Gynecomastia is the abnormal enlargement of the male breast tissue. It is an extremely common condition that can be found in up to 70% of growing males and 30% of adults.
This condition should be differentiated from lipomastia which is the presence of areolar tissue next to the adipose tissue without the subareolar and dense breast tissue.
There seems to be a hormonal misbalance between the breast inducing hormones (estrogens) and the inhibiting hormones (androgens). Most cases are benign and self-limited or upon removal the underlying cause such as medications.
In a small proportion of the cases this condition can be associated with an underlying disease such as a defective androgen receptor, increased aromatization of androgens to estrogens or the alteration of other hormones such as :
- Insulin-like growth factor (IGF) 1, IGF-2 and
- Luteinizing hormone (LH) and human chorionic gonadotropin (hCG). Conditions such as aging, renal failure and dialysis, cirrhosis, hyperthyroidism, cirrhosis, prostate cancer and HIV are among the most frequent. Other causes are listed in table 1.
The diagnostic approaches aim to differentiate the gynecomastia from lipomastia, rule out breast cancer and determine a possible etiology. Up to 25% of the cases have an idiopathic gynecomastia, that leaves 75% of cases that must be studied.
A detailed medical history should explore the onset, duration, systemic symptoms, weight gain, medications and exposition to estrogens. The examination should focus on the subareolar fibrous tissue, symmetry, galactorrhea, the virilization, secondary sexual development, signs of kidney or liver disease.
In most cases, the physical examination and medical history are enough to diagnose and rule out other conditions.
In suspicious cases, a morning serum level of testosterone and LH, FSH prolactin levels, and routine liver, kidney, and thyroid function tests can be helpful. Routine mammograms and breast ultrasonography are not recommended.
The American society of plastic surgeons propose a useful four grade a classification:
Grade I: Small breast enlargement with a localized button of tissue around the areola
Grade II: Moderate breast enlargement exceeding areolar boundaries, with edges that are indistinct from the chest
Grade III: Moderate breast enlargement exceeding areolar boundaries, with edges that are distinct from the chest, and with skin redundancy present
Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast
For lipomastia the weight loss is the first therapeutic approach. A surgical procedure should be proposed only if it fails.
The treatment is not necessary for asymptomatic men with pubertal gynecomastia or in men with long-standing asymptomatic gynecomastia unless there is a cosmetic issue.
In addition, the other conditions associated with gynecomastia should be carefully studied to determine the causes. Treat the underlying cause should be the focus of the management. The non-responsive cases or those generating anxiety should also consider a surgical treatment.
Based on the classification the surgical procedures, patients with lipomastia, grade I or II gynecomastia with palpable glandular tissue can be treated with vacuum/power-assisted liposuction and subcutaneous mastectomy.
For grade III or IV, added to the liposuction technique and mastectomy, a skin retraction technique from ultrasound, helium plasma or radiofrequency can avoid a skin resection. For grade IV additional procedures of mastopexy should be considered. In most cases, a close drain is required for a week.
As a result, to approach an enlarged male breast, a careful clinical examination is mandatory to diagnose underlying conditions that can be serious and often requires an interdisciplinary team. Most cases do not require any treatment more than observation.
Only after a correct diagnosis and a medical treatment a surgical alternative can be offered.
Narula HS, Carlson HE. Gynaecomastia—pathophysiology, diagnosis, and treatment. Nature Publishing Group. 2014;10(11):684-698.
2. Erkekoglu P, Durmaz E, Kızılgün M, et al. Low zinc levels may contribute to gynecomastia in puberty. Journal of Trace Elements in Medicine and Biology. 2017;44:274-278.
3. Palareti G, Legnani C, Cosmi B, et al. Comparison between different D-Dimer cutoff values to assess the individual risk of recurrent venous thromboembolism: analysis of results obtained in the DULCIS study. Int Jnl Lab Hem. 2015;38(1):42-49.
4. Kim DH, Hwan Byun Il, Lee WJ, Rah DK, Kim JY, Lee DW. Surgical Management of Gynecomastia: Subcutaneous Mastectomy and Liposuction. Aesthetic Plastic Surgery. September 2016:1-8.
5. Mentz HA, Ruiz-Razura A, Newall G, Patronella CK, Miniel LA. Correction of Gynecomastia Through a Single Puncture Incision. Aesthetic Plastic Surgery. 2007;31(3):244-249.
6. Jacobeit J, Kliesch S. Gynäkomastie: Diagnostik und Therapie. Dtsch Med Wochenschr. 2008;133(49):2567-2571.
7. Innocenti A, Melita D, Mori F, Ciancio F, Innocenti M. Management of Gynecomastia in Patients With Different Body Types. Annals of Plastic Surgery. 2017;78(5):492-496.
8. Lee J-H, Kim I-K, Kim T-G, Kim Y-H. Surgical Correction of Gynecomastia with Minimal Scarring. Aesthetic Plastic Surgery. 2012;36(6):1302-1306.
9. Atiyeh BS, Chahine F, El-Khatib A, Janom H, Papazian N. Gynecomastia: Simultaneous Subcutaneous Mastectomy and Areolar Reduction with Minimal Inconspicuous Scarring. Aesthetic Plastic Surgery. September 2015:1-6.
10. Laituri CA, Garey CL, Ostlie DJ, Peter SDS, Gittes GK, Snyder CL. Treatment of adolescent gynecomastia. Journal of Pediatric Surgery. 2010;45(3):650-654.