In patients with low fat content, care was taken to remove all of the glandular tissue. Bodybuilders’ fat content is negligible compared with patients who have a high fat content where the surgeon may have to leave more of the glandular tissue. Sharp undermining was performed initially under direct vision to an area that extended to the area around the NAC. The remaining tissue was dissected bluntly when possible, while always staying within the confines of the outer border of the gland. On the deep layer, undermining tissues remained strictly above the pectoral fascia. Penetration of the fascia resulted in unnecessary hemorrhage and potential contour deformities. In addition, excessive bleeding was encountered more frequently with dissection on the far lateral aspect compared with the medial side of the gland. Meticulous hemostasis was achieved throughout with electrocautery. Care was taken to excise the entire gland as one entity, resulting in a single specimen. All glandular specimens were sent for pathologic analysis. This approach, which circumvents the need for piecemeal excisions, resulted in fewer complications and less operative time.
In 3% of the cases, a ¼-inch Penrose drain was placed through the surgical incision or the axilla for a total of 24 to 72 hours. Compression dressing was applied over the surgical site for 3 to 5 days. No antibiotics were prescribed postoperatively.
Postoperative instructions consisted of light activity with restricted range of motion of the shoulders for the first week. This is because of the attachment of the pectoral muscle to the proximal humerus. Movement of the pectoralis muscle often results in increased bleeding because of the excessive vascularity in bodybuilders. Motion is permitted in the elbow and wrist early in the postoperative period, as it is unrelated to the pectoralis muscle. Elastic compression dressing was applied over the chest for 5 days. Patients were instructed to keep the dressing intact and dry for that time, with minimal activities. Desk work is allowed after 3 to 5 days. More physical work was restricted for at least 1 to 2 weeks. Modified activity was resumed after 1-week follow-up with light, non–chest-related exercises for 2 to 3 weeks. Any exercise resulting in movement of the pectoralis muscles, including lifting, extension, or abduction of the shoulders, was discouraged. For example, patients were asked to wear button-up shirts to avoid arm lifting on the first week after surgery. A regular chest exercise regimen was resumed after 4 to 6 weeks.
Patients were followed up for a minimum of 12 months and up to 5 years. Satisfaction ratings were collected from all patients at a 1-year interval. Patients were contacted by phone or email over the remaining 3 to 4 years. Given the limited data in the literature regarding satisfaction rates in gynecomastia surgery, each patient was also asked to complete our Joint Commission on Accreditation of Healthcare Organizations patient satisfaction survey. (See Supplemental Digital Content 1, which shows an example of a patient satisfaction form provided for each patient at 1-year follow-up, http://links.lww.com/PRSGO/A240.) These surveys were collected over the past 13 years.
The specimens appear to have a unifying shape of a head, body, and tail (Fig. 10). The head is semicircular in shape and is located more medially toward the sternum. The majority of the glandular tissue consists of a body located immediately deep to the NAC. The tail appears to taper off of the body more laterally and toward the insertion of the pectoralis major muscle onto the humerus.
In all cases, the glandular tissue was inseparable from the NAC. This required direct sharp incision to complete the excision. Despite the aggressive resection of the gland at the NAC level, no cases of complete NAC necrosis were encountered. In 23 cases, which is 0.4% of the patients, we identified minor skin edge necrosis, which did not alter the aesthetic outcome. There were no instances of nipple necrosis or cases where skin excisions were necessary. Seromas occurred in 10% of patients. At the deep layer, the gland was separated from the pectoralis fascia by a soft areolar tissue in which undermining was achieved with manual blunt dissection. Undermining with a sharp instrument was performed in secondary or revision cases because of the dense adhesions.
Despite the varying degrees of tissue size or patient presentation, these findings have been consistent. Only 3 specimens contained a neoplastic growth, which did not distort the configuration of the gynecomastia tissue. In December of 2014, a young 32-year-old man was diagnosed with ductal carcinoma in situ that required bilateral mastectomies. Another patient in his early 60s was diagnosed with metastatic prostate cancer found in the gynecomastia specimen after having prostatectomy in the past. The metastatic breast cancer had a poor prognosis and was sent to an oncologist and was treated by estrogen analogue, such as diethylstilboestrol.
The female breast is a well-studied gland with common features of ducts, lobules, fat, and stromal tissue.12 Unlike the female breast, male glandular tissue contains no lobules.14 Gynecomastia is the benign enlargement of this glandular tissue. The histologic classification of gynecomastia relies on the degree of stromal and ductal proliferation.5 Transient gynecomastia presents as a florid pattern with an increase in budding ducts and cellular stroma. The type of gynecomastia that many surgeons encounter in the operating room has likely been present for more than a year and, therefore, is more fibrous in nature. Extensive stromal fibrosis with minimal ductal proliferation is common in these cases.
