Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

FIGURE 56.9 The preoperative markings for a superomedial pedicle technique with a keyhole pattern skin resection. Note that
the position of the nipple-areolar complex is generally within or just below the vertical limbs of the keyhole pattern.
Infiltrate for SAL if indicated. With the breast base under tension, perform all planned incisions including
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the new NAC position, and deepithelialize the superomedial pedicle. Proceed with SAL. Make incisions
along the caudal border of the medial flap directly down to chest wall, leaving the pectoralis fascia intact.
Continue incisions around the superomedial pedicle up to the new NAC position by avoiding any
undermining of the pedicle. The pedicle should rotate easily.
Incise along the medial and lateral thirds of the IM fold directly down to chest wall, but in the central
third bevel cephalically to allow some soft tissue to remain to fill potential dead space that may persist
after superomedial pedicle rotation. Dissect around the new NAC position ∼1.5 to 2 cm into the breast
tissue and then bevel caudally to create a platform for the rotated NAC to rest on. Incise along the vertical
and horizontal aspects of the lateral flap, leaving at least 3 cm of thickness to the flap at the tip. Taper the
dissection cephalically along the lateral flap (Figure 56.10). This resection is important for reduction of
lateral fullness and achieving coning. Resect the specimen from the chest wall en bloc, leaving the
pectoralis fascia intact. Weigh the specimen. Divide into medial, central, and lateral aspects for pathology.
Carefully incise the dermis at the base of the pedicle for ease of rotation into the new NAC position.
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FIGURE 56.10 The relative thicknesses of the dissection of the superomedial pedicle and upper flaps, leaving a support shelf
of breast tissue below the new nipple-areolar complex position for projection.
Place pillar sutures (2-0 absorbable) in the deep tissues of the vertical limbs of the tips of the medial and
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lateral flaps. These are placed ∼2 to 3 cm below the flap corners and should assist in coning the breast
when tied without skin distortion (Figure 56.11). A second pillar suture can be placed slightly more
superficially. Approximate the skin edges with staples, advancing the upper flaps on the IM fold to avoid
dog-ears medially and laterally. Staple the vertical incision. In the sitting position check for symmetry,
volume, and position on the chest wall. Modify as necessary. The NAC position has already been
determined and can only be minimally changed. After confirming that the NAC is oriented correctly,
staple it into position.
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FIGURE 56.11 The upper flaps are then sutured together with pillar sutures and the superomedial pedicle is rotated about 90°.
Confirm the correct orientation of the new nipple-areolar complex position with the preoperative markings.
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Superomedial Pedicle With Vertical Skin Resection
In patients with good skin elasticity, small to moderate amounts of planned tissue resection, and a
reasonable distance between the papule and IM fold, a vertical skin resection approach may be used that
will eliminate the transverse IM incisions. This approach relies upon lower pole skin contraction after
elevating thin flaps down to the IM fold. Resection of breast tissue under the skin flaps is identical to the
resection of breast tissue performed for the superomedial pedicle with a keyhole pattern. The vertical
approach can significantly decrease the risk for hypertrophic scarring medially and laterally. A full
understanding of the superomedial pedicle keyhole approach allows transitioning to this technique more
easily. If the NAC is positioned high in the superior aspect of the keyhole pattern, the surgeon may want
to consider using a superior pedicle. 8
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Preoperative Markings
The surgeon must be familiar with the key differences in the surgical markings for the vertical approach.
Mark the breast in a similar manner to the standard superomedial pedicle reduction with a keyhole
pattern, except just dot the transverse incisions at the IM fold and the medial and lateral flaps. These
marks create a reference on the surface where the resection will be performed underneath the thin skin
flaps (also called ghost areas). Extend down the vertical limbs beyond the transition point to the medial
and lateral flaps of the keyhole pattern. The vertical limbs will continue caudally to ∼3 to 4 cm above the
IM fold and join in a gentle curve. The breast tissue will be resected caudally to this point to level of the
IM fold. The scar will shorten as the tissues heal and the breast will drop down to a new higher IM fold,
leaving just a vertical scar below the NAC.
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Operative Technique
Once on the table, reinforce and remeasure the lines previously described. The superomedial pedicle and
the new position and size of the NAC will be marked. The key points will be tattooed as in previous
markings. The incisions are made by avoiding the dotted transverse and IM incisions of the previously
described keyhole pattern. Deepithelialize the superomedial pedicle as usual and then begin by
undermining the ghost areas between the dotted lines down to the IM fold (Figure 56.12). The skin flaps
should be thin with minimal fat, but avoiding injury to the dermis. In patients with very thin
subcutaneous tissue overlying the breast, dissection may proceed directly on the breast capsule. Once the
undermining is completed under the ghost areas, the breast resection is identical to the instructions in the
previously described technique for the superomedial pedicle, but with less skin resection.
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FIGURE 56.12 The intended resection of tissues and the ghost areas above the medial and lateral areas of breast tissue
resection.
After the resection of breast tissue, place the pillar sutures in the usual location in the upper flaps and
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rotate the NAC into position. The vertical incision is closed in either a single or a double layer. Do not
attempt to shorten the incision during the closure for the first 2 cm below the NAC. This will place the 6-
o’clock position of the NAC under tension caudally and distort its shape. Shorten the incision with a
cinching closure beginning about 2 cm below the NAC (Figure 56.13). Barbed sutures may be helpful. It
may also be beneficial to hold the skin at the inferior apex of the vertical limbs with a hook retractor
during the closure. The final resulting caudal fullness that persists in many cases can be purse stringed or
just closed. This redundant tissue can be dressed with a small temporary bolster of Vaseline gauze held
by tape for 7 to 10 days.
