Sex Hormone Profile in Pubertal Boys With Gynecomastia and Pseudogynecomastia.

CONTENT: Gynecomastia (defined by proliferation of glandular elements) and pseudogynecomastia (defined by adipose tissue) are frequent in pubertal boys. An association with sex hormones and the growth hormone axis has been discussed. OBJECTIVE: The objective of this work is to compare sex hormones, insulin-like growth factor 1 (IGF-1), and insulin-like growth factor binding protein 3 (IGFBP-3) between boys with gynecomastia and pseudogynecomastia (separation by ultrasound). DESIGN: An observational study was performed. SETTING: The setting of this study was an outpatient clinic. PARTICIPANTS: A total of 124 pubertal boys (mean age 14 ±â€…2 years) with breast enlargement and 84 healthy boys (mean age 14 ±â€…2 years) without breast enlargement participated in this study. INTERVENTIONS: No interventions were performed. MAIN OUTCOME MEASURES: Measurements were taken for sex hormones (progesterone, estradiol [E2], estriol, estrone, androstendione, testosterone [T], dihydrotestosterone) measured by liquid chromatography-tandem mass spectrometry, as well as gonadotropins, prolactin, IGF-1, and IGFBP-3. RESULTS: Eighty-six boys suffered from gynecomastia and 38 from pseudogynecomastia. In boys with gynecomastia, the E2/T ratio (median 22, interquartile range [IQR] 8-75) was significantly (P < .05) higher compared to boys with pseudogynecomastia (median 12, IQR 5-21) or healthy controls without breast enlargement (median 18, IQR 6-44) even after adjustment for testes volume. T concentrations were significantly (P < .05) lower in boys with gynecomastia (median 1.8, IQR 0.7-4.2 nM/L) compared to boys with pseudogynecomastia (median 4.3, IQR 1.4-6.9 nM/L) or healthy controls without breast enlargement (median 3.1, IQR 0.6-7.6 nM/L). Boys with gynecomastia did not differ from boys with pseudogynecomastia according to other sex hormones, prolactin, IGF-1, or IGFBP-3 concentrations. CONCLUSIONS: True gynecomastia is characterized by a relative T deficiency to E2 concentrations in contrast to pseudogynecomastia.

Comparison of curative effects between mammotome-assisted minimally invasive resection (MAMIR) and traditional open surgery for gynecomastia in Chinese patients: A prospective clinical study.

To analyze and compare prospectively the curative effects between mammotome-assisted minimally invasive resection (MAMIR) and traditional open surgery (TOS) for gynecomastia in Chinese male patients, a total of 60 patients suffering from grade I and II gynecomastia, evaluated by automated whole-breast ultrasound (AWBU), were recruited and randomly divided into TOS and MAMIR groups (each n = 30). The postoperative scar size, healing time, patient hospital stay, postoperative satisfaction, postoperative pain, and complications including edema and bruising were analyzed. The participants were followed up for 1 week, 1 month, 6 months, and 1 year after surgery. Compared with patients who received TOS, patients in the MAMIR group had significantly smaller scar sizes (0.40 ± 0.08 cm vs 5.34 ± 0.38 cm, P < 0.01), shorter healing times (3.67 ± 0.71 days vs 7.90 ± 0.92 days, P < 0.01), and hospitalization (2.60 ± 0.62 vs 7.17 ± 0.83 days, P < 0.01), as well as higher postoperative satisfaction (4.70 ± 0.60 vs 3.20 ± 0.55 scores, P < 0.01), respectively. Patients in the MAMIR group experienced postoperative mild pain significantly more often than those in the TOS group (6.70 ± 1.06 vs 4.13 ± 0.78 scores, P < 0.01, respectively), but with significantly less postoperative severe pain (53.33% vs 0.00%, P < 0.000). While the incidence rate of edema and bruises was significantly higher in the MAMIR group compared with the TOS group (47% vs 17%, P = 0.013 and 54% vs 20%, P = 0.007, respectively). MAMIR had advantages for curative effects compared with traditional open surgery. However, the recurrence rate in patients needs to be further studied.

Defining the Aesthetic Units of the Male Chest and How They Relate to Gynecomastia Based on 635 Patients.

Gynecomastia awareness and treatment have increased significantly. Treatment of gynecomastia is now one of the most popular procedures requested by men. There are many gynecomastia classification systems that have been described. The usefulness of these classifications in the diagnosis and treatment of modern gynecomastia is unknown and has fostered confusion among surgeons and patients. This article elucidates the topographic pattern consistently seen in gynecomastia patients and relates this to the diagnosis and treatment of gynecomastia. The proposed gynecomastia zone classification is a simple and objective method to clinically describe gynecomastia and direct appropriate treatment.

