Gynecomastia is defined as hyperplasia of breast tissue that occurs in male patients. This happens because of a hormonal imbalance between testosterone and estrogen, with the decrease of the former and the growth of the latter. In many cases, gynecomastia can resolve spontaneously, and there is no need for specific treatment, but if it persists, surgical treatment can be performed. Gynecomastia can be determined by numerous factors such as endocrinological ones, oncological ones, certain classes of drugs or chronic kidney and liver disease. Growth of estrogen levels can be attributed to estrogen (adrenocortical) secreting neoplasms or to the excessive transformation of testosterone into estrogen under the action of tissue aromatase. Anabolic steroids, calcium channel blockers, digitalis, spironolactone, ketoconazole and marijuana or alcohol consumption can also be involved in the appearance of gynecomastia.^1-4

Bilateral gynecomastia usually occurs during mid-puberty, afterwards the changes of appearance decrease proportionally with age, peaking again between the ages of 50 and 69 when at least one out of four men are affected.^1,3,5 Very rarely there is a problem of differential diagnosis between gynecomastia and breast cancer. There are few citations of unilateral localization of gynecomastia in medical literature. The clinical examination most often sets the diagnosis, the tumorous formations having a hard consistency and being often adherent to the surrounding tissue.^1,5

Case report

A 14-year-old patient, from the rural area, was referred by the family doctor to our unit, where he was admitted between 31.07.2017 and 02.08.2017. From his personal history, reported by both the patient and his parents, we came to know that breast hypertrophy began at the age of three or four (aproximately about ten years previously), having a progressive and slow increase in dimensions. Heredo-collateral history has not identified another family member suffering from this condition or other endocrinological disease that might have genetic determinism. The patient also had a very good general health status (supported by blood tests that had normal values ​​for his age – hemoleucogram, coagulogram, biochemistry, ionogram and glycemia), not having any other medical history of significant illnesses or past surgeries.

The clinical exam revealed an overweight adolescent (height 170 cm, weight 83 kg, BMI 28.78 Kg/sqm).⁶ The disposition of adipose tissue was gynoid (predominantly in hips and breasts). The skin showed no pathological changes, being normally coloured and hydrated, with the muscular and skeletal system being perfectly functional. The blood pressure at admission was 120/50 mmHg, and the heart rate was 54 beats/min. No anomalies were present in the respiratory, digestive and renal systems.

Prior to admission in our facility, the boy was examined by an endocrinologist. According to the consultation, the boy didn’t suffer from any endocrinological disease, his estrogen and prolactin levels being within the normal range. The patient did not use any medication on a regular basis, he was not a smoker, and did not consume drugs or alcohol, so we could conclude that he suffered from idiopathic pubertal gynecomastia.

The clinical examination of the patient confirmed the diagnosis of gigantic bilateral pubertal gynecomastia: breasts were greatly enlarged; in both breasts excess adipose tissue and hard glandular one could be felt on palpation; there were no detectable tumoral or tumor-like structures in the hypertrophic tissue and no palpable axillary lymphadenopathies; no changes were present in the aspect of the areolas and nipples, nor in the peri-areolar skin.

We opted for a reduction mammoplasty, adapted to the patient's needs, especially suited for the important breast hypertrophy. Under general anesthesia, we performed an "inverted T" reduction (according to the pre-operative drawing) (Figure 1), slightly modified, based on the superior vascular pedicle.

Figure 1. Pre-operative markings. Slight assymmetry: left breast larger and more lateraly situated compared to the right one

The breast is vascularized by perforators from the internal mammary artery, acromial-thoracic artery, lateral thoracic artery, and intercostal perforators. The innervation for the areolas is provided by the anterior and lateral cutaneous branches of the intercostal nerves three, four and five. The decision concerning vascular pedicle orientation is taken with the aim of achieving an aesthetic and functional result, maintaining at the same time a good vascularization and sensitivity in the areola-nipple complex, without causing injuries to this structure.^7,8 Bilateral incisions were performed according to the preoperative drawing, circularly tangent to the areola on the upper arch, continued with the inverted "T" at the lower pole, with the preservation of the bilateral areola-nipple complex (Figure 2).

