GYNECOMASTIAIn the majority of boys with gynecomastia there are no medical abnormalities. The ideal patient seeks surgical correction at an early stage of enlargement, when the chest wall can be restored to normal masculine appearance.
Gynecomastia occurs in two different forms. The first appears in adolescent boys with the onset of puberty. It is characterized by development of a true breast gland just beneath the nipple areola. This may vary in size from grape size to a more impressive plum. In the majority of boys with gynecomastia there are no medical abnormalities. In very rare instances this finding may be associated with decreased testosterone and the prescence of feminizing hormones. In such rare patients other feminizing body changes are present distinguishing them from the more typical patients. Affected adolescents may withdraw from sports or other experiences which expose the chest. Many will compensate by lifting weights in an attempt to build up the pectoral muscles. Self-consciousness may lead to a diminished body image, which fosters painful feelings at a crucial time of male adolescent development.
There is no reason to delay surgical treatment of such boys. Advice to allow them to "outgrow"; the condition is misleading, as these glands will not disappear. The breast gland of puberty leads to maturing development of a fuller small breast in the young adult male. Surgical treatment of the abnormal gland development is performed through a peri-areola incision, which heals without conspicuous scarring. Patients wear a compression band for a few weeks postoperative to control reactive swelling.
The second form of gynecomastia is more common. These breast enlargements are primarily fatty. In most cases no breast gland is felt although one may be present in some patients. This form is labeled pseudo-gynecomastia, as breast tissue is absent. Men with this abnormality may develop moderate to full-size breasts, which can become pendulous in later years. This is an embarrassing deformity in any adult man. Causes vary from idiopathic (unknown) to associated liver disease, marijuana smoking, obesity or the administration of estrogen for treatment of prostate cancer.
Pseudo-gynecomastia is readily treated by liposuction of the fatty breasts. Best results are achieved in the earliest enlargements, as long term stretching of breast skin leads to sagging of male breasts just as in women. Once this occurs excess skin may not redrape well in spite of the use of compression garments. Significant contour improvement will still be accomplished but such patients may be left with some degree of skin wrinkling. This can be excised as a secondary procedure at the inframammary line but will leave an external scar line.