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Indications for and results of surgical therapy for male gynecomastia
Indications for and Results of Surgical Therapy for Male Gynecomastia Mario Colombo-Benkmann, MD, PhD, Benedikt Buse, MD, Josef Stern, MD, Christian Herfarth, MD, Heidelberg, Germany
BACKGROUND: The objective of our study was to analyze factors determining diagnostic versus cosmetic indication and postoperative results in the treatment of gynecomastia. PATIENTS AND METHODS: Data from 100 patients and 141 breasts were analyzed retrospectively, and reevaluated by questionnaire (n ⴝ 81) and clinical examination (n ⴝ 33). Except for 2 patients, all underwent subcutaneous mastectomy through various incisions. RESULTS: Diagnostic surgery was exclusively performed in unilateral, nodular gynecomastia being preferentially of grade I. Higher grade, bilateral gynecomastia led mainly to cosmetic surgery. Minor complications (skin retraction, hypertrophic scars, hypesthesia, skin redundancy) occurred in 53% of patients and significantly more often in grade III or II gynecomastia. Each incision was preferentially associated with specific sequelae. However, 86% of patients were satisfied with surgical results. CONCLUSIONS: Laterality, consistency, grade, and age at onset of symptoms determine surgical indication. Despite the high number of sequelae due to preoperative grade and selected incision, most patients are satisfied with postoperative results. Am J Surg. 1999;178:60 – 63. © 1999 by Excerpta Medica, Inc.
B
reast resection in men is performed for restitution of a male chest contour (cosmetic indication) or histological clarification of suspicious breast lesions (diagnostic indication). Several studies have investigated different surgical techniques for treatment of gynecomastia and their outcome, but until now no study has scrutinized the determinants leading to specific indications for surgery. We aimed to evaluate patients’ characteristics that lead to a specific indication and surgical procedure. Moreover, we analyzed the parameters influencing complications and postoperative results.
From the Department of Surgery, University of Heidelberg, Heidelberg, Germany. Requests for reprints should be addressed to Mario ColomboBenkmann, MD, PhD, Department of Surgery, University of Mu¨nster, Waldeyerstrasse 1, 48149 Mu¨nster, Germany. Manuscript submitted November 2, 1998, and accepted in revised form April 19, 1999.
60
© 1999 by Excerpta Medica, Inc. All rights reserved.
PATIENTS AND METHODS In 100 patients, operated on from 1988 till 1996 for gynecomastia vera, a retrospective analysis was performed. Mean age at the time of surgery was 31 years (⫾16 [9 to 78]). Preoperatively, physical and endocrinological examinations, ultrasound of breasts and axillae, and mammography of the enlarged breasts were performed in all patients. All excised specimens were examined histologically. Patients referred for histological clarification of a breast mass were assigned to the diagnostic cohort (n ⫽ 30), while 70 patients underwent cosmetic surgery. Patients were graded according to Simon’s criteria,1 with grade I gynecomastia in 39, grade II in 49, and grade III in 12 patients. Unilateral gynecomastia was observed in 51, bilateral changes in 49 patients, 8 of whom had bilateral disease of different grades (I and II), being classified as grade II patients, since only grade II breasts were treated. After a mean follow-up of 57 months (⫾34 [10 to 122]), 61 patients with cosmetic and 20 patients with diagnostic surgery answered a questionnaire evaluating emotional state, postoperative course, weight changes, postoperative medication, recurrences, reoperations, and assessment of and satisfaction with cosmetic results. A physical follow-up examination was performed in 33 patients. Statistical analysis comprised the F-test, Student’s t test for unrelated cohorts, Fisher’s exact test, chi-square test, and Wilcoxon test.
