Loading...

The term gynecomasty is derived from the Greek word “gyne” which means “breast as a woman.” Gynecomasty is a benign increase in the male breasts, which occurs as a result of hypertrophy or increase of the gland parenchyma of the breast and accumulation of  the adipose subcutaneous tissue. Gynecomasty can sometimes manifest in the secretion of a small amount of milk or similar discharge. Statistically, one of three men younger than 40 years suffers from a certain degree of gynecomasty, and nearly half of men above 50 has the increased men’s breasts. Such a situation is often the physiological phenomenon in newborns, adolescents and adult men, but it can also be a consequence of the disease. The causes of gynecomasty are often unknown, although it is generally considered that this is a disbalance of the sexual hormones or tissues reaction to it. The prominent male breasts therefore may arise due to the hypertrophy of the gland breast tissue, abundant deposit of the adipose tissue, and usually this is a combination of the above factors. Gynecomasty represents a big psychological problem with boys of adolescent age. The boys with gynecomasty are often subjected to mocking of peers at school, which results in a feeling of shame, discomfort, inferiority complex, introvertness or withdrawal into oneself, which can lead to long-lasting psychological trauma. The boys with such an issue withdraw into shell, which causes further delay in the emotional and sexual development. For example, adolescents and adult men do not reveal their breasts at the beach, but swim in T-shirts for fear of the reaction of the environment. They often wear wide T-shirts because normal-sized T-shirts reveal the outlines of the increased male breasts. The practice often meets patients who have never took their clothes off at the beach or at the pool. The successful correction of gynecomasty results in a dramatic change of psychosocial behavior of such patients.

Causes

Gynecomasty may be physiological and pathological. The physiological gynecomasty appears in newborns, before puberty or during aging. Many cases of gynecomasty are idiopathic, meaning they have no clear causes. The pathological causes of gynecomasty are chronic taking of drugs including hormones and/or steroids, high level of estrogen in serum, reduced production of testosterone, defects of the male sex hormones receptors, chronic liver and kidney disease, HIV and other chronic diseases. In 25% of cases the cause of gynecomasty is not known. Drugs cause 10 to 20% of cases in the adult men. These are the following medicines: Cymetidin, Omeprazol, spyronolactone, imatinib, imatinib mesilate, finasteride and certain antipsychotics. Some of them affect directly the breast tissue while the others increase the secretion of prolactyn from the hypophyse. Androsteredion, which is used as a supplement to diet, can lead to increase in the breasts with heightened estrogen activity. Drugs used in treating the prostate cancer such as antiandrogens can also cause gynecomasty. It is considered that chronic use of marijuana can be a potential cause, although the details are controversial. The heightened levels of estrogen in serum (the female sexual hormones) may occur in some testicular tumors or within the hyperfunction of the thyroid gland. Obesity often leads to growth of the estrogen level in the blood. In addition, reduced production of the male sexual hormones, testosterone, may be the reason of gynecomasty. The excessive use of anabolic androgen steroids may cause gynecomasty. In practice, there are often cases of young athletes, especially men who are engaged in body building, who come for the correction of gynecomasty. In 90% percent of such cases these people have previously used anabolic steroids, and hence arises the connection between the anabolic steroids and gynecomasty. Although the cessation of taking the above medications can lead to the disappearance of gynecomasty, surgical therapy is often needed to eliminate the hypertrophic breast tissue. Therefore, the potential causes of gynecomasty are:

–          puberty

–          long-term use of steroids

–          obesity

–          consuming marijuana (which is still not confirmed)

–          tumours

–          hereditary disorders

–          chronic liver disease

–          side-effects of taking many drugs

–          castration

–          Klinefelter syndrome

–          Gilbert syndrome

–          the aging process

The division of gynecomasty

There are three main types of gynecomasty

1. Fatty or lipomasty
2. Glandular gynecomasty – hypertrophy of the glandular tissue
3. Mixed type

Fatty gynecomasty is caused solely by the localized deposits of the adipose tissue in the mammary area. It can often be seen as a part of diffuse obesity and with older men. Such gynecomasty is also called lipomasty. When palpating fatty gynecomasty, the  male breast tissue is softer, and the shape is somewhat lowered. Radiologically, a clear difference between the loose adipose tissue and the thicker and harder gland tissue is evident. The lowered and large male breast often forms the inframammary fold as in women. Fatty gynecomasty can be successfully corrected by applying hydroliposuction, without removing the mammary glands.

