madman
Super Moderator
Contemporary Management of Gynecomastia (2022)
Dennis J. Hurwitz, BS, MD, Armando A. Davila, BS, MD
INTRODUCTION/HISTORY/DEFINITIONS/ BACKGROUND
Gynecomastia is a common benign enlargement of the breast occurring in more than one-third of males.1 Although the deformity can be fleeting, for those that it persists many are so distressed by poor self-image, depression, anxiety, and social phobia that they seek surgical removal.2,3 Contemporary management enables smoother correction of deformity with fewer complications and optimally extends to masculinization of the torso with results captured by photo documentation of chest mobility and dynamics.
Once pathologic increases in systemic estrogen and malignancy are ruled out, plastic surgeons most often operate on idiopathic gynecomastia arising from hormonal imbalance acting on a supersensitive glandular bud or caused by increased endogenous or exogenous administered circulating estrogen or estrogenlike hormones. Associated with a variable degree of fat usually related to body adiposity, glandular gynecomastia varies from slight to considerable firm masses emanating from the areolas. Minimal adiposity gynecomastia, commonly seen in low body mass index (BMI) bodybuilders, is an obliquely oriented, easily isolated firm tube with more mass lateral than medial.4 Adipose-laden gynecomastia is more spherical with less defined borders. Pseudogynecomastia exhibits sparse gland interspersed in adipose, presenting in obese and older patients, and after massive weight loss. As the breast increases in size so may the areola and breast skin envelope, which needs reduction.
Initially, the magnitude of deformity and its psychosocial impact is assessed. Minimal procedures are easily accepted, whereas complex operations that may entail significant pain, scarring, and risk must be matched by patient antipathy. Because of its simplicity based on breast size and tissue laxity, the Simon classification5 was slightly modified to sort out most treatment options (Table 1). Grade I is minor enlargement without skin redundancy. Grade IIa is moderate enlargement without skin redundancy. Grade IIb is moderate enlargement with nipple ptosis/deformity and/or minor skin redundancy. Grade IIIa is marked enlargement with nipple ptosis/deformity with skin redundancy. Grade IIIb is marked enlargement with sagging breasts and upper torso skin redundancy. Beyond social inhibitions, if there is a concern about masculinity, we introduce surgical enhancement. Patients either limit their operation to the offending gynecomastia or embrace further surgery for masculinization. As more requests for male body contouring occur, correction of gynecomastia becomes a secondary consideration, so a comprehensive approach is expected.
Because contemporary management offers masculinization of the chest and remaining torso
through high-definition liposculpture and excisional surgery, basic masculine aesthetics are introduced. For a more comprehensive 360 torso review that relates sculpture techniques to presenting body type read in this Clinics issue “The Male Abdominoplasty,” by Michael Stein and Alan Matarasso; Gynecomastia and Male Chest Wall Contouring by Douglas Steinbrech and Eduardo Gonzalez; and “High-Definition Liposculpture in Men” by Hoyos and coworkers.6 For our aesthetic purposes, skin tightly wraps to reveal the broad muscles of a dominant upper body. A barrel-like rib cage is draped by large, thick, and flat Pectoralis Major, Trapezius, and Latissimus Dorsi muscles. The lateral edges of these muscles are defined with further pectoral prominence of its midportion and along the lateral border of the sternum. Broad shoulders extend further by apple-like deltoids. Anterior chest definition is completed with inferior Pectoralis fullness superior to a short horizontal flattened adherence near the fifth rib.
