What is Gynaecomastia?
The term gynaecomastia comes directly from the Greek word literally meaning : female breast. Normally male breast tissue is vestigial and any enlargement more than 0.5cm is the standard for diagnosis. The normal male nipple diameter is 2.8 cm (range 2-4cm). The distance from the top of the breast bone to the nipple is normally about 20 cm.
How common is gynaecomastia?
It is far more common than commonly thought – up to 65 % of pubertal males having some degree of gynaecomatia. In later life up to 40 % of males over the age of 65 have some degree of gynaecomastia. Bilateral involvement is very common and occurs in up to 90 % of cases, although the enlargements are often not symmetrical.
What causes gynaecomastia?
Essentially the cause of gynaecomastia is an alteration in the Testosterone : Oestrogen ratio. In about 25 % of cases, no underlying mechanism will be found.
The processes may be considered either physiological (non-disease) or pathological (disease) :
A. Physiological (Non-Disease State)
1. Neonatal – due to maternal oestrogens – no treatment is required.
2. Puberty – occurring in the majority of males. Treatment is indicated if the enlargement is significant or present for more than 1-2 years.
3. Old age – from the 6th decade onwards lowered testosterone production is the cause.
B. Pathological (Disease States)
1. Drugs taken for Therapeutic reasons, such as Hormonal (Ostrogen & Anti-androgens), Anti-hypertensives (High blood pressure medication), Anti-nausea agents (Cimetadine), Antibiotics (Ketoconazole), Sedatives (Diazepam) and Anti-cancer Drugs. Drugs taken for recreational reasons (Heroin, marijuana and alcohol are all implicated)
3. Metabolic Disorders
4. Congenital (rare genetic disorders)
How do we investigate gynaecomastia?
The history of the disorder and any other relvent medial information is essential and can usually narrow the potential causes significantly. A general and systemic medical examination is also essential. A testicular examination is always required. Specific medical photography is important for documentation. I personally used a 3D medical imaging system from Canfield. Special Investigations are reserved for equivocal cases or where additional documentation is required. Generally, some basic blood tests are usually done and a full endocrine screen may be considered on a case by case basis. Ultrasound examination of the breast is occasionally done and MRI is rarely required. A breast biopsy is also occasionally recommended.
How do we grade gynaecomastia ?
Generally, this is clinical and is somewhat subjective. The higher the grade, the more difficult the operation and the less impressive the outcome. Grade I is the most common. There is a pathological classification, which is less useful because tissue is required. It is usually only helpful ad hoc, when it confirms that a specific treatment was the correct option. Generally, once the pathological process has moved from “Florid” to “Fibrous” surgery is the only successful option.
Clinical – Simon’s Classification (Simon, PRS, 1973)
Grade I Small enlargement. No skin excess
Grade II A Moderate enlargement. No skin excess
Grade II B Moderate enlargement. Skin excess
Grade III Marked enlargement with skin excess
Is there a role for Non-Operative Management?
There is indeed. In the neonatal and in most cases of pubertal gynaecomastia no treatment is required and normalization is expected. Certain cases which are Drug induced may be treated similarly with withdrawl, with the caveat that after 1 year, fibrous changes make surgery the only option. Sometimes medical management may be successful. Treatment is either with Danazol (an antiangrogen) or Tamoxifen (an antioestrogen) for a period of 6 months. Tamoxifen is more effective and better tolerated than danazol, but has a higher recurrence rate.
How is the surgery for gynaecomastia performed?
Usually a general anaesthetic in hospital is required, but selected grade I cases may be performed under conscious sedation in the outpatient theatre. I generally use the Dufourmantel infra-areolar approach (A) almost exclusively. The reasons are improved scarring and improved sensation which are both very important to patients the transverse transareolar approach (B) and the radial (hemitransverse) areolar approach (C) are in my opinion inferior techniques. In extreme cases, the recently described Boomerang flap may be required, but scars may be a problem (see below)
I always add an extensive chest wall liposuction to every gynaecomastia procedure to assist with skin shrinkage, to improve the contour and even any irregularities. I have not had great success with liposuction alone as a treatment for gynaecomastia, although this has been described.
I prefer the Dufourmental approach even for higher grades as my experience is similar to that of Wiesman. No initial skin resection is performed and a second stage in 6-9 months can be considered. Generally using this approach there is a decreased need (only 30 %) for conversion to the Wise pattern (see below) which is a very disfiguring scar for a male to bear. (Wiesman, IM et al. AM J Surg 2004; 53:97-101).
I have started using Pelleve to improve the skin tone in the post-operative period and the results are generally encouraging.