RESULTS In addition to enlargement, breast pain was the most common symptom in 26 grade I (55%), 16 grade II (34%), and 5 grade III (11%) patients (P ⬎0.05). Patients with diagnostic surgery (n ⫽ 22; 73%) were more often affected (P ⬍0.001) than those with cosmetic surgery (n ⫽ 25; 36%). Mastitis occurred in 1 patient and galactorrhea in 3 patients with diagnostic surgery. Among 81 patients completing the questionnaire, 56 patients (69%) with cosmetic surgery reported severe preoperative emotional distress, but there was no association between emotional impairment and grade of gynecomastia. Ultrasonography and mammography showed benign changes in 96% and 97% of patients, respectively, while in the remainder lesions were suspicious for malignancy or fibroadenoma (n ⫽ 1). This was not confirmed by final histology. Obese patients (n ⫽ 18; body mass index ⱖ25 kg/m2) had more often grade III (n ⫽ 10, 83%; P ⬍0.001) than grade II (n ⫽ 5; 10%) or grade I (n ⫽ 3; 8%) gynecomastia, being bilateral in 78% (n ⫽ 14; P ⬍0.01). All obese patients had histological changes specific for gynecomastia. Unilateral nodular gynecomastia occurred more often (P ⬍0.001) in grade I (n ⫽ 31; 80%) than in grade II (n ⫽ 12; 25%) and grade III (n ⫽ 3; 25%) breasts, and diagnos0002-9610/99/$–see front matter PII S0002-9610(99)00108-7
SURGICAL THERAPY FOR MALE GYNECOMASTIA/COLOMBO-BENKMANN ET AL
Figure 1. Distribution of the various incisions among the different grades of gynecomastia. Bold lines signify incisions while the dotted area in the third drawing from above signifies resected skin. Percentages are calculated with reference to the number of breasts with a specific stage of gynecomastia.
tic surgery was performed solely in grade I (n ⫽ 28) and II (n ⫽ 2) patients with unilateral uninodular changes. Bilateral disease was predominant in grade II (n ⫽ 37; 75%) and III patients (n ⫽ 9; 75%; P ⬍0.001) and more often diffuse (grade II n ⫽ 24, P ⬍0.01; grade III n ⫽ 7, P ⬍0.05) than nodular. All grade III and 96% of grade II patients underwent cosmetic surgery, but only 28% of grade I patients (P ⬍0.001). At the time of surgery mean age was 44 years (⫾17 [15 to 8]) in the diagnostic cohort, and 27 years (⫾13 [9 to 75]) in patients with cosmetic surgery (P ⬍0.001). The diagnostic group was operated on 3 months (⫾1.8 [0.3 to 6]) after initial symptoms, cosmetic patients after a mean of 66 months (⫾60 [3 to 276]; P ⬍0.001). A total of 141 breasts were operated on, exclusively under general anesthesia. Subcutaneous mastectomy was performed in 98 patients, combined with liposuction in 1 of them. Owing to suspicious mammography, elevated tumor markers, and malignant histology in frozen sections, radical mastectomy was performed in 2 patients with diagnostic surgery; yet final paraffin histology revealed exclusively gynecomastia vera. Grade I and II breasts were predominately treated through an inferior periareolar incision (P ⬍0.001) (Figure 1). More extended incisions were chosen exclusively in grade II and III gynecomastia (Figure 1). Except for 2, all patients with diagnostic surgery had periareolar incisions. In each one, partial areolar necrosis after concentric circle operation, intraoperative injury of the areola, and secondary wound healing occurred. Postoperative hematoma developed in 15 patients and in 11% of operated breasts (Figure 1). Three hematomas required reoperation.
