Chapter 9 Management of Gynecomastia

Gynecomastia may be defined as enlargement of the male breast. However, from a surgical point of view, it may be more helpful to view the condition as a persistent enlargement of the breast as transient breast enlargement during puberty is actually a normal finding occurring in up to 65% of normally developing adolescent boys. It is this persistence that generally motivates patients to seek treatment as the enlarged breast can create a significant contour deformity when compared to the appearance of a normal male chest contour. From a therapy standpoint, there are three main presentations of gynecomastia that require slightly different approaches when it comes to designing an appropriate course of treatment.

Adolescent gynecomastia – As a consequence of the changing hormonal environment that occurs in the adolescent male, end organ responses in the character and size of the breast can occur. As a result, variable thickening and enlargement of the breast is commonly associated with early sexual development beginning as early as age 12. The likely cause of this end organ response is related to a change in the ratio of normal circulating hormones responsible for secondary sexual development. In the majority of cases, these changes are short lived and the breast simply regresses back to a more normal appearance over a time period of 1 to 2 years. However, in a small subset of patients, these changes can persist, resulting in an enlarged breast contour.

The hallmark finding in patients with adolescent gynecomastia is a firm, fibrous mass of tissue that develops directly under the areola (Figure 9.1). This mass can be variable in size and can herniate through the elastic areolar skin, resulting in a very obvious contour abnormality. In addition, it is not uncommon for a surrounding fibrofatty stroma of varying volume to develop in concert with the subareolar mass. The magnitude of this fatty overgrowth is directly related to the body habitus of the patient with more obese patients tending to demonstrate a more dramatic increase in the size of the breast (Figure 9.2). Along with the general breast overgrowth can be noted an excess of skin to the point that actual ptosis of the breast mound can be noted (Figure 9.3). Finally, as a result of the enlarged subareolar breast bud along with the general increase in the volume of the breast, the diameter of the areola can increase significantly, all of which combines to create a decidedly abnormal breast contour for a young adolescent male (Figure 9.4).

Figure 9.1 Adolescent gynecomastia very often presents as an isolated fibrous mass directly under the areola. This mass causes a variable protrusion through the elastic areolar skin along with widening of the areolar diameter.

Figure 9.2 With increasing levels of obesity, the surrounding fibrofatty stroma can undergo significant hypertrophy leading to the formation of a prominent breast-like contour. In adolescent boys such as this, it is easy to understand the emotional trauma that can result from such a condition.

Figure 9.3 As the breast enlarges, the elastic skin envelope can exhibit varying degrees of ptosis. In severe cases, the magnitude of the deformity can be dramatic.

Figure 9.4 As the volume of the breast increases, the areolar diameter can widen, creating an overall look similar to that seen in adolescent girls with a tuberous breast deformity.

Senescent gynecomastia – Alternatively, persistent gynecomastia can develop later in life, generally after the age of 50. Here the nature of the enlarged breast is slightly different as the fibrofatty component of the breast tends to be more predominant (Figure 9.5). Generally, the patient will experience a gradual enlargement of the breast that develops over the course of a year or more and this enlargement will often be tied to an overall gain in weight. A subareolar thickening may be noted but the enlargement of the breast is more diffuse in the older male and often there will be associated fatty deposition under the arm and higher up onto the chest wall toward the clavicle. Again, a change in the ratio of the sex hormones may be responsible for this change in body habitus with the natural decline in circulating levels of testosterone that is noted with advancing age being the likely etiologic factor. These patients generally seek treatment in an effort to restore a more normal overall male chest wall contour.

Figure 9.5 (A,B) Senescent gynecomastia in a 60-year-old man. With advancing age, the general size of the breast has increased to the point where it has become uncomfortable for the patient to wear even casual clothing such as golf shirts without being conscious of the prominent breast contour. In this setting, the etiology for the breast enlargement is hypertrophy of the surrounding fibrofatty stroma as opposed to a prominent subareolar breast bud. Treatment is therefore directed more at a general volume reduction of the breast as opposed to direct subareolar excision.

