Gynecomastia

Description
General anesthesia is usually used, but local anesthesia and IV sedation may be
preferred. Gynecomastia is enlargement of the male breast. The causes of gynecomastia
include chromosome abnormalities such as Klinefelter’s syndrome, renal
or hepatic disease, endocrine dysfunction, exogenous or endogenous hormones,
and other drugs, particularly cimetidine and marijuana. Incidence increases with
increasing age.
There are additional peaks in incidence at puberty (gynecomastia
praecox) and ages 20–24. Mammography, U/S, and FNA or core-needle biopsy
usually secure the diagnosis. Gynecomastia can be treated medically by cessation
of the offending agent or therapy with tamoxifen, clomiphene, and danazol, with
up to 83 % resolving. Radiation therapy has also been used to treat gynecomastia.
Most adolescent gynecomastia will resolve without treatment; however, it may be
psychologically diffi cult to wait years. Surgical management is very effective for
all types of gynecomastia. Liposuction can be used alone or in conjunction with
open excision, but many of the patients treated with liposuction alone complain
of a residual subareolar mass and excess skin may be a problem. A peri-areolar
incision is made 50 % of the circumference of the areola and can be extended
laterally. Subcutaneous mastectomy is used with breast tissue dissected from the
nipple- areolar complex without devascularizing the nipple. Cosmesis is achieved
by tapering the edges or liposuction. Hemostasis and suction drainage can reduce
hematoma formation. Absorbable interrupted sutures and running subcuticular skin
suture are often used for closure.
Anatomical Points
Gynecomastia can be unilateral or bilateral even when caused by drugs. The palpable
mass of breast tissue is usually subareolar. Masses in other locations of the
breast are not likely to be gynecomastia.
Perspective
It is important to discuss with the patient the risk of poor cosmesis,
as the primary reason for surgery is often to improve appearance. Postoperative
hematoma is best avoidable by careful hemostasis. Infection is rare. Seroma formation
may occur and it can be aspirated if it is large or left to resolve if small.
Recurrent seromas can be unpredictable and tedious and last for >1 month. The
breasts may be unequal in size when the patient has recovered fully from surgery.
There may be excess skin that is unsatisfying to the patient. Both of these conditions
may require another operation. Acute postoperative pain is common and is easily
managed with oral analgesics. Chronic pain is rare. Some patients may experience
heightened sensation of the nipple temporarily, but this usually resolves. Numbness
or paresthesias of the nipple are also possible. The axilla complications are not present
as axillary surgery is not typically included.
Major Complications
A large hematoma may require evacuation and control of the bleeding with further
surgery. If a large hematoma is not drained, it may drain spontaneously or
rarely dissipate. Large hematomas also increase risk of infection . Although sometimes
unpredictable, poor cosmesis may arise due to unequal breast size, excessive
skin, dimpling, scarring, or persistence of a subareolar mass, and may occasionally
necessitate further surgery to improve the outcome. However, most men do not
complain of breast deformity. Chronic pain or paresthesia is not common, but can
be signifi cant problems.