Gynecomastia is an enlargement of male breast tissue. It can be caused by an imbalance of estrogen and androgen hormones. Common causes include puberty, certain drugs, liver disease, and hypogonadism. Clinical presentation involves a tender lump under the nipple. Diagnosis is usually made clinically but blood tests and imaging may be used in some cases. Treatment depends on severity but includes waiting for spontaneous resolution, medication to balance hormones, liposuction to remove fat, and mastectomy to remove breast tissue. Surgery aims to remove excess tissue and achieve a natural male chest shape.

1. GYNAECOMASTIA
Dr Syed Aftub Uddin
MS ( Phase B) General Surgery
Chittagong Medical College Hospital.

4. GYNAECOMASTIA
• Gynecomastia is derived
from the Greek terms
gynec (feminine) and
mastos (breast).
• It is hypertrophy of male
breast more than usual
due to increase in ductal
(epithelial) and connective
tissue (stromal) elements
often attaining features of
female breast.

6. It is an imbalance between the stimulatory effects
of estrogens and inhibitory effects of androgens
on the growth of breast tissue.
Gynaecomastia

7. Physiological: normal in puberty.
Idiopathic gynecomastia – 25%
• Pubertal gynecomastia – 25%
• Drug-induced gynecomastia 25%
• Cirrhosis/malnutrition – 8%
• Primary hypogonadism – 8%
• Testicular tumors – 3%
• Secondary hypogonadism – 2%
• Hyperthyroidism – 1.5%
• Renal disease – 1%
• Dialysis associated gynecomastia
• Hyperprolactinemia
• Klinefelter’s syndrome
Gynaecomastia
Etiology

8. • Unilateral or bilateral.
• Symmetrical or asymmetrical
• A "disk" like tender lump is palpable, with smooth
surface.
• Often well-localised, small, firm or hard nodule under
the areola
• In the nonobese male, breast tissue measuring at least 2
cm in diameter
Clinical Presentation

10. Peak periods for physiological gynecomastia
There are three peak periods of physiological
gynecomastia.
1. In neonates—transplacental transfer of maternal
Estrogen (regresses completely by the end of 1st year)
2. Puberty—transient gynecomastia occur in up to
60% of boys (regresses after 2 years)
3. Late in life—progressive testicular dysfunction and
reduction of serum testosterone level and elevated
luteinizing hormone level (LH).

11. • Simon’s classification of gynaecomastia:
Group 1—Minor visible type without skin redundancy
Group 2 A—Moderate without skin redundancy
Group 2 B—Moderate with minor skin redundancy
Group 3—Gross pendulous breast
Gynaecomastia

12. Histological stages in Gynecomastia
Two histological stages are seen:
a. Proliferative stage/florid (early stage) less than a
year:
• Ductal proliferation and ductal hyperplasia
• Stroma is loose and edematous
• Clinically breast pain and tenderness
• Acinar development not seen in males
because it needs progesterone
b. Quiescent stage or inactive or asymptomatic
over 12 months (late stage):
• Reduction in proliferation
• Dilatation of ducts
• Fibrosis of stroma.

13. Gynaecomastia
Differential
Diagnosis

14. Gynaecomastia
Breast
carcinoma
Pseudogynecomastia
Neurofibroma /
Hematoma
Lipoma/
Lymphangioma
Differential
Diagnosis

15. Pseudogynecomastia
Enlargement of the breast because of fat
deposition rather than to glandular proliferation
that is seen in obese men.
There will be generalized obesity.
There will not be any history of breast pain or tenderness.

16. The investigations for asymptomatic group
must be kept to a minimum.
1. Liver Function Test
2. Renal Function Test
3. Thyroid Function Test .
If normal re-evaluation is done after 6 months.
Investigation

17. b. Men with recent breast enlargement with breast pain
and tenderness (symptomatic)do the following:
1. Serum total & free testosterone level
2. Luteinizing hormone
3. FSH
4. Estradiol
5. Prolactin
6. Human chorionic gonadotropin
7. Urinary 17 Ketosteroids for feminizing
adrenal tumors
8. Sex chromatin study—if Klinefelter’s
syndrome is suspected.
Investigation

18. c. Imaging studies should not be ordered,
unless indicated clinically or by blood results.
1. USG/mammogram of breast
2. FNAC/core biopsy breast
3. Open biopsy of the breast
4. Testicular ultrasound scan
5. CT scan of the adrenal
6. MRI scan of pituitary.
Investigation