Glandular gynecomasty is caused solely by hypertrophy or the gland tissue increase in the breasts. When palpating such a breast, the hard gland tissue can be clearly located just beneath the nipple, and often a patient feels pain when the pressure is stronger. Such a breast has a conical shape and has no formed inframammary fold. Hydroliposuction and surgical removal of the hypertrophic mammary glands corrects this type of gynecomasty completely. Hydroliposuction is necessary to avoid the appearance of the concave male breast that would emerge after the isolated removal of the glands because of the surrounding cluster of the adipose subcutaneous tissue in the mammary area, in order to achieve the optimal shape of the mammary area. The additional reason for the application of hydroliposuction in this type of gynecomasty is much easier surgical removal of the increased mammary glands, because the gland tissue can be clearly separated from the surrounding adipose tissue.

Mixed gynecomasty is the most common type of gynecomasty, and is caused by simultaneous hypertrophy of the mammary glands and the layers of the adipose tissue in the mammary area. When palpating, the hard gland tissue can usually be clearly distinguished from the surrounding softer adipose tissue, and it can be  proven by  X-rays image or utrasound. The surgical method of choice is hydroliposuction of the mammary areas and removal (extirpation) of the mammary glands.

Procedure

The first step is preoperative examination of the patient to determine which type of gynecomasty he suffers from. The approach to each patient is strictly individual. A thorough family and personal history is taken to try to isolate the possible cause of gynecomasty. Patient’s wishes and expectations from the procedure are carefully observed. After the consultation, the examination follows (palpation, inspection, possibly radiological and ultrasound treatment). The important part of the examination is a psychological evaluation of each patient. It is necessary to detect any possible asymmetry of the male breasts which is a very common case, and to demonstrate it to the patient in front of the mirror. Depending on the size and type of gynecomasty, the patient must be familiar with the type of anesthesia. If the areal of gynecomasty is smaller in diameter, then reinforced local anesthesia is applied. In the case of a large area or extreme gynecomasty, the patient will go through the procedure that is performed under general anesthesia. It is important to measure preoperatively the scope of the chest at the level of the nipple to determine the exact size of a garment a patient must wear a few weeks after the cosmetic corrections. In addition, the scope measurement is done in the  postoperative period, so the reduction of the chest achieved by the operating procedure can be exactly determined.

Surgical procedure

Before the procedure a patient must undergo thorough preoperative tests. If all the required tests are within normal limits, a patient can go on with the procedure. First, preoperative marking of the area which will be operated is done using the surgical markers.

The next step is beginning the surgical procedure.

The following step is injecting the solution which consists of the local anesthetic (usually lidocaine), epinephrine and saline solution. The aim of injection is to achieve shrinkage of the small blood vessels in the subcutaneous adipose tissue and facilitate the removal of the adipose tissue with as little bloody content as possible. In this way, the content of the liposuction bottle is almost exclusively adipose tissue, and the loss of blood minimal. In addition, the application of the solution helps separation of the gland and adipose breast tissue from the pectoral muscles and significantly reduces the risk of the muscle injury and bleeding. The specified procedure makes it easier to perform hydroliposuction because it reduces the resistance of the tissue to the penetration of the liposuction cannulas.

After injecting the solution, a minimal incision on the edge of the mammary area is made, through which a cannula of 4 mm in diameter penetrates the area of gynecomasty. In our polyclinic we use only the thinnest liposuction cannulas (diameter of 3 and 4mm) because such cannulas help achieving the optimal contouring and excellent aesthetic result in the end of the postoperative period, and the tissue is minimally traumatized.

