Gynaecomastia, or male breast enlargement, is a commonly occurring problem. The enlargement usually consists of increased fat, ductal and stromal tissue.

The causes of gynaecomastia can be considered physiological and pathological and understood as an imbalance between circulating androgens and estrogens. Physiological gynaecomastia occurs at birth, puberty and old age (greater than 65). Pathological gynaecomastia has a long list of causes including drugs (therapeutic and recreational), obesity, adrenal, pituitary and thyroid disease, liver and renal failure. A number of tumours may also cause gynaecomastia: testicular, adrenal, pituitary, lung and stomach. 1% of breast cancer occurs in males and unilateral gynaecomastia should alert the examining physician to this possibility.

Recreational drugs commonly implicated include alcohol, heroine, marijuana and anabolic steroids (recreational/abused). Therapeutic medications include (but are not limited to) estrogens, androgens, spironolactone, cimetidine, ranitidine, ketoconazole, amiodarone, digoxin, nifedapine, reserpine and verapamil and antiretroviral therapy2.

The diagnosis of gynaecomastia is based on a good history and clinical examination. History should explore the onset of symptoms, assess all medication and drugs, and enquire about endocrine and organ systems. A thorough physical examination of the breast itself, looking at symmetry, feeling for consistency and any masses. The testes, thyroid, liver and adrenals should be palpated for any abnormalities.

In a healthy adult with longstanding stable gynaecomastia, history and clinical examination is all that is required. If any abnormalities on examination are identified, targeted investigations should be ordered. These may include blood tests (U&E, TFT, LFT, estradiol, testosterone, DHEA, LH, FSH), radiological investigations (testicular ultrasound, mammogram, breast ultrasound, breast core biopsy, abdominal CT). Referral to a specialist physician is recommended for management of the underlying disorder, prior to referral to a plastic surgeon for correction of the gynaecomastia1.

Classification of gynaecomastia is simple based on Simon’s classification:
Grade 1: mild
Grade2a: moderate without skin excess
Grade 2b: moderate with skin excess
Grade 3: severe

Treatment of gynaecomastia may be conservative, especially in adolescent age group (66% of peripuberty males are affected) where most cases resolve at 1 year. Medication is of no value in reducing the size of established or growing male breast. In larger gynaecomastia, and especially long standing gynaecomastia, surgery is the mainstay of therapy. Liposuction is often the first choice as it is minimally scarring and may allow removal of glandular and fatty tissue and encourage skin contraction. In very large cases, and in very longstanding gynaecomastia, the breast may become fibrous and not amenable to liposuction. In these cases, surgical excision is the only option. Incisions can be placed below, through or around the areolar, and in cases of excess skin, larger skin excisions may require breast reduction patterns of excision. The goal is a flat breast with minimal scarring. After surgery, compression garments are worn for at least a month and drains may be left in place as seromas and haematomas are not uncommon3,4.

The diagnosis, assessment and management of gynaecomastia is satisfying for the physician and brings immense relief to the patient. The condition evokes anxiety relating to the underlying cause, concerns about cancer, and embarrassment of their physical appearance.

1. Thorne CH. Grabb and Smith’s Plastic Surgery. 7th edition. Philadelphia: Lippincott Williams and Wilkins; 2014.615–620
2. Zinn RJ, Serrurier C, Takuva S, Sanne I, Menezes CN. HIV-associated lipodystrophy in South Africa: The impact on the patient and the impact on the plastic surgeon. Journal of Plastic Reconstructive and Aesthetic Surgery. 2013;66:839-844
3. Tashkandi M, Al-Qattan M , Hassanain J et al.The Surgical Management of High-Grade Gynecomastia Plast Surg 2004;53:17–20
4. Rohrich R, Ha R, Kenkel J, Adams W. Classification and Management of Gynecomastia: Defining the Role of Ultrasound-Assisted Liposuction. Plastic and Reconstructive Surgery 2003;11(2):909-923

Richard ZinnAUTHOR | Mr Richard Zinn
Mr Zinn is a plastic, reconstructive and aesthetic surgeon specialising in a broad range of plastic surgery procedures. These include cosmetic and functional eyelid surgery, facial cosmetics, reconstructive and aesthetic breast surgery, skin cancer, hand surgery and microsurgery.
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