Gynecomastia, or abnormal breast tissue enlargement in men. The aim of treatment is restoration of a normal male chest contour while minimizing the evidence of surgery and protecting the nipple areolar complex. Although excisional techniques have traditionally been the accepted standard, liposuction has now become established as the prime surgical modality either alone or in combination with more invasive methods.
Basic science
Gynecomastia is thought to primarily result from an increased estrogen to androgen ratio since estrogens stimulate breast tissue while androgens antagonize its effects. This hormonal imbalance may therefore arise from an absolute or relative excess of estrogens, or an absolute decrease of androgen levels or their action.
Etiologically gynecomastia can be physiological or pathological in nature. The former may occur during three different age groups.
A thorough history is important to determine the underlying cause of gynecomastia and rule out breast cancer and other tumors. On the other hand, it should be noted that around 25% of gynecomastia cases may be idiopathic. Salient points include patient age, onset and duration of breast enlargement, symp-toms of associated pain, recent weight change, and a systems review with particular attention to possible endocrine and liver abnormalities. Medications and recreational drug use need to ascertained as they may cause 10–20% of gynecomastia cases.
On physical examination, gynecomastia is usually bilateral and felt as glandular tissue under the nipple areolar complex and extends to a variable size in all directions. It needs to be differentiated from pseudogy-necomastia or lipomastia, which is adipose tissue hypertrophy without glandular proliferation. physical examination should include assessment of secondary sexual development and the thyroid, as well as looking for signs of chronic kidney or liver disease. When examining the genitalia, it is also important to look for any testicular masses or atrophy. Liver enlargement may sometimes be encountered. There is no increased risk of breast cancer in patients with gynecomastia when compared with the unaffected male population.s The exception is patients with Klinefelter syndrome. These patients have an approximately 60 times increased risk of breast cancer
Bio-chemical assessment includes tests for liver, kidney, and thyroid function; and serum levels of testosterone, prolactin, follicle-stimulating hormone, and luteinizing hormone. Additional tests may be necessary in cases of recent or symptomatic gynecomastia to rule out tumors.2 For example, serum levels of estrogens, human chori-onic gonadotrophin (hCG), dehydroepiandrosterone (DHEA), and urinary 17-ketosteroids.
2b and 3 types need skin excision ( in same sitting or 4-6 months later).
Letterman and Schuster‘ created a classification system based on the type of correction: 1: intra-areolar incision with no excess skin; 2: intra-areolar incision with mild redundancy corrected with excision of skin through a superior periareolar scar; and 3: excision of chest skin with or without shifting the nipple.
Rohrich et al. in a paper discussing the utility of ultrasound-assisted liposuction in the treatment of gynecomastia, developed the following classification: grade I: minimal hypertrophy (<250 g of breast tissue) without ptosis; grade 2: moderate hypertrophy (250 to 500 g of breast tissue) without ptosis; grade 3: severe hypertrophy (>500 g breast tissue) with grade I ptosis; grade IV: severe hypertrophy with grade 2 or3 ptosis.
Types of gynecomastia
Three types of gynecomastia have been described: florid, fibrous, and intermediate. The florid type is characterized by an increase in ductal tissue and vascularity. A minimal amount of fat is mixed with the ductal tissue. The fibrous type has more stromal fibrosis with few ducts. The intermediate type is a mixture of the two. The type of gynecomatia is usually related to the duration of the disorder. Florid gynecomastia is usually seen when the breast enlargement is of new onset within 4 months. The fibrous type is found in cases where gynecomastia has been present for more than 1 year. The intermediate type is thought to be a progression from florid to fibrous and is usually seen from 4 to 12 months.
Medical management
Most cases of gynecomastia do not require treatment as they are benign and self-limiting. Weight loss should be recommended for male patients with pseu-dogynecomastia in the first instance. Medical therapies essentially focus on correcting the imbalance of androgens and estrogens. furthermore, medications are probably most effective during the active, proliferative phase of gynecomastia. In patients with long-standing gynecomastia of over 1 year, medical treatment is often ineffective as the breast glandular tissue progresses to irreversible dense fibrosis and hya-linization. Such cases should be considered for surgical treatment. When treatment is indicated, most patients do not need a trial of medical therapies and are best managed with surgery, which is the mainstay modality.
