Summary

Concept

Gynecomastia: consists of the enlargement of breast tissue in men

Pseudogynecomastia: Increase in breast volume due to an increase only in fat, without changes in breast gland volume. It can also be called lipomastia.

Persistent pubertal macromastia: This is the name given to gynecomastia that began in puberty and did not resolve spontaneously for reasons not yet fully understood.

History

The first reported cases of this condition date back to the 18th Egyptian dynasty, in which images of Pharaoh Tutankhamun and his family appear with gynecomastia.

The first surgical description was made by Paulus Aegineta, who lived between 625 and 690 B.C., with a submammary wedge resection, reported as Aboul Cassis surgery.

Curiosity: Paulus Aegineta was a Greek physician known for writing the medical encyclopedia: Medical Compendium in Seven Books. For many years in the Byzantine Empire, this work contained the sum of all Western medical knowledge and was unmatched in its accuracy and perfection.

Epidemiology

It has 3 incidence peaks:

- Neonatal, due to maternal hormone influence
- Adolescence, due to pituitary, adrenal, and testicular imbalance
- Andropause, due to decreased testosterone production, increased conversion to estrogen due to increased body fat accumulation (adipose tissue aromatase)

- 65% of gynecomastia patients are in the 14/15 age group
- 7.5% persist after 17 years of age
- accounts for 10% of all plastic surgeries performed on men (USA)
- accounts for 18% of surgeries performed on patients between 13 and 19 years old

Classification

Gynecomastia has several classifications. The most common are:

1) Nydick 1961

- Gland limited to the retroareolar region, not reaching the areolar margin

- Gland extends to the areolar margin

- The increase in gland volume extends beyond the areolar border

2) Tanner 1971 -

Stage 1: prominent nipple -

Stage 2: breast bud phase; elevation of the breast and areola -

Stage 3: greater enlargement of the breast and areola, without separation of contours -

Stage 4: projection of the areola and papillae to form a secondary mound above the breast -

Stage 5: protrusion only of the papillae

3) Simon 1973

Grade I: small visible breast enlargement; no skin redundancy;

Grade IIA: moderate breast enlargement without skin redundancy;

Grade IIB: moderate breast enlargement with skin redundancy;

Grade III: moderate breast enlargement with defined skin redundancy (pendulous female breasts)

4) Deutinger and Freilinger 1986

- Grade 1: chest wall poor in tissue; breast tissue localized behind and around the nipple; no excess skin;

- Grade 2: adipose chest wall; generalized changes; female-like breasts acquired during puberty;

- Grade 3: generalized changes; excess adipose tissue, skin redundancy, inframammary fold and ptosis.

5) Cohen 1987

- Group 1: glandular gynecomastia;

- Group 2: glandular gynecomastia with ptosis;

- Group 3: gynecomastia with adipose tissue; - Group 4: gynecomastia with adipose tissue with glandular component.

6) Rohrich 2003

- Grade I: minimal hypertrophy (<250 g of breast tissue), without ptosis; IA: primarily glandular; IB: primarily fibrous;

- Grade II: moderate hypertrophy (200-500 g of breast tissue), without ptosis; IIA: primarily glandular; IIB: primarily fibrous;

- Grade III: hypertrophy (>500 g of breast tissue), with Grade I glandular or fibrous ptosis;

- Grade IV: severe hypertrophy with Grade II or III glandular or fibrous ptosis

Causes

Gynecomastia can be caused by: genetic diseases, endocrinological diseases, cancer, use of medications and drugs, but most often the cause is unknown. If no clinically treatable cause is identified, and the condition persists for more than 2 years, surgical treatment is indicated.

See some causes:

Metabolic Changes:

- Malnutrition
- Liver Diseases
- Hyperthyroidism
- Kidney failure

Drugs:
- Marijuana
- Heroin
- Alcohol (Alcoholism)

Neoplasms (Cancer):
- Testicular cancer
- Other cancers

Defects in testosterone synthesis

Androgen insensitivity syndromes

Differential diagnosis (Breast cancer)

Idiopathic

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Treatment

Clinical treatment

Clinical treatment can be done with antiandrogens (Danazol) and antiestrogens (Tamoxifen), however this treatment must be performed by a specialist doctor, as these medications have side effects and can cause complications for the patient.

