Gynecomastia is the increase in size of male breasts due to hypertrophy and hyperplasia of the mammary tissue or fatty tissue (false gynecomastia) or both
Gynecomastia comes from the Greek words “gyne” and “mastos” which mean woman and breast, respectively and refers to any condition that causes excessive growth of the male breast tissue.
The male breast consists of the mammary gland and fat called adipose tissue. Patients with advanced gynecomastia have excess skin and sagging breasts.
Galen, the prominent Greek physician of the Roman Empire, was the first to use the word “gynecomastia” in the 2nd century AD to describe the unusual growth of male breast tissue.
Paul of Aegina, one of the pioneering physicians in Byzantium, described the first breast surgery for treating gynecomastia in the 7th century AD.
The problem
Patients who suffer from gynecomastia find no sympathy and feel ashamed and embarrassed.
Coaches, other kids, even parents may cause psychological trauma to patients with gynecomastia.
Patients must seek information about what exactly gynecomastia is and how they can handle the situation.
Gynecomastia therefore involves the increase in size of the male breast. The growing tissue may consist of the mammary gland or the fatty tissue or a combination thereof. Some cases may also involve excess skin as well as sagging breasts.
Pictures of Gynecomastia
Patients present with enlarged breasts which are also asymmetric in 1/3 of cases. Some patients develop gynecomastia on one breast only.
There are 3 types of gynecomastia as per the Webster’s Classification (1934)
Type 1. Patients with enlarged mammary gland; treated through surgery.
Type 2. Patients with fatty tissue and enlarged mammary gland – pseudo gynecomastia – treatment through liposuction and surgery.
Type 3. This is type 1 and type 2 combined with excess skin.
Simon’s classification of gynecomastia (1973).
Small yet visible increase of breast size
2a. Moderate increase of breast size but normal skin.
2b. Moderate increase of breast size and small degree of excess skin.
3 Very large breast. Breast ptosis. Large degree of excess skin.
Causes of Gynecomastia - Tests
Neonatal gynecomastia
This is due to estrogens taken by the mother.
It subsides within a few weeks or months; treatment is not necessary.
Pubertal gynecomastia
Usually appears at the age of 13. Breasts can be painful, and a disk-like mass can be palpated, right underneath the nipple and areola. This is due to hormone changes during puberty.
This condition starts to subside after the age of 15. It is normal to see gynecomastia cases first appearing in puberty and then gradually subsiding.
Pathological gynecomastia
This could be attributable to the lack of testosterone, the increase of estrogens or high rates of androgens conversion into estrogens (Klinefelter Syndrome; adrenal glands tumour, pituitary tumour; poor diet).
This involves 85% of gynecomastia cases and calls for surgical treatment. It’s a case all plastic surgeons treat in their surgeries.
Pathophysiology
In most cases of gynecomastia, the cause remains unknown. Breast cancer is not evident while it is associated with idiopathic gynecomastia. Patients with Klinefelter syndrome and gynecomastia may face an increased possibility of developing breast cancer.
In boys, the main hormone involved is testosterone which is secreted by the testicles. In girls, the main hormones are estrogens secreted by the ovaries. Both hormones are secreted in both genders. Gynecomastia is the result of an imbalance between estrogens in the breasts that cause size increase, and androgens acting against breast enlargement. A shift in the androgen-estrogen ratio has been identified in many cases of gynecomastia.
Tests
Patient history and clinical examination are important in the diagnosis of gynecomastia. Cases that remain unchanged over the years do not call for further investigation.
The Klinefelter syndrome calls for an antibody test.
The doctor may also ask for hepatic enzyme and hormone levels test (FSH, LH, HCG, TSH, T3, T4).
Increased levels of estrogens and 17-Ketosteroids in urine are suggestive of adrenal glands tumour.
The New Triple Surgery Approach
Η Ρ.Υ.Α.Α.Λ. τεχνική είναι μια νέα τεχνική που περιλαμβάνει συνδυασμό τριών πραγμάτων.
Λιώσιμο λίπους και σύσφιξη με ραδιοσυχνότητες και αφαίρεση αδένα με λιποαναρρόφηση.
A new triple surgery approach combines the use of radiofrequency and ultrasound to liquefy breast fat and allow skin firming. The mammary gland is excised, and liquid fat is removed with liposuction.
