Gynaecomastia
It is the most common, benign condition of male breasts: five in every ten men, teenagers, adults or elderly have gynaecomastia. Men who have an exaggerated development of their breasts can often feel embarrassed, especially teenagers who may abstain from socializing. Fortunately, plastic surgery offers several alternative treatments for gynaecomastia, including quick and painless procedures.
The term gynaecomastia was introduced by Claudius Galenus, known as Galen, important Roman physician of the second century. It was formerly defined as an abnormal development of the breast adipose tissue, which is currently defined as pseudogynaecomastia or false gynaecomastia. It is a very frequent, physiological condition which may occur in three phases of a man’s life: at birth, puberty and senescence. Gyne (in Greek means woman) + masto (relatative to breasts), literally, female breasts or breasts with feminine shape, gynaecomastia is the term used in clinical practice to describe a disorder that affects men with excessive development of breasts. This female breast disorder affects men only, since carriers develop breasts which are very similar to female breasts, both in volume and in shape, and it can affect only one or both breasts. A priori, it is a benign condition; nevertheless, it can hide an underlying disease. This dysfunction occurs mainly due to physiological, pathological or idiopathic causes, affecting mainly teenagers at puberty.
The Zamarian Clinic offers the best gynaecomastia treatment to prevent embarrassment and constraints caused by this unaesthetic condition, always caring for the welfare of his patients.
Causes of gynaecomastia
Physiological and hormonal
One of the most common causes of gynaecomastia, it is due to alterations in the physiological balance of hormones in our body, generally steroids, including sexual hormones. In this case, the presence of adjacent diseases is not detected. It may affect newborn babies, teenagers during puberty, reaching its peak age-specific incidence around 13 and 14 years of age while, in elderly people, it reaches greater incidence after 70 years of age.
Breast enlargement in newborn babies is the result of high concentrations of maternal steroids and progesterone, which does not need treatment since it recedes in a few weeks. In teenagers, however, gynaecomastia has high incidence levels since it occurs in a period in which the patient is going through puberty, characterised by large and sudden hormonal changes. Physiological gynaecomastia in teenagers is characterised by the appearance of an asymmetrical breast enlargement and hypersensitivity in the region. Senile physiological gynaecomastia has no concrete definition but it has been suggested that it may be an accelerated activity of the secondary peripheral aromatising enzyme together with possible hypogonadism related to aging. It hardly ever shows significant alterations although nipple atrophy and enlargement of the areolas may occur in more acute degrees.
Pathological
Pathological gynaecomastia, on the other hand, is the result of some pre-existing diseases in the body which also leads to hormonal imbalance. Causes are divided into tumoural and non-tumoural and can affect individuals of any age, so there is no age range with greater incidence since its development depends exclusively on the disease.
Tumoural causes can be detected inside or outside the testicles. i.e., the disease may be caused by testicular or extra-testicular tumours. This definition is normally used since the testicles involve great part of the sexual hormones. Non-tumoural causes, however, may occur due to cellular senescence in aging, hypogonadism, endocrinopathy (hormones dysfunction), hepatopathies (an abnormal or diseased state of the liver such as alcoholic and non-alcoholic cirrhosis), thyroid diseases, alterations in the nutritional state, true hermaphroditism, among others. Pathological gynaecomastia causes should be treated before its resulting unaesthetic deviations.
Idiopathic
Derived from the Greek idios (personal, peculiar) + patheia (suffering), an idiopathic reason can mean an unknown and obscure cause or a spontaneous onset. Idiopathic gynaecomasty is the most common among them and is caused by unknown factors or uncertain motives.
Drug-related
Dr. Walter Zamarian Jr. explains that “in addition to the physiological, pathological and idiopathic causes, there are certain drugs which, when used excessively, may trigger gynaecomastia, an enlargement of male breasts”. They can be divided into medications and drugs with known and unknown mechanisms such as
- drugs that act as aestrogen such as diethylbestrol, oral contraceptives, digitalis drugs, cosmetics with aestrogens;
- drugs that inhibit testosterone production: Ketoconazole, metronidazole, cimetidine, flutamide, spironolactone, ranitidine;
- drugs that increase endogenous production of aestrogens: gonadotropines, clomiphene;
- cardiovascular drugs (like the antiarhythmics, the cardionics and vasodilators): amiodarone, digoxin, nifedipine, verapamil;
- drugs with unknown mechanisms: isoniazid, methyldopa, captopril, cyclic antidepressants, diazepam, heroin, marijuana, alcohol.
That is why, among other reasons, it is necessary to know the patient's history and the medications or drugs he/she is taking or used to take. Because of this, Dr. Zamarian requests some laboratory tests and talks with the patients during the consultation to be able to make the correct gynaecomastia diagnosis. Patients who take any of these drugs should stop taking them before undergoing plastic surgery.