The aesthetic goals of the treatment of gynecomastia have traditionally been limited to near-total glandular resection, smooth contour transition to surrounding subcutaneous tissue, and removal of loose skin, leaving proper nipple-areolar complex (NAC) position and shape with as few scars as possible. Because of the pubescent onset of gynecomastia and the potential for gender ambiguity this focused approach may leave a sense of inadequate masculinity. With the advent of improved, reliable, and safe male-specific operations and liposculpture, selected patients should be offered more thorough body contouring surgery. Hence, in addition to the obliteration of the gynecomastia, contemporary management offers a tight-skinned upper torso that reflects underlying musculature enhanced by perimeter etching and lipoaugmentation that should extend surgically throughout the torso.7 Critically, the inframammary fold (IMF), which lies about one interspace below the inferior pectoral border, needs to be obliterated. Conversely, accentuating the IMF through an inferior chest transverse excision is disastrously feminizing. Although not always obvious standing erect, when leaning residual lax skin drapes over the constructed IMF, revealing a deflated but still sagging breast. The ideal nipple projects several millimeters and is surrounded by a flat, transversely oriented 1.5 to 2.0 cm X 2.5 to 3.0 cm oval areola, lying several centimeters medial and superior to the inferior/lateral junction of the Pectoralis Major muscle. Repositioning of a ptotic nipple relates to dynamic Pectoralis Major muscles rather than skeletal landmarks or absolute numbers or ratios. Large, rounded, and protruding areolas need reshaping.
Ignored by most plastic surgeons, but not by the body-conscious patient, are dynamic shape changes of the chest as the Pectoralis Major morphs from relaxation to full contraction, and with different positions of the arms and body. Demonstrating and photographing these subtle relationships are appreciated by the patient, aid in treatment planning, and thoroughly document outcomes. For example, Case 1 is a 49-year-old man with a BMI of 26, moderate enlargement, nipple ptosis, and moderate skin redundancy, grade IIb (Figs. 1 and 2). Descending deep and inferior to the NAC, relaxed Pectoralis muscles are visually inseparable from the gynecomastia (see Fig 1, top). The contracted Pectoralis major rises and bulges toward the clavicles isolating the periareolar rounded gynecomastia (see Fig 1, bottom). Raising the arms stretches, elevates, and flattens the Pectoralis muscle to isolate the breast mound visually and palpably (Fig 2, left). On leaning, the gland with excess skin that is loosely adherent to the Pectoralis muscle disturbingly droops (see Fig 2, left). Because the contracted Pectoralis muscle or raised arms leave no muscle fill deep and inferior to the areola, gynecomastia correction should be planned accordingly. For a thorough visual appraisal of results, comprehensive photographic documentation of gynecomastia and its treatment should include arms to the side, contracted Pectoralis muscle, extended arms, and diving position. Using VASERlipo (Solta Medical, Bothell, WA) and BodyTite (InMode, Irving, CA) (discussed later), total correction is documented in these various positions (Figs. 3 and 4).
*TECHNIQUES
*DISCUSSION
Since 2017, one or more combinations of the following nine procedures correct gynecomastia and further enhance masculinity:
1. Infra-areolar glandular excision
2. Barbed sutured areolarplasty
3. Inframammary fold disruption
4. UAL ablation and adipose evacuation of the chest
5. VASERlipo of the torso with muscular definition
6. Bipolar radiofrequency tissue tightening
7. Boomerang pattern excision, inferior pedicle areolaroplasty with/without J-torsoplasty
8. Lateral torso hockey stick with or without double incision mastectomy with pedicled or free graft areolaroplasty
9. Lipoaugmentation of the pectoralis and deltoid muscles
SUMMARY
We find healthy young men with minimal glandular tissue (grade I, IIa) respond incredibly well with no residual deformity through either transareolar direct excision and/or UAL. For patients grade IIb up to IIIa, VASERlipo is followed by BodyTite. If needed, glandular pull-through excision completes the correction with or without barbed sutured areolarplasty. More severe cases require excisional skin tightening, with a variety of patterns suitable for each patient depending on their deformity. What sets plastic surgeons apart is recognizing, predicting, and executing tissue reconstructive procedures assisted by new technology and innovative techniques leaving a proper sculptured result under moderate skin tension that heals rapidly with the fewest and thinnest scars possible rather than a one-size-fits-all approach.