Modified Treatment Algorithm for Pseudogynecomastia After Massive Weight Loss.

BACKGROUND: Pseudogynecomastia is the increased aggregation of fatty tissue in the area of the male breast with resultant female appearance. Two forms can appear: pseudogynecomastia after massive weight loss (pseudogynecomastia obese [PO]) and pseudogynecomastia, which is caused only by adipose tissue (pseudogynecomastia fat). For PO, only the Gusenoff classification with corresponding operative treatment options exists. However, this classification is limited by the fact that it underestimates the extensive variability of residual fat tissue and skin excess, both crucial factors for operative planning. For this reason, we propose a modification of the treatment algorithm for the Gusenoff classification based on our results to achieve more masculine results. MATERIALS AND METHODS: A total of 43 male patients with PO were included in this retrospective study (grade 1a, n = 1; grade 1b, n = 1; grade 2, n = 17; grade 3, n = 24). Forty-two mastectomies with a free nipple-areola complex (NAC) transposition (grades 2 and 3) and 1 with a subcutaneous mastectomy (grade 1a) with periareolar lifting were performed. A retrospective chart review was performed to obtain data regarding age, body mass index, body mass index loss, weight loss, reason for weight loss, comorbidities, nicotine, and additional procedures, postoperative sensitive on the NAC transplants and complications. RESULTS: None of the free-nipple grafts were lost. Forty (95%) of 42 patients with mastectomy had a resensitivity on the NAC. CONCLUSIONS: For pseudogynecomastia, the treatment algorithm of the Gusenoff classification should be modified and adapted according to our recommendations to achieve more optimal masculine results.

Gynecomastia: histological appearance in different age groups.

OBJECTIVE: Gynecomastia is a common finding in the male population which is mostly idiopathic. The aim of our study was to analyze the histological differences in young and old patient groups and its association with recurrence rates. METHODS: Three hundred and five gynecomastia patients (555 breasts) undergoing surgical treatment from 1997 to 2015 were divided into four groups: Group 1: 13-17 years, Group 2: 18-30 years, Group 3: 31-49 years and Group 4: 50-83 years. They were evaluated concerning clinical classification, histological differences and association with antiandrogen or steroids/immunosuppressive therapy. RESULTS: We found that the rate of florid gynecomastia was higher in older patient groups, while fibrous gynecomastia was more common in adolescents and young adults (p = .0180). Glandular gynecomastia was more frequent in younger patients, while in the older patient groups, lipomatous gynecomastia was more common (p = .0006). Patients presenting with florid gynecomastia showed a higher rate of recurrence than patients with the fibrous type of gynecomastia (12.5 and 4.7%, respectively). Of note, 18.75% of florid gynecomastia was associated with antiandrogen agents or steroid/immunosuppressive therapy, while only 4.69% of fibrous gynecomastia was associated with antiandrogenic or immunosuppressive therapy. However, there was no increase of recurrence rates in patients using antiandrogen agents or undergoing steroid/immunosuppressive therapy. CONCLUSIONS: Fibrous gynecomastia was found to be more common in adolescents and young adults, while the florid type was more frequent in older patients. Patients presenting with florid gynecomastia showed a higher rate of recurrence than patients with the fibrous type of gynecomastia.

Management of Adolescent Gynecomastia: An Update.

Gynecomastia refers to an enlargement of the male breast caused by benign proliferation of the glands ducts and stromal components including fat. It is the most common form of breast swelling seen in adolescent males. During pubertal development, gynecomastia can develop as a result of transient relative imbalances between androgens and estrogens. Pubertal gynecomastia is self-limited in 75 to 90% of adolescents and regresses over 1 to 3 years. However it may cause significant psychological stress and depression in adolescents. For boys with persistent gynecomastia that is causing substantial tenderness or embarrassment a tailored approach of close follow-up and use of anti-estrogen drugs may be recommended. These drugs block the effects of estrogens in the body and can reduce the size of the breasts somewhat. It appears that pharmacological therapy of persistent adolescent gynecomastia is reasonable effective if given early in the course of the disease and more successful in cases with small or moderate breast enlargement.  However, neither of these drugs is universally approved for the treatment of gynecomastia because the risks and benefits have not been studied completely. Surgical approach may be needed under special conditions for cosmetic reasons. In this update, we review the different published trials for managing adolescent gynecomastia.

Gynecomastia Classification for Surgical Management: A Systematic Review and Novel Classification System.

