The senior authors, Dr. Emil Bisaccia and Dr. Dwight A. Scarborough, are authors of the textbook The Columbia Manual of Dermatologic Cosmetic Surgery. Gynecomastia is a common condition that can be disfiguring and psychologically distressing. It occurs in 30% to 50% of healthy men1 and up to 65% of adolescent boys. 2Causes include endocrine disorders, hormonal imbalances, medications, and rare tumors and syndromes. Up to 25% of cases are idiopathic and it is a physiologic finding in certain age groups. Pseudogynecomastia can also result from obesity. Medical management of gynecomastia with hormonal agents such as tamoxifen and danazol garners mixed results and recurrence is common. 3 Definitive treatment with surgical correction is preferred in most cases. We describe a tumescent liposuction technique that may also be followed by limited direct excision for optimal results. Clinical Characteristics of Gynecomastia True vs. Pseudogynecomastic Gynecomastia is a proliferation of glandular tissue and is palpable as a firm, mobile disc-like nodule beneath the areola. Pseudogynecomastia is due to accumulation of fatty tissue without proliferation of glandular tissue, and a distinct nodule is not palpable on exam. Gynecomastia is usually asymptomatic, but can be tender, especially early in the onset of the condition. Both bilateral and unilateral benign gynecomastia can occur. When unilateral, it is more likely to be left-sided for an unknown reason. 2 Severity Scale Severity of gynecomastia is graded on the McKinney and Simon, Hoffman and Kohn scales (American Society of Plastic Surgeons, 2002). • Grade I: Small breast enlargement with localized button of tissue that is concentrated around the areola • Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest • Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy present • Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast. Causes of Gynecomastia Age Groups Affected Gynecomastia is considered a physiologic finding in three age groups. From 60% to 90% of newborns have transient enlargement of breast tissue due to placental transfer of maternal estrogens. 4 Rare cases due to metabolic derangement secondary to congenital liver or heart diseases have been reported.,sup>5 The second peak in incidence occurs during adolescence. Up to 65% of 14-year-old boys can develop gynecomastia, which typically resolves within 2 years.2 The third peak occurs in adults age 50 to 80 years old, and is related to decreased androgen production and increase in body fat. 6 Pathologic Causes There are a number of pathologic causes of gynecomastia, which ultimately lead to an imbalance of serum estrogen and androgen levels. In males, the majority of estrogens, in the form of estradiol and estrone, are converted from androgen precursors testosterone and androstenedione by aromatase in extraglandular tissues, such as adipose, liver, and muscle. Estrogens stimulate and androgens inhibit breast tissue development. An imbalance in the ratio of estrogens to androgens such that serum levels of estrogen are higher than that of androgens may result in gynecomastia. 7 Alterations in serum levels of estrogen or androgens can occur in numerous situations. Neoplasms such as testicular Leydig-cell tumors, feminizing adrenal tumors, human chorionic gonadotropin-secreting tumors can cause an imbalance in estrogen and androgen levels, as can chronic liver disease, 8 chronic heart failure, 9 renal failure, Klinefelter’s Syndrome, hypogonadism, obesity, aging, and, rarely, stressful life events. 10 In addition, the interaction of sex hormone-binding globulin with circulating estrogen and testosterone can lead to a disruptions in the levels of bound and unbound hormones, such as in hyperthyroidism in which elevated sex hormone-binding globulin results in a relative increase of free estrogen compared with testosterone. 11 Of note, gynecomastia occurs in 20% to 40% of hyperthyroid men. 12 Medications cause up to 20% to 25% of gynecomastia1 (See Table 1). Antihypertensive drugs comprise the largest class of medications causing gynecomastia, with spironolactone being the most common agent. 13 Spironolactone causes increased metabolism of testosterone, androgen receptor inhibition, increased production of estrogen by aromatization, and displacement of estrogen from sex hormone-binding globulin. 