Gynecomastia: Air-Assisted Minimally Invasive Surgery

[madman]

Abstract

Background

Gynecomastia is a benign condition that develops due to the proliferation of breast tissue in men. Surgical excision is the most effective treatment method. Minimally invasive techniques can be used to avoid visible scarring. We evaluated the efficacy and safety of air-assisted subcutaneous mastectomy in the treatment of gynecomastia.


Patient and Methods

10 patients with gynecomastia underwent air-assisted subcutaneous mastectomy and liposuction through a single axillary incision, between June 2022 and February 2023. Demographic and clinical data of the patients, duration of surgery, and complications were recorded. The satisfaction levels of the patients regarding physical appearance, mental status, and social environment were measured. The body Q questionnaire was performed preoperatively and in the postoperative third month.


Results

The median age was 26 (range, 18-54). Surgical excision was measured as a median of 69 gr (range, 41-177), and liposuction volume was measured as a median of 210 ccs (range, 63-400). The median operation time was 50 minutes(range, 21-60) for excision and 21 minutes (range, 20-75) for liposuction. Body, chest, and nipples related appearance satisfaction levels were measured preoperatively as a median of 44 (range, 36.5-52), 31 (range, 27.5-39), and 51.5 (range,21-69.8) points vs postoperatively as 92 (range, 92-100), 93 (range, 93-94.8) and 90 (range, 90-100) points, respectively. The patients had a median follow-up of 6 months (range, 3-11). No complications were observed during the follow-up period.


Conclusion

Air-assisted subcutaneous mastectomy and liposuction is a feasible technique that may provide good cosmetic outcomes by avoiding anterior chest wall scarring.




Introduction

Gynecomastia is a benign condition that develops due to the proliferation of breast tissue in men. Physiological gynecomastia is common in newborns, adolescents, and elderly men.1 To reveal the etiology of gynecomastia, careful anamnesis, physical examination, hormone tests, and ultrasonography should be performed. Breast tumors and endocrine or systemic diseases should be excluded. Gynecomastia rarely requires surgical treatment for cosmesis and analgesia. Surgery is preferred for patients with prolonged symptoms and for whom medical treatment is ineffective.1,2

Surgery for gynecomastia may cause complications such as contour irregularity, nipple-areola complex collapse and distortion, subtotal glandular resection, ischemia, necrosis, and hypertrophic scarring.3 Minimally invasive surgical techniques are used in the treatment of gynecomastia to improve cosmetic results and reduce complication rates.4–10 Vacuum-assisted biopsy and liposuction are minimally invasive methods for gynecomastia. These methods can be performed through a small incision from the anterior axillary line and the inframammary fold.11 Recently endoscopic mastectomy has been described as an alternative technique.12–17

We aimed to share our experience with a novel technique: air-assisted subcutaneous mastectomy through a single axillary incision. We also evaluated the efficiency and safety of this technique also its effects on patient satisfaction.








Patients with gynecomastia suffer from anxiety, depression, and social phobia. Successful surgery cosmetically corrects the chest area and it also has a positive effect on psychological well-being.20 Similarly, in our study, mental and social environment satisfaction levels that were evaluated using Body-Q scales were found to be high in patients who underwent gynecomastia surgery.

Air-assisted minimally invasive mastectomy has many advantages over open surgery, such as a small incision, less tissue trauma, increased nipple viability, and early healing. Besides this technique is not suitable for patients who require skin excision.

Air-assisted nipple-areola-sparing mastectomy and liposuction is a safe and effective alternative for the surgical treatment of gynecomastia. This technique also achieves increased physical appearance, mental status, and social environment-related satisfaction levels. The operation time is shorter in air-assisted minimally invasive surgery compared to endoscopic techniques. Air-assisted minimally invasive surgery can be performed as an alternative method for surgical treatment of gynecomastia in inexperienced hands for patients who don’t require skin excision. Although our results are promising, studies with a larger number of patients are needed.

 

[madman]

Figure 1. Aspiration-type cannula with the hand pump.

 

[madman]

Figure 2. Preoperative photographs.

 

[madman]

Figure 3. Preoperative and early postoperative images of a patient who underwent air-assisted minimally invasive surgery and liposuction.