A surgeon introduces the cannula through the minimal incision and performs hydroliposuction, that is, removes the adipose tissue from the selected area. We need to emphasize that the cannula only removes the adipose tissue, and it is not possible to use it to eliminate the hard, hypertrophic gland tissue. During the hydroliposuction, from 200 to 1000 ml of adipose tissue can be removed.

The picture shows the bloodless parts of the adipose tissue in the liposuction tube removed during the hydroliposuction.

The picture shows the apparatus for hydroliposuction during the procedure and the removed adipose tissue.

The picture shows the liposuction cannulas of 3, 4, 6 and 7 mm in diameter. In the “Polyclinic Ostojić” most of the hydroliposuctions are done using the thinnest cannulas of 3 and 4 mm in diameter which allow quick evacuation of the adipose tissue, significantly better control of the surface contours of the mammary area, and the trauma of the surrounding tissue is significantly less than when using the cannulas larger in diameter.

In the “Polyclinic Ostojić” hydroliposuction is performed using only the thinnest cannulas (in the picture a surgeon is holding the cannula in his right hand) with minimal damage to the blood vessels in the adipose tissue, which has resulted in the adipose tissue removal with the minimal blood loss. Another important reason is much nicer contouring of the entire area, which is best seen in the pictures before and after. This means that there is no visible prominence and recess. After the hydroliposuction of the mammary area, the redundant adipose tissue is removed, and the picture clearly shows the nipple prominence which is made by the hard and increased mammary gland which can not be removed by liposuction. This means that the gland must be removed with the classical surgical method.

After finishing hydroliposuction of the left mammary area, there is a visible difference between the left and the right, unoperated area. We continue with the removal of the left mammary gland.

Now we perform a semicircular periareolar incision around the nipple through which we will remove the increased mammary gland. The incision is made very precisely on the borderline between the areola and the surrounding skin, which, with the precise sewing of the wound by the principles of the aesthetic surgery, guarantees invisibility of the scar. Bloodless operational procedures are clearly seen. In the depth of the incision a white tissue of the hypertrophic mammary gland is visible, which will be removed.

We precisely separate the areola skin and the nipple from the gland beneath.

We gradually separate the gland tissue from the rest of the surrounding adipose tissue and skin and take out the mammary gland.

The condition after the complete removal of the mammary glands. A pit is visible, whose bottom is the large pectoral muscle, and on the edges the adipose tissue remained that is necessary to leave because it is pervaded with the blood vessels for supplying and normal functioning of the skin. The adipose tissue can not and must not be completely removed because this would lead to the skin atrophy and provide a great chance for the appearance of unaesthetical hollows in the treated area.

Sewing the minimal skin incision through which we introduced the liposuction cannulas with the very thin atraumatic thread (Nylon 6-0) so the scar would be almost invisible.

Sewing the semicircular incision with the running suture (Nylon 5-0). The running suture in this case provides the best adherence of the edges of the incision and also provides the fastest and the best healing of the wound and almost invisible scar. We have been using this way of sewing in practice for the past few years. Previously, we have been using the intracutaneous suture, and we have determined that the running suture creates less visible scar because of better adherence of the edges of the incision.

Gynecomasty correction has ended. All sutures are sewn. In the picture the removed hypertrophic mammary glands in actual size are visible. The proportion between the size of the mammary glands and the entire chest is shown, and it is obvious what was the cause of the aesthetic problem. The following procedure is the sterile wound bending. Immediately after the completion of bending, a patient is given a special gynecomasty garment which should be worn for a minimum of 4, and optimally 6 weeks. A garment must not be taken off for the the first postoperative week, and after that period it can be taken off for half an hour a day during taking a shower. Wearing a garment is obligatory because it compresses the entire area and prevents bleeding. Wearing a garment enables better tightening of the skin and adapting to the reduced subcutaneous basis caused by the removal of the adipose  tissue and mammary glands. A garment warns patients that they must avoid physical activity for at least four weeks, and it represents a certain protection from the potential trauma of the mammary area. The most unwanted activities include streching of the chest toward the front and back, and the friction movements of the mammary area, because they slow down the healing of the superfitial and deep layers of the tissue, they encourage a chance of bleeding, the emergence of serom and longer duration of swelling. The most important function of a garment is to maintain the contoured aesthetic result obtained by the surgical procedure. The size of a garment is accurately determined by the preoperative measuring of the scope of the chest.