14, 15 Other antihypertensives, such as calcium channel blockers, angiotensin-converting enzyme inhibitors, a-receptor blockers, and centrally acting agents like clonidine have also been reported to cause gynecomastia. 16 Ketoconazole, 17 flutamide and other androgen receptor blockers, antipsychotics, atorvastatin, 18 proton pump inhibitors, chemotherapeutic drugs, the receptor tyrosine kinase inhibitor sunitinib, 19 phenytoin, penicillamine, and recreational drugs such as alcohol, marijuana and amphetamines have all been implicated in gynecomastia. Finally, breast cancer is a very rare cause of gynecomastia in men, about 1% in one study. 7 Clinically suspicious lesions tend to be hard, unilateral masses, not subareolar in location, with skin dimpling, nipple retraction or discharge, and axillary adenopathy present in some cases. Treatment for Benign Gynecomastia Surgical correction of gynecomastia is the definitive treatment for benign gynecomastia. Techniques involving various types of liposuction (eg, ultrasound-assisted, power-assisted liposuction), direct excision, and more recently, a combination of liposuction and direct excision or pull-through technique has been described. 20-23 However, very firm or fibrous breast tissue may not be amenable to liposuction and can result in residual gynecomastia, as fibrous attachments adhering to the breast stroma makes complete removal difficult. 24-25 Direct excision is the treatment of choice for most cases of true gynecomastia. This procedure can be performed under local or tumescent anesthesia, conscious sedation, or general anesthesia. The glandular tissue is resected by sharp dissection via a periareolar incision. Resected tissue should always be sent for pathological analysis as malignancies are detected in rare instances. Adverse events resulting from direct excision are uncommon. A saucer deformity, in which the nipple-areola complex is tethered to chest wall, can occasionally occur. 24 Hematomas and seromas are other potential adverse events related to excision.25, 26 Our Approach to Pseudogynecomastia The majority of our male breast liposuction is done for pseudogynecomastia,27 as described below, with the sculpted removal of underlying fat yielding an excellent chest contour. However, for those patients with associated prominent breast buds, we use a technique that combines liposuction with delayed direct excision. Basic Procedure — Male Breast Liposuction • IV Sedation — The procedure is performed with IV sedation in an accredited ambulatory surgery center. • Tumescent liposuction is performed to contour the anterior chest and periaxillary chest wall. • A vest is worn for 2 weeks after liposuction. Surgical Excision of Breast Bud Tissue Six to eight weeks after undergoing the above procedure, the patient returns for surgical excision of the breast tissue. • IV Sedation — As with basic procedure above, this is performed with IV sedation in an accredited ambulatory surgery center. • Incision and resection — A periareolar incision of 180 degrees is made and the fibrous glandular stromal tissue is resected (See Figure 1). Fibrosis secondary to prior liposuction creates a bloodless plane in which the tissue can be easily resected, minimizing the risk of post-operative hematoma. • Closure and compression — A layered closure using 4-0 Vicryl and 5-0 Prolene is then performed followed by 72 hours of compression. • Follow up Care — Standard wound care and limited exercise is recommended for 10 to 14 days. Summary Although generally benign, gynecomastia can be a cause for male embarrassment and thus a significant cosmetic concern. Our technique of tumescent liposuction followed by direct excision of the breast bud for select patients is a safe and effective treatment with optimal cosmetic results. n Dr. Bisaccia is a practicing dermatologist and Clinical Professor of Dermatology at the Columbia University of Physicians and Surgeons in New York City. Dr. Lu is a Fellow in an ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologic Surgeons in Morristown, NJ. Dr. Rogachefsky is a practicing dermatologist and is the Program Director of the ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ. Dr. Scarborough is a practicing dermatologist and Assistant Clinical Professor of Medicine, Division of Dermatology, at the Ohio State University Hospital in Columbus, OH. Disclosures: Drs. Bisaccia, Lu, Rogachefsky and Scarborough disclose that they have no real or apparent conflicts of interest or financial interests or arrangements with any companies or products mentioned in this article. References 1. Bembo SA, Carlson HE. Gynecomastia: its features, and when and how to treat it. Cleve Clin J Med. 2004 Jun;71(6):511-517. 