 

[madman]

Table 1. Patient Characteristics.

 

[madman]

Table 2. Preoperative and Postoperative BODY-Q Scores.

 

[tmaxey1]

What are the costs of gyno surgery these days?
I have a 14 year old son who has it from puberty. Took him to pediatrician who assured us 90% of the time it "goes away on its own". Bullcrap. This Dr refused to give him tomoxifan or any AI and now its a problem.

Anyone know what these procedured costs these days?
I should be able to bill the F'n pediatrician.

 

[madman]

What are the costs of gyno surgery these days?
I have a 14 year old son who has it from puberty. Took him to pediatrician who assured us 90% of the time it "goes away on its own". Bullcrap. This Dr refused to give him tomoxifan or any AI and now its a problem.

Anyone know what these procedured costs these days?
I should be able to bill the F'n pediatrician.

If anything get a second opinion before jumping to any conclusions.

Gynecomastia: Medical Management/Surgery

Gynecomastia in boys is breast enlargement due to hormonal imbalances, including androgen-estrogen changes and other hormone effects. Common causes include puberty, obesity, drugs, and hypogonadism. Other conditions like liver/renal problems, thyrotoxicosis, Klinefelter syndrome, tumors, and...

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*Pubertal gynecomastia, which refers to breast enlargement in boys during puberty, typically resolves on its own in 85-90% of cases within 6 months to 2 years. This should be explained to both the boy and his parents, especially when the gynecomastia is less severe.

Management of Gynecomastia and Male Benign Diseases

Management of Gynecomastia and Male Benign Diseases (2022) Manish M. Karamchandani, MD, Gabriel De La Cruz Ku, MD, Bradford L. Sokol, BS, Abhishek Chatterjee, MD MBA, Christopher Homsy, MD GYNECOMASTIA Definition Gynecomastia is the benign enlargement of the male breast due to the increased...

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*Pubertal gynecomastia is estimated to have a prevalence anywhere between 22% and 69% in adolescent boys with most cases occurring between ages 13 and 14 after the onset of testicular development.4–7 Lack of consistency regarding the size of palpable glandular tissue required for diagnosis may explain the wide range in reported prevalence among adolescents.2,8 Approximately 95% to 97% of pubertal gynecomastia cases will resolve without treatment within 18 months of initial discovery.1,4 Persistent pubertal gynecomastia accounts for approximately 25% of all cases of gynecomastia.9

*Medical management of gynecomastia should be centered around the physical examination, imaging/biopsy, and laboratory findings. Underlying conditions such as malignancy or endocrine disorders should be addressed first because the resolution of the condition can reduce the amount of glandular tissue. Offending medications and drugs should be discontinued when possible. For idiopathic and pubertal cases, selective estrogen receptor modulator (SERM) therapy with raloxifene and tamoxifen can be effective.18,25 SERM therapy can also be trialed in patients who have refractory gynecomastia in which the underlying cause has been treated. Aromatase inhibitor therapy can also be useful in the treatment of true gynecomastia. Anastrozole has been found to be effective in pubertal gynecomastia18; however, in adults, it has been found to have little to no effect.26 Testosterone has been reported to be successful in cases of hypogonadism27; however, it may increase gynecomastia rather than decrease the amount of tissue, particularly if the patient is eugonadal.

*Most cases of gynecomastia are benign and self-limiting; however, if gynecomastia has been present for greater than 12 months, it is unlikely that it will resolve with discontinuation of offending medications or with medical treatment because the glandular tissue has likely developed irreversible fibrosis and hyalinization.17 In these scenarios, surgical excision by an experienced plastic surgeon is the most effective treatment. It is important to note that gynecomastia itself is a benign condition and does not need treatment unless there are aesthetic and psychological reasons for pursuing treatment.




post #6

Approach to Gynecomastia in Primary Care Clinics

An Approach to Gynecomastia in Primary Care Clinics (2022) Kavya Bharathidasan, MD, Jordan Curl, BS, Vedesh Kumar Babu, MD, Shaili Felton, MD, and Kenneth Nugent, MD Abstract Gynecomastia is a more common finding in primary care clinics than is recognized. Because this finding can be easily...