Clinical treatment works in initial cases of gynecomastia. Patients with large glands and excess skin will not benefit from this treatment, and direct surgical treatment is indicated.

Danazol: is a substance with affinity for androgen receptors, presenting androgenic and antiandrogenic effects

Tamoxifen: is an antiestrogenic substance

- Other similar medications: Clomiphene, Raloxifene

Aromatase inhibitors (such as Letrozole, Anastrozole, Fadrozole, Exemestane) are medications that may have a positive effect in the treatment of gynecomastia, but there are not enough studies proving their benefit.

Surgical treatment

The traditional surgical treatment of gynecomastia consists mainly of ADENECTOMY (resection of the mammary gland). It may or may not be associated with LIPOSUCTION, and may or may not be associated with SKIN RESECTION. There are other surgical options such as the use of laser or ultrasound, but these require more studies to be reliable. The cost of this surgery with these devices and materials is not justified, as traditional treatment can provide satisfactory results. Due to the detachment of tissues and being a highly vascularized area, drains may be used in the postoperative period to avoid the formation of collections such as hematoma and seroma. In addition to the use of drains, there are already studies showing similar results without the use of drains by performing adhesion stitches to reduce the dead space, i.e., the place where fluids can accumulate post-operatively. The main complications of this surgery are: Hematoma, Seroma, Asymmetries, Surface irregularities, Unaesthetic scars

The surgical incision, or “cut”, for adenectomy is usually around the areola, to minimize scarring. The surgery can be performed under local or general anesthesia, depending on each case. Hospital stay is short, usually not exceeding 24 hours.

The risks of this procedure are minimal and are associated with poor adherence to postoperative care, which requires approximately 4 weeks without physical activity and correct use of elastic compression garments.

Scars: Around the areola, which can be extended laterally if there is too much excess skin. There may be small scars at the drain exits, if used, or if liposuction is performed.

Anesthesia: Local anesthesia and sedation, or general anesthesia.

Hospitalization: Can be performed on an outpatient basis, meaning discharge on the same day.

Post-operative / Recovery: Approximately 1 to 2 months, the use of post-operative compression garments may be recommended, and the return to physical activities is gradual.

Intercurrences: Formation of hematoma, ecchymosis, seroma, scars, asymmetries.

https://youtu.be/APqgIBISk7w Description

Plastic surgeon Dr. Fernando Amato (CRM 133826) talks about the enlargement of mammary glands in men, called Gynecomastia. Learn how to be treated by watching the video!

Transcript

Hello, I'm Dr. Fernando Amato.

Today I'm going to talk about gynecomastia.

Gynecomastia is the enlargement of the mammary gland
in men, meaning a man can have an enlarged

mammary gland.

The most affected age group is adolescents,
but it's clear that when this enlargement

of the mammary gland is identified,
it requires an adequate investigation,

because there are diseases that can occur
at the same time; it can even be a symptom of

a much more serious disease.

Treatment can even be done with medication
in an initial phase, but when the breast has already grown

quite a lot and there has been skin distension,
the treatment is surgical and is indicated when symptoms persist

for more than one or two years.

How is the surgical treatment?

A cut is made around the areola to
remove the gland, and part of the gland is removed.

Often, the patient already has a lot of skin, so
an adjustment of the skin can be made with a slightly larger incision,

and when there is excess fat along with gynecomastia,
liposuction can also be performed.

https://youtu.be/HOVsOUC7rl8 Description

In this video, Dr. Fernando Amato, Plastic Surgeon at Instituto Amato, will talk about: Learn EVERYTHING about Gynecomastia A controversial topic worth discussing. These patients suffer from their contour, often feeling embarrassed to take off their shirt in front of others or even wear certain T-shirts that reveal more. The indication for surgery, in most cases, is aesthetic, but in some patients. This enlargement of the breasts, in addition to causing loss of self-esteem and quality of life, in exacerbated cases, such as large volume breasts, can present local changes such as dermatitis and skin infections in the fold regions due to friction.