2. Nydick M, Bustos J, Dale JH Jr, Rawson RW. Gynecomastia in adolescent boys. JAMA. 1961;178:449–454. 3. Ting AC, Chow LW, Leung YF. Comparison of tamoxifen with danazol in the management of idiopathic gynecomastia. Am Surg. 2000 Jan;66(1):38-40. 4. Devalia HL, Layer GT. Current concepts in gynecomastia. Surgeon. 2009 Apr;7(2):114-9. 5. da Costa D, Al Khusaiby S, Ghazal H, Nair A. Clinical picture: a newborn with gynaecomastia. Lancet. 2001. Jan 6;357(9249):14. 6. Braunstein GD. Gynecomastia. N Engl J Med. 1993;328:490–495. 7. Johnson RE, Murad MH. Gynecomastia: pathophysiology, evaluation, and management. Mayo Clin Proc. 2009 Nov;84(11):1010-1015. 8. Kuper H et al. Estrogens, Testosterone and sex hormone binding globulin in relation to liver cancer in men. Oncology. 2001;60:355-360. 9. Jankowska et al. Circulating estradiol and mortality in men with systolic chronic heart failure. JAMA. 2009 May 13;301(18):1892-1901. 10. Gooren LJG, Daantje CRE. Psychological stress as a cause of intermittent gynecomastia. Horm Metab Res. 1986; 18:424. 11. Meikle AW. The interrelationships between thyroid dysfunction and hypogonadism in men and boys. Thyroid. 2004; 14 Suppl 1:S17-25. 12. Chopra IJ 1975 Gonadal steroids and gonadotropins in hyperthyroidism. Med Clin North Am. 59:1109–1121. 13. Mosenkis A, Townsend RR. Gynecomastia and antihypertensive therapy. J Clin Hypertens (Greenwich). 2004;6(8)469-470. 14. Haynes BA, Mookadam F. Male gynecomastia. Mayo Clin Proc. 2009 Aug;84(8):672. 15. Rose LI et al. Pathophysiology of spironolactone-induced gynecomastia. Ann Intern Med. 1977;87(4):398-403. 16. Prisant LM, Chin E. Gynecomastia and hypertension. J Clin Hypertens (Greenwich). 2005 Apr;7(4):245-248. 17. Eil C. Ketoconazole binds to the human androgen receptor. Horm Metab Res. 1992 Aug;24(8):367-370. 18. Hammons KB, Edwards RF, Rice WY. Golf-inhibiting gynecomastia associated with atorvastatin therapy. Pharmacotherapy. 2006 Aug;26(8):1165-1168. 19. Bellardini P et al. Onset of male gynecomastia in a patient treated with sunitinib for metastatic renal cell carcinoma. Clin Drug Investig. 2009;29(7):487-490. 20. Morselli PG. “Pull-through”: A new technique for breast reduction in gynecomastia. Plast Reconstr Surg. 1996;97:450–454. 21. Hammond DC, Arnold JF, Simon AM, Capraro PA. Combined use of ultrasonic liposuction with the pull-through technique for the treatment of gynecomastia. Plast Reconstr Surg. 2003;112:891–895; discussion 896–897. 22. Esme DL et al. Combined use of ultrasonic-assisted liposuction and semicircular periareolar incision for the treatment of gynecomastia. Ann Plast Surg. 2007 Dec;59(6):629-34. 23. Lista F, Ahmad. J. Power-assisted liposuction and the pull-through technique for the treatment of gynecomastia. Plast Reconstr Surg. 2008 Mar;121(3):740-7 24. Hammond D. Surgical correction of gynecomastia. Plast Reconstr Surg. July 2009;124(1) Supplement: 61e-68e 25. Ratnam BV. A new classification and treatment protocol for gynecomastia. Aesthet Surg J. 2009 Jan-Feb;29(1):26-31. 26. Tarcoveanu E et al. Surgical treatment of gynecomastia. Chirurgia (Bucur). 2008 Nov-Dec;103(6):643-50. 27. Bisaccia, E and Scarborough DA. The Columbia Manual of Dermatologic Cosmetic Surgery. New York :McGraw-Hill, 2002.
Surgical Correction of Gynecomastia