Surgical management
Well-established surgical techniques for gynecomastia treatment include various forms of liposuction, open glandular excision, skin reduction, and combinations of these.
General Anesthesia as day care except in patients where excision of skin is planned. All patients receive perioperative broad-spectrum antibiotic prophylaxis at general anesthetic induction. Patients are marked preoperatively in the upright sitting position highlighting the inframammary fold, breast boundaries, planned stab-incision sites, and concentric topography-type marks centered on the most prominent portion of the breast. Infiltration with superwet technique done (300 mg per litre lignocaine).
SAL
Liposuction of Breast is done however residual subareolar tissue is a frequently encountered complication with this technique. SAL is not suitable for severe cases or in breasts with primarily fibrous tissue. It can be effective in soft breasts even if large, but good skin quality is important for later contraction and avoiding the need for skin resection. Liposuction allows the achievement of better breast contours with minimal scarring. Cross-tunnel suctioning for larger breasts, ptotic breasts, and those with excess skin or well-defined inframammary folds makes SAL more effective. The laterally placed incision in the inframammary fold allows better access for the liposuction to the whole breast laterally and medially. Cross-tunnel suctioning for larger breasts, ptotic breasts, and those with excess skin or well-defined inframammary folds makes SAL more effective. Such extensive cross-suctioning enables more consistent contraction of the skin and allows it to redrape with less waviness and irregularity. A 4.6 mm or 5.2 mm Mercedes cannula is used for the initial suction employing the palm down and pinch techniques. Finer refinement by 3 mm or 3.7 mm Mercedes cannula. Once a satisfactory contour is obtained, the surrounding fat is feathered to avoid a noticeable saucer deformity, and any well-defined inframammary fold as determined preoperatively is deliberately disrupted in order to avoid the gynecoid (female) contour of the breast. When liposuction is unsuccessful at removing all of the tissue required to achieve a good result, the pull-through technique is added. In this technique, either the lateral or periareolar incision is opened slightly (about 1.5 em) and the residual tissue is grasped. The tissue is pulled out through the wound and removed with scissors or electrocautery
UAL is more effective for firmer Breast tissue . By emulsifying breast fat, it is particularly useful for addressing dense, fibrous gynecomastia. It has also been suggested that UAL results in less postoperative bruising, a smoother breast contour, better postoperative skin contraction, and less surgeon fatigue. The well described UAL endpoints73 are determined by loss of tissue resistance, aspirate volume, blood-tinged appearance of the aspirate, and planned treatment time. UAL induces skin contraction also.
Open approach
Liposuction is frequently not effective for very glandular tissue, small discrete breast buds, and body builders as the latter have large amounts of glandular tissue with little fat. Open excision via an inferior periareolar approach11 is the traditional approach. Various other incisions have been described such as circumareolar, periareolar, transareolar, circumepithelial. The liposuction serves a number of purposes such as pretunneling to facilitate resection, reducing bleeding and bruising, and partially breaking down the breast tissue. After liposuction the tissue can be resected via a number of access incisions. At least a 1 cm disc of breast tissue is left under the areola to prevent a depression of the nipple areolar complex. Excess skin may be reduced in same or different sitting according to the acceptance of scar by the patient.
Skin reduction There are a number of procedures used to reduce excess skin in gynecomastia. In patients with obvious skin excess or very large breasts, skin reduction techniques should also be planned usually at the same time as the open excision of the breast tissue or as a second stage, a minimum of 4–6 months later. There is, however, no consensus on when and how to undertake skin resection.
Post operative
Drains are not routinely used, except for large resections or when skin reduction is performed, such as in post massive weight loss patients.
Dr Deepak Rathore
drkamleshsurgeryaiims
Dr. Nupur Aggarwal
Plasticsurgeryexams 