The purpose of surgical treatment in Gynecomastia is:
a) to reinstate the shape of the male breast b) to correct any abnormalities in the breast, nipple and areola c) to lift the breast and remove excess skin, if any. d) to manage the inframammary fold, if present
The surgical approach to be selected depends on:
1. possible excess skin 2. possible hypertrophic fat 3. mammary gland hypertrophy
In 2010 we introduced a triple surgery approach for gynecomastia, the so-called RUEGL.
The triple approach involves:
a) radio-frequency assisted liposuction (R) b) ultrasound- assisted liposuction (U) c) excision (E) of the mammary gland (G) and Liposuction (L)
What is Radio-Frequency Assisted Liposuction?
This is the familiar bodytite technique. Radio-frequencies can tighten the skin and liquefy fat. Bodytite is a state-of-the-art technology for radiofrequency - assisted lipolysis (using electricity at a specific frequency). The equipment operates on a computer that emits radio-frequency, and a small hand piece. The thin hand piece ends up in a fine 2mm gauge needle. The needle is inserted in the breast through a small 3mm incision and 1) aspirates the fat, 2) uses radio-frequency to break down the mammary gland and 3) to tighten the skin around the breast. Radio-frequency heats the fibroblasts making the skin firmer.
Fibroblasts are collagen-producing cells, and collagen, as we all know, is responsible for our skin’s firmness. The equipment stimulates the fibroblasts, increases and improves collagen production bringing about firmer skin.
What is ultrasound-assisted liposuction?
Ultrasound allows additional fat dissolving that could not be achieved with bodytite alone. They also help in making the skin firmer.
Why use both techniques:
Because of fat that might be resistant to one technique but could be managed well with the other technique.
So, while until recently multiple incisions were necessary in treating gynecomastia, radio-frequency and ultrasound now allow us to proceed with only one 3 mm incision.
Surgery is performed with local anaesthesia and sedation and lasts about 1-2 hour. The patient can go home on the same day. There are no stitches or drains that need to be removed. The patient only needs to wear a compression garment for 2-4 weeks.
How is the mammary gland excised?
The mammary gland must almost always be removed for the surgeon to get a good result when treating gynecomastia.
Many incisions have been used in the past.
In extreme cases of gynecomastia, the surgeon needs to remove the skin and lift the nipple. This is where the purse-string technique is used for nipple reconstruction and skin removal
The major advantage of this technique is that the incision around the nipple disappears completely 3 months after the procedure.
In gigantic gynecomastia, the surgeon may need to remove the mammary gland along with fat and skin and reposition the areola on the free skin graft.
How is the inframammary fold corrected?
This is one of the toughest issues in treating gynecomastia. The surgeon uses bodytite and ultrasound to break down the connective tissue that restrains the skin and forms the fold. The device destroys the fibrous tissue and makes the fold disappear. The surgeon then proceeds with superficial liposuction up to the mid-abdomen level.
Medical treatment
There are various drugs available for treatment such as tamoxifen (Dimoxifen). However, there are no prospective studies demonstrating the effectiveness of such pharmaceutical products.
Cases of Gynecomastia
Gynecomastia: Case 1
Male breast with gynecomastia
Case analysis
Mammary gland enlargement
Fatty tissue enlargement
Small amount of excess skin
Inframammary fold displays similar to a female breast
Asymmetry
Stage 1 - Treatment
The first step is to infiltrate the breast with saline + adrenaline + xylocaine. The adrenaline solution causes vascular contraction and thus bleeding is minimized. Xylocaine allows for pain minimization. This solution facilitates the use of radiofrequency and ultrasound.
Stage 2
The bodytite device is inserted into the breast through a 0.3cm incision made in the armpit. The breast is divided in 4 areas and radiofrequency is applied on the entire surface of the breast.
When the desired firmness is achieved, the surgeon proceeds with stage 3
Stage 3
The surgeon uses the ultrasound equipment for targeting fat and for firming at the same time. It has been found that the use of both devices allows for better firming of the skin and effective fat dissolution.
Stage 4
All fat is aspirated from the breast through fine cannulas.
Stage 5
The mammary gland is excised through a very small incision.
Stage 6
The inframammary fold is corrected. Male breasts have no inframammary fold. The liposuction cannulas along with radio-frequency are used to correct this defect. The surgeon must work further below the fold towards the abdomen.
The patient may return home on the same day. Surgery lasts 1 to 3 hours. No drains are used. The patient may return to work in 2 days. He must wear a compression garment around his chest for 2-3 weeks.
Complications
Hematoma; Asymmetry; Inflammation; Changes in breast sensation; Hygroma; Residual skin; Pain at the incision site etc.
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