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Breast development in pediatric patients from birth to puberty

Abstract Breast tissue undergoes a series of changes from birth to puberty. The majority of the changes are transient, and related to physiological hormonal changes. Although the breast is identical in both sexes at birth, its histology and development will eventually differ. It is important...

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Introduction

Boys and girls undergo endocrinological changes that influence normal breast development until puberty. In some children, these hormonal changes can lead to an unusual but transient appearance, potentially becoming a source of anxiety to patients and their parents and a source of confusion to clinicians and radiologists. From birth to puberty, pathological conditions of the breast are mostly benign and very often a transient part of normal development. Furthermore, malignant breast lesions, especially the adult-type primary breast carcinoma, in the pediatric population are exceedingly rare [1–3]. Most breast changes in the pediatric population can be diagnosed clinically, but sometimes imaging evaluation is recommended. Ultrasound (US) is the imaging modality of choice to evaluate the breast in pediatrics [4, 5]. Thus, familiarity with these transient changes and the occasional pathological conditions is important in order to avoid unnecessary and costly work-ups and to prevent stress and anxiety for patients and parents.




Breast changes in boys during puberty

At the beginning of puberty in boys, levels of estrogen increase transiently, stimulating the growth of breast tissue; however, this is quickly followed by a surge in testosterone, antagonizing the estrogen effect. The lack of a progesterone surge in boys precludes the development of terminal lobular units. This means that there is a temporary proliferation of breast ducts and stroma followed by their rapid involution. Cooper ligaments are also absent in boys, whereas pectoralis muscles are more prominent than in girls. The sonographic appearance of the normal pubertal breast in boys is no different from its prepubertal appearance with visualization of subcutaneous fat and a faint nipple shadow [38–40]




Gynecomastia in the adolescent boy

Gynecomastia is defined as the development of mammary glandular tissue in the male, more precisely ductal and stromal tissue proliferation, due to an imbalance of the testosterone/ estrogen ratio [38, 41]. Gynecomastia is commonly seen during early and mid-puberty, with a reported incidence of 30% to 60% at this age [41].

Gynecomastia can be unilateral or bilateral, symmetrical or asymmetrical, and synchronous or metachronous. Laboratory testing usually fails to reveal abnormal circulating estrogen and/or androgen levels. Most cases of physiological gynecomastia resolve spontaneously as androgen levels continue to rise later in puberty, lasting no longer than 2 years [42, 43]. Upon physical examination, a subareolar, palpable, mobile lump, sometimes tender, is palpated. Occasionally, US is requested to rule out a mass or to differentiate it from pseudogynecomastia or lipomastia, which is the focal accumulation of adipose tissue, usually in overweight adolescents, that is always bilateral [40, 44]. Three patterns of gynecomastia have been described on US imaging: 1) a nodular pattern occurring in the early phase, seen as a hypoechoic disc-shaped mass beneath the nipple surrounded by fatty tissue (Fig. 5); 2) a dendritic pattern during the chronic phase, seen as a flame shape of hypoechogenicity in the retroareolar region with irregular margins that infiltrate the adjacent subcutaneous fat (Fig. 6); and 3) a diffuse pattern, seen on sonography, identical to the female dense heterogeneous breast [4, 38, 44, 45]. In US, lipomastia is seen as diffuse adipose tissue proliferation without fibroglandular tissue. No discrete mass should be present and, different from gynecomastia, no distinct borders are identified (Fig. 7) [40]. Treatment is not necessary in most cases because physiological pubertal gynecomastia resolves spontaneously. However, when gynecomastia is severe and persistent, pharmacological treatment or surgery might be indicated [46].

Pathological gynecomastia is rare in pediatric patients and young adults, and it is secondary to elevated levels of exogenous or endogenous estrogens or to low production of testosterone [46]. The age of appearance and progression of gynecomastia is very important, with adolescents with late-onset gynecomastia deserving a more detailed evaluation. A thorough clinical history, including the age of pubertal development, exposure to hormones, medications with antiandrogenic actions, consumption of marijuana, and family history of gynecomastia, should be explored (Table 1) [47]. US evaluation of the testicles is indicated when testicular asymmetry is found or a mass is palpated upon physical examination. If suspected, especially when FSH levels are elevated, a karyotype should be ordered to exclude Klinefelter syndrome.