Enlargement of the male breast, referred to as gynecomastia, is a condition resulting from proliferation of the glandular component of the breast. It is defined clinically by the presence of a rubbery or firm mass or tissue that extends concentrically from the nipples and is usually bilateral. Gynecomastia should be differentiated from pseudogynecomastia (lipomastia), which is characterized by fat deposition without glandular proliferation.
Etiologies are multiple and include hormonal imbalance, recreational drug use, particularly marijuana, methamphetamine and heroin, use of performance enhancing drugs, most notably anabolic steroids, and a myriad of medications including those used to treat ulcers (Cimetidine), epilepsy (Dilantin), Digitalis and other heart medications, those medications used to treat AIDS, a number of chemotherapeutic agents as well as several antianxiety and antidepressant medications. The etiology may be idiopathic, that is, of unknown origin, as well.
As is true for most patients, a thorough history and physical examination are critical to the diagnosis as are an array of laboratory tests and imaging studies.
Management has included benign neglect for pubertal gynecomastia, treatment of any underlying primary disorder or systemic illness, use of pharmacologic agents as well as an array of surgical approaches. Psychosocial factors inclusive of loss of self-esteem and overt embarrassment typically prompt surgical intervention. Operative procedures have included a multitude of techniques based upon the presence of glandular tissue, fatty tissue, or a combination thereof. These techniques include direct excision and those that provide for reduction through liposculpture. Direct excision techniques traditionally utilize a periareolar incision located at the juncture of the areola and adjacent skin though cases that require sizable reduction might entail a more substantive procedure utilizing an incision that both encircles the areola and traces the inframammary fold. Liposculpture is often a key element of most gynecomastia surgeries either as the principle, or sole, procedure or as a complement to the excision procedures delineated above. Liposculpture techniques utilized for this purpose include suction-assisted lipoplasty, ultrasonic-assisted lipoplasty or laser-assisted lipoplasty. The preference of the surgeon largely dictates which modality is utilized.
Breast Revision Surgery
Breast revision surgery encompasses a multitude of procedures that address those individuals who maintain issues consequent to a previous breast surgery. This surgery may be categorized as either aesthetic (cosmetic) or reconstructive in nature. Although the category of procedure may be distinct, the concerns and considerations relative to each are not dissimilar and, indeed, overlap.
Both aesthetic (cosmetic) and reconstructive procedures have been associated with issues consequent to the presence of a mammary prosthesis, or implant, or those that simply relate to breast aesthetics, or a combination thereof. These issues may be the result of poor communication, a lack of compliance or technical error. Regardless of the root cause, correction mandates an accurate history, physical examination and diagnosis with a well conceived treatment plan.
Implant-related issues may include capsular contracture, which is a term used to denote firmness, or hardening, of the breast, implant deflation or rupture, the use of devices which are too large, too small, or those which are malpositioned. It might also entail problems of deficient coverage with resultant rippling, palpability or poor aesthetics. Corrective measures most notably include capsulectomy, or capsule removal, the safe and efficacious removal of an implant or implant material, pocket modification via internal suture fixation and the need to re-position the implant to ameliorate the symptom complex of rippling, palpability and poor aesthetics referenced above. Issues that relate to overall breast aesthetics may include asymmetry, matters of breast shape or size and poorly healed, conspicuous incisions. Corrective measures require attention to detail and the satisfactory modification of each contributing factor.
In sum, the surgeon must have a grasp of breast aesthetics and those issues delineated above. They, too, must have the technical expertise and experience necessary to address these concerns and to remedy them.