Dennis J. Hurwitz, BS, MD, Armando A. Davila, BS, MD
INTRODUCTION/HISTORY/DEFINITIONS/ BACKGROUND
Gynecomastia is a common benign enlargement of the breast occurring in more than one-third of males.1 Although the deformity can be fleeting, for those that it persists many are so distressed by poor self-image, depression, anxiety, and social phobia that they seek surgical removal.2,3 Contemporary management enables smoother correction of deformity with fewer complications and optimally extends to masculinization of the torso with results captured by photo documentation of chest mobility and dynamics.
Once pathologic increases in systemic estrogen and malignancy are ruled out, plastic surgeons most often operate on idiopathic gynecomastia arising from hormonal imbalance acting on a supersensitive glandular bud or caused by increased endogenous or exogenous administered circulating estrogen or estrogenlike hormones. Associated with a variable degree of fat usually related to body adiposity, glandular gynecomastia varies from slight to considerable firm masses emanating from the areolas. Minimal adiposity gynecomastia, commonly seen in low body mass index (BMI) bodybuilders, is an obliquely oriented, easily isolated firm tube with more mass lateral than medial.4 Adipose-laden gynecomastia is more spherical with less defined borders. Pseudogynecomastia exhibits sparse gland interspersed in adipose, presenting in obese and older patients, and after massive weight loss. As the breast increases in size so may the areola and breast skin envelope, which needs reduction.
Initially, the magnitude of deformity and its psychosocial impact is assessed. Minimal procedures are easily accepted, whereas complex operations that may entail significant pain, scarring, and risk must be matched by patient antipathy. Because of its simplicity based on breast size and tissue laxity, the Simon classification5 was slightly modified to sort out most treatment options (Table 1). Grade I is minor enlargement without skin redundancy. Grade IIa is moderate enlargement without skin redundancy. Grade IIb is moderate enlargement with nipple ptosis/deformity and/or minor skin redundancy. Grade IIIa is marked enlargement with nipple ptosis/deformity with skin redundancy. Grade IIIb is marked enlargement with sagging breasts and upper torso skin redundancy. Beyond social inhibitions, if there is a concern about masculinity, we introduce surgical enhancement. Patients either limit their operation to the offending gynecomastia or embrace further surgery for masculinization. As more requests for male body contouring occur, correction of gynecomastia becomes a secondary consideration, so a comprehensive approach is expected.
Because contemporary management offers masculinization of the chest and remaining torso
through high-definition liposculpture and excisional surgery, basic masculine aesthetics are introduced. For a more comprehensive 360 torso review that relates sculpture techniques to presenting body type read in this Clinics issue “The Male Abdominoplasty,” by Michael Stein and Alan Matarasso; Gynecomastia and Male Chest Wall Contouring by Douglas Steinbrech and Eduardo Gonzalez; and “High-Definition Liposculpture in Men” by Hoyos and coworkers.6 For our aesthetic purposes, skin tightly wraps to reveal the broad muscles of a dominant upper body. A barrel-like rib cage is draped by large, thick, and flat Pectoralis Major, Trapezius, and Latissimus Dorsi muscles. The lateral edges of these muscles are defined with further pectoral prominence of its midportion and along the lateral border of the sternum. Broad shoulders extend further by apple-like deltoids. Anterior chest definition is completed with inferior Pectoralis fullness superior to a short horizontal flattened adherence near the fifth rib.