Two patients (1.4%) had unilateral seromas, being managed conservatively. Follow-up revealed more frequently recurrent enlargement in grade II and III (P ⬍0.05) patients (Table). Reoperations, performed in all affected breasts after a mean interval of 49 months (⫾26 [21 to 98]), revealed truly recurrent gynecomastia in 2 patients only. Retractions of the areola (Figure 2A) occurred in 29 (36%) patients, significantly more often (P ⬍0.05) in grade III than grade II and I breasts (Table I). Among approaches, the concentric circle operation was most often affected (P ⬍0.001) (Table). Hypertrophic scars (Figure 2B) developed with highest frequency in grade III breasts (P ⬍0.01), mainly after submammary incisions (P ⬍0.001; Table). Hypesthesia occurred exclusively after periareolar incisions (P ⬎0.05), 94% of which occurred in grade II breasts (P ⬍0.01). Redundant skin occurred more often (P ⬍0.05) in grade III than in grade II or I breasts, occurring mainly after concentric circle operations, with breasts (n ⫽ 7) from obese patients (n ⫽ 4) being affected more often (P ⬍0.05). No ectopic areola or chest wall irregularities were observed. Bilaterally extended periareolar incisions showed no complications. Seventy patients (86%) were satisfied, with an adequately reconstituted male chest contour. The remainder (n ⫽ 11) were less satisfied or dissatisfied, because of recurrent enlargement (n ⫽ 6) and/or minor complications (n ⫽ 5). Dissatisfaction occurred more often in grade II (n ⫽ 6) and III (n ⫽ 5) patients (P ⬍0.05). Preoperative emotional distress was assuaged in 46 (82%) out of 56 patients.
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SURGICAL THERAPY FOR MALE GYNECOMASTIA/COLOMBO-BENKMANN ET AL
TABLE Distribution of Complications among Grades and Incisions in Breasts Evaluated by Follow-up Incisions
Patients Breasts (n ⫽ 118)
Complications Recurrences
Retractions
Hyertrophy
Hypesthesia
Redundant skin
Grades
Semicircular Periareolar
I II III
69 31 63 4
I II III I II III I II III I II III I II III
Extended Semicircular Periareolar
Concentric Circle
Submammary
Total
4
4
4
4 2
8
6
81 31 67 20
5 [8%] 4 [100%] 9 [29%] 24 [38%] 3 [75%] 2 [7%] 6 [10%]
9 (8%)
44 (37%) 8 [100%] 16 (14%) 2 [25%]
16 [25%] 1 [25%] 2 [7%] 3 [5%]
6 [100%] 17 (14%)
8 (7%) 3 [38%]
Percentages in brackets are calculated with reference to the respective number of breasts of a specific grade operated on through a particular incision, while percentages in parentheses are calculated with reference to the total number of breasts.
COMMENTS The surgical treatment of gynecomastia has two objectives: reconstitution of a male chest contour and histological clarification of suspicious breast lesions. Our data demonstrate that age of patients, consistency, grade, and laterality of gynecomastia determine the indication for surgery. Unilateral, uninodular, low-grade disease in older men with breast pain intensify patients’ attention for breast enlargement and physicians’ awareness of the need for rapid histological clarification, indicated by a short interval between initial symptoms and surgery. In contrast, higher grade, bilateral gynecomastia in young patients causes the physician to await spontaneous regression despite emotional distress in these patients, indicated by a longer observation period, which in turn may allow breasts to grow further with consequentially higher grades and bilateral gynecomastia. Moreover, we found bilateral, highgrade gynecomastia preferentially in obese patients, which conforms with significantly higher body weight in patients with gynecomastia.2 Diagnostic imaging had a minor influence on surgical indication, since indication for surgery was principally based on clinical findings. Therefore, diagnostic imaging should be left to clinically selected cases. Subcutaneous mastectomy was the preferred procedure attaining the main objectives in most of our patients. In agreement with other authors,3 excision biopsy was favored to achieve definite histological clarification, since aspiration cytology in gynecomastia can hardly distinguish the proliferative phase of gynecomastia from breast cancer. The two mastectomies performed in patients without can62