FIGURE 56.13 Distribute the redundant tissue during the closure of the vertical approach inferiorly to avoid distorting the
shape of the nipple-areolar complex postoperatively.
There is the possibility of this residual redundancy needing some eventual resection transversely under
local anesthesia, but the surgeon should wait at least 4 to 6 months as it frequently resolves on its own.
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Amputation/Free Nipple Graft
If the anticipated length of the inferior pedicle or superomedial pedicle raises concern of potential
vascular compromise of the NAC, consider an amputation/free nipple graft technique. 9 This approach is
generally ideal for patients with macromastia of excessive proportions that may limit pedicle viability,
final aesthetics, and planned reduction goals. Generally, this refers to patients with a nipple to IM fold
distance >20 cm. This technique may also be appropriate if there are breast scars that cross planned skin
flaps or pedicles. This approach may also be preferred in the setting of a history of previous reduction
mammoplasty of known or unknown technique, a history of radiation or for patients with systemic
vascular issues due to connective tissue disorders, with an extensive smoking history, or autoimmune
disorders. This technique allows the surgeon to achieve an excellent result with some projection and
volume. Counsel the patient regarding the loss of NAC sensation and the risks of NAC graft failure. Even
with these limitations, it is important for plastic surgeons to be able to utilize this technique.
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Preoperative Markings
The preoperative markings are identical to the standard keyhole pattern described earlier (Figure 56.14).
Because this technique is usually performed in the setting of very heavy breasts, remember to correct for
the elasticity of the upper skin by lowering the final nipple position markings as needed. The major
difference from previously described markings is that the width of the vertical portions of the keyhole
may change once the resection is completed. The length of these vertical limbs should be 6 to 7 cm
depending on the final size considered. Also, plan to leave a mound of lower breast tissue at the IM fold,
which improves final projection.
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FIGURE 56.14 Preoperative markings for amputation/free nipple graft with suction-assisted lipectomy and depiction of the
nipple-areolar complex harvested as a full-thickness graft.
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Operative Technique
With the breast under mild tension, remove the NAC as full-thickness graft. It may be easier to keep the
NAC thin to reduce the time needed to perform defatting. Also consider amputation of the tip of the
nipple papule in circumstances where the length of the papule exceeds 1 cm to help it to survive as a full-
thickness graft. Place it on a labeled moist sponge on the back table to prevent operating room staff from
accidentally discarding it.
Deepithelialize a small lower flap along the IM fold (Figure 56.15). Incise down to the chest at the IM fold
tapering cephalically over this small mound. The upper flap is incised along the caudal edge directly
down to the chest wall, avoiding any undermining.
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FIGURE 56.15 Following resection of breast tissue and deepithelialization of a central triangle. The new nipple-areolar
complex position should then be confirmed and prepared for the full-thickness skin graft and bolster.
The breast tissue that was amputated will then be resected and weighed. Staple the upper incision to the
lower advancing from the medial and lateral corners of the upper flaps centrally. The flaps should come
together at the planned vertical marks but, depending on the size of the remaining breast, this triangle
may need to be enlarged or reduced to achieve good approximation of the skin edges. Staple the vertical
limbs together and assess the new breast size and shape. Mark out the new vertical limbs as needed,
remove staples, and now deepithelialize the triangle.
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Restaple the skin edges together again, and in the sitting position, mark the new NAC positions
symmetrically and very thinly deepithelialize this area. After closing the horizontal and vertical incisions,
secure the NAC grafts to their new positions with tie-over bolsters (Figure 56.16). Drains are not
necessary. SAL laterally can help contour as needed.
FIGURE 56.16 Final closure with a tie-over bolster for the amputation/free nipple graft technique.
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Suction-Assisted Lipectomy
This technique is helpful ideally for treating limited macromastia in circumstances when the breast tissue
contains a high proportion of fatty tissue, the planned reduction would not require significant excision of
overlying skin, and the skin has good elasticity. 10 For more dense breasts, modified suction equipment
(i.e., ultrasonic, reciprocating, laser assisted) may be more helpful. We consider this for limited
asymmetries, small reductions, and previous reductions with asymmetry needing additional volume
removal, or for patients who have undergone previous reductions of unknown techniques and are not
candidates for amputation with free nipple grafts. This procedure may be performed in a single or a
staged manner that may include mastopexy after successful SAL.
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Postoperative Complications ( FIGURE 56.17)
FIGURE 56.17 Potential complications following breast reduction.
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Acute Complications
Hematoma
Estimated to occur in up to 4% of cases. 11 It is important to recognize a hematoma early as it may result in
vascular compromise to the NAC. Although surgical drains may initiate an earlier diagnosis, they will
not prevent a hematoma from occurring. A small, localized hematoma can be directly drained or allowed
to liquefy and then evacuated with a large bore needle or fat harvesting cannula in 1 to 2 weeks
postoperatively.
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Delayed Wound Healing
Estimated to occur in 10% of cases. Usually occurs at the lower skin trifurcation (T-junction), but may also
occur along any incision lines. It may be due to the flaps closed too tightly over the remaining mound or
in patients with any history of scars, or active smoking. It is not uncommon for mild epidermolysis to
occur, which is treated with conservative wound care. To prevent wound healing complications, consider
tacking the dermis to the breast capsule at the flap corners with absorbable sutures to avoid stripping the
underlying blood supply.
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Seroma
Leaving a small mound of breast tissue at the midline along the IM fold in the superomedial pedicle
breast reduction approach helps to avoid this complication. If significant SAL of the lateral breast is
performed, consider leaving a surgical drain overnight which helps remove residual tumescent fluid.