The aesthetic goals of the treatment of gynecomastia have traditionally been limited to near-total glandular resection, smooth contour transition to surrounding subcutaneous tissue, and removal of loose skin, leaving proper nipple-areolar complex (NAC) position and shape with as few scars as possible. Because of the pubescent onset of gynecomastia and the potential for gender ambiguity this focused approach may leave a sense of inadequate masculinity. With the advent of improved, reliable, and safe male-specific operations and liposculpture, selected patients should be offered more thorough body contouring surgery. Hence, in addition to the obliteration of the gynecomastia, contemporary management offers a tight-skinned upper torso that reflects underlying musculature enhanced by perimeter etching and lipoaugmentation that should extend surgically throughout the torso.7 Critically, the inframammary fold (IMF), which lies about one interspace below the inferior pectoral border, needs to be obliterated. Conversely, accentuating the IMF through an inferior chest transverse excision is disastrously feminizing. Although not always obvious standing erect, when leaning residual lax skin drapes over the constructed IMF, revealing a deflated but still sagging breast. The ideal nipple projects several millimeters and is surrounded by a flat, transversely oriented 1.5 to 2.0 cm X 2.5 to 3.0 cm oval areola, lying several centimeters medial and superior to the inferior/lateral junction of the Pectoralis Major muscle. Repositioning of a ptotic nipple relates to dynamic Pectoralis Major muscles rather than skeletal landmarks or absolute numbers or ratios. Large, rounded, and protruding areolas need reshaping.
Ignored by most plastic surgeons, but not by the body-conscious patient, are dynamic shape changes of the chest as the Pectoralis Major morphs from relaxation to full contraction, and with different positions of the arms and body. Demonstrating and photographing these subtle relationships are appreciated by the patient, aid in treatment planning, and thoroughly document outcomes. For example, Case 1 is a 49-year-old man with a BMI of 26, moderate enlargement, nipple ptosis, and moderate skin redundancy, grade IIb (Figs. 1 and 2). Descending deep and inferior to the NAC, relaxed Pectoralis muscles are visually inseparable from the gynecomastia (see Fig 1, top). The contracted Pectoralis major rises and bulges toward the clavicles isolating the periareolar rounded gynecomastia (see Fig 1, bottom). Raising the arms stretches, elevates, and flattens the Pectoralis muscle to isolate the breast mound visually and palpably (Fig 2, left). On leaning, the gland with excess skin that is loosely adherent to the Pectoralis muscle disturbingly droops (see Fig 2, left). Because the contracted Pectoralis muscle or raised arms leave no muscle fill deep and inferior to the areola, gynecomastia correction should be planned accordingly. For a thorough visual appraisal of results, comprehensive photographic documentation of gynecomastia and its treatment should include arms to the side, contracted Pectoralis muscle, extended arms, and diving position. Using VASERlipo (Solta Medical, Bothell, WA) and BodyTite (InMode, Irving, CA) (discussed later), total correction is documented in these various positions (Figs. 3 and 4).
*TECHNIQUES
*DISCUSSION
Since 2017, one or more combinations of the following nine procedures correct gynecomastia and further enhance masculinity:
1. Infra-areolar glandular excision
2. Barbed sutured areolarplasty
3. Inframammary fold disruption
4. UAL ablation and adipose evacuation of the chest
5. VASERlipo of the torso with muscular definition
6. Bipolar radiofrequency tissue tightening
7. Boomerang pattern excision, inferior pedicle areolaroplasty with/without J-torsoplasty
8. Lateral torso hockey stick with or without double incision mastectomy with pedicled or free graft areolaroplasty
9. Lipoaugmentation of the pectoralis and deltoid muscles
SUMMARY
We find healthy young men with minimal glandular tissue (grade I, IIa) respond incredibly well with no residual deformity through either transareolar direct excision and/or UAL. For patients grade IIb up to IIIa, VASERlipo is followed by BodyTite. If needed, glandular pull-through excision completes the correction with or without barbed sutured areolarplasty. More severe cases require excisional skin tightening, with a variety of patterns suitable for each patient depending on their deformity. What sets plastic surgeons apart is recognizing, predicting, and executing tissue reconstructive procedures assisted by new technology and innovative techniques leaving a proper sculptured result under moderate skin tension that heals rapidly with the fewest and thinnest scars possible rather than a one-size-fits-all approach.