Preoperative evaluation
Consultation
When considering male breast augmentation, the patient must go through a previous physical checkup and consultation. In patients who are not obese, palpation of at least 2cm of subareolar breast tissue will confirm the diagnosis of gynaecomastia. During the examination, a true gynaecomastia may be diagnosed when a certain amount of firm and mobile retroareolar fibrous elastic tissue, for being glands, is found together with a demarcation between the firm tissue and adjacent fat. By exclusion, in case the palpation shows soft, loose tissue, it is generally diagnosed as pseudogynaecomastia, a situation in which only fat and no glandular disk is identified.
Types
Basically, there are three types of gynaecomastia: true gynaecomastia, pseudogynaecomastia and a combination of both, mixed in together.
True gynaecomastia is characterised by hypertrophy and benign hyperplasty of breast glands, generally caused by hormonal alterations. Pseudogynaecomastia is characterised by an increase of fat in the breasts, i.e., the local adipose tissue gains more volume. Mixed gynaecomastia, on the other hand, is characterised by both hypertrophy of the breast glands and accumulation of fat in the region. In general, types of breast enlargement in men is related to the duration of the dysfunction: pseudogynaecomastia recedes more easily, true gynaecomastia shows an intermediate receding process while the mixed is the most complex of all, lasting longer and may not recede without surgical intervention.
Importance of the diagnosis
As mentioned before, it is important for the plastic surgeon to have the correct gynaecomastia diagnosis, since it interferes not only in the choice of treatment but it can also be misinterpreted as other similar symptoms such as those found in:
- Breast carcinomas: breast enlargement in men should be considered since 1 % of all carcinomas are diagnosed in men;
- Benign fatty tumour: the fatty tumour is basically an accumulation of fat on the subcutaneous layer of the skin. In most cases, an asymptomatic, palpable and of firm and elastic consistency fatty tumour is found, making a bump on the skin;
- Neurofibromatosis: neurofibromatosis is a common benign tumour made of Schwann cells, fibroblasts and perineurial cells which is generally located in the peripheral nervous system;
- Obesity: gynaecomastia is frequently misinterpreted as obesity for having several characteristics similar to those of gynaecomastia.
Classic classification (Simon & cols.)
To use as a criteria during the patient’s evaluation, there is a scale developed by Simon et col. that classifies the degree of gynaecomasty severity, also known as the classic classification. Degrees II b and III already characterizes the so-called macrogynaecomastia, which are considered severe stages of this dysfunction.
- Degree I: minimum breast augment, with no skin excess;
- Degree II a: moderate breast augment with no skin excess;
- Degree II b: moderate augment with skin excess;
- Degree III: marked breasts augment with skin excess and ptosis - simulates female breasts.
Modern classification (Cordova e Moschella)
There is also a more modern typology presented by Cordova and Moschella which classifies gynaecomastia by severity, adopting three criteria: size, skin distension and ptosis level (drop).
- Degree I: discrete breast augment and limited protrusion to the areolar region;
- Degree II: evident/clear gland volume augment enough to determine the inframammary sulcus, with no ptosis, i.e., the papillary-areola complex remains above the sulcus;
- Degree III: the presence of a certain degree of breast ptosis and skin excess, but the papillary-areola complex is located up to 1 cm below the sulcus;
- Degree IV: intense ptosis, pendulous breast with lots of skin excess and the CAP line located more than 1 cm below the sulcus.
Having analysed and classified the patient according to these criteria, Dr. Zamarian can, safely, develop a surgical plan for the treatment.
Required tests
Dr. Zamarian requests some lab tests before the patient goes under gynaecomastia. The tests provide a history of the patient as well as information on medications, and drugs that could have caused the excessive breast augment. There are also some internal alterations in some organs associated with gynaecomastia which can be detected by liver, kidneys, adrenal cortex, lungs, pituitary (hypophysis), gonad and/or prostate glands tests. Usually, Dr. Zamarian requests a complete blood test, a urine test, an electrocardiogramme, and a cardiologist evaluation before performing plastic surgery on male breasts, for security reasons. In less severe cases, when the gynaecomastia diagnosis is still nuclear, an ultrasound of the breasts is useful to ward off lipomastia, detect malignancy and evaluate breast tissue volume. In case of a possible tumour, Dr. Zamarian recommends that the patient undergoes a mammography.
Anaesthesia
During the gynaecomastia procedure, Dr. Zamarian opts for general anaesthesia delivered by highly qualified anaesthesiologists. He uses the modern general anesthesia procedure, with cutting-edge medications, which brings patients back to consciousness around three minutes after the surgery.