cer in final histology underline that excision biopsy is the first step in evaluating suspicious breast lesions. Although large amounts of breast tissue can be removed through a small incision, limited exposure of the operative field is a decisive factor for the development of hematoma, hypesthesia, and retractions, since they occurred in a high frequency after periareolar incisions. Very small periareolar incisions and blind dissection cause hematomas in a high number of patients (62.5%),4 while in circumareolar approaches they are much rarer.5 Contrarily, the extent of resection, i.e., preoperative grade, had no influence on the frequency of hematoma, but sharp excision as such seems to be decisive, since in liposuction hemorrhage occurs only if this procedure is combined with sharp excision.6 In contrast, hypesthesia occurred almost exclusively in grade II gynecomastia, indicating that amount of resected tissue in combination with a small incision is significant for nerve injury. However there was no increased frequency of hematoma in patients experiencing hypesthesia or vice versa. Retractions result from overexcision of subcutaneous tissue with adherence of areola and periareolar skin to the thoracic wall. Thus, sufficient prepectoral fat and retroareolar tissue must be left. Since many retractions occurred after periareolar incisions, again, overresection of subcutaneous tissue in these patients is a result of insufficient exposure of the operative field. Thus, excision of large amounts of breast tissue should be carried out through an incision wide enough to prevent such complications. We recommend a periareolar incision with bilateral extensions, since it was not associated with any sequelae, although
THE AMERICAN JOURNAL OF SURGERY® VOLUME 178 JULY 1999
SURGICAL THERAPY FOR MALE GYNECOMASTIA/COLOMBO-BENKMANN ET AL
operation had the highest percentage of retractions and was the only procedure in which partial areolar necrosis occurred. Thus, in concentric circle operations, resections tend to be to excessive despite sufficient exposure. On the other hand, skin resection was insufficient, since skin was redundant postoperatively in three breasts treated by this procedure. This demonstrates the variability of postoperative skin shrinkage and the unreliability of preoperative skin measurements. In comparison with our results, the literature reports a lower incidence of sequelae after liposuction. Thus, liposuction should be given preference over conventional resection whenever feasible. However, if there is any doubt about the nature of a breast lesion, excision is mandatory,9 and can be satisfactorily achieved through a periareolar incision. Also, liposuction does not suffice if skin resection is necessary. Nevertheless, despite the high number of complications, the majority of our patients were satisfied with the attained reconstitution of their chest contour as reflected by the high ratio of emotionally relieved patients.
REFERENCES
Figure 2. A. Anterior oblique view of a left breast after a concentric circle operation. While the scar is inconspicuous, the areola is retracted. B. Anterior oblique view of a left breast after a semicircular inferior periareolar incision, with a clearly visible hypertrophic scar.
others7 reported of hypertrophic scars. Contrarily, submammary incisions, which led in 100% to hypertrophic visible scars, are not to be favored. Regarding skin resection, many procedures have been proposed. One study8 evaluating the concentric circle operation reported no sequelae besides hematoma in 8.5% of patients. We could not confirm these results, since this
1. Simon BE, Hoffman S, Kahn S. Classification and surgical correction for gynecomastia. Plast Reconstr Surg. 1973;51:48 –52. 2. Georgiadis E, Papandreou L, Evangelopoulou C. Incidence of gynecomastia in 954 young males and its relationship to somatometric parameters. Ann Hum Biol. 1994;21:579 –587. 3. Sandler B, Carman C, Perry RR. Cancer of the male breast. Am Surg. 1994;60:816 – 820. 4. Eade GG. The radial incision for gynecomastia excisions. Plast Reconstr Surg. 1974;54:495– 497. 5. Huang TT, Hidalgo JE, Lewis SR. A circumareolar approach in surgical management of gynecomastia. Plast Reconstr Surg. 1982;69: 35– 40. 6. Courtiss EH. Gynecomastia: analysis of 159 patients and current recommendations for treatment. Plast Reconstr Surg. 1987;79:740 – 750. 7. Deutinger M, Freilinger G. Die gyna¨komastie. Versuch einer klassifizierung und operative ergebnisse. Handchirurgie. 1986;18: 239 –241. 8. Schrudde J, Petrovici V, Steffens K. Chirurgische therapie der ausgepra¨gten gyna¨komastie. Chirurg. 1986;57:88 –91. 9. Samdal F, Kleppe G, Amland PF, Åbyholm F. Surgical treatment of gynecomastia. Scand J Plast Reconstr Hand Surg. 1994;28: 123–130.