Pathologic gynecomastia – Gynecomastia occurring during the relative extremes of life, i.e. in teenage boys or middle to aged to older men, is not an unexpected finding as it can develop as a normal consequence of changing hormonal levels that can occur at these times in life. Gynecomastia developing suddenly at any other time must be considered to be a pathologic finding until proven otherwise. An example of a case of pathologic gynecomastia would be the sudden development of a fibrous type of gynecomastia in an otherwise healthy 35-year-old man with no change in medication or drug history. In such a patient, a tumor that may be actively secreting sex hormone-like compounds must be suspected and an appropriate workup undertaken. Other factors that might arouse suspicion for pathologic gynecomastia include rapid onset, pain, bilateral involvement and tissue overgrowth that is predominantly fibrous and located in the subareolar area.

One specific variant of pathologic gynecomastia is that which occurs as a result of exogenous hormone administration. Gynecomastia has been noted to develop as a result of recreational drug use with marijuana being widely recognized as a common cause of the condition. Also, young males involved in the sport of bodybuilding will sometimes develop a very discrete and fibrous subareolar type of gynecomastia secondary to the use of either injectable or oral testosterone or testosterone precursor-like drugs, along with a whole host of other anabolic steroid type substances. Screening for any history of drug use becomes particularly important in these types of patients in order to clarify the etiology of the condition and, as well, to develop an appropriately targeted treatment plan. Specifically, it is highly advisable that such patients discontinue all exogenous drug use prior to undergoing any form of surgical treatment.

Indications for Treatment

Although pain may occasionally be noted in patients with gynecomastia, it is most certainly the altered chest contour along with the emotional sequelae of the condition that motivates nearly all patients to seek treatment. This is particularly true in adolescent males. It must be recognized that the teenage years are a vitally important time period during which significant social and emotional growth occurs. In these patients, even modest cases of gynecomastia can result in social withdrawal and avoidance of any situation that will require the patient to take his shirt off. As a result, important social activities including participation on athletic teams, swimming and even casual interaction with other peers are avoided secondary to the embarrassment the patient feels about his appearance. Once gynecomastia is recognized, it is reasonable to delay definitive surgical excision for up to 2 years or more, as some patients will spontaneously regress on their own as their internal hormonal environment stabilizes. Typically, this will occur by the age of 15. However, should any degree of social withdrawal become noticeable as a result of the condition, it is entirely reasonable and recommended to proceed with surgical treatment.

Special mention must be made concerning those patients who present with gynecomastia in association with significant obesity. Certainly, in these patients, the major cause of the enlarged breast contour is the excess general fatty accumulation. Although some stromal overgrowth in the subareolar region may be present, it is generally overwhelmed by the significant amount of fat present in the breast. This combination can often lead to surprising levels of breast development that can result in significant breast ptosis (Figure 9.6). Therefore, while any first line therapy would best be directed primarily at weight loss, the adverse effect such breast development can have on a patient who is likely already struggling with body image issues can be quite damaging. For this reason, it is very reasonable and even advisable to proceed with surgical correction of gynecomastia in the obese. Normalizing the contour of the chest wall may well allow the patient to make appropriate lifestyle changes later in life as he matures that will lead to a healthier body composition.

Figure 9.6 In the obese, the prominence of the breast contour can be striking even taking into account the generalized elevation in the body mass index. Restoration of such patients back to a normal male chest contour can assist greatly in allowing normal social development to take place unencumbered with feelings of deformity.

In older men, the enlargement of the breast has typically occurred over a longer period of time in association with a progressive weight gain. As such, the composition of the breast is largely fatty in nature. In these cases, there is generally less of an emotional overtone to the condition and, as a result, less urgency in arriving at a surgical solution. If lifestyle changes are either unsuccessful or simply declined by the patient, appropriate treatment is often directed at the entire anterior and lateral chest wall in an effort to recontour the whole of the upper anterior torso.

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