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GYNAECOMASTIA

Overview

  • Benign proliferation of glandular tissue in the male breast

  • Pseudogynaecomastia - Excessive development of the male breast from subareolar fat deposition without glandular proliferation

  • Bilateral in up to 75%

  • Aetiology​

    • Idiopathic​

    • Physiologic

      • Neonatal​

      • Pubertal

      • Elderly

    • Pathologic​

      • Increased oestrogen or reduced testosterone

      • Chronic renal or liver disease

      • HIV

    • Pharmacologic

      • Antiandrogens​

      • Antibiotics - Isoniazid, ketoconazole, metronidazole

      • Antiulcer - Cimetidine, ranitidine, proton pump inhibitors

      • Chemotherapy - Alkylating agents, methotrexate, vinca alkaloids

      • Cardiovascular - Digoxin, verapamil, diltiazem, nifedipine, amiodarone, captopril, enalapril

      • Psychoactive - Diazepam, antipsychotics, antidepressants

      • Drugs of abuse - Marijuana, alcohol, amphetamines, heroin, methadone

  • Histologic classification​

    • Florid​ - Increased ducts and cellular stroma​​

    • Intermediate

    • Fibrous - Extensive stromal fibrosis, minimal duct proliferation

Overview

Patient assessment

  • History

    • Age of onset​

    • Duration

    • Symptoms

      • Pain​

      • Lumps

      • Galactorrhoea

    • Past medical history (see above)​

    • Drug history

      • Anticoagulants​

      • Risk factors for wound healing

      • Cause of gynaecomastia

    • Social history

      • Recreational drug use (see above)

      • Smoking history

Patient assessment

Classification

  • Simon classification

    • Grade I - Small enlargement without skin excess​

    • Grade IIa - Moderate enlargement without skin excess

    • Grade IIb - Moderate enlargement with skin excess

    • Grade III - Marked enlargement with excess skin, mimicking female breast ptosis

Classification

Management

  • Treatment or removal of cause

  • Surgical treatment:​​

    • Liposuction

    • Excision of excess glandular tissue and repositioning of nipple areola complex:

      • Principles in line with breast reduction

      • Incisions

        • Periareolar incision​

        • Transaxillary incision

    • Free nipple grafting

      • Allows en bloc resection of skin and breast tissue​

      • Risk of graft failure and consequent nipple loss

Management
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