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Vascular Compromise
If the breast reduction is designed and executed correctly, this is a rare complication involving the NAC
and hopefully only temporary after the pedicle elevation, positioning, and rotation. It can be difficult to
evaluate if local anesthetic with epinephrine was used during the case. Try to identify the underlying
cause for vascular compromise and release sutures as needed to avoid necrosis and loss of the NAC.
Assess the NAC for proper rotation or consider additional reduction of breast to decrease intrinsic
pressure. Vascular compromise also can result in fat necrosis and fibrosis, thus potentially leading to the
need for future biopsies or operative interventions. Removal of the NAC as a full-thickness graft and
regrafting can be done but has limited results. History of radiation therapy, Raynaud disease,
scleroderma, and smoking increases risk for vascular compromise.
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Long-term Complications
Asymmetry
Identify and point out asymmetries to the patient preoperatively, including chest wall, costal margins,
manubrium, IM folds, or anticipated discrepancies in the amount of breast volume that will be resected.
Furthermore, try to predict the volume discrepancies between the breasts preoperatively.
Intraoperatively, sit the patient up to determine symmetry by visual inspection and palpation. Use of a
sterile bra in the operating room helps to recognize volume differences. Preoperative breast asymmetries
will be more obvious after a symmetrical resection. Small to medium differences may be treated
postoperatively with SAL.
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Fibrosis and Fat Necrosis
Fibrosis may resolve with time and massage and generally is not visible. This finding may cause anxiety
for the patient and lead to unnecessary testing or breast biopsies. Fibrosis and fat necrosis may also affect
future mammography. Occasionally an area of firmness may be an inclusion cyst, which is a result of
inadequate deepithelialization of the pedicle.
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Inability to Breastfeed
The impact of breast reduction on ability to breastfeed postoperatively appears largely related to
preservation of the subareolar parenchyma. Rates of successful breastfeeding range from <5% for
techniques with no preservation of subareolar parenchyma such as an amputation/free nipple graft to
75% to 100% for techniques with full preservation of the subareolar parenchyma. 12
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Inverted Nipples
If the patient has a history of periodic nipple inversion, inform them that it might worsen postoperatively.
This may improve with time and scar massage, but might require future surgical correction. Nipples that
are always inverted will usually remain that way postoperatively.
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Loss of Nipple Areolar Sensation
This rare complication tends to be a transient, and some patients may even experience hypersensitivity
that resolves eventually. Be sure to counsel the patient preoperatively regarding this potential
complication. To prevent loss of nipple sensation, avoid injury to the pectoralis fascia and if possible,
leave small amounts of soft tissue over the muscle, design a wider inferior pedicle base, and avoid
undermining the superomedial pedicle. Ask patients preoperatively about their nipple sensation, because
not infrequently women with macromastia have some reduced sensation at baseline.
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Hypertrophic Scarring
This complication is more likely to occur in patients with a propensity for developing these scars, if there
is increased tension on the closures, and also in situations with delayed wound healing. It may help to
assess other scars on the patient. A vertical approach avoids the lateral and medial IM incisions, which, in
the senior author’s experience, are more likely to develop hypertrophic scarring. Potential interventions
to address hypertrophic scarring include silicone sheeting, steroid injections, fractional CO2 laser
resurfacing, and scar revision. In our experience, true keloid scarring is a rare complication in breast
surgery.
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High NAC Position
This complication is extremely difficult to correct without significant additional scarring. It is best to
avoid this issue by properly planning NAC position and anticipating additional elevation of the new
NAC due to weight reduction and the overlying skin elasticity. Undercorrection of the final NAC height
can be revised with a small mastopexy or crescentic excision at a later date. 13 The final NAC position of
the inferior pedicle and amputation/free nipple graft techniques can be adjusted to a small degree
intraoperatively at the initial procedure. In the superomedial pedicle technique, the NAC position is
typically determined prior to the incisions because it is integral to the design of the pedicle and resection.
Finally, if the NAC position is too high, consider a lower concentric skin excision at the IM fold to reduce
the distance of the nipple to IM fold or further reducing the overall breast size.
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Discovery of Breast Cancer
Although not a true complication (unless missed on a mammogram or exam), this finding will affect the
planned treatment by the surgical oncology team. Preoperative mammograms are important, and age
40 years has been suggested for screening depending on family history. 14 All specimens go to pathology
and by dividing the specimen into medial, central, and lateral components, the patient may not need to
undergo additional surgery if the location and extent of the carcinoma resection can be determined.
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Questions
1. What are the reported rates for the following complications:
a. Delayed wound healing
b. Hematoma 16
c. Seroma
d. Nipple areola loss
d.
Loss of nipple sensation 17
2. A 43-year-old woman is seeking a plastic surgery consultation for symptoms associated with
macromastia. She reports shoulder grooving, shoulder and back pain, recurrent intertrigo in her IM
folds, and difficulty exercising because of her large breasts. She has large, grade III ptotic breasts,
with sternal notch to nipple and nipple to IM fold distances of 30 and 25 cm, respectively. Which
operation is most appropriate to achieve breast reduction in this patient?
a. Inferior pedicle with keyhole pattern skin resection
b. Superomedial pedicle with keyhole pattern skin resection
c. Amputation and free nipple graft
d. SAL and mastopexy
3. A 32-year-old woman presents for a consultation about breast reduction procedures. She
underwent breast reduction 10 years ago by an unknown technique and the operative reports are no
longer available. Since that time, she has gained 50 pounds and her breasts have increased in size as
well. On examination, she has well-healed scars from a previous keyhole pattern skin resection. She
has grade II ptotic breasts with sternal notch to nipple and nipple to IM fold distances of 24 and
12 cm, respectively. Which approach is most appropriate and safe for this patient?
a. Superomedial pedicle
b. Inferior pedicle
c. Resection of inferior wedge of breast tissue
d. Amputation/free nipple graft 15
e. SAL and mastopexy
1. Answer: 10%, 4%, 10-15%, 1%, and 2%.
2. Answer: c. When the nipple to IM fold distance is greater than 20 cm, that the surgeon should
consider using an amputation/free nipple graft technique to reduce the risk for postoperative
vascular issues to the NAC. Often, this technique is also needed for women of much larger body
habitus with associated comorbidities and the resulting need to limit anesthesia time for patient
safety.