The senior authors, Dr. Emil Bisaccia and Dr. Dwight A. Scarborough, are authors of the textbook The Columbia Manual of Dermatologic Cosmetic Surgery. Gynecomastia is a common condition that can be disfiguring and psychologically distressing. It occurs in 30% to 50% of healthy men1 and up to 65% of adolescent boys. 2Causes include endocrine disorders, hormonal imbalances, medications, and rare tumors and syndromes. Up to 25% of cases are idiopathic and it is a physiologic finding in certain age groups. Pseudogynecomastia can also result from obesity. Medical management of gynecomastia with hormonal agents such as tamoxifen and danazol garners mixed results and recurrence is common. 3 Definitive treatment with surgical correction is preferred in most cases. We describe a tumescent liposuction technique that may also be followed by limited direct excision for optimal results. Clinical Characteristics of Gynecomastia True vs. Pseudogynecomastic Gynecomastia is a proliferation of glandular tissue and is palpable as a firm, mobile disc-like nodule beneath the areola. Pseudogynecomastia is due to accumulation of fatty tissue without proliferation of glandular tissue, and a distinct nodule is not palpable on exam. Gynecomastia is usually asymptomatic, but can be tender, especially early in the onset of the condition. Both bilateral and unilateral benign gynecomastia can occur. When unilateral, it is more likely to be left-sided for an unknown reason. 2 Severity Scale Severity of gynecomastia is graded on the McKinney and Simon, Hoffman and Kohn scales (American Society of Plastic Surgeons, 2002). • Grade I: Small breast enlargement with localized button of tissue that is concentrated around the areola • Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest • Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy present • Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast. Causes of Gynecomastia Age Groups Affected Gynecomastia is considered a physiologic finding in three age groups. From 60% to 90% of newborns have transient enlargement of breast tissue due to placental transfer of maternal estrogens. 4 Rare cases due to metabolic derangement secondary to congenital liver or heart diseases have been reported.,sup>5 The second peak in incidence occurs during adolescence. Up to 65% of 14-year-old boys can develop gynecomastia, which typically resolves within 2 years.2 The third peak occurs in adults age 50 to 80 years old, and is related to decreased androgen production and increase in body fat. 6 Pathologic Causes There are a number of pathologic causes of gynecomastia, which ultimately lead to an imbalance of serum estrogen and androgen levels. In males, the majority of estrogens, in the form of estradiol and estrone, are converted from androgen precursors testosterone and androstenedione by aromatase in extraglandular tissues, such as adipose, liver, and muscle. Estrogens stimulate and androgens inhibit breast tissue development. An imbalance in the ratio of estrogens to androgens such that serum levels of estrogen are higher than that of androgens may result in gynecomastia. 7 Alterations in serum levels of estrogen or androgens can occur in numerous situations. Neoplasms such as testicular Leydig-cell tumors, feminizing adrenal tumors, human chorionic gonadotropin-secreting tumors can cause an imbalance in estrogen and androgen levels, as can chronic liver disease, 8 chronic heart failure, 9 renal failure, Klinefelter’s Syndrome, hypogonadism, obesity, aging, and, rarely, stressful life events. 10 In addition, the interaction of sex hormone-binding globulin with circulating estrogen and testosterone can lead to a disruptions in the levels of bound and unbound hormones, such as in hyperthyroidism in which elevated sex hormone-binding globulin results in a relative increase of free estrogen compared with testosterone. 11 Of note, gynecomastia occurs in 20% to 40% of hyperthyroid men. 12 Medications cause up to 20% to 25% of gynecomastia1 (See Table 1). Antihypertensive drugs comprise the largest class of medications causing gynecomastia, with spironolactone being the most common agent. 13 Spironolactone causes increased metabolism of testosterone, androgen receptor inhibition, increased production of estrogen by aromatization, and displacement of estrogen from sex hormone-binding globulin. 14, 15 Other antihypertensives, such as calcium channel blockers, angiotensin-converting enzyme inhibitors, a-receptor blockers, and centrally acting agents like clonidine have also been reported to cause gynecomastia. 