Gynecomastia Treatment & Management
Generally, no treatment is required for physiologic gynecomastia. Pubertal gynecomastia resolves spontaneously within several weeks to 3 years in approximately 90% of patients. Breasts greater than 4 cm in diameter may not completely regress.
Identifying and managing an underlying primary disorder often alleviates breast enlargement. If hypogonadism (primary or secondary) is the cause of gynecomastia, parenteral or transdermal testosterone replacement therapy is instituted.
However, testosterone does have the potential to exacerbate gynecomastia through the aromatization of the exogenous hormone into estradiol.
For patients with idiopathic gynecomastia or with residual gynecomastia after treatment of the primary cause, medical or surgical treatment may be considered.
A major factor that should influence the initial choice of therapy for gynecomastia is the condition’s duration. It is unlikely that any medical therapy will result in significant regression in the late fibrotic stage (a duration of 12mo or longer) of gynecomastia.
As a result, medical therapies, if used, should be tried early in the condition’s course. The diagram below is a suggested treatment approach for patients presenting with breast enlargement.
Suggested algorithm for the management of gynecomastia.
Reduction mammoplasty is considered for patients with macromastia or long-standing gynecomastia or in persons in whom medical therapy has failed.It is also considered for cosmetic reasons (and for accompanying psychosocial reasons).
More extensive plastic surgery may be required in patients with marked gynecomastia or who have developed excessive sagging of the breast tissue due to weight loss. If surgery is necessary for patients with pseudogynecomastia, liposuction may be warranted.
Selective Estrogen Receptor Modulators
Selective estrogen receptor modulators inhibit estrogen effects.
Clomiphene (Clomid, Serophene)
Clomiphene stimulates the release of pituitary gonadotropins.
Tamoxifen competitively binds to the estrogen receptor, producing a nuclear complex that decreases deoxyribonucleic acid (DNA) synthesis and inhibits estrogen effects.
Surgical resection (subcutaneous mastectomy)
The choice of surgical technique depends on the likelihood of skin redundancy after surgery. Generally, skin shrinkage is greater in younger individuals than in older individuals. Many different incisions have been described for the excision of male breasts.
The most common approach is the intra-areolar incision, or Webster incision. The Webster incision extends along the circumference of the areola in the pigmented portion and is the preferred approach used by the author.
The length of the incision varies according to the specific anatomy of the patient. The glandular breast tissue has a greater density than adipose tissue. The glandular tissue is not amenable to liposuction.
The Webster intra-areolar incision is placed in the inferior hemisphere. See the image below.
The Webster intra-areolar incision is placed in the inferior hemisphere.
This incision may be enlarged by lateral and medial extensions, though this is rarely required. See the image below.
The Webster intra-areolar incision may be enlarged by lateral and medial extensions.
The transverse nipple-areola incision may be used, but it may often be associated with limited exposure and nipple distortion may result. See the image below.
The transverse nipple-areola incision.
The triple-V incision is an additional approach that has been advocated. See the images below.
A periareola incision followed by another outer circle of skin. The skin in between is removed and the outer circle has a purse-string closure, which is approximated to the smaller circle. This completes the peiareola donut mastopexy.
Forty-eight-year-old male gynecomastia patient
with breast ptosis.
Three months postoperative after a superior lift,
triple-V incision. The areola is elevated so the
inframammary fold nearly eliminated.
The transaxillary incision has been recommended because of its advantage of scars on the chest wall; however, its disadvantage is that it causes glandular resection to be more difficult and incomplete. Obtaining adequate hemostasis is also very difficult through this approach.
In severe gynecomastia, skin resection and nipple transposition techniques may occasionally be necessary. The most common type is the Letterman technique. After the skin is resected, the nipple-areola complex is rotated superiorly and medially based on a single dermal pedicle. See the image below.
The most common technique for skin resection and nipple transposition is the Letterman technique.
Sometimes, in massive gynecomastia, an en bloc resection of excessive skin and breast tissue and free nipple grafting can be performed, but such cases are extremely unusual. See the image below.
In massive gynecomastia, an en bloc resection of excessive skin and breast tissue and free nipple grafting can be performed using an elliptical incision with a nipple-areola graft.
In patients with an abnormal inframammary crease, wide undermining into the abdominal skin may be required to optimize the result.
