Male Breast Enlargement

Background

Gynecomastia is derived from the Greek terms gynec (feminine) and mastos(breast). The literal translation, male breasts, relates to any condition that results in excessive development of breast tissue in males. Males may rarely develop  breast cancer, but this is often associated with testicular atrophy.

Male breast volume is composed of a combination of ductal and stromal tissue, commonly referred to as glandular tissue, and an increase in adipocygland cells and fat cells.  Some patients may have a lot of lose skin and hanging of the breasts due to that.


Before Surgery


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This picture is taken three months after surgery.

Before Surgery Front view
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Three months after surgery, Front view

 

The first recorded description of a reduction mammaplasty was by Paulas of Aegina in the seventh century AD, who referred to the condition as an "effeminacy of men." Several medical and surgical treatments of gynecomastia were described in the 1800s.

Gynecomastia results in an increase in breast tissue in males that, when problematic, is readily detectable by other individuals. The increased tissue may be breast glandular tissue, adipose (fatty) in nature, or a combination of the two. This results in significant functional and psychological limitations. The physical deformation may also be exquisitely painful. As a general rule, the glandular tissue is significantly more painful than the fatty tissue. Situations like gym class may require children or adolescents to remove their shirts in the presence of other students. This can put a boy with gynecomastia in danger not only of embarrassment but also of physical harm.

Most patients have never heard of this condition until the family physician identifies it. The physician may be unaware of the possible causes of the condition and its psychological impact. After initial presentation, boys are frequently advised to ignore the gynecomastia and are told that it will go away. Fortunately, in most instances, cases of minimal subareolar pubertal-onset gynecomastia do regress as puberty progresses.

Individuals with no regression or even progression of the deformity often receive little or no understanding about the shame and humiliation they experience. Coaches, sergeants, physicians, parents, and peers (both boys and girls) can inflict damage out of ignorance, cruelty, or both. Postural and clothing modifications to mask the deformity are the norm in these patients from puberty through adulthood. For example some patients may permanently slouch to hide the gynecomastia and will avoid wearing T shirts.

Frequency

Gynecomastia can occur in persons of any age. During adolescence, males develop firmness around the breast as the breast bud enlarges due to the hormonal fluxes of puberty. The subareolar firmness which normally develops regresses with time. Breast tissue is typically present on a microscopic level in male patients; a small amount of breast tissue is normal. The visible appearance of breast tissue in a male is abnormal. Breast tissue increases with Animal food intake. Dairy, Meat Fish and Eggs increase the estrogen levels of the body. The effect increases with ageing.

 Nydick et al reported 65% of boys "may have the problem" but cautioned that it typically resolves. Webster noted the incidence of gynecomastia to be around 8% in a series of naval patients, while Williams noted that 40% of men examined in his series of autopsies had gynecomastia to some degree. Approximately 40% of healthy men and up to 70% of hospitalized men have palpable if not visible breast tissue. The incidence of some degree of palpable breast tissue in males increases to more than 60% in those in the seventh decade of life in one series.

Physiologic gynecomastia occurs primarily in newborns and in adolescents at puberty. In the newborn, the neonatal breast results from the action of maternal estrogens, placental estrogens, or both in concert. The increased breast tissue usually disappears in a few weeks. Neonatal gynecomastia is not a problem that requires surgical intervention.

Adolescent gynecomastia, by definition, is initiated during puberty. The median age of onset is 13 years. Breast tissue growth is often asymmetrical, and the breasts are frequently tender. Adolescent gynecomastia usually regresses by the latter teen years. Note that the normal course during puberty is for a palpable, often visible, mass below the areola that begins to resolve in the mid teen years. While continued visible enlargement in the size of the breast is not normal in a teenager, residual palpable gynecomastia may be present in one or both breasts through the mid teen years. The authors would stress that the norm would be progressive diminution of any visible or palpable deformity through this period. In each case, the clinician must evaluate the degree of tissue present, the clinical presentation, and the physical and psychological effects on the patient.

