Gynaecomastia: Surgery could be one option

DR RANJEET S BARAL

n I am a 25-year-old male.

I have a problem of enlarged breasts. I have had this

problem since early

adolescence. I read

somewhere that this should disappear in a few years but it hasn’t happened. How can I get rid of this problem and get a flat chest?

— Anonymous

When a male person’s breasts take the shape of female breasts, the medical terminology is gynaecomastia which is a tender glandular enlargement of the male breast. It is not an uncommon physiological phenomenon in pubescent boys which usually spontaneously resolves within a year or two. It is also seen in androgen abuse among athletes, endocrine disorders, HIV treated patients, tumours, alcohol abuse, medication side effects and in elderly men. Therefore there are several laboratory tests required to come to a definitive diagnosis.

Gynaecomastia results from an imbalance in hormone levels in which levels of estrogen (female hormones) are increased relative to levels of androgens (male hormones). Gynaecomastia that occurs in normally-growing infant and pubertal boys that resolves on its own with time is known as physiologic gynaecomastia. Gynaecomastia caused by transient changes in hormone levels with growth usually disappears on its own within six months to two years. All individuals, whether male or female, possess both female hormones (estrogens) and male hormones (androgens). During puberty, levels of these hormones may fluctuate and rise at different levels, resulting in a temporary state in which estrogen concentration is relatively high.

Occasionally, gynaecomastia that develops in puberty persists beyond two years and is referred to as persistent pubertal gynaecomastia and this is the category where you fall in. I empathise with you as it is an emotionally traumatic issue but you are not alone because in recent survey as much as 60 per cent of male population are affected in one way or the other.

Of course there are other causes of gynaecomastica like malnutrition, liver cirrhosis, trauma, infection, testicular disorders, hyperthroidism, renal failure, cannabis use and as side effect of medications.

Surgical correction is reserved for patients with severe or persistent gynaecomastia. The other option would be endoscopic transaxillary liposuction and subcutaneous mastectomy in others. In your case it would be what we commonly see in some of the adolescence boys but since it has not spontaneously resolved for more than two years, you should seek a surgical option to permanently cure your condition, probably a plastic surgeon would be the better choice. Some of the standard procedure followed is as follows: pseudogynaecomastia, True gynaecomastia, combined pseudogynaecomastia (fatty tissue) and true gynaecomastia (breast tissue), severe gynaecomastia, periaureolar (incision around the nipple aureola complex) male breast reduction.

Classical breast reduction with superior or inferior flaps: this is for larger breasts (C, D) and leaves an inverted incision and periaurieolar incision. It is used very rarely.

Vertical incision breast reduction that results in a vertical subareolar scar (not horizontal scar) in large breasts: this is new and exciting

alternative.

Like with all treatments some of the common side effects are scarring, surgical site depression and reduced sensation over surgery area. Lastly, one must remember here is small percentage of recurrence even after surgery.

Again, there are medications used in certain painful cases like aromatase inhibitors and tamoxifen and male testosterone replacement for elderly people. However, as of now, the first two medications are not the front line therapy and surgery has come to stay as more compatible option.

—