On imaging, subareolar glandular tissue can be seen and at times can be markedly asymmetric. On ultrasound, hypoechoic to hyperechoic tissue is seen extending from behind the nipple. Gynecomastia can be avascular or hypervascular on color Doppler imaging depending on the stage of development, with more vascular flow seen in chronic cases of gynecomastia.14
For the clinician who is surgically removing the gynecomastia issue, these gross anatomic findings are crucial as they can assist in guiding the surgeon with his/her complete removal of the specimen. As the surgeon proceeds medially toward the sternum, dissection should be performed with care to remove the head of the glandular tissue, which can occasionally extend medially to the pectoralis muscle edge. Laterally, the gland can even extend further beyond the anterior axillary fold.
Care must be taken to avoid bleeding from the lateral thoracic artery and thoracoacromial artery and medially from the intercostal artery. Bleeding can be brisk and persistent as patients may lose up to 500 or 600 cc. In this study, every attempt was made to limit the extent of the scar to the original areolar incision. Thus far, there were only 2 cases in which there was a need to extend the incision to control bleeding. If a case of uncontrolled hemorrhage is encountered, we recommend that an extension of the original incision is created, or in rare cases, there may be a need to create an incision laterally to facilitate direct vision. Ultimately, aesthetics should not compromise the safety of the patient in any scenario.
In secondary cases, the gland has already been partially excised and the anatomy has been altered. Instead of searching for the classis configuration of a head, body, and tail, the surgeon must search for the remnants of the glandular tissue. Remnant tissue could be found anywhere and scarring and adhesion are the rule, not the exception. Bleeding is more common, operative time is extended, and the rate for postoperative complications is increased. These include seromas, hematomas, and contour deformities. Penetration of the pectoral fascia can cause similar outcome in the immediate postoperative period.
In bodybuilders, the described classic configuration of the glandular tissue exists but there is minimal fatty cushioning between the gland and fascia. It is easier to injure and penetrate the pectoralis fascia. Therefore, hematomas and seromas are also more common in these patients.8 In the senior author’s (MB) experience, bodybuilders with a particularly large glandular tissue were found to have a triad of symptoms in many cases. These include pain, tenderness, and rarely discharge, or a combination of those symptoms. Intraoperatively, it seems that some may have also had an inflammatory component to the surrounding tissue around the gland. We speculate that this can explain the existence of increased adhesions in these cases. Subsequently, dissection becomes more tedious with increased chance for bleeding.
In conclusion, we present a large series of gynecomastia specimens with a unifying finding of a head, body, and tail. Realization of this anatomy can serve as a guide to gynecomastia surgeons to facilitate a more thorough exploration and subsequently a sufficient amount of the gland excision. Despite our experience with extensive direct excision of the gland, we recommend for the novice surgeon to be less aggressive with the excision at the NAC layer. As additional experience is gained, it is expected that the clinical judgment of the surgeon will increase, and a proper amount of tissue can be excised without increasing the chance for tissue necrosis or recurrence.
1. Johnson RE, Murad MH. Gynecomastia: pathophysiology, evaluation, and management. Mayo Clin Proc. 2009;84:1010–1015.
2. Niewoehner CB, Nuttal FQ. Gynecomastia in a hospitalized male population. Am J Med. 1984;77:633–638.
3. Braunstein GD. Clinical practice. Gynecomastia. N Engl J Med. 2007;357:1229–1237.
4. Wise GJ, Roorda AK, Kalter R. Male breast disease. J Am Coll Surg. 2005;200:255–269.
5. Bannayan GA, Hajdu SI. Gynecomastia: clinicopathologic study of 351 cases. Am J Clin Pathol. 1972;57:431–437.
6. Rohrich RJ, Ha RY, Kenkel JM, et al. Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction. Plast Reconstr Surg. 2003;111(2):909–923; discussion 924–925.
7. Courtiss EH. Gynecomastia: analysis of 159 patients and current recommendations for treatment. Plast Reconstr Surg. 1987;79:740–753.
8. Blau M, Hazani R. Correction of gynecomastia in body builders and patients with good physique. Plast Reconstr Surg. 2015;135:425–432.
9. Johnson RE, Kermott CA, Murad MH. Gynecomastia - evaluation and current treatment options. Ther Clin Risk Manag. 2011;7:145–148.
10. Netter FH. Atlas of Human Anatomy. 1995.8th ed. Summit, NJ: Ciba-Geigy Corporation.
11. Rohen JW, Yokochi C. Color Atlas of Anatomy. 1993.3rd ed. New York, NY: Igaku-Shoin Medical Publishers, Inc.
12. Agur AMR, Dalley AFI. Grant’s Atlas of Anatomy
. 2009.12th ed. Baltimore: Lippincott Williams & Wilkins.
13. Abrahams P. The Atlas of the Human Body. 2002.San Diego: Thunder Bay Press.
14. Iuanow E, Kettler M, Slanetz PJ. Spectrum of disease in the male breast. AJR Am J Roentgenol. 2011;196:W247–W259.
15. Babigian A, Silverman RT. Management of gynecomastia due to use of anabolic steroids in bodybuilders. Plast Reconstr Surg. 2001;107:240–242.
Supplemental Digital Content
Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.