3. Answer: c. It is important to know that breast rereduction can be performed safely, even when the
previous technique is unknown. The surgeon should appreciate that there is minimal amount of skin
excision in this rereduction described by the clinical scenario and thus a vertical or horizontal pattern
skin resection would be appropriate to achieve the desired result. In an outcome study of rereduction
by Mistry et al., a resection of a small wedge of breast tissue in the lower pole was performed safely
in most cases. 15 The NAC then relies on a random pattern blood supply. In circumstances of a much
larger breast, the amputation/free nipple graft technique may be the safest option. However, in this
case that technique would likely leave the patient described here with breasts that are much smaller
than she desires. There is no need to reelevate pedicles such as the superomedial or inferior pedicles
in this situation.
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References
Jaspars, JJ, Posma, AN, van Immerseel, AA, Gittenberger-de Groot, AC. The cutaneous innervation of the female breast and nipple-areola
complex: implications for surgery. Br J Plast Surg. 1997;50(4):249-259.
Sarhadi, NS, Shaw Dunn, J, Lee, FD, Soutar, DS. An anatomical study of the nerve supply of the breast, including the nipple and areola. Br J
Plast Surg. 1996;49(3):156-164.
Available at . Accessed June 4, 2018.
Schnur, PL, Schnur, DP, Petty, PM, et al. Reduction mammaplasty: an outcome study. Plast Reconstr Surg. 1997;100(4):875-883.
Wuringer, E, Mader, N, Posch, E, Holle, J. Nerve and vessel supplying ligamentous suspension of the mammary gland. Plast Reconstr Surg.
1998;101(6):1486-1493.
Hamdi, M, Van Landuyt, K, Tonnard, P, et al. Septum-based mammaplasty: a surgical technique based on Wuringer’s septum for breast
reduction. Plast Reconstr Surg. 2009;123(2):443-454.
Hall-Findlay, EJ. A simplified vertical reduction mammaplasty: shortening the learning curve. Plast Reconstr Surg. 1999;104(3):748-759. This
landmark article discusses modifications to the standard vertical reduction mammoplasty technique in a series of 400 breasts. The author made this
technique easier and more reliable through a medial dermoglandular pedicle, avoiding undermining of skin, and not using pectoralis fascia sutures.
Lejour, M, Abboud, M, Declety, A, Kertesz, P. Reduction of mammaplasty scars: from a short inframammary scar to a vertical scar. Ann Chir
Plast Esthet. 1990;35(5):369-379. Although not the initial description of the vertical skin resection for breast reduction, this study provided the
foundation for procedural advances in breast reduction such as the superomedial pedicle with a vertical skin resection by Hall-Findlay in the 1990s.
Oneal, RM, Goldstein, JA, Rohrich, R, et al. Reduction mammoplasty with free-nipple 
 transplantation: indications and technical
refinements. Ann Plast Surg. 1991;26(2):
 117-121.
Gray, LN. Update on experience with liposuction breast reduction. Plast Reconstr Surg. 2001;108(4):1006-1010.
Cunningham, BL, Gear, AJ, Kerrigan, CL, Collins, ED. Analysis of breast reduction complications derived from the BRAVO study. Plast
Reconstr Surg. 2005;115(6):1597-1604.
Kraut, RY, Brown, E, Korownyk, C, et al. The impact of breast reduction surgery on breastfeeding: systematic review of observational
studies. PLoS One. 2017;12(10).
Spear, SL, Albino, FP. Management of the high-riding nipple after breast reduction. Clin Plast Surg. 2016;43(2):395-401.
Greco, R, Noone, B. Evidence-based medicine: reduction mammaplasty. Plast Reconstr Surg. 2017;139(1):230e-239e.
Mistry, RM, MacLennan, SE, Hall-Findlay, EJ. Principles of breast re-reduction: a reappraisal. Plast Reconstr Surg. 2017;139(6):1313-1322.
Pannucci, CJ, Wachtman, CF, Dreszer, G, et al. The effect of postoperative enoxaparin on risk for reoperative hematoma. Plast Reconstr Surg.
2012;129(1):160-168.
Nahabedian, MY, Mofid, MM. Viability and sensation of the nipple-areolar complex after reduction mammaplasty. Ann Plast Surg.
2002;49(1):24-31.
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C H A P T E R 5 7
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Gynecomastia
Ashley N. Amalfi and Nicole Z. Sommer
Key Points
Gynecomastia is physiologically normal and transient during the neonatal period, puberty, and in
old age.
Persistent or asymmetric gynecomastia should be evaluated by thorough history and physical exam,
assessing for systemic or exogenous pathology as the cause of breast enlargement.
Gynecomastia is the result of an imbalance of hormone levels. Alterations in the ratio of estrogens to
androgens caused by systemic illness, neoplasm, pharmacologic agents, or other idiopathic factors
may contribute.
Gynecomastia can have significant social, emotional, and psychological impacts on adolescents, and
practitioners should screen patients accordingly and provide appropriate resources and care.
The plastic surgeon should evaluate the excess stromal tissue, adipose tissue, skin redundancy,
degree of ptosis, and size and location of the nipple areolar complex to formulate an individualized
surgical plan.