Figure 2. During surgery: left breast, „inverted T” and „in block” excision of excess skin, fat and mammary tissues; right breast after excision

The fat and cutaneous excess was removed "in block” (as a whole) by dissecting it into anatomical planes using the electric scalpel. Hemostasis was carefully done by electrocauterization. No drains were used. We used absorbable monofilament, synthetic thread (3.0 PDO) for deep sutures and thinner one of the same type (PDO 4.0) for the intradermal suture. The operation was performed under general anesthesia (intubation) and the patient received antibiotic prophylaxis (ceftriaxone – two vials of 1 g). Immediately after surgery our patient received pain-killers and anti-inflammatory drugs to minimize the pain and discomfort created by the intervention.

The patient was operated on the day of admission, and was discharged two days after the intervention. Daily dressings were performed both on the first post-operative day and on the day of discharge, the bleeding being extremely low and the surgical wound lacking pathological secretions, with minimal inflammatory signs. On the first post-operative day, slight ischemia was observed at the lower pole of the right areola, which immediately resolved spontaneously. The patient wore a compressive garment (vest) continuously for three weeks (24h/24h) and then only at night for another three weeks (12h/24h). He returned to the bi-weekly dressings’ change for two weeks after surgery, when the intradermic sutures were removed. He then returned to regular check-ups at one month, three months and six months. The patient was advised to use a silicone gel for the prevention of abnormal scarring immediately after suture removal, which he had to use daily for six months. He was also advised to avoid straining physical activities during recovery. Although the patient followed our indications, a development of hypertrophic scarring was observed one month post-operatively. This type of abnormal healing was probably due to the fact that the patient belonged to the age group with increased prevalence of pathological scarring (10-20 years).⁹ He was given intralesional injections (one per month three months in a row) of a corticoid-based product, which effectively reduced the development of hypertrophic scars with satisfactory results and stopped the pathological evolution of the scars (Figure 3). Despite of the discomfort caused by this type of scarring, the patient and his parents are very pleased with the outcome, and both we and the parents could see a significant improvement in the patient’s self-esteem.

 Figure 3. Results at 5 months after surgery and intralesional injections with corticoids. Scars that are becoming less conspicuous.

Gynecomastia is a condition with serious negative implications from both psychological and psychosocial point of view, especially for a teenager. Our role was to restore the shape of the mammary gland corresponding to a male patient.

Our patient didn’t have any endocrinological comorbidities, thus his condition belongs to the group of idiopathic gynecomastia, which is the most common type of gynecomastia. He can also be included in the group of teenage boys, which represent 65% of all gynecomastia cases, thus the majority.^4,10

The patient was also overweight, with a gynoid distribution of adipose tissue. Other therapeutic options could have been the use of anti-estrogen medication, but the literature does not recommend this approach if the disorder is older than a year.¹¹ Radiotherapy may also have good results, either alone or in combination with other treatments, but optimal outcomes in cases of significant mammary hypertrophy are only obtained surgically.^11,12Another approach from a surgical point of view could have been liposuction, but it is used as a tool for grade I or IIA gynecomastia in the Simon classification, thus in those with excess adipose tissue but without excess skin. In IIb and III cases (including our patient), surgical excision of glandular and cutaneous fat excess is recommended, liposuction being only a possible addition of surgical technique.¹³

The particularity of the case: we used an "inverted T" surgical technique based on the upper pedicle in an attempt to preserve proper innervation and vascularization, obtaining at the same time an optimal aesthetic result.

The challenge in this case resulted from the gigantic bilateral breast volume and the attempt to adapt a generally described technique and personalize it to this patient, without damaging vascularization and innervation of the areole and breast tissue. At the same time, we tried obtaining the maximum aesthetic result that reduces the psychological impact of the pathology on the teenage boy. Medical literature cites multiple surgical techniques for such cases, the "inverted T" being referred to as a relatively common technique, but requiring extensive surgical experience and especially a very good clinical experience to know when to choose such a technique⁹ andhow to apply it. We considered this the optimal approach, as it was a case with excess skin, a lot of adipose and breast tissue. There are advantages and disadvantages of this technique, no method being superior to another in terms of results.¹² This one allows us to have good intraoperative visibility, preserving the upper pole, to excise the cutaneous and fatty excess entirely, while maintaining adequate sensitivity at the areolar level. The possible occurrence of hypertrophic scars is one of the disadvantages of this method.

