What is the criteria and procedure for gynecomastia surgery?

Gynecomastia Surgery: Criteria and Procedure

Gynecomastia surgery is indicated when persistent breast enlargement causes significant psychological distress or physical discomfort, and should be performed using the most appropriate surgical technique based on the severity of the condition and presence of skin redundancy. 1

Diagnostic Evaluation Before Surgery

Before considering surgical intervention, a proper diagnostic evaluation is essential:

• Clinical assessment:

  • Differentiate true gynecomastia (glandular tissue proliferation) from pseudogynecomastia (fatty tissue deposition) 2
  • Assess for bilateral vs. unilateral presentation (gynecomastia is bilateral in approximately 50% of patients) 2
  • Evaluate physical characteristics: soft, rubbery, or firm mobile mass directly under the nipple 2
  • Note any pain (gynecomastia is more likely to be painful than cancer, especially when present <6 months) 2

• Imaging (when clinical examination is indeterminate):

  • Ultrasound is often the initial imaging modality, especially in younger men 2
  • Mammography may be needed if ultrasound findings are suspicious or indeterminate 2
  • Digital breast tomosynthesis (DBT) can be considered as an alternative to mammography 2

• Laboratory tests to identify underlying causes:

  • Hormonal imbalances (estrogen/androgen ratio) 3
  • Liver, kidney, or endocrine disorders 3, 4
  • Medication effects 4

Indications for Surgical Treatment

Surgery is indicated when:

1. Persistent breast enlargement causes significant psychological distress or embarrassment 5
2. Physical discomfort is present 1
3. Diagnostic evaluation of suspected breast lesions is needed 5
4. Medical management of underlying causes has failed to resolve the condition 4
5. The condition has been stable for at least 6-12 months 3

Surgical Techniques

The choice of surgical technique depends on the severity of gynecomastia and presence of skin redundancy:

Mild to Moderate Gynecomastia

• Liposuction techniques:

  • Standard liposuction
  • Power-assisted liposuction
  • Ultrasound-assisted liposuction
  • Can be performed through minimal incisions 1

• Arthroscopic morcellation and endoscopic techniques:

  • Address fibrous component while minimizing scarring
  • Utilize liposuction incisions 1

• Direct excision:

  • Through periareolar incisions
  • Simple approach for fibrous tissue removal
  • Avoids need for additional instrumentation 1

Moderate to Severe Gynecomastia with Skin Redundancy

• Complete circumareolar approach with purse-string suture:
  • Ideal for moderate to severe ptotic glandular breast enlargements
  • Addresses skin redundancy and areolar enlargement
  • Creates good aesthetic contour with fewer complications 5

Severe Gynecomastia with Significant Skin Redundancy and Ptosis

• Breast amputation with free nipple grafting:
  • Most effective option for extreme cases
  • Addresses significant skin excess 1

Anesthesia Options

• Regional anesthesia options:

  • Thoracic segmental spinal anesthesia
  • Erector spinae plane block
  • Benefits include better neuroendocrine stress response regulation, reduced analgesic requirements, and decreased postoperative nausea and vomiting 6

• General anesthesia:

  • May be required for more extensive procedures

Postoperative Considerations

• Compression garments to reduce swelling and support healing
• Pain management typically requires minimal analgesics when regional anesthesia is used 6
• Follow-up to assess for complications such as hematoma, seroma, or scar revision needs
• Approximately 20% of patients may require scar revision (based on the 2/10 revision rate reported) 5

Common Pitfalls and Caveats

• Failure to identify underlying causes: Always investigate potential physiological or pathological factors before proceeding with surgery 3, 4
• Inappropriate technique selection: Matching the surgical approach to the severity of the condition is crucial for optimal outcomes 1
• Unrealistic expectations: Patients should be counseled about potential scarring and realistic aesthetic outcomes
• Inadequate skin resection: In cases with significant skin redundancy, failure to address excess skin can result in poor aesthetic outcomes 5, 1
• Delayed intervention: Early treatment is recommended to minimize emotional distress and physical discomfort 4