19. 1. Spontaneous improvement is seen in 85% without
treatment
2. When Gynecomastia has been present for > 2 years,
medical therapy is unlikely to be effective
3. Medical therapy should be limited to only 6 months
4. Stop the drugs causing gynecomastia
5. Gynecomastia following chemotherapy will resolve
spontaneously
6. Treat the hyperthyroidism
7. Surgical removal of testicular/adrenal tumors
8. Hypogonadism is treated with testosterone
Principles of management of
Gynecomastia

20. Medications: In some cases, medications may be used to
treat gynecomastia. These may include
 selective estrogen receptor modulators (SERMs) like
tamoxifen or raloxifene, which work by blocking the
effects of estrogen on breast tissue.
 Aromatase inhibitors, such as anastrozole or letrozole,
can also be used to reduce estrogen production.
 Danazol to inhibit gonadotropin secretion
Medications are typically recommended for individuals with
mild gynecomastia or those in whom the condition is
expected to resolve on its own.
Medical Rx

21. Non-surgical procedures: Non-surgical treatment
options are available for individuals with mild to
moderate Gynecomastia who prefer to avoid
surgery.

22. Cryolipolysis: Also known as "coolsculpting," this
procedure freezes and destroys fat cells in the breast
area. It is generally effective for reducing mild fat deposits
but may not be suitable for glandular tissue.

24. Radiofrequency-assisted lipolysis:
This technique uses heat generated by radiofrequency
energy to break down and reduce fat in the breast area.
Similar to cryolipolysis, it is more effective for fat reduction
than glandular tissue.

25. Laser-assisted lipolysis: In this procedure, laser energy is
used to liquefy and remove excess fat. It is most effective
for fatty gynecomastia.

26. Indications of Surgery in Gynecomastia
1. Gynecomastia of longer duration (>1 year)
2. Continued growth
3. Psychological or cosmetic problem
4. Tenderness
5. Suspected malignancy
Gynaecomastia

27. Gynaecomastia
The choice of surgical technique depends on the
specific characteristics of the Gynecomastia and
the desired outcome.
Surgical Procedures:
• Liposuction
• Mastectomy,
• Subtotal mastectomy,
• Subcutaneous mastectomy,
• Reduction mammoplasty

28. Liposuction: Liposuction is a common surgical technique
used to treat gynecomastia when the enlargement is
primarily due to excess fatty tissue.
Liposuction alone is suitable for individuals with minimal
glandular tissue enlargement and predominantly fatty
gynecomastia.
Tumescent liposuction: The most common type of
liposuction.
Gynaecomastia

29. The surgeon then makes
small incisions into your
skin in pre-marked areas
and inserts a cannula (thin
tube) into your skin. The
cannula is connected to a
vacuum that suctions fats
and fluids from your body.
Meanwhile, your body fluid
will be replenished through
an intravenous line.

31. Mastectomy: Mastectomy is a more extensive surgical
procedure that involves the removal of glandular tissue
from the breasts. There are two common types of
mastectomy procedures:
Subcutaneous mastectomy using the donut mastopexy
technique : This technique involves making an incision
around the edge of the areola (the dark skin surrounding
the nipple) and removing the excess glandular tissue
through this incision. It is typically suitable for individuals
with mild to moderate gynecomastia.

33. Subcutaneous Mastectomy
It is removal of entire breast with retaining skin over the
breast,areola and nipple.
It is done through a submammary Gaillard Thomas
incision.
Adequate skin flap is raised with flap containing
subcutaneous fat which maintains the blood supply of
the flap and prevents flap necrosis. Entire breast is
removed using fine scissor dissection or cautery
dissection. After haemostasis drain is placed.

34. Circumareolar (Webster’s) incision.

35. Traditional Mastectomy: This procedure involves making
an incision along the lower edge of the areola and
sometimes extending vertically downwards. It allows for
more extensive removal of glandular tissue and is
suitable for individuals with severe gynecomastia or
significant skin excess.

36. In some cases, liposuction and mastectomy may be
combined to achieve optimal results.

37. In conclusion, endoscopic
subcutaneous mastectomy for
gynecomastia had satisfactory
esthetic results and no significant
postoperative complications. It is an
appropriate surgical approach for
gynecomastia, providing that skilled
operators and suitable endoscopic
technology are available.

38. Expectation after
Treatment
The results are visible
immediately after surgery but
it may take about three to six
months to achieve final
results.

39. Complications of surgery for
Gynecomastia
1. Nipple/areolar ischemia
2. Nipple distortion
3.Risk of saucer deformity
4. Hematoma
5. Seroma
6. Infection
7. Skin redundancy
8. Skin necrosis
9. Breast asymmetry.