Two-stage breast reduction for moderate-to-severe gynecomastia
For moderate-severe gynecomastia, a 2-stage surgical procedure may be an option. The first stage is liposuction followed by a Webster-type periareola incision and removal of gland, fat, and fibrous tissue to obtain a nice contour.
The second stage is performed 4-6 months later, after the blood supply has reestablished itself from below and allows for a periareola donut mastopexy.
The advantage of this technique is the limited incision around the nipple-areola complex. It should be stressed that in the majority of cases, adequate skin contraction occurs to obviate the need for skin resection.
Minimally invasive gynecomastia surgery
Incision for minimally invasive gynecomastia surgery.
Minimally invasive gynecomastia surgical procedures have been proposed. The so-called “pull-through technique” described by Moreslli in 1996 has been further refined by Hammond et al, Bracaglia et al, and Lista and Ahmad.
A very small (approximately 5 mm) incision is made at the areolar edge, and liposuction is followed by releasing the glandular tissue from the overlying areola and pulling it through the incision, thus the pull-through technique.
The major advantage is the smaller incision, although the periareola incision that is typically used is very difficult to see. This technique is only used in well-selected patients with minimal impact on the final result.
Preoperatively, the surgeon should outline the incision and estimate the thickness and depth of fat and breast tissue to be removed.
Liposuction is performed after the infiltration of tumescent solution. A combination of ultrasonic-assisted liposuction (UAL), power-assisted liposuction (PAL), and traditional liposuction can be used.
The surgical dissection, which proceeds after the liposuction, entails a dissection that is extended to the pectoralis major fascia. The fat and breast tissue are excised en bloc from the pectoralis fascia.
Hemostasis is achieved with a Bovie electrocautery instrument. A catheter may need to be inserted to prevent postoperative hematoma; however, with the use of tumescent solution that contains epinephrine, this is rarely required.
Teimourian and Pearlman, first introduced liposuction with surgical resection in the 1980s. Recently, the advent of ultrasonic liposuction has improved the results of gynecomastia correction.
In liposuction-assisted mastectomy, less compromise of the blood supply, nipple distortion, saucer deformity, and areola slough occur. In addition, the postoperative complications (eg, hemorrhage, infection, hematoma, seroma, necrosis) are fewer with this technique than with open surgical resection.
However, liposuction-assisted mastectomy is not effective for correcting glandular gynecomastia. Therefore, the fatty and glandular components of the breast must be assessed prior to any surgical intervention. Few patients can be sufficiently treated with liposuction only.
The technique used depends on the degree of gynecomastia and the skin elasticity. The percentage of patients that benefit from open surgical resection to optimize the final results has continued to increase. Surgical open resection is required in most cases.
If the gynecomastia requires surgical resection, the Webster intra-areolar incision is typically the most appropriate. Prior to surgical resection, the breast is infiltrated with tumescent solution and liposuction is performed.
For massive breast gynecomastia, more skin removal and deeper excision are necessary. With an accurate estimation of the extent of the hypertrophied tissue and the thickness of the fat on the chest wall, the dissection should reach the pectoralis major muscle fascia very near to the preoperatively estimated breast limits.
The hypertrophied tissue is then excised from pectoralis major fascia. Hemostasis is secured, and a surgical drain may, rarely, be placed. Subcutaneous tissues are reapproximated, and the skin is closed subcuticularly. A compression vest is used postoperatively. Some surgeons rarely use drains, while others almost always use them.
Liposuction-assisted mastectomy is the most popular method used for pseudogynecomastia. The liposuction cannulas are inserted through a 3-mm areolar incision or an incision in the anterior axilla along the pectoralis major tendon.
The surgeon removes fatty and minimal glandular tissues. For small and moderate gynecomastia, suction lipectomy is extended to the clavicle, to the sternum, to 2 cm below the inframammary crease, and to the axilla.
For moderate to large gynecomastia, suction lipectomy is extended to the postaxillary fold. In the overwhelming majority of patients, liposuction is performed in conjunction with excision.
Compression garments are applied for at least 4 weeks. A small amount of blood, injection fluid, and liquified fat may leak from the incision sites for approximately 24 hours.
The patient may resume his physical activities within few days. Exercise is resumed a few days after surgery and is gradually increased over time. Patients return to work typically after 1-2 days. Drains may or may not be used, depending on the experience of the surgeon and the patient presentation.