Ideal proportions in the male breast are quite different compared to the female breast, as to create a
masculine appearing chest contour postoperatively.
Each patient should be approached as an individual to evaluate the patient’s desired aesthetics.
Sometimes, a staged approach is necessary to achieve an ideal result.
Gynecomastia is the benign enlargement of glandular breast tissue in males. It is the most common breast
condition in males. 1 At various stages of development, male breast growth is a normal and transient
physiologic response to the balance of androgens and estrogens in the body. Persistent or asymmetric
gynecomastia should be evaluated by a thorough history and physical exam, looking for systemic or
exogenous pathology as the cause of breast enlargement. This often requires the cooperation of a
multidisciplinary team that includes plastic surgery, primary care, endocrinology, and psychiatry.
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Natural History
Physiologic breast growth is hormonally driven, and the trimodal distribution of gynecomastia is
testament to this. We see normal breast development in males during the neonatal period, puberty, and
in aging men. Neonatal mastauxe, or breast enlargement of the newborn, is directly correlated to
circulating maternal estrogens, and is seen in almost 70% of infants. A small breast bud of 1 to 2 cm is
often palpable in the newborn. As maternal estrogen levels fall, some neonates experience a surge of
prolactin, which may cause the temporary secretion of milk. Within the first month of life, hormones
normalize, and these self-limiting symptoms dissipate. 2
The second peak in gynecomastia is seen during puberty, and can last for a period of months to years. Up
to 65% of adolescent boys experience transient gynecomastia during this period of development. 3 An
elevated ratio of circulating estradiol to testosterone during puberty is thought to be causative, with an
onset between the ages of 10 and 13 years. Approximately 4% of males will have persistent gynecomastia
beyond this period, defined by breast bud enlargement of greater than 4 cm.
Senile gynecomastia is attributed to decreases in testosterone and an increase in adipose tissue, leading to
the peripheral conversion of androgens to estrogens. Once again, this imbalance of hormones leads to
breast enlargement that affects up to 65% of men. 4
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Pathophysiology
Various pathologies that disrupt the delicate hormone balance and result in androgen deficiency, or
estrogen excess, can lead to the development of gynecomastia. Systemic disease, neoplasm,
pharmacologic agents, or other idiopathic factors may be the causative agents (Table 57.1). Thorough
workup by plastic surgeon, primary care physicians, and endocrinologists may be necessary to evaluate
the underlying illness or agents that cause male breast enlargement.
TABLE 57.1
Pathologic Causes of Gynecomastia
Endocrine
Testicular
Hypogonadism
Klinefelter syndrome (XXY)
Adrenal
Congenital adrenal hyperplasia
Cushing syndrome
Thyroid
Hyperthyroidism
Hypothyroidism
Disorders of sexual differentiation
Androgen insensitivity syndrome
17-B-hydroxysteroid dehydrogenase deficiency
Aromatase excess syndrome
Systemic
Chronic liver disease
Chronic kidney disease
Refeeding syndrome
Malnutrition
Neoplasms
Breast carcinoma
Testicular tumors
Leydig cell
Sertoli cell
Adrenal cortical carcinoma
Lung carcinoma
Liver carcinoma
hCG-secreting tumors
Infectious
HIV
Other
Obesity
Medications and illicit drugs are the most common causes of gynecomastia in men (Table 57.2).
Antiandrogens, steroids, antipsychotics, and antiretrovirals are some of the more common classes of
medications implicated. Illicit drugs including marijuana, alcohol, and heroine, as well as anabolic
steroids are well-documented causes of gynecomastia. When possible, offending agents should be
discontinued to evaluate for resolution of symptoms. A softening and dissipation of the glandular breast
enlargement should be seen within 1 month of discontinuation of the offending agent.
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TABLE 57.2
Pharmacologic Causes of Gynecomastia
Illicit Drugs of Abuse
Marijuana
Anabolic steroids
Alcohol
Opiates
Amphetamines
Hormone and Hormone Modulators
Testosterone
Estrogen
Flutamide
Bicalutamide
Leuprolide
Finasteride
Gn-RH analogs
Prednisone
Cardiovascular Medications
Calcium channel blockers
Spironolactone
Digoxin
ACE inhibitors
Amiodarone
Psychiatric Medications
Benzodiazepines
Phenothiazines
Tricyclic antidepressants
Olanzapine
Haloperidol
Risperidone
Antimicrobials and Antiretrovirals
Ketoconazole
Metronidazole
Isoniazid
Protease inhibitors
Nucleoside reverse transcriptase inhibitors
Chemotherapeutics
Methotrexate
Imatinib
Cyclophosphamide
Alkylating agents
Vinca alkaloids
Antireflux Medications
Cimetidine
Omeprazole
Ranitidine
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Patient Evaluation
Thorough evaluation by the treating provider is necessary to look for underlying pathology as the cause
of gynecomastia. In an adolescent with suspected disorders of sexual differentiation and hormone
differences, referral to a pediatric endocrinologist is warranted. Often, no true etiology is found and the
gynecomastia is thought to be idiopathic. In a review by Cordova et al., 102 of 123 patients had idiopathic
gynecomastia without an identifiable cause. 5
All patients with gynecomastia require thorough history and physical examination. A full record of
previous and current medications, including supplements as well as illicit drugs, should be obtained. For
pediatric patients, it is often wise to examine them privately, so that they feel comfortable sharing any
illegal consumption without the retribution of a parent present.
Physical exam should begin with the palpation of the breast for any discernible masses. The breast bud
beneath the nipple areolar complex should be palpated, and is often tender to the patient with idiopathic
gynecomastia. Glandular breast tissue should be differentiated from diffuse fatty enlargement of the male
breast, often termed pseudogynecomastia. Asymmetries of the breasts and chest wall should be noted.