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BACKGROUND: The objective of our study was to analyze factors determining diagnostic versus cosmetic indication and postoperative results in the treatment of gynecomastia. PATIENTS AND METHODS: Data from 100 patients and 141 breasts were analyzed retrospectively, and reevaluated by questionnaire (n ⴝ 81) and clinical examination (n ⴝ 33). Except for 2 patients, all underwent subcutaneous mastectomy through various incisions. RESULTS: Diagnostic surgery was exclusively performed in unilateral, nodular gynecomastia being preferentially of grade I. Higher grade, bilateral gynecomastia led mainly to cosmetic surgery. Minor complications (skin retraction, hypertrophic scars, hypesthesia, skin redundancy) occurred in 53% of patients and significantly more often in grade III or II gynecomastia. Each incision was preferentially associated with specific sequelae. However, 86% of patients were satisfied with surgical results. CONCLUSIONS: Laterality, consistency, grade, and age at onset of symptoms determine surgical indication. Despite the high number of sequelae due to preoperative grade and selected incision, most patients are satisfied with postoperative results. Am J Surg. 1999;178:60 – 63. © 1999 by Excerpta Medica, Inc.
B
reast resection in men is performed for restitution of a male chest contour (cosmetic indication) or histological clarification of suspicious breast lesions (diagnostic indication). Several studies have investigated different surgical techniques for treatment of gynecomastia and their outcome, but until now no study has scrutinized the determinants leading to specific indications for surgery. We aimed to evaluate patients’ characteristics that lead to a specific indication and surgical procedure. Moreover, we analyzed the parameters influencing complications and postoperative results.
From the Department of Surgery, University of Heidelberg, Heidelberg, Germany. Requests for reprints should be addressed to Mario ColomboBenkmann, MD, PhD, Department of Surgery, University of Mu¨nster, Waldeyerstrasse 1, 48149 Mu¨nster, Germany. Manuscript submitted November 2, 1998, and accepted in revised form April 19, 1999.
60
© 1999 by Excerpta Medica, Inc. All rights reserved.
PATIENTS AND METHODS In 100 patients, operated on from 1988 till 1996 for gynecomastia vera, a retrospective analysis was performed. Mean age at the time of surgery was 31 years (⫾16 [9 to 78]). Preoperatively, physical and endocrinological examinations, ultrasound of breasts and axillae, and mammography of the enlarged breasts were performed in all patients. All excised specimens were examined histologically. Patients referred for histological clarification of a breast mass were assigned to the diagnostic cohort (n ⫽ 30), while 70 patients underwent cosmetic surgery. Patients were graded according to Simon’s criteria,1 with grade I gynecomastia in 39, grade II in 49, and grade III in 12 patients. Unilateral gynecomastia was observed in 51, bilateral changes in 49 patients, 8 of whom had bilateral disease of different grades (I and II), being classified as grade II patients, since only grade II breasts were treated. After a mean follow-up of 57 months (⫾34 [10 to 122]), 61 patients with cosmetic and 20 patients with diagnostic surgery answered a questionnaire evaluating emotional state, postoperative course, weight changes, postoperative medication, recurrences, reoperations, and assessment of and satisfaction with cosmetic results. A physical follow-up examination was performed in 33 patients. Statistical analysis comprised the F-test, Student’s t test for unrelated cohorts, Fisher’s exact test, chi-square test, and Wilcoxon test.
