✍️ Gynecomastia- In a Nutshell

Gynecomastia is the most common condition affecting the male breast. It affects 32%–65% of all men. Gynecomastia can be physically and psychologically harmful to the patient and hence surgical correction is needed in many circumstances. Many grading classification systems and surgical approaches exist including the one by Dr. Sreekar Harinatha that was published in the Brazilian Journal of Plastic Surgery

Methods of surgical treatment of grade I gynecomastia vary and include gland removal only, gland removal in combination with liposuction, etc. Most authors agree that skin resection is not indicated for patients with grade I gynecomastia.

Gland removal can be done using various techniques, including a traditional, larger, 2-cm infra-areolar incision for direct excision, or a small 6–8 mm infra-areolar or inferolateral quadrant incision for “pull through” or “orange peel” techniques for direct excision. Both techniques include grasping of the breast tissue through a small incision with removal of the breast tissue from surrounding structures under direct visualization.

A large variety of surgical approaches was also noted for the treatment of grade II gynecomastia like in Grade I.

An even wider variety of surgical techniques exists for grade III gynecomastia, including gland isolation with central subdermal plexus pedicle, with posteroinferior subdermal plexus pedicle, liposuction + gland removal, breast amputation through inframammary fold (IMF) approach with free nipple graft, etc. Several of these surgical approaches have been previously detailed in this report for the treatment of grades I and II gynecomastia.

No definitive, universally accepted algorithm exists regarding the ideal surgical approach for the treatment of gynecomastia based on severity. Each patient must be considered individually, and the treatment decided upon should be tailored as such. Given the wide variety of acceptable surgical techniques available regardless of patient severity, several factors should be considered. These include patient scarring/tendency for poor scarring, patient comfort with the possibility of revision, patient comfort with the presence of skin redundancy, and other specific circumstances such as the presence of tuberous breast deformity, size of the nipple, and large nipple-to-IMF (Infra-mammary fold) distances, as seen in massive weight loss patients.

Based on the published literature and personal experience, Dr. Sreekar Harinatha provides the following surgical algorithm based on the Simon grading system to assist the plastic surgeon in determining the most appropriate surgical approach for each individual patient.

The first step in the determination of appropriate surgical treatment should be the grading of the patient’s gynecomastia based on Simon’s grade. For patients with grade I gynecomastia, the patient’s previous scars should be examined. If the patient is known to form hypertrophic scars or keloids, excision of glandular tissue should be avoided as an unsightly periareolar scar may cause distress to the patient. In this case, liposuction alone should be chosen as the modality treatment of choice. Conversely, if that patient does not scar poorly, liposuction in addition to SSPM may be chosen.

For patients with grade II gynecomastia, the question regarding the presence of excess skin should be considered. If that patient does not have excess skin but does have an enlarged NAC, gland removal ± liposuction may be utilized. If the patient does not have excess skin and NAC is not enlarged, we advocate for the use of gland removal+ liposuction. If significant excess skin exists regardless of NAC size, we advocate for the use of secondary skin tightening.

Finally, for patients with grade III gynecomastia, the primary question we consider pertains to the nipple-to-IMF distance. If that distance is >10 cm, we advocate for the use of simple mastectomy via the IMF approach with free nipple grafting, as the amount of resection necessary to achieve an acceptable contour would likely revascularize the NAC. If the nipple-to-IMF distance is <10 cm, we advocate for the use of gland removal ± liposuction.

✍️ Tests for Gynecomastia

 When one talks about the tests for a gynecomastia patient, it has two facets to it

  1. Tests to check for causes of gynecomastia
  2. Test mandatory to check if the patient is fit for surgery

Once the doctor suspects its gynecomastia, then the next step is to check if there is indeed a hormonal issue or its idiopathic in nature. The word idiopathic itself means that the cause is unknown. It accounts for over 70-90% of all cases of gynecomastia. However, before diagnosing someone as ‘Idiopathic gynecomastia’ the doctor needs to rule out a few things. The other category of patients belongs to ‘Secondary gynecomastia’ wherein there is a proven cause for gynecomastia as was enlisted above. 

Apart from the drug-induced gynecomastia that may be easier to diagnose, the doctor should bear in mind other hormone disorders. Laboratory evaluation is indicated only if the clinical assessment suggests a secondary underlying cause. It is not needed for boys at puberty for enlargement due to fat (pseudogynecomastia) and for men taking drugs known to cause gynecomastia. 