Pathologic gynecomastia may be due to testosterone deficiency, increased estrogen production, or increased conversion of androgens to estrogens. The pathological conditions associated with gynecomastia include congenital anorchia,Klinefelter syndrome, testicular feminization, hermaphroditism, adrenal tumors, liver disorders, pituitary tumors, and malnutrition.

Many pharmacological agents have been linked to gynecomastia. These drugs can be categorized by their mechanisms of action. The first type is drugs that act exactly like estrogens (eg, diethylstilbestrol, birth control pills, digitalis, estrogen-containing cosmetics). The second type is drugs that enhance endogenous estrogen formation (eg, gonadotropins, progesterone, clomiphene). The third type is drugs that inhibit testosterone synthesis and action (eg, ketoconazole, metronidazole, and cimetidine). The final type is drugs that act by unknown mechanisms (eg, isoniazid,[6] methyldopa, captopril, tricyclic antidepressants, diazepam, marijuana, heroin). While heavy marijuana use has been linked to gynecomastia in rats, the relationship in humans is at best poorly documented. Chronic alcohol abuse may result in hepatocellular destruction and scarring which may result in gynecomastia. Adult patients should be routinely questioned about alcohol abuse or addiction.

A link between testicular atrophy, Klinefelter syndrome, and breast cancer has been noted. Longstanding, stable gynecomastia in an otherwise healthy male does not require an extensive medical workup.

In boys, the main sex hormone is testosterone, which is secreted by the testes. In girls, the main sex hormone is estrogen, which is secreted by the ovaries. However, both hormones are secreted in both sexes. Some production of estrogen occurs in the testes, and some production of testosterone occurs in the ovaries. Gynecomastia has long been considered the result of an imbalance between estrogens, which stimulate breast tissue, and androgens, which antagonize this effect. An alteration in the normal ratio of estrogen to androgen has been found in patients with gynecomastia in association due to many different reasons.

Estradiol is the growth hormone of the breast in women, and an excess of estradiol leads to the proliferation of breast tissue. Under normal circumstances, most estradiol in men is derived from the peripheral conversion of testosterone and adrenal estrogen. The basic mechanisms of physiologic gynecomastia have been postulated to represent a decrease in androgen production, an absolute increase in estrogen production, and an increased availability of estrogen precursors for peripheral conversion to estradiol. See the image below.



 

The etiology of most cases of gynecomastia remains unknown. The number of breast malignancies does not appear to be increased in patients with idiopathic gynecomastia. Patients who present with gynecomastia and have Klinefelter syndrome do exhibit an increased incidence of breast malignancies. Pensler et al noted that patients with Klinefelter syndrome exhibited elevated estrogen and progesterone receptors in their breast tissue.[  The presence of elevated estrogen and progesterone receptors in patients with Klinefelter syndrome provides a potential mechanism by which these patients may develop breast neoplasms. By contrast, patients with idiopathic gynecomastia did not demonstrate an increased number of estrogen or progesterone receptors. Also, the binding affinity of the receptors in both groups were not affected. The absence of elevated progesterone or estrogen receptors in patients with idiopathic gynecomastia helps to explain why these patients rarely manifest breast malignancy.

 

Patients present with an increase in breast tissue, which is asymmetric in one third of cases. The degree of asymmetry between the 2 sides varies widely. Some patients present with unilateral gynecomastia, while other individuals have a size discrepancy between the 2 sides that ranges from moderate to severe. Breast tenderness may also be noted in one third of patients. Enlargement is usually central and symmetric, although occasionally it is eccentric.

In 1934, Webster classified gynecomastia into 3 types. The first is glandular. Patients with a glandular component require surgical removal of the gland. The second is fatty glandular. With the fatty glandular form, surgery combined with liposuction allows good contouring. The third is simple fatty. In the cases that are primarily fatty in nature, liposuction alone provides good results.

