Gynecomastia

Gynecomastia is defined as benign enlargement of the male breast due to proliferation of the glandular tissue.

Gynecomastia is the result of imbalance between the estrogens and testosterone in the male body whereby the stimulatory effect of estrogen on breast tissue exceeds the inhibitory effect of testosterone.

Often, gynecomastia occurs at birth, but most cases are discovered during puberty, with the peak incidence between 14-15 years of age. When occurring during puberty the condition is usually self-limited and will regress within 2 years.

Gynecomastia can be classified either physiological or pathological.

Physiological gynecomastia is usually seen in newborns, adolescents or aging men. In neonates, circulating maternal estrogens at birth stimulate neonatal breast tissue to hypertrophy. This condition usually resolves spontaneously within a few weeks. The average age of onset of adolescent gynecomastia is 14 years and it commonly disappears by 20 years of age.

Pathological gynecomastia includes estrogen excess(estrogen secretion from neoplasms-testicular, lung, pituitary, or increased substrate for the actions of peripheral aromatase-cirrhosis, thyroid excess, adrenal disease and starvation), androgen deficiency (congenital anorchai, Klinefelter’s syndrome, androgen resistance, defects in testosterone synthesis and secondary testicular failure), or drugs that interfere with normal estrogen-testosteron balance(estrogens, marijuana, heroin, gonadotropins, inhibitors of testosterone).

Treatment

Before considering treatment, it is important to keep in mind that gynecomastia may regress spontaneously. Although surgery is indicated as a diagnostic procedure, patients often request surgery as treatment for the physical discomfort or emotional distress that is common in men with this condition. Most patient who visit a plastic surgeon request treatment for psychological reasons.

Surgery remains the accepted standard for management of gynecomastia, especially in patients with long standing gynecomastia and fibrotic breast tissue. Surgical options can range from simple excision to a more complex, inferior pedicle breast reduction. The two most widely used surgical techniques are the subcutaneous mastectomy and liposution-assisted mastectomy.

Subcutaneous mastectomy

Several approaches may be used when performin an open subcutaneous mastectomy. The choice of incision should be guided by the degree of gynecomastia present.Patients with small or moderate gynecomastia may have an intra-areolar incision along the inferior hemisphere of the nipple (Webster incision).

Moderate or massive gynecomastia may require skin resection along with nipple relocation or nipple grafting. With massive gynecomastia, en bloc resection of skin and breast tissue with free nipple grafting can be performed through an elliptical incision.

In cases of severe gynecomastia, the dissection my be carried to the level of the pectoralis major fascia and may require the use of postoperative suction drains.

Liposuction-Assisted Mastectomy

For several years we perform endocopic assisted mastectomy with liposuction through an axillary incision in lieu of open mastectomy. With this technique there is less compromise of the blood supply as well as a decreased risk of nipple distortion. Postoperative complications such as hemorrhage, infection, hematoma, seroma and nipple necrosis have been minimized with suction lipectomy.

More recently we introduced in our clinic a new approach in gynecomastia treatment – ultra-sound-assisted liposuction(UAL). It has been introduced in conjunction with standard liposuction as a safe and effective method of treatment for gynecomastia, especially in cases where dense fibrous tissue is involved.

The ultrasound probe is introduced through an axillary or inframammary incision and advanced through the dense parenchymal tissue. Energy from the ultrasound waves cavitates and emulsifies breast parenchyma that may be removed via suction lipectomy.

Cosmedica Clinic recommends: We strongly recommend to our patients that have a small or moderate grade of gynecomastia, to choose for the liposution – assisted mastectomy, because of its benefits in short and long term postoperative recovery.