16 Ketoconazole, 17 flutamide and other androgen receptor blockers, antipsychotics, atorvastatin, 18 proton pump inhibitors, chemotherapeutic drugs, the receptor tyrosine kinase inhibitor sunitinib, 19 phenytoin, penicillamine, and recreational drugs such as alcohol, marijuana and amphetamines have all been implicated in gynecomastia. Finally, breast cancer is a very rare cause of gynecomastia in men, about 1% in one study. 7 Clinically suspicious lesions tend to be hard, unilateral masses, not subareolar in location, with skin dimpling, nipple retraction or discharge, and axillary adenopathy present in some cases. Treatment for Benign Gynecomastia Surgical correction of gynecomastia is the definitive treatment for benign gynecomastia. Techniques involving various types of liposuction (eg, ultrasound-assisted, power-assisted liposuction), direct excision, and more recently, a combination of liposuction and direct excision or pull-through technique has been described. 20-23 However, very firm or fibrous breast tissue may not be amenable to liposuction and can result in residual gynecomastia, as fibrous attachments adhering to the breast stroma makes complete removal difficult. 24-25 Direct excision is the treatment of choice for most cases of true gynecomastia. This procedure can be performed under local or tumescent anesthesia, conscious sedation, or general anesthesia. The glandular tissue is resected by sharp dissection via a periareolar incision. Resected tissue should always be sent for pathological analysis as malignancies are detected in rare instances. Adverse events resulting from direct excision are uncommon. A saucer deformity, in which the nipple-areola complex is tethered to chest wall, can occasionally occur. 24 Hematomas and seromas are other potential adverse events related to excision.25, 26 Our Approach to Pseudogynecomastia The majority of our male breast liposuction is done for pseudogynecomastia,27 as described below, with the sculpted removal of underlying fat yielding an excellent chest contour. However, for those patients with associated prominent breast buds, we use a technique that combines liposuction with delayed direct excision. Basic Procedure — Male Breast Liposuction • IV Sedation — The procedure is performed with IV sedation in an accredited ambulatory surgery center. • Tumescent liposuction is performed to contour the anterior chest and periaxillary chest wall. • A vest is worn for 2 weeks after liposuction. Surgical Excision of Breast Bud Tissue Six to eight weeks after undergoing the above procedure, the patient returns for surgical excision of the breast tissue. • IV Sedation — As with basic procedure above, this is performed with IV sedation in an accredited ambulatory surgery center. • Incision and resection — A periareolar incision of 180 degrees is made and the fibrous glandular stromal tissue is resected (See Figure 1). Fibrosis secondary to prior liposuction creates a bloodless plane in which the tissue can be easily resected, minimizing the risk of post-operative hematoma. • Closure and compression — A layered closure using 4-0 Vicryl and 5-0 Prolene is then performed followed by 72 hours of compression. • Follow up Care — Standard wound care and limited exercise is recommended for 10 to 14 days. Summary Although generally benign, gynecomastia can be a cause for male embarrassment and thus a significant cosmetic concern. Our technique of tumescent liposuction followed by direct excision of the breast bud for select patients is a safe and effective treatment with optimal cosmetic results. n Dr. Bisaccia is a practicing dermatologist and Clinical Professor of Dermatology at the Columbia University of Physicians and Surgeons in New York City. Dr. Lu is a Fellow in an ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologic Surgeons in Morristown, NJ. Dr. Rogachefsky is a practicing dermatologist and is the Program Director of the ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ. Dr. Scarborough is a practicing dermatologist and Assistant Clinical Professor of Medicine, Division of Dermatology, at the Ohio State University Hospital in Columbus, OH. Disclosures: Drs. Bisaccia, Lu, Rogachefsky and Scarborough disclose that they have no real or apparent conflicts of interest or financial interests or arrangements with any companies or products mentioned in this article. References 1. Bembo SA, Carlson HE. Gynecomastia: its features, and when and how to treat it. Cleve Clin J Med. 2004 Jun;71(6):511-517. 