Transcript

Hello! I'm Dr.

Fernando Amato and today I'm going to
talk about gynecomastia.

Do you know what gynecomastia is?
Gynecomastia,

it is the enlargement of men's breasts,
basically due to the increase in mammary gland tissue,

but the enlargement
of men's breasts can also occur due to fat.

What we call pseudogynecomastia.
Generally, in gynecomastia, where there is

an increase in gland, there is also
an accumulation of fat.

This fat deposit.

Well, the causes of
gynecomastia are varied.

So we don't call it a
disease in itself, but a sign or symptom,

which is breast enlargement.

There are three main peaks of
breast enlargement in men.

One is during the breastfeeding phase when the baby
is still a child and breastfeeding, and due to

the influence of the female hormone from the mother's breast that comes
through the milk, this hormone comes through

the milk, there is a stimulation of the mammary
gland. Usually in babies, the gland

enlarges a little and then
it decreases and returns to normal.

The second moment of breast enlargement in
men is during the pubertal period, where there is a

hormonal imbalance and, yes, breast enlargement can happen,
and usually there is a regression. And the third moment of mammary gland

enlargement, which is also physiological,
is during andropause, that is, when male hormones

fall and, yes, there is
an influence on the mammary gland,

increasing the mammary gland
in this andropause when the man loses male hormone.

So there are these three physiological causes,
but there are also other causes.

Among them are testicular cancer,
lung cancer. A differential diagnosis,

since we are talking about cancer, is breast cancer.
It is not gynecomastia, but breast cancer

can cause breast enlargement with a lump,
so it is a differential diagnosis

that needs to be investigated.

There are also uses of medications, use
of hormones, people who use

anabolic steroids, hormones to increase
muscle volume can also have this stimulation

in the mammary gland and breast
enlargement.

Also obesity, obesity is important
to know why? There is an enzyme called

aromatase. This enzyme converts male
hormones into female hormones, and,

estrogen. That's why there is an increase in
gynecomastia in obese patients. Also,

the use of some drugs, such as marijuana,
can also cause this imbalance and

influence breast volume. Among these
causes, there are several causes and many

cases end up being idiopathic, that is,
they remain undiagnosed, and this is the most common and what

frustrates patients the most, not knowing the
cause, what led to this glandular enlargement.

Most likely, it may have been one of these
peaks, especially during puberty, when the

adolescent has glandular enlargement
and it does not regress.

It regresses in almost all cases during
puberty, but in about 5% to 10%

of cases, it does not regress. When there is a
persistence of these idiopathic cases,

without identifying a cause, medication-related.
What caused this, when failing to identify it

after two years,

the treatment ends up being surgical,
mainly for aesthetic, psychological, and self-confidence reasons,

but there are also extreme cases that can even have breast
sagging, can have chafing, just like

a large breast.

All the discomforts that a large breast already
causes in a woman can cause in a man, and

with a negative psychological impact.

And how is it, what do we do, what
exams do we end up ordering to

investigate?

We order thyroid exams, we
end up ordering hormonal exams, testosterone,

estrogen, we order hormones related
to the pituitary gland, we order breast ultrasound,

mammography to rule out
nodules or other causes,

the differential diagnosis. And the surgery,

how is the surgery? The surgery consists
of this resection of the excess gland.

Please note, it is the excess gland.

We don't perform a
mastectomy, which is the removal of the gland.

We need to
resect up to the nipple.

So, because we preserve the nipple, we often
end up leaving some gland, and this can even favor

a recurrence of gynecomastia.

That's why investigation is important. Investigating
gynecomastia even helps us avoid

a recurrence after
surgical treatment.

So, with gynecomastia, we perform this glandular resection
and it can be associated with liposuction

to remove this excess fat, and sometimes for patients who have

a lot of skin,

we need to perform skin resection
and repositioning.

Well, this is what I can help
you understand about gynecomastia.

If you have any questions, comment,
ask, don't hesitate to ask.

Like and share this video
with anyone who might need it.

Thank you!

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