BACKGROUND: Gynecomastia is a common deformity of the male breast, where certain cases warrant surgical management. There are several surgical options, which vary depending on the breast characteristics. To guide surgical management, several classification systems for gynecomastia have been proposed. METHODS: A systematic review was performed to (1) identify all classification systems for the surgical management of gynecomastia, and (2) determine the adequacy of these classification systems to appropriately categorize the condition for surgical decision-making. RESULTS: The search yielded 1012 articles, and 11 articles were included in the review. Eleven classification systems in total were ascertained, and a total of 10 unique features were identified: (1) breast size, (2) skin redundancy, (3) breast ptosis, (4) tissue predominance, (5) upper abdominal laxity, (6) breast tuberosity, (7) nipple malposition, (8) chest shape, (9) absence of sternal notch, and (10) breast skin elasticity. On average, classification systems included two or three of these features. Breast size and ptosis were the most commonly included features. CONCLUSIONS: Based on their review of the current classification systems, the authors believe the ideal classification system should be universal and cater to all causes of gynecomastia; be surgically useful and easy to use; and should include a comprehensive set of clinically appropriate patient-related features, such as breast size, breast ptosis, tissue predominance, and skin redundancy. None of the current classification systems appears to fulfill these criteria.

[Surgical treatment of gynecomastia: an algorithm]. / Chirurgische Therapie der Gynäkomastie: Ein Algorithmus.

INTRODUCTIONS: Gynecomastia is a persistent benign uni- or bilateral enlargement of the male breast ranging from small to excessive findings with marked skin redundancy. In this paper we introduce an algorithm to facilitate the selection of the appropriate surgical technique according to the presented morphological aspects. PATIENTS AND METHODS: The records of 118 patients (217 breasts) with gynecomastia from 01/2009 to 08/2012 were retrospectively reviewed. The authors conducted three different surgical techniques depending on four severity grades. The outcome parameters complication rate, patient satisfaction with the aesthetic result, nipple sensitivity and the need to re-operate were observed and related to the employed technique. RESULTS: In 167 (77%) breasts with moderate breast enlargement without skin redundancy (Grade I-IIa by Simon's classification) a subcutaneous semicircular periareolar mastectomy was performed in combination with water-jet assisted liposuction. In 40 (18%) breasts with skin redundancy (Grade IIb) a circumferential mastopexy was performed additionally. An inferior pedicled mammaplasty was used in 10 (5%) severe cases (Grade III). Complication rate was 4.1%. Surgical corrections were necessary in 17 breasts (7.8%). The patient survey revealed a high satisfaction level: 88% of the patients rated the aesthetic results as "very good" or "good", nipple sensitivity was rated as "very good" or "good" by 83%. CONCLUSION: Surgical treatment of gynecomastia should ensure minimal scarring while respecting the aesthetic unit. The selection of the appropriate surgical method depends on the severity grade, the presence of skin redundancy and the volume of the male breast glandular tissue. The presented algorithm rarely leads to complications, is simple to perform and shows a high satisfaction rate and a preservation of the nipple sensitivity.

[Surgical treatment for gyncomastia].

OBJECTIVE: To introduce different surgical treatment for gyncomastia at different grades. METHODS: 37 cases with gynecomastia were divided into three grades as: grade I with fat as main tissue, grade II with proliferated fibro-gland as main tissue, grade III with big and ptosis breasts and sagging skin. Different surgical methods were chosen according to the different grades of gyncomastia. These include liposuction, subareolar fibroglandular tissue removing, combined technique of the two methods, and breasts resection with free transplantation of nipple-areola complex. RESULTS: All patients were satisfied for the appearance of post-operative flat male chest. Complications, such as scar, numbness of nipple and areola were acceptable for them. CONCLUSIONS: Different surgical methods should be chosen for the gynecomastia at different grades. It can improve both the physical and psychological problems for patients.

[Surgical therapy of gynecomastia]. / Chirurgische Therapie bei Gynäkomastie.

Nowadays surgical intervention is an essential part of the treatment of idiopathic gynecomastia. Choosing the right method is crucial and is based on the current status in the clinical and histological evaluation. Before finalizing the process of choosing a specific method a prior interdisciplinary evaluation of the patient is necessary to ascertain clear indications for a surgical intervention. Liposuction is one of the methods which have become popular in recent years. The advantages are the possible combination with traditional techniques, such as subcutaneous mastectomy or periareolar mastopexy. The main indication is for gynecomastia stage IIa/b and is justifiable due to the reduction in surgical complications and scarring. Furthermore this technique provides an excellent aesthetical outcome for the patient. A total of 162 patients suffering from gynecomastia stages I-III (according to Simon) were surgically treated between 2000 and 2010 and these cases were retrospectively evaluated. The results showed a decline in the use of a T-shaped incision in combination with subcutaneous mastectomy with periareolar tightening compared to an increase in the use of subcutaneous mastectomy in combination with liposuction. The excised tissue should always be sent for histological examination to make sure no malignant cells were present.