In cases of secondary gynecomastia without a clear cause, laboratory tests should be advised and must include, liver, kidney, and thyroid function tests (to exclude the respective causative medical conditions), as well as hormonal tests. The hormonal analysis is always in a series of tests as a part of the evaluation. They include:

  1. Estrogen level
  2. Total and free testosterone
  3. Luteinizing Hormone
  4. Follicle-stimulating hormone
  5. Prolactin
  6. And occasionally hCG, DHEASO4 or 17 ketosteroids, SHBG and αFetoprotein
  7. If the patient’s testes are small, the patient’s karyotype (chromosomal analysis) should be done to exclude Klinefelter’s Syndrome.

If all tests are negative, the patient should be diagnosed with idiopathic gynecomastia. Sometimes it is indeed advisable to have an endocrinologist look at such patients, as there may be other important than just gynecomastia. It is especially more prudent to meet one to reveal significant variations. Early stages of secondary gynecomastia can be medically treated through the gland and do not always regress and may end up needing procedure to sort the gland. 

Ultrasonography and mammography can occasionally be used to differentiate fat from breast tissue or if there are abnormal masses especially in terms of consistency. Scans are definitely when the patient has one of the signs suggestive of a cancer lump. Other than these, as may be necessary also to ascertain breast tissue that feels abnormal or feels irregular in places. Mammography is about 90% sensitive and 90% specific for cancers compared with benign masses in men. 

However, a biopsy is the only way to make a definitive diagnosis. Patients with a hard, irregular, or asymmetrical mass, nipple discharge (bloody or non-bloody), enlarged armpit lymph nodes, or a mass fixed to skin or the chest wall must have a biopsy. Usually, a core biopsy is recommended over the fine needle or excisional biopsy. In core biopsy, a small amount of tissue is taken via a small hole under local anesthesia. It is more accurate over the commonly done fine needle biopsy. In a fine needle biopsy, an injection is given and the feels obtained through it are examined under a microscope. Since the amount of cell sone gets from such biopsy is very small, the chances of error are consequently high. An excision biopsy is one where the lump is removed in its entirety and sent for testing. While this is the most accurate, it is reserved for specific cases where the diagnosis with routine biopsies are not confirmatory.

Rarely done tests include: 

Ultrasound of testes: If there is any abnormality in the testes on examination, or if there is a raised beta-hCG or alpha-fetoprotein.

Abdominal Scans: If a tumor of the adrenal glands or the testes is thought to be responsible for the gynecomastia after hormonal analysis.

Chest X-ray: If a lung tumor is suspected as a cause for gynecomastia. Sometimes tutors in other tissues may be hormonally active, meaning they may produce hormones which in turn may lead to gynecomastia. Though these are rare, one does come across such cases and a quite often a diagnostic dilemma.

Once these diagnostic tests are done as necessary, the next set of tests are for those planning to undergo the corrective procedures. Since the procedures can be theoretically done under local or general anesthesia, the test also varies depending on the anesthesia planned. For a gynecomastia surgery under local anesthesia, no additional tests are needed, if the patient is clinically fit and has a clear unremarkable history. When the procedure is planned under general anesthesia a set of tests are mandatory.

  1. Complete blood counts
  2. Blood sugar levels
  3. Coagulation parameters: PT, INR, and aPTT
  4. Kidney function tests: Serum Creatinine and Urea levels
  5. Other tests that are often done are: HIV screening, HBsAg to check for hepatitis B, HCV, etc
  6. Apart from these routine tests, a few more may be advised depending on the patient’s age, medical history, and the factors. These include Echocardiography, Chest X-rays, ECG, Liver function tests, Sickle cell tests, etc. Cardiac (heart) evaluation becomes necessary when an older patient comes for corrective surgery. Occasionally a consultation with a cardiologist or the relevant physician is needed before surgery.
  7. COVID test for Gynecomastia: Currently there are no clear guidelines or consensus for conduction COVID tests for any gynecomastia patient.

This post is an excerpt from Dr Sreekar Harinatha’s highly acclaimed book on gynecomastia titled ‘The Male Breast: What You Should Know about Gynecomastia’. It’s available on Amazon on the link here.