RESULTS In addition to enlargement, breast pain was the most common symptom in 26 grade I (55%), 16 grade II (34%), and 5 grade III (11%) patients (P ⬎0.05). Patients with diagnostic surgery (n ⫽ 22; 73%) were more often affected (P ⬍0.001) than those with cosmetic surgery (n ⫽ 25; 36%). Mastitis occurred in 1 patient and galactorrhea in 3 patients with diagnostic surgery. Among 81 patients completing the questionnaire, 56 patients (69%) with cosmetic surgery reported severe preoperative emotional distress, but there was no association between emotional impairment and grade of gynecomastia. Ultrasonography and mammography showed benign changes in 96% and 97% of patients, respectively, while in the remainder lesions were suspicious for malignancy or fibroadenoma (n ⫽ 1). This was not confirmed by final histology. Obese patients (n ⫽ 18; body mass index ⱖ25 kg/m2) had more often grade III (n ⫽ 10, 83%; P ⬍0.001) than grade II (n ⫽ 5; 10%) or grade I (n ⫽ 3; 8%) gynecomastia, being bilateral in 78% (n ⫽ 14; P ⬍0.01). All obese patients had histological changes specific for gynecomastia. Unilateral nodular gynecomastia occurred more often (P ⬍0.001) in grade I (n ⫽ 31; 80%) than in grade II (n ⫽ 12; 25%) and grade III (n ⫽ 3; 25%) breasts, and diagnos0002-9610/99/$–see front matter PII S0002-9610(99)00108-7
SURGICAL THERAPY FOR MALE GYNECOMASTIA/COLOMBO-BENKMANN ET AL
Figure 1. Distribution of the various incisions among the different grades of gynecomastia. Bold lines signify incisions while the dotted area in the third drawing from above signifies resected skin. Percentages are calculated with reference to the number of breasts with a specific stage of gynecomastia.
tic surgery was performed solely in grade I (n ⫽ 28) and II (n ⫽ 2) patients with unilateral uninodular changes. Bilateral disease was predominant in grade II (n ⫽ 37; 75%) and III patients (n ⫽ 9; 75%; P ⬍0.001) and more often diffuse (grade II n ⫽ 24, P ⬍0.01; grade III n ⫽ 7, P ⬍0.05) than nodular. All grade III and 96% of grade II patients underwent cosmetic surgery, but only 28% of grade I patients (P ⬍0.001). At the time of surgery mean age was 44 years (⫾17 [15 to 8]) in the diagnostic cohort, and 27 years (⫾13 [9 to 75]) in patients with cosmetic surgery (P ⬍0.001). The diagnostic group was operated on 3 months (⫾1.8 [0.3 to 6]) after initial symptoms, cosmetic patients after a mean of 66 months (⫾60 [3 to 276]; P ⬍0.001). A total of 141 breasts were operated on, exclusively under general anesthesia. Subcutaneous mastectomy was performed in 98 patients, combined with liposuction in 1 of them. Owing to suspicious mammography, elevated tumor markers, and malignant histology in frozen sections, radical mastectomy was performed in 2 patients with diagnostic surgery; yet final paraffin histology revealed exclusively gynecomastia vera. Grade I and II breasts were predominately treated through an inferior periareolar incision (P ⬍0.001) (Figure 1). More extended incisions were chosen exclusively in grade II and III gynecomastia (Figure 1). Except for 2, all patients with diagnostic surgery had periareolar incisions. In each one, partial areolar necrosis after concentric circle operation, intraoperative injury of the areola, and secondary wound healing occurred. Postoperative hematoma developed in 15 patients and in 11% of operated breasts (Figure 1). Three hematomas required reoperation.