Another classification described by Simon in 1973 groups the patients into categories according to the size of the gynecomastia   Group 1 is minor but visible breast enlargement without skin redundancy. Group 2A is moderate breast enlargement without skin redundancy. Group 2B is moderate breast enlargement with minor skin redundancy. Group 3 is gross breast enlargement with skin redundancy that simulates a pendulous female breast. Patients in groups 1 and 2 require no skin excision, but the breast development associated with group 3 is so marked that excess skin must be removed.

 

Generally, gynecomastia is a benign condition. Longstanding cases do not require histologic examination of surgically removed tissue. Rapid changes in the size of the breast, especially when unilateral in nature, may represent a malignancy particularly when pharmacologic manipulation can be ruled out. Also, changes in breast size in a patient with Klinefelter syndrome should be viewed with caution.

Surgical intervention is indicated in patients for diagnostic purposes or, most commonly, for patients who request treatment for physical modification. Most patients who visit a plastic surgeon request treatment for improvement of the obvious physical deformity which enhances psychological and physical wellbeing. These patients seek treatment because they find that the condition, which is readily apparent in everyday life, adversely impacts day-to-day activities under various circumstances. The physical deformation necessitates behavioral modifications that have numerous implications in the lives of the patients who are affected. Patients wear loose clothing and often avoid exposure in showers and swimming pools. Patients in high school and college are reticent to participate in any athletic activity that may directly or inadvertently require removal of one's shirt, exposing the chest.

Patients with gynecomastia typically slouch forward and roll the shoulders toward the midline in an effort to camouflage the deformation. The aforementioned posturing has a submissive connotation to the public with whom they interact. Patients return for postoperative appointments standing tall. In cases involving teenagers, parents typically remark "I have been trying to have him stand up straight for years!" The postural changes alone, which result at all age levels both sitting and standing, have numerous positive implications in peer-to-peer interactions. The confidence a patient gains after surgery becomes a life-changing event.

The surgeon primarily targets the fatty component of the breast. The glandular tissue is quite dense and is extremely resistant to removal by any method other than direct excision. As previously mentioned, longstanding stable cases of gynecomastia do not routinely require histological examination of the excised tissue.

See the images below.

Resected tissue. Note that the white tissue, which

esected tissue. Note that the white tissue, which is glandular breast tissue, has a higher density than the fat (adipose) tissue. The thick and dense glandular tissue in not ammenable to liposuction.Resected gynecomastia tissue. Courtesy of Miguel D

Resected gynecomastia tissue.

 

Liposuction-assisted mastectomy with or without gland excision for gynecomastia patients can be performed under local anesthesia, intravenous conscious sedation, or general anesthesia. The choice of sedation should be determined preoperatively by the physician and patient. Any significant medical problems, such as heart disease, lung disease, or diabetes, must be excluded before the procedure is performed. Rapid or unusual progression or presentation of the disease may require endocrinologic evaluation, which is optimally preformed prior to any surgical intervention. If the etiology of the gynecomastia is related to an adrenal or pituitary tumor, the tumor should be addressed prior to any attempt to correct the gynecomastia. If the gynecomastia is related to drug use, the use of the offending agent should be stopped prior to surgery.

Males who are upset with the appearance of their chest may also have substantial psychological issues. A boy who is being abused or humiliated commonly focuses on some part of his external appearance to avoid dealing with internal pain that he feels unable to manage or control. What may have started as a minor physical condition can be a cover for much deeper emotional issues that no amount of surgery can resolve. While Yost has demonstrated that more than 91% of individuals who have had surgery are happy with the procedure and would recommend surgery to a friend, individuals who require multiple surgeries may need to be screened for body dysmorphic disorder (BDD) and referred for treatment.