2. Nydick M, Bustos J, Dale JH Jr, Rawson RW. Gynecomastia in adolescent boys. JAMA. 1961;178:449–454. 3. Ting AC, Chow LW, Leung YF. Comparison of tamoxifen with danazol in the management of idiopathic gynecomastia. Am Surg. 2000 Jan;66(1):38-40. 4. Devalia HL, Layer GT. Current concepts in gynecomastia. Surgeon. 2009 Apr;7(2):114-9. 5. da Costa D, Al Khusaiby S, Ghazal H, Nair A. Clinical picture: a newborn with gynaecomastia. Lancet. 2001. Jan 6;357(9249):14. 6. Braunstein GD. Gynecomastia. N Engl J Med. 1993;328:490–495. 7. Johnson RE, Murad MH. Gynecomastia: pathophysiology, evaluation, and management. Mayo Clin Proc. 2009 Nov;84(11):1010-1015. 8. Kuper H et al. Estrogens, Testosterone and sex hormone binding globulin in relation to liver cancer in men. Oncology. 2001;60:355-360. 9. Jankowska et al. Circulating estradiol and mortality in men with systolic chronic heart failure. JAMA. 2009 May 13;301(18):1892-1901. 10. Gooren LJG, Daantje CRE. Psychological stress as a cause of intermittent gynecomastia. Horm Metab Res. 1986; 18:424. 11. Meikle AW. The interrelationships between thyroid dysfunction and hypogonadism in men and boys. Thyroid. 2004; 14 Suppl 1:S17-25. 12. Chopra IJ 1975 Gonadal steroids and gonadotropins in hyperthyroidism. Med Clin North Am. 59:1109–1121. 13. Mosenkis A, Townsend RR. Gynecomastia and antihypertensive therapy. J Clin Hypertens (Greenwich). 2004;6(8)469-470. 14. Haynes BA, Mookadam F. Male gynecomastia. Mayo Clin Proc. 2009 Aug;84(8):672. 15. Rose LI et al. Pathophysiology of spironolactone-induced gynecomastia. Ann Intern Med. 1977;87(4):398-403. 16. Prisant LM, Chin E. Gynecomastia and hypertension. J Clin Hypertens (Greenwich). 2005 Apr;7(4):245-248. 17. Eil C. Ketoconazole binds to the human androgen receptor. Horm Metab Res. 1992 Aug;24(8):367-370. 18. Hammons KB, Edwards RF, Rice WY. Golf-inhibiting gynecomastia associated with atorvastatin therapy. Pharmacotherapy. 2006 Aug;26(8):1165-1168. 19. Bellardini P et al. Onset of male gynecomastia in a patient treated with sunitinib for metastatic renal cell carcinoma. Clin Drug Investig. 2009;29(7):487-490. 20. Morselli PG. “Pull-through”: A new technique for breast reduction in gynecomastia. Plast Reconstr Surg. 1996;97:450–454. 21. Hammond DC, Arnold JF, Simon AM, Capraro PA. Combined use of ultrasonic liposuction with the pull-through technique for the treatment of gynecomastia. Plast Reconstr Surg. 2003;112:891–895; discussion 896–897. 22. Esme DL et al. Combined use of ultrasonic-assisted liposuction and semicircular periareolar incision for the treatment of gynecomastia. Ann Plast Surg. 2007 Dec;59(6):629-34. 23. Lista F, Ahmad. J. Power-assisted liposuction and the pull-through technique for the treatment of gynecomastia. Plast Reconstr Surg. 2008 Mar;121(3):740-7 24. Hammond D. Surgical correction of gynecomastia. Plast Reconstr Surg. July 2009;124(1) Supplement: 61e-68e 25. Ratnam BV. A new classification and treatment protocol for gynecomastia. Aesthet Surg J. 2009 Jan-Feb;29(1):26-31. 26. Tarcoveanu E et al. Surgical treatment of gynecomastia. Chirurgia (Bucur). 2008 Nov-Dec;103(6):643-50. 27. Bisaccia, E and Scarborough DA. The Columbia Manual of Dermatologic Cosmetic Surgery. New York :McGraw-Hill, 2002.
The senior authors, Dr. Emil Bisaccia and Dr. Dwight A. Scarborough, are authors of the textbook The Columbia Manual of Dermatologic Cosmetic Surgery. Gynecomastia is a common condition that can be disfiguring and psychologically distressing. It occurs in 30% to 50% of healthy men1 and up to 65% of adolescent boys. 2Causes include endocrine disorders, hormonal imbalances, medications, and rare tumors and syndromes. Up to 25% of cases are idiopathic and it is a physiologic finding in certain age groups. Pseudogynecomastia can also result from obesity. Medical management of gynecomastia with hormonal agents such as tamoxifen and danazol garners mixed results and recurrence is common. 