Surgical outcome: we achieved a good surgical result, reduced the breast projection and volume in the sagittal and transversal planes, preserved the areolas and limited the postoperative scars, so that the end result was not very visible and disturbing to the patient. Our role was to restore the anatomical shape of the region corresponding to a male breast.

Gynecomastia is still a challenging pathology, most of the cases not having an identifiable cause, as we mentioned earlier. In such situations, as the patient’s one, it is very important to get a detailed analysis of his history, a complete endocrinological consultation and a clinical examination to set the diagnosis. Gynecomastia in children can be reversible, but a patient who has a slow and continuous development over 10 years, as in our case, cannot fit into such a pattern. Thus, surgery remains the standard of treatment for this condition, as we have previously mentioned. For a good global result, it is necessary to personalize a technique that will suit the particularity of the case. This requires extensive pre-operative documentation and surgical and clinical experience with such cases. A great deal of attention should be paid to the postoperative care of these patients to prevent possible complications such as hematoma, seroma or hypertrophic scarring. It is therefore necessary that the postoperative protocol includes a good management of pain and inflammation, wearing elastic bandages or compressive vests for 6 weeks, limiting physical activity and making minimal movements with the arms in the first few days. Thereafter, the daily activities are gradually resumed, with sport activities starting after two months. We also advise immediate and long-term post-operative check-ups, removal of sutures at two weeks after surgery and monitoring at one, three, six and 12 months.

1. Beers MH, Porter RS, Manualul Merck de diagnostic și tratament, ediția a XVIII-a, Bucharest: ALL; 2009.

2. Ansstas G. Gynecomastia. 2018. Accessed on: 03.01.2018. Available at: https://emedicine.medscape.com/article/120858-overview

3. Ferraro GA, De Francesco F, Romano T, et al. Clinical and surgical management of unilateral prepubertal gynecomastia. Int J Surg Case Rep 2014;5:1158-61. [Crossref]

4. Janis JE. Essentials of plastic surgery, Second Edition, USA, St. Louis, Missouri/ Boca Raton, Florida: Quality Medical Publishing & CRC Press; 2014. [Crossref]

5. Mayo Clinic Staff. Enlarged breasts in men (gynecomastia). 2018. Accessed on: 03.01.2018. Available at: https://www.mayoclinic.org/diseases-conditions/gynecomastia/symptoms-causes/syc-20351793

6. Centers for Disease and Control Prevention. About Adult BMI. 2017. Accessed on: 03.01.2018. Available at: https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html

7. Gabriel A. Breast anatomy. 2016. Accessed on: 03.01.2018. Available at: https://reference.medscape.com/article/1273133-overview#a2

8. Wong C, Vucovich M, Rohrich R. Mastopexy and reduction mammoplasty pedicles and skin resection patterns. Plast Reconstr Surg Glob Open 2014;2:e202. [Crossref]

9. Berman B. Keloid and hypertrophic scar. 2017.Accessed on: 03.01.2018. Available at: https://emedicine.medscape.com/article/1057599-overview#a6

10. Brown DL, Borschel GH, Levi B. Michigan manual of plastic surgery, 2nd Edition. Philadeplphia, USA: Lippincott Williams & Wilkins; 2014.

11. Braunstein GD, Anawalt BD. Patient education: Gynecomastia (breast enlargement in men) (Beyond the Basics). In: UpToDate, Post, TW (Ed), Waltham, MA: UpToDate; 2014.

12. Johnson RE, Kermott CA, Hassan Murad M. Gynecomastia – evaluation and current treatment options. Ther Clin Risk Manag 2011;7:145-48. [Crossref]

13. Murali B, Vijayaraghavan S, Kishore P, et al. Cross-chest liposuction in gynecomastia, Indian J Plast Surg. 2011;44:81-86. [Crossref]