 

History and physical examinations are key elements used when considering the diagnosis of gynecomastia. Longstanding stable cases in an adult do not require blood tests other than those that would be required for an outpatient surgery. For routine outpatient surgery in healthy individuals aged less than 40 y,

Blood work should include liver function tests and assays for follicle-stimulating hormone, luteinizing hormone, human chorionic gonadotropin, thyroid-stimulating hormone, thyroxine, estrogen, estradiol, and testosterone levels in children and in individuals with progressive disease.

. If a patient has a history of bleeding with wisdom tooth extraction or adenoid surgery, further investigation should be performed to rule out medical bleeding such as von Willebrand disease.

See the image below.


Flow chart of the workup to determine the etiology of gynecomastia.

A sex chromatin study should be performed to exclude Klinefelter syndrome when appropriate.

Elevated estrogen and 17-ketosteroid levels in urine indicate the presence of a feminizing adrenal tumor.

If indicated by the patient's history, physical examination, and laboratory results, preoperative workup may include an ultrasound examination of the testes and breasts, computed tomography scan of adrenal glands, magnetic resonance imaging of sella turcica, and mammography when appropriate.

Excisional biopsy or fine-needle aspiration of breast tissue should be performed if a breast tumor is suspected.

Excised tissue should be sent for histological examination to exclude malignancy in appropriate cases. Approximately 1% of all primary breast tumors are reportedly found in men, and breast cancer accounts for 0.7% of all male cancers. As previously mentioned, unilateral cases with rapid progression should be viewed with suspicion.

Histologic Findings

Gynecomastia has 3 recognized pathological patterns, as follows:

  • The first type, the florid type, is characterized by an increase in the number and length of ducts, proliferation of ductal epithelium, periductal edema, a highly cellular fibroblastic stroma and hypervascularity, and the formation of pseudolobules. The florid type is the most common in patients with gynecomastia of less than 4 months' duration.
  • The second type, the fibrous type, is characterized by dilated ducts with minimal proliferation of epithelium, an absence of periductal edema, and an almost acellular fibrous stroma without adipose tissue. The fibrous type is the most common in patients with gynecomastia that lasts for 4-12 months.
  • The third type, the intermediate type, is an overlapping pattern of both the florid and the fibrous types.

Surgical Therapy
The objectives of surgical management for breast gynecomastia are (1) to restore the normal male breast contour and (2) to correct deformity of the breast, nipple, or areola. The surgical options for the patient with gynecomastia are mastectomy, liposuction-assisted mastectomy, or a combination of the 2 approaches. Most patients receive maximal benefit from a combined approach.

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. 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 cresant lift, triple-V incision. Note how the areola is elevated so the inframammary fold nearly eliminated. Courtesy of Miguel Delgado, MD.
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.
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. See the images below.



Fifteen-year-old boy with severe gynecomastia.

Postoperative photo after stage 1 gland excision and liposuction through a Webster incision. Note the significant contraction of the skin, but laxity is still present.

Postoperatively, after periareola donut mastopexy. Patient seen 3 months after sugery. The skin laxity has been improved.
Minimally invasive gynecomastia surgery
See the image below.


Incision for minimally invasive gynecomastia surgery.
Minimally invasive gynecomastia surgical procedures have gained popularity. The so-called "pull-through technique" described by Moreslli in 1996 has been further refined by Hammond et al,[13] Bracaglia et al,[14] and Lista and Ahmad.[15] 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. This technique is used in well-selected patients. See the images below.


Glandular tissue being pulled through.

Breast gland pulled through from each side. Courtesy of Miguel Delgado, MD.

Preoperative photo before the pull-through technique.

Postoperative photo after pull through technique.
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. The authors presently use a combination of ultrasonic-assisted liposuction (UAL), power-assisted liposuction (PAL), and traditional liposuction. 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.

Liposuction-assisted mastectomy
Teimourian and Pearlman, first introduced liposuction with surgical resection in the 1980s.[16] 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.