3 Definitive treatment with surgical correction is preferred in most cases. We describe a tumescent liposuction technique that may also be followed by limited direct excision for optimal results. Clinical Characteristics of Gynecomastia True vs. Pseudogynecomastic Gynecomastia is a proliferation of glandular tissue and is palpable as a firm, mobile disc-like nodule beneath the areola. Pseudogynecomastia is due to accumulation of fatty tissue without proliferation of glandular tissue, and a distinct nodule is not palpable on exam. Gynecomastia is usually asymptomatic, but can be tender, especially early in the onset of the condition. Both bilateral and unilateral benign gynecomastia can occur. When unilateral, it is more likely to be left-sided for an unknown reason. 2 Severity Scale Severity of gynecomastia is graded on the McKinney and Simon, Hoffman and Kohn scales (American Society of Plastic Surgeons, 2002). • Grade I: Small breast enlargement with localized button of tissue that is concentrated around the areola • Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest • Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy present • Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast. Causes of Gynecomastia Age Groups Affected Gynecomastia is considered a physiologic finding in three age groups. From 60% to 90% of newborns have transient enlargement of breast tissue due to placental transfer of maternal estrogens. 4 Rare cases due to metabolic derangement secondary to congenital liver or heart diseases have been reported.,sup>5 The second peak in incidence occurs during adolescence. Up to 65% of 14-year-old boys can develop gynecomastia, which typically resolves within 2 years.2 The third peak occurs in adults age 50 to 80 years old, and is related to decreased androgen production and increase in body fat. 6 Pathologic Causes There are a number of pathologic causes of gynecomastia, which ultimately lead to an imbalance of serum estrogen and androgen levels. In males, the majority of estrogens, in the form of estradiol and estrone, are converted from androgen precursors testosterone and androstenedione by aromatase in extraglandular tissues, such as adipose, liver, and muscle. Estrogens stimulate and androgens inhibit breast tissue development. An imbalance in the ratio of estrogens to androgens such that serum levels of estrogen are higher than that of androgens may result in gynecomastia. 7 Alterations in serum levels of estrogen or androgens can occur in numerous situations. Neoplasms such as testicular Leydig-cell tumors, feminizing adrenal tumors, human chorionic gonadotropin-secreting tumors can cause an imbalance in estrogen and androgen levels, as can chronic liver disease, 8 chronic heart failure, 9 renal failure, Klinefelter’s Syndrome, hypogonadism, obesity, aging, and, rarely, stressful life events. 10 In addition, the interaction of sex hormone-binding globulin with circulating estrogen and testosterone can lead to a disruptions in the levels of bound and unbound hormones, such as in hyperthyroidism in which elevated sex hormone-binding globulin results in a relative increase of free estrogen compared with testosterone. 11 Of note, gynecomastia occurs in 20% to 40% of hyperthyroid men. 12 Medications cause up to 20% to 25% of gynecomastia1 (See Table 1). Antihypertensive drugs comprise the largest class of medications causing gynecomastia, with spironolactone being the most common agent. 13 Spironolactone causes increased metabolism of testosterone, androgen receptor inhibition, increased production of estrogen by aromatization, and displacement of estrogen from sex hormone-binding globulin. 14, 15 Other antihypertensives, such as calcium channel blockers, angiotensin-converting enzyme inhibitors, a-receptor blockers, and centrally acting agents like clonidine have also been reported to cause gynecomastia. 16 Ketoconazole, 17 flutamide and other androgen receptor blockers, antipsychotics, atorvastatin, 18 proton pump inhibitors, chemotherapeutic drugs, the receptor tyrosine kinase inhibitor sunitinib, 19 phenytoin, penicillamine, and recreational drugs such as alcohol, marijuana and amphetamines have all been implicated in gynecomastia. Finally, breast cancer is a very rare cause of gynecomastia in men, about 1% in one study. 