battalion's soldiers have been diagnosed with significant gynecomastia on the left side. All that pounding on the same spot has stimulated the production of hormones that cause breast growth. Maybe there is something to slapping your way to larger breasts.

Gynecomastia

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