The nipple areolar complex should be evaluated for size, shape, and location. A thyroid and testicular
exam should be performed to thoroughly evaluate for underlying systemic pathology.
Less than 1% of all breast malignancies develop in males. Although rare, breast cancer must always
remain on the differential diagnosis when examining breast enlargement in male patients. One should
specifically palpate for discernible masses located outside of the nipple areolar complex and evaluate for
significant asymmetry. Skin dimpling, nipple retraction, nipple discharge, and bleeding are all symptoms
suggestive of malignancy. 6 If there is concern based on physical exam, further workup is necessary with
an ultrasound or mammogram. In patients with Klinefelter syndrome, their risk of developing breast
cancer is almost 60 times greater than the general male population, and excisional surgical techniques are
preferred in this high-risk population.
A variety of classification schemes exist to further describe the degree of deformity. Despite their
differences, all of these classification systems focus on the degree of breast enlargement as well as the skin
redundancy and nipple ptosis seen with these deformities. Simon’s classification is a historic and well-
referenced system used to evaluate gynecomastia, and includes these basic variables (Table 57.3). 7 Other
factors to be evaluated include skin elasticity, and the size and shape of the nipple areolar complex, which
are not accounted for in this classification system.
TABLE 57.3
Simon Gynecomastia Classification System
Grade
Breast Enlargement
Skin Excess
1
Small
None
2a
Moderate
None
2b
Moderate
Skin redundancy
3
Marked
Skin redundancy
Psychological implications of gynecomastia in adolescents are well documented. Nuzzi et al. reported a
significant impact on adolescent social functioning, mental health, and self-esteem, regardless of the
severity or grade of the gynecomastia. 8 These patients often exhibit anxieties and social phobias, with
many teenagers refusing to participate in physical education or sports. The treating physician should
consider referral for counseling or psychiatric treatment as an adjunct to medical and surgical
management for these patients. 9 Due to these psychological effects, gynecomastia in adolescents is
sometimes considered medically necessary by some insurance companies. If gynecomastia is adversely
affecting a patient’s mental health and wellbeing, it is reasonable to ask for prior authorization for
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coverage of surgical correction in the appropriate patient.
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Nonoperative Management
Nonsurgical management of gynecomastia should be explored first. Any offending agents should be
discontinued to allow for resolution of symptoms. Underlying disease processes should be controlled and
treated, and their effect noted. For those with pseudogynecomastia, weight loss is an effective strategy to
reduce the amount of adipose tissue and help improve the contour of the chest.
In most instances, no causative agent or illness is identified, and the gynecomastia is considered
idiopathic. Many small-scale clinical trials have evaluated the efficacy of tamoxifen, a selective estrogen
receptor modulator, on the treatment of gynecomastia. Khan et al. reported complete resolution of
gynecomastia in 83.3% of their patients treated with tamoxifen, with noted decrease in breast tenderness
for 84% of men during treatment. 10 Despite multiple randomized and nonrandomized trials in the
literature, tamoxifen is not yet approved by the Food and Drug Administration as a treatment for
gynecomastia. Clomiphene citrate has also been trialed in small studies, with minimal improvement in
the adolescent population. 11
Patients with prostate cancer treated with bicalutamide monotherapy commonly experience
gynecomastia and mastodynia. These patients may receive off-label prophylactic or therapeutic treatment
with tamoxifen or anastrazole, an aromatase inhibitor, with varying levels of efficacy. Tamoxifen, when
taken as a prophylactic measure at 10 to 20 mg daily, is shown to be most effective in these patients.
Prophylactic radiotherapy has also been found to be effective at mitigating approximately one third of the
gynecomastia and mastodynia seen with bicalutamide therapy. 12
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Surgical Management
If exogenous causes are controlled and the patient’s gynecomastia persists for at least 1 year, surgical
treatment is warranted. Surgical treatment options vary depending on the severity of the gynecomastia.
The goal of surgical management is to achieve a more masculine appearing chest while managing
realistic patient expectations. Operative procedures are designed to remove the excess glandular and fatty
tissue, reduce the diameter of the nipple areolar complex, relocate the nipple to the appropriate position
on the chest wall, and achieve symmetry.
All patients should be marked preoperatively in the sitting or standing position. The sternal notch,
midline, and inframammary fold are marked. The nipple areolar complex is also marked and measured.
Areas of glandular and fatty excess are delineated. The border of the pectoralis major muscle is palpated
and transposed onto the skin (Figure 57.1).
FIGURE 57.1 Preoperative markings for gynecomastia correction show the sternal notch and midline marked, as well as the
inferior periareolar incision. The arrow delineates the superior medial pedicle that will be used to preserve nipple viability. The
inframammary fold is marked and will be disrupted via liposuction, along with fatty deposits on the inferior chest, which have
been circled.
Suction-assisted lipectomy is an excellent option for patients with minimal to moderate tissue and skin
excess. If the breast enlargement is predominantly adipose tissue, liposuction is an ideal method to
remove the unwanted fat and create a more pleasing contour (Figure 57.2). The use of ultrasound-assisted
liposuction has broadened the indications for liposuction, as it is able to address the firmer glandular
breast tissue under the nipple areolar complex. The ultrasound-
 assisted device uses a process of fat
emulsification via cavitation, which is highly effective at disrupting dense, glandular tissue. This
technique also offers skin tightening as an additional benefit when performed in a more superficial plane.