Preoperative Details
A standard preoperative workup that is age-appropriate should be performed. Long-standing cases of idiopathic gynecomastia that are stable do not require routine endocrine evaluation. Avoiding aspirin or other blood thinners is critical since postoperative hematomas are common.

Intraoperative Details
Surgical resection
The technique used depends on the degree of gynecomastia. The incidence of resection to optimize the final results has continued to increase. The authors have found that 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. The authors use a compression vest postoperatively, which has made drains unnecessary in the overwhelming majority of patients.

The coauthor widely elevates the skin from the underlying fibro-fatty-glandular tissue after tumescent liposuction is performed. The skin elevation is aggressive in the "face lift" plane, which takes advantage of maximal skin contracture. The patient is then sat up to 80 on the operating room table and resection is performed. This nearly emulates the standing position and how the patient evaluates his outcome. A suction drain is most always used and comes out in the hair-bearing part of the axilla.

Liposuction-assisted mastectomy
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 the 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 conjunction with excision.

Postoperative Details
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

 

Follow-up
Patients are usually seen 1 week postoperatively and once a month for the first 6 months. The final results are not fully appreciated for up to a year. See the images below.


Preoperative anteroposterior view of a patient with idiopathic gynecomastia.



Preoperative lateral view of a patient with gynecomastia.

Postoperative view of patient after surgical glandular excision and combined ultrasonic-assisted liposuction (UAL) and power-assisted liposuction (PAL).

Postoperative view of above patient. Note that while the glandular and fatty tissue have been removed, the nipples remain in the preoperative position relative to each other. Also note the significant skin retraction postoperatively.

Thirteen-year-old with adolescent gynecomatia. Gland excision with liposuction only, no skin excision. Note the degree of skin contraction. A secondary periareola-skin resection could remove the small fold.

Twenty-six-year-old man with adolescent gynecomastia.

Four months postoperatively after gland excision and liposuction. Note large, thick areola do not seem to contract or shrink as well.

Complications

Hematoma (most common; see images below)
Breast asymmetry
Nipple or areola necrosis
Nipple or areola inversion
Infection
Sensory changes
Painful scar
Contour deformity
Conspicuous scar
Skin redundancy
Seroma
Hyperinflamatory pigmentation
A postoperative hematoma is shown below.


Regardless of the etiology of gynecomastia, the prognosis is excellent when surgery is performed by a surgeon experienced with the disorder. In pathological-induced gynecomastia, medical and surgical treatment of the cause is required. In drug-induced gynecomastia, withdrawal of the medication leads to some regression in 60% of patients; however, this is typically inadequate and requires surgical intervention. If the gynecomastia is of long duration, it is unlikely to spontaneously regress.

Future and Controversies
Drug-induced gynecomastia and gynecomastia due to long-term exposure to estrogen are believed by some to increase a patient's risk for breast cancer. However, numerous clinical studies have failed to show the relationship between breast cancer and gynecomastia. The only study which shows clear association between gynecomastia and male breast cancer is with Klinefelter syndrome; patients who have gynecomastia and Klinefelter syndrome are at about 50% increased risk of male breast cancer. Drug-induced gynecomastia is the second most common cause of gynecomastia. Significant studies have been conducted to research the effects of the drugs that cause gynecomastia; however, much additional work is required.

If the gynecomastia patient is not satisfied with an otherwise excellent surgical result or a clear history of abuse from having the condition is noted, therapy may be required, and the appropriate referral should be recommended. Resolving any severe overlying emotional issues produces a much higher satisfaction rate with the surgical outcome in these individuals.

The enhanced awareness of gynecomastia in men appears to parallel the interest in cosmetic procedure for men in general. Plastic surgical procedures in men continue to show a steady rise in the United States. Men had over 750,000 cosmetic procedures, 8% of the total in 2010, according to the American Society for Aesthetic Plastic Surgery. The number of cosmetic procedures for men has increased over 88% from 1997.

In general, the management of gynecomastia is not controversial; its typically benign nature and the indications for medical and surgical management are well established.