Two patients (1.4%) had unilateral seromas, being managed conservatively. Follow-up revealed more frequently recurrent enlargement in grade II and III (P ⬍0.05) patients (Table). Reoperations, performed in all affected breasts after a mean interval of 49 months (⫾26 [21 to 98]), revealed truly recurrent gynecomastia in 2 patients only. Retractions of the areola (Figure 2A) occurred in 29 (36%) patients, significantly more often (P ⬍0.05) in grade III than grade II and I breasts (Table I). Among approaches, the concentric circle operation was most often affected (P ⬍0.001) (Table). Hypertrophic scars (Figure 2B) developed with highest frequency in grade III breasts (P ⬍0.01), mainly after submammary incisions (P ⬍0.001; Table). Hypesthesia occurred exclusively after periareolar incisions (P ⬎0.05), 94% of which occurred in grade II breasts (P ⬍0.01). Redundant skin occurred more often (P ⬍0.05) in grade III than in grade II or I breasts, occurring mainly after concentric circle operations, with breasts (n ⫽ 7) from obese patients (n ⫽ 4) being affected more often (P ⬍0.05). No ectopic areola or chest wall irregularities were observed. Bilaterally extended periareolar incisions showed no complications. Seventy patients (86%) were satisfied, with an adequately reconstituted male chest contour. The remainder (n ⫽ 11) were less satisfied or dissatisfied, because of recurrent enlargement (n ⫽ 6) and/or minor complications (n ⫽ 5). Dissatisfaction occurred more often in grade II (n ⫽ 6) and III (n ⫽ 5) patients (P ⬍0.05). Preoperative emotional distress was assuaged in 46 (82%) out of 56 patients.
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SURGICAL THERAPY FOR MALE GYNECOMASTIA/COLOMBO-BENKMANN ET AL
TABLE Distribution of Complications among Grades and Incisions in Breasts Evaluated by Follow-up Incisions
Patients Breasts (n ⫽ 118)
Complications Recurrences
Retractions
Hyertrophy
Hypesthesia
Redundant skin
Grades
Semicircular Periareolar
I II III
69 31 63 4
I II III I II III I II III I II III I II III
Extended Semicircular Periareolar
Concentric Circle
Submammary
Total
4
4
4
4 2
8
6
81 31 67 20
5 [8%] 4 [100%] 9 [29%] 24 [38%] 3 [75%] 2 [7%] 6 [10%]
9 (8%)
44 (37%) 8 [100%] 16 (14%) 2 [25%]
16 [25%] 1 [25%] 2 [7%] 3 [5%]
6 [100%] 17 (14%)
8 (7%) 3 [38%]
Percentages in brackets are calculated with reference to the respective number of breasts of a specific grade operated on through a particular incision, while percentages in parentheses are calculated with reference to the total number of breasts.
COMMENTS The surgical treatment of gynecomastia has two objectives: reconstitution of a male chest contour and histological clarification of suspicious breast lesions. Our data demonstrate that age of patients, consistency, grade, and laterality of gynecomastia determine the indication for surgery. Unilateral, uninodular, low-grade disease in older men with breast pain intensify patients’ attention for breast enlargement and physicians’ awareness of the need for rapid histological clarification, indicated by a short interval between initial symptoms and surgery. In contrast, higher grade, bilateral gynecomastia in young patients causes the physician to await spontaneous regression despite emotional distress in these patients, indicated by a longer observation period, which in turn may allow breasts to grow further with consequentially higher grades and bilateral gynecomastia. Moreover, we found bilateral, highgrade gynecomastia preferentially in obese patients, which conforms with significantly higher body weight in patients with gynecomastia.2 Diagnostic imaging had a minor influence on surgical indication, since indication for surgery was principally based on clinical findings. Therefore, diagnostic imaging should be left to clinically selected cases. Subcutaneous mastectomy was the preferred procedure attaining the main objectives in most of our patients. In agreement with other authors,3 excision biopsy was favored to achieve definite histological clarification, since aspiration cytology in gynecomastia can hardly distinguish the proliferative phase of gynecomastia from breast cancer. The two mastectomies performed in patients without can62