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Rohrich et al. discussed their technique of tumescence and ultrasound-assisted liposuction followed by
traditional liposuction to achieve excellent cosmetic results in their gynecomastia patients. 13 With any of
the various types of liposuction, it is important that fanning liposuction of the entire chest be performed
to create a smooth and pleasing contour. The surgeon should intentionally disrupt the inframammary
fold, because such dermoglandular attachment is feminizing (Figure 57.3). Instead, the lower pole may be
contoured via liposuction to emphasize the inferior border of the pectoralis major muscle and create more
masculine definition.
FIGURE 57.2 This patient with minimal fatty gynecomastia without skin excess underwent liposuction correction of
gynecomastia. A–C. Preoperative photographs. D–F. Postoperative photographs.
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FIGURE 57.3 Intraoperative photo of a liposuction technique to efface the inframammary fold and create a more masculine
lower pole contour.
In patients with moderate glandular excess as well as moderate skin excess, it is advisable to stage skin
excision by performing liposuction or direct glandular excision first. If there is good skin elasticity, the
loose skin envelope will contract following surgery. In older individuals or those with poor elasticity, a
second procedure may be necessary to trim the excess skin and improve shape. A period of at least 6 to
12 months postoperatively allows the tissue to retract, and the decision to pursue further skin excision
can then be made. Most patients will exhibit adequate skin retraction, and do not elect further surgery.
For those that require skin excision, incisions are often limited, and the amount of skin removed is far less
than if it had been completed at the initial surgery. It is important to manage patient expectations related
to skin and nipple appearance, and the potential need for staged procedures.
For patients with minimal to moderate excess that is predominantly glandular, a direct excision technique
is preferred. A limited periareolar incision offers access to the parenchyma for direct excision and creates
a well-concealed scar. Placing the incision along the inferior lateral aspect of the areola further shadows
the incision and leads to a minimally perceptible scar. Another technique involves a transareolar incision,
hiding the scar in the pigmented areola in a transverse manner (Figure 57.4). Using a pull-through
technique, the dense breast parenchyma is delivered through the limited incision and removed in
piecemeal fashion using a pair of sharp scissors or electric cautery. In larger patients, this periareolar
incision may be extended laterally onto the breast skin in an omega pattern to gain better access to the
breast. With direct excision techniques, the surgeon has better visualization and more control of the
resection. A mastectomy is performed through this approach to remove the entire glandular breast. It is
imperative that a mound of at least 1.5 cm of gland be left below the nipple areolar complex to prevent
over resection and a concavity below the nipple. The flaps are created with some subcutaneous tissue to
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prevent a concave postoperative appearance of the male chest. It is preferred to leave too much tissue
here, as it can be further trimmed to improve the contour at the end of the procedure. Liposuction may be
used as an adjunct to a direct excisional technique, and fanning is performed to optimize contour.
FIGURE 57.4 This patient with moderate glandular gynecomastia without skin excess underwent direct excision via
transareolar approach for correction of gynecomastia. A–C. Preoperative photographs. D–F. Postoperative photographs.
Gynecomastia is often accompanied by an increased diameter of the nipple areolar complex, contributing
to the feminine appearance of the chest. After liposuction or direct excision, some retraction in the size of
the nipple areolar complex is expected. However, if the areolar diameter is very large, or the skin has
poor elasticity, reduction of the diameter of the areola should be considered at the time of the initial
surgery. A circumareolar mastopexy pattern may be performed with deepithelialization to reduce the
diameter of the areola and possibly skin envelope (Figure 57.5). Some puckering of the tissue occurs
initially, but this settles out postoperatively. This could also be performed in a staged manner if retraction
in the areolar diameter does not occur postoperatively.
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FIGURE 57.5 A. Preoperative AP view of patient with moderate glandular gynecomastia and enlarged areolas. B.
Intraoperative photo after deepithelialization of excess areola and a pull-through technique demonstrating the dense glandular
bud of tissue beneath the nipple areolar complex. C. Immediate postoperative result showing improved chest contour and
areolar diameter.
Patients with moderate to severe enlargement and skin excess require excisional techniques that address
both the glandular and skin redundancy. If the nipple lies at or slightly below the fold, a periareolar
excision may be sufficient to remove the skin excess. When the nipple is more ptotic and there is marked
tissue excess, a reduction mammoplasty approach is necessary. The skin is excised in a vertical pattern,
wise pattern, or in a total amputation technique with an inframammary scar only. The nipple may be left
on a glandular pedicle to preserve vascularity and sensation. This is sometimes difficult in larger breasted
males, as a glandular pedicle requires that significant breast tissue be preserved, often leaving the male
breast larger than is cosmetically desirable. The nipple can also be preserved on a dermal pedicle to
reduce bulk; however, the blood supply is less reliable with such a technique. Alternatively, a direct
amputation technique with free nipple grafting may be indicated (Figure 57.6). Patients should be well
informed of the consequences of free nipple grafting, including graft loss, sensory changes, pigment loss,
and asymmetry.
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FIGURE 57.6 This patient with marked glandular excess and significant skin redundancy underwent IMF amputation with free
nipple grafting. A–C. Preoperative photographs. D–F. Postoperative photographs.
Relocating the nipple in these patients is one of the most challenging aspects of gynecomastia surgery.
Unlike the female breast, the nipple should be placed inferior and lateral at the level of the inferior border
of the pectoralis muscle. A variety of complex mathematical formulas have been postulated to help with
nipple placement. Beckenstein et al. studied normal male subjects and determined an ideal sternal notch
to nipple distance to be 20 cm, with 21 cm between each nipple. The average diameter of a male nipple in
their study is 2.8 cm. 14 Shulman et al. extrapolated on the data, creating a three point mathematical ratio
based upon the patient’s own height and chest circumference to determine the ideal nipple position.