7 Clinically suspicious lesions tend to be hard, unilateral masses, not subareolar in location, with skin dimpling, nipple retraction or discharge, and axillary adenopathy present in some cases. Treatment for Benign Gynecomastia Surgical correction of gynecomastia is the definitive treatment for benign gynecomastia. Techniques involving various types of liposuction (eg, ultrasound-assisted, power-assisted liposuction), direct excision, and more recently, a combination of liposuction and direct excision or pull-through technique has been described. 20-23 However, very firm or fibrous breast tissue may not be amenable to liposuction and can result in residual gynecomastia, as fibrous attachments adhering to the breast stroma makes complete removal difficult. 24-25 Direct excision is the treatment of choice for most cases of true gynecomastia. This procedure can be performed under local or tumescent anesthesia, conscious sedation, or general anesthesia. The glandular tissue is resected by sharp dissection via a periareolar incision. Resected tissue should always be sent for pathological analysis as malignancies are detected in rare instances. Adverse events resulting from direct excision are uncommon. A saucer deformity, in which the nipple-areola complex is tethered to chest wall, can occasionally occur. 24 Hematomas and seromas are other potential adverse events related to excision.25, 26 Our Approach to Pseudogynecomastia The majority of our male breast liposuction is done for pseudogynecomastia,27 as described below, with the sculpted removal of underlying fat yielding an excellent chest contour. However, for those patients with associated prominent breast buds, we use a technique that combines liposuction with delayed direct excision. Basic Procedure — Male Breast Liposuction • IV Sedation — The procedure is performed with IV sedation in an accredited ambulatory surgery center. • Tumescent liposuction is performed to contour the anterior chest and periaxillary chest wall. • A vest is worn for 2 weeks after liposuction. Surgical Excision of Breast Bud Tissue Six to eight weeks after undergoing the above procedure, the patient returns for surgical excision of the breast tissue. • IV Sedation — As with basic procedure above, this is performed with IV sedation in an accredited ambulatory surgery center. • Incision and resection — A periareolar incision of 180 degrees is made and the fibrous glandular stromal tissue is resected (See Figure 1). Fibrosis secondary to prior liposuction creates a bloodless plane in which the tissue can be easily resected, minimizing the risk of post-operative hematoma. • Closure and compression — A layered closure using 4-0 Vicryl and 5-0 Prolene is then performed followed by 72 hours of compression. • Follow up Care — Standard wound care and limited exercise is recommended for 10 to 14 days. Summary Although generally benign, gynecomastia can be a cause for male embarrassment and thus a significant cosmetic concern. Our technique of tumescent liposuction followed by direct excision of the breast bud for select patients is a safe and effective treatment with optimal cosmetic results. n Dr. Bisaccia is a practicing dermatologist and Clinical Professor of Dermatology at the Columbia University of Physicians and Surgeons in New York City. Dr. Lu is a Fellow in an ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologic Surgeons in Morristown, NJ. Dr. Rogachefsky is a practicing dermatologist and is the Program Director of the ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ. Dr. Scarborough is a practicing dermatologist and Assistant Clinical Professor of Medicine, Division of Dermatology, at the Ohio State University Hospital in Columbus, OH. Disclosures: Drs. Bisaccia, Lu, Rogachefsky and Scarborough disclose that they have no real or apparent conflicts of interest or financial interests or arrangements with any companies or products mentioned in this article. References 1. Bembo SA, Carlson HE. Gynecomastia: its features, and when and how to treat it. Cleve Clin J Med. 2004 Jun;71(6):511-517. 2. Nydick M, Bustos J, Dale JH Jr, Rawson RW. Gynecomastia in adolescent boys. JAMA. 1961;178:449–454. 3. Ting AC, Chow LW, Leung YF. Comparison of tamoxifen with danazol in the management of idiopathic gynecomastia. Am Surg. 2000 Jan;66(1):38-40. 4. 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