Gynaecomastia is a benign enlargement of the male breast gland that can occur particularly in young patients after the end of puberty.
In the post-pubertal age group, its frequency is up to 35%. Physiological gynaecomastia can occur after birth and usually disappears spontaneously. In older age (over 65), there is an increased incidence due to a decline in testosterone production and a shift in the oestrogen/testosterone ratio in favour of oestrogen.
There are various histological forms of gynaecomastia. The most common form consists of a combination of excess fatty and glandular tissue. The breast enlargement can be one-sided or two-sided.
The idiopathic form usually occurs during or after the end of puberty and often disappears by itself without requiring medical or surgical intervention.
The causes of gynaecomastia are varied. In addition to the most common idiopathic form, there are genetic causes (congenital gynaecomastia) and age-related factors associated with a decline in testosterone production. Certain medicines such as anabolic steroids, oestrogens, antibiotics, proton pump inhibitors, digitoxin, antidepressants, barbiturates and finasteride can also cause gynaecomastia.
Other possible causes are tissue changes such as testicular or adrenal tumours and paraneoplastic syndromes. Endocrine diseases such as secondary hypogonadism, Klinefelter syndrome, Cushing’s syndrome, congenital adrenal hyperplasia, hypothyroidism and hyperthyroidism can also be associated with gynaecomastia.
Metabolic causes such as chronic kidney failure, dialysis, liver disease and malnutrition can contribute to the development of gynaecomastia. Certain drugs such as alcohol, heroin, marijuana and amphetamines can also cause gynaecomastia.
If gynaecomastia is suspected, it is important to have a medical examination in order to determine the exact cause and, if necessary, initiate appropriate treatment.
Here is a summary list of the possible causes of gynaecomastia:
1. Idiopathic (unexplained cause)
2. Congenital (genetic) causes
3. Age (decline in testosterone production)
4. Medicines:
– Anabolic steroids
– Oestrogens
– Antibiotics
– Proton pump inhibitors
– Digitoxin
– Antidepressants
– Barbiturates
– Finasteride
5. Tissue neoplasms:
– Testicular tumour (Sertoli-Leydig cell tumour)
– Adrenal tumour
– Paraneoplastic syndromes
6. Endocrine diseases:
– Secondary hypogonadism
– Klinefelter syndrome
– Cushing’s syndrome
– Congenital adrenal hyperplasia
– Hypothyroidism
– Hyperthyroidism
7. Metabolic causes:
– Chronic kidney failure
– Dialysis
– Liver disease
– Malnutrition
8. Drugs:
– Alcohol
– Heroin
– Marijuana
– Amphetamines
Please note that this is only a general list and does not cover all possible causes. An accurate diagnosis requires a medical examination.
Grading of gynaecomastia according to Simon et al. (1973):
– Grade I: slightly visible breast enlargement without excess skin
– Grade IIa: moderate breast enlargement without excess skin
– Grade IIb: moderate breast enlargement with slight excess skin
– Grade III: female-shaped breast with inframammary fold, ptosis and marked excess skin
The aim of plastic surgical treatment is to restore a male appearance without conspicuous scarring. Those affected often suffer from severe psychological pressure, social withdrawal and psychological problems because of the feminised breast shape. Large epidemiological studies have shown that there is no link between gynaecomastia and male breast cancer, except in Klinefelter syndrome, where the risk is increased. Nevertheless, removed tissue should be examined histopathologically, as incidental findings of malignant and semi-malignant tumours have been described after gynaecomastia surgery.
The preoperative clinical examination includes a detailed history and the assessment of various findings such as the duration of symptoms, one-sided or two-sided findings, size, consistency and symmetry of the breast, the presence of breast nodules and lymph nodes, size, shape and sensitivity of the nipples, mastodynia and galactorrhoea. The duration of symptoms is particularly important, as the enlarged glandular tissue becomes fibrotic after a longer period and spontaneous regression can then no longer be expected. Further investigations include endocrine/hormonal tests and ultrasound examinations. If the finding is one-sided, mammography is also recommended. If findings are unclear, fine-needle aspiration can also be carried out for further diagnosis.
Surgical treatment of gynaecomastia comprises various operative techniques to restore the male breast shape. A frequently used method is subcutaneous mastectomy, in which the excess glandular tissue is removed through a small incision without tightening the skin. If there is pronounced excess skin, combined techniques with skin tightening and breast reduction procedures can be used. Liposuction is also frequently used, particularly for pseudogynaecomastia and forms with predominantly fatty/glandular excess without skin removal.
After the operation, patients wear a compression vest for 6–8 weeks to reduce common complications such as haematomas and seroma formation. Rarely, wound healing problems, epidermolysis, skin necrosis, asymmetries and loss of nipple sensation may occur.
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