Using these simple measurements, the new nipple should be located at 0.722 of the patient’s height. At
that level, chest circumference is then measured, and the distance between the nipple areolar complexes
should be 0.213 of the circumference. Finally, the patient’s height is multiplied by 0.104, which should
correlate to the distance between the sternal notch and new nipple location. 15
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Special Patient Populations
Certain patient populations deserve specific attention and evaluation to help with comprehensive
surgical planning. 16 In the postbariatric patients, skin elasticity should be evaluated. The entire chest wall
should be examined for redundant, loose tissue extending from the breast to the lateral axilla. Due to
volume loss and tissue redundancy, these patients often require the direct excision of skin in both the
vertical and horizontal direction. Hurwitz described a successful technique with a boomerang-patterned
excision in these patients. 17 With this approach, the ptotic nipple areolar complex is relocated, while
simultaneously excising breast and torso laxity in the patient. This pattern may then be extended laterally
to remove lateral tissue excess on the male chest and axilla.
Bodybuilders are another population specifically affected by gynecomastia. The cause of the breast
enlargement in this population may be anabolic steroid use, or related to the hormones in over the
counter supplements used to maintain their muscular habitus. The breast enlargement often persists in
these patients with low body fat, despite cessation of the offending agents. 18 Persistent stromal and
periductal tissue becomes fibrotic with time, and this tissue is unlikely to dissipate if longstanding. In
bodybuilders, the gynecomastia is usually glandular and fibrotic, as these patients have a paucity of body
fat. Surgical intervention should be planned according to the pathology, and minimally invasive
techniques such as liposuction are less effective in these patients. Direct excision of the enlarged gland via
a pull-through technique is often indicated.
Pseudogynecomastia refers to enlargement of the male breast in the morbidly obese. In this population
there is significant adiposity in all areas of the body, and the breast is not spared. Due to excess skin and
adipose tissue, an open approach with skin excision is often necessary. The treating physician should
always counsel these patients on preoperative weight loss to decrease risk of major surgical complications
and to achieve a desired cosmetic result.
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Postoperative Management
Following all types of surgical intervention, postoperative compliance with compression is essential to
achieve an optimal cosmetic result. Suction drains should be considered in patients after direct excision,
or when there is significant dead space present. Compression should be applied with specialized
garments or compression wraps to allow the tissue to heal down to the chest wall and prevent seroma
formation. The patients should continue compression for up to 3 months postoperatively throughout the
healing process to reduce postoperative edema and ensure a flat contour.
Complications of surgical intervention include under resection, over resection, contour irregularity, and
asymmetry. Patients may also experience hematomas, seromas, scarring, and infection. Patients with
direct excision via a limited incision are the most likely to experience hematoma, as the visibility with this
technique may be poor, leading to postoperative bleeding complications. When ultrasound-assisted
liposuction is used, contact burns may occur, especially at the port entry site when moist towels are not
used to protect the skin. In patients with skin excess and relocation of the nipple, partial or complete
nipple loss and sensory changes may occur.
Most patients are quite satisfied with their outcomes after surgical correction of gynecomastia. They
report confidence with their new appearance, and consistently report improved quality of life in all
aspects, especially social functioning regardless of the stage of the gynecomastia treated. 19
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Questions
1. A 20-year-old male presents with complaints of painful enlargement of breasts bilaterally. He
notes that his breast enlargement began about 4 years earlier and has not dissipated. He is
embarrassed to take off his shirt in the summer to swim and refuses to participate in organized
sports. History, physical examination, and workup should include all of the following except:
a. History of illicit drug use
b. Testicular exam
c. Mammography
d. Medication history
2. A 53-year-old man is referred to your plastic surgery office for gynecomastia. On examination, he
has a painless, firm mass of 2 cm located lateral to the nipple areolar complex in the left breast. He
first experienced bloody nipple discharge about 6 months ago, and then discovered the breast
enlargement. The right breast appears to be normal, and the remainder of his physical exam is
unremarkable. Which of the following is the next step in the workup of this patient?
a. Mammography
b. Referral to Endocrinology
c. Observation and follow-up in 3 months
d. Observation and follow-up in 1 year
3. Which of the following grouping contains a medication or drugs NOT associated with
gynecomastia?
a. Amphetamines, anabolic steroids, marijuana
b. Digoxin, ACE inhibitors, spironolactone
c. Benzodiazepines, risperidone, haloperidol
d. Cephalosporins, metronidazole, isoniazid
4. A healthy 32-year-old man with a BMI of 23.5 comes to your office for evaluation of asymptomatic
gynecomastia that has been present for 15 years. He does not have any medical problems, take any
medications, or use illicit drugs. On evaluation, he has firm, rubbery tissue below the nipple areolar
complex bilaterally. The nipple areolar complex is located at the inferior border of the pectoralis
major muscle and is 28 mm in diameter. The remainder of his physical exam is normal. Which of the
following is the appropriate recommendation for this patient?
a. Limited periareolar incision with a pull-through direct excision technique
b. Suction-assisted lipectomy with disruption of the inframammary fold
c. Wise pattern reduction mammoplasty with inferior dermoglandular pedicle
d. Breast amputation technique with free nipple grafting
5. A 13-year-old boy comes to the office accompanied by his mother. For the last 2 years, the patient
has had progressive increase in size of his breasts. The boy refuses to participate in physical
education, and is suffering from failing grades due to his unwillingness to participate. On physical
exam, he has marked bilateral breast development with well-defined inframammary folds. No true
masses are identified. The patient has underdeveloped testes, and his body habitus and overall
appearance is quite feminine. Following your examination, what is the most appropriate next step?
a. Ultrasound-assisted liposuction technique
b. Mammography
c. Referral to pediatric endocrinology
d. Breast amputation with free nipple grafting
1. Answer: c. A thorough history and physical examination are necessary to evaluate patients with
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