A new classification and treatment protocol for gynecomastia.

BACKGROUND: It is not uncommon to encounter patients who have undergone surgery for gynecomastia but who were not fully satisfied with the results. Although various approaches and techniques based on presurgical classification systems aimed at yielding the best possible surgical outcomes have been offered, standardized recommendation that is generally accepted by surgeons is lacking. OBJECTIVE: The author reports on a new classification system and treatment protocol for the surgical treatment of gynecomastia. METHODS: A system was developed that classifies patients into 3 types based on skin elasticity, presence of an inframammary fold (IMF), and mammary ptosis. Surgical excision of the breast mass was followed by a combination of destruction of the IMF, ultrasound-assisted lipoplasty (UAL) of the chest wall, ultrasound stimulation of the breast skin, and periareolar deepithelialization, depending on the gyneocomastia classification. RESULTS: This classification and the treatment protocol were applied to 30 patients, 13 to 60 years of age, between January 2005 and December 2007. Among these patients, 12 were classified as type 1, 6 as type 2, and 12 as type 3. Follow-up ranged from 3 to 18 months. Complications were common to all types of cases and techniques. They included 2 hematomas, 1 wound dehiscence, 5 cases of residual gynecomastia in those patients who underwent UAL alone, and 3 minor aesthetic problems near areolae. CONCLUSIONS: The proposed new classification and treatment protocol were found to help solve problems associated with surgical outcomes for all types of gynecomastia, although the issue of residual gynecomastia in patients undergoing UAL alone requires further study.

Surgical management of Gynaecomastia: outcomes from our experience.

The study aims to assess the morbidity and outcomes associated with gynaecomastia surgery. Between 1998 and 2007, 748 males with a mean age 44.67 years (10-90) were referred to us with breast-related symptoms. From these only 65 patients (102 breasts), with a median age of 26 years (11-82) had an operation for gynaecomastia. We considered for the purpose of the study each operated breast as an individual case. Overall, 42 cases of grade I gynaecomastia, 40 with grade II and 20 with grade III were treated mainly with subcutaneous mastectomies, 22 with skin reduction. Acute major complications requiring intervention occurred in 12 cases. Twenty-three cases required a late corrective operation for unsatisfactory results. The surgical approach appears to be the most important determinant of good cosmesis with the circumareolar approach to give the better results. The majority of the patients can be managed conservatively. Surgical candidates should be made aware of the significant morbidity.

The surgical management of high-grade gynecomastia.

It is now well accepted that low grades of gynecomastia are best treated with liposuction alone. However, the surgical management of the high-grade gynecomastia (Simon's grade III) has remained problematic because both liposuction and conventional subcutaneous mastectomy (without skin excision) have frequently resulted in significant residual skin redundancy, requiring a second operation for skin resection. Our preferred approach to high-grade gynecomastia has been the single-stage subcutaneous mastectomy and circumareolar concentric skin reduction with deepithelialization. However, in the rare case of tubular breast deformity in the male and also in patients with gynecomastia who underwent massive weight loss, simple mastectomy and free nipple graft is performed. Therefore, these 2 groups of patients will be excluded from the current series. Twenty-four consecutive males with high-grade gynecomastia were reviewed. All patients underwent subcutaneous mastectomy with concentric skin resection. There were no major complications such as infection, hematoma, seroma, or nipple-areola complex necrosis. The main disadvantage of the technique was the mild residual skin redundancy, which was noted in all 24 patients. This redundancy, however, was never severe enough to require a secondary procedure, and all patients were satisfied with the final result.

Cirugía de acceso mínimo para ginecomastia: shaver-lipoaspiración / Minimal access surgery for gynecomastia: shaver-lipoaspiration

La ginecomastia es una patología de alta incidencia, que puede causar un serio deterioro en la calidad de vida y problemas psicológicos. Etiológicamente pueden dividirse en fisiológicas, patológicas, por medicamentos e ideopáticas, representando estas últimas las más frecuentes. En cuadros de larga evolución la cirugía es el tratamiento de elección. Las técnicas escisionales son las más difundidas, resecándose el tejido glandular a través de un acceso periareolar o transareolar. La lipoaspiración es un recurso complementario, para mejorar el contorno. Este enfrentamiento no está exento de complicaciones. Se presenta una nueva alternativa terapéutica para el manejo quirúrgico de ginecomastias mediante el shaver y lipoaspiración. Se analiza la técnica, presentandose los resultados de 5 pacientes tratados de esta menera, discutiéndose posteriormente algunos puntos de interés en relación a esta patología.