cer in final histology underline that excision biopsy is the first step in evaluating suspicious breast lesions. Although large amounts of breast tissue can be removed through a small incision, limited exposure of the operative field is a decisive factor for the development of hematoma, hypesthesia, and retractions, since they occurred in a high frequency after periareolar incisions. Very small periareolar incisions and blind dissection cause hematomas in a high number of patients (62.5%),4 while in circumareolar approaches they are much rarer.5 Contrarily, the extent of resection, i.e., preoperative grade, had no influence on the frequency of hematoma, but sharp excision as such seems to be decisive, since in liposuction hemorrhage occurs only if this procedure is combined with sharp excision.6 In contrast, hypesthesia occurred almost exclusively in grade II gynecomastia, indicating that amount of resected tissue in combination with a small incision is significant for nerve injury. However there was no increased frequency of hematoma in patients experiencing hypesthesia or vice versa. Retractions result from overexcision of subcutaneous tissue with adherence of areola and periareolar skin to the thoracic wall. Thus, sufficient prepectoral fat and retroareolar tissue must be left. Since many retractions occurred after periareolar incisions, again, overresection of subcutaneous tissue in these patients is a result of insufficient exposure of the operative field. Thus, excision of large amounts of breast tissue should be carried out through an incision wide enough to prevent such complications. We recommend a periareolar incision with bilateral extensions, since it was not associated with any sequelae, although
THE AMERICAN JOURNAL OF SURGERY® VOLUME 178 JULY 1999
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operation had the highest percentage of retractions and was the only procedure in which partial areolar necrosis occurred. Thus, in concentric circle operations, resections tend to be to excessive despite sufficient exposure. On the other hand, skin resection was insufficient, since skin was redundant postoperatively in three breasts treated by this procedure. This demonstrates the variability of postoperative skin shrinkage and the unreliability of preoperative skin measurements. In comparison with our results, the literature reports a lower incidence of sequelae after liposuction. Thus, liposuction should be given preference over conventional resection whenever feasible. However, if there is any doubt about the nature of a breast lesion, excision is mandatory,9 and can be satisfactorily achieved through a periareolar incision. Also, liposuction does not suffice if skin resection is necessary. Nevertheless, despite the high number of complications, the majority of our patients were satisfied with the attained reconstitution of their chest contour as reflected by the high ratio of emotionally relieved patients.
REFERENCES
Figure 2. A. Anterior oblique view of a left breast after a concentric circle operation. While the scar is inconspicuous, the areola is retracted. B. Anterior oblique view of a left breast after a semicircular inferior periareolar incision, with a clearly visible hypertrophic scar.
others7 reported of hypertrophic scars. Contrarily, submammary incisions, which led in 100% to hypertrophic visible scars, are not to be favored. Regarding skin resection, many procedures have been proposed. One study8 evaluating the concentric circle operation reported no sequelae besides hematoma in 8.5% of patients. We could not confirm these results, since this
1. Simon BE, Hoffman S, Kahn S. Classification and surgical correction for gynecomastia. Plast Reconstr Surg. 1973;51:48 –52. 2. Georgiadis E, Papandreou L, Evangelopoulou C. Incidence of gynecomastia in 954 young males and its relationship to somatometric parameters. Ann Hum Biol. 1994;21:579 –587. 3. Sandler B, Carman C, Perry RR. Cancer of the male breast. Am Surg. 1994;60:816 – 820. 4. Eade GG. The radial incision for gynecomastia excisions. Plast Reconstr Surg. 1974;54:495– 497. 5. Huang TT, Hidalgo JE, Lewis SR. A circumareolar approach in surgical management of gynecomastia. Plast Reconstr Surg. 1982;69: 35– 40. 6. Courtiss EH. Gynecomastia: analysis of 159 patients and current recommendations for treatment. Plast Reconstr Surg. 1987;79:740 – 750. 7. Deutinger M, Freilinger G. Die gyna¨komastie. Versuch einer klassifizierung und operative ergebnisse. Handchirurgie. 1986;18: 239 –241. 8. Schrudde J, Petrovici V, Steffens K. Chirurgische therapie der ausgepra¨gten gyna¨komastie. Chirurg. 1986;57:88 –91. 9. Samdal F, Kleppe G, Amland PF, Åbyholm F. Surgical treatment of gynecomastia. Scand J Plast Reconstr Hand Surg. 1994;28: 123–130.
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