Postoperative period

In the postoperative period there is no pain because the patient receives intramuscular injections of analgetics. The mild pain that may occur in the following days can be simply resolved by taking the peroral analgetics. In the first two postoperative days the body temperature can slightly rise (up to 38°C), but that does not mean infection; this is a normal postoperative, resorptive temperature. The hematomas of  the mammary area are most visible 2-4 days after the procedure, and usually they last for 3-4 weeks. Recovery can be accelerated by the lymphatic drainage treatment. The sutures from the hydroliposuction incision are taken out the seventh day, and the sutures from the semicircular periareolar incision can be removed after 2 weeks. It is best not to moisturize the wounds the first postoperative week, and after that the bend is taken off and leaves open wounds. It is recommended to take shower with children’s baths, for such baths irritate the operational incisions the least. The aesthetic result is final after 3-4 months, and the patients can return to their normal life activities several days after the operation.

Complications

The postoperative complications are very rare. Possible complications include:

• infection (at the “Polyclinic Ostojić” we apply antibiotics routinely in intravenous injections immediately before, then 8 and 16 hours after the procedure, and a patient continues to take the broad-spectrum antibiotics after discharging from the Polyclinic, and thus minimizes the possibilities of infection)
• bleeding (using the cannulas of 3 and 4 mm in diameter we significantly reduce the possibility of injuring the blood vessels larger in diameter and so reduce the possibility of postoperative bleeding)
• fat embolism (using the cannulas of 3 and 4 mm in diameter we significantly reduce the possibility of fat embolism, because cannulas of  such diameter bypass the blood vessels larger in diameter)
• hypertrophic scars and keloids (very rarely met in practice, and arising from the superfluous creation of the scar tissue in some patients, which is preoperatively impossible to estimate, unless the patient himself is aware of such tendencies in their own families or in their own organism on the basis of the past experience). Because of that, patients should have frequent control examinations in the first few postoperative months, so we can promptly respond to such scars by applying special anti-scar gels and steroid injections)
• unwanted aesthetic effects in the form of the mild pits or swelling which can later be corrected by applying bipolar radiofrequency (Vela Smooth or Vela Shape devices).

APPENDIX

The example of extreme gynecomasty

This is the case of extreme asymmetric gynecomasty. The preoperative level of all sexual hormones in serum is normal. The given example is very rarely met in medical practice and is a great aesthetic problem for the patient.

Applying the solution of local anesthetic. The extremely conical shape of the huge mammary gland is visible. It is important to mention that this is the gynecomasty caused mainly by the hypertrophy of the mammary glands.

No matter this is a dominantly gland gynecomasty, the hydroliposuction of the mammary area must be done first to achieve the optimal aesthetic result and to avoid the visible edge pits, which would inevitably appear after the isolated removal of the glands. In this way liposuction allows smoothing of the surface and contouring of the whole mammary area.

Hydroliposuction is completed and the surrounding adipose tissue around the nipples is removed as shown in the picture left, where it is visible that between the fingers remains extremely small amount of the adipose tissue. In the picture right the enormous mammary gland that can not be removed by hydroliposuction and that can only be removed by the direct surgical approach is shown.

It is visible that the liposuction cannula can not penetrate through the hard-glandular tissue even with the greatest manual effort.

The surgical removal of the glands is completed, and the semicircular incisions are sewn with the running sutures.

The life size of the removed glands is shown in relation to the size of the pectoral girdle.

The incision through the removed glandular tissue is shown. White tissue represents the hypertrophic mammary gland which is partly pervaded with the clusters of yellow adipose tissue. The diameter of the glands removed is 10 cm. Each gland removed has to be patohistologically analyzed. Usually, most of the removed hypertrophic mammary glands has a diameter of 3 to 5 cm. The incision through the gland shows that the optimal aesthetic result is achieved through a combined surgical approach: by the hydroliposuction of the mammary area and the complete removal of the increased male mammary glands.