Case: Gynecomastia

Authors: Christian Kaare Paaskesen med. student, Hasan Gökcer Tekin, MD, Mia Demant, MD, Magnus Balslev Avnstorp, MD and Mia Steffensen, MD

Patient history

A man in his 50s was referred to our tertiary care unit due to bilateral breast hypertrophy. Prior to referral, secondary causes for gynecomastia were ruled out. He was evaluated and tested for metabolic, endocrine and drug-related disorders. He had symptoms of severe psychosocial discomfort, pain and tenderness related to his breast hypertrophy. His body mass index was 28 and a pinch test determined his breast hypertrophy as mainly glandular, with little fatty tissue. The evaluation of the patient was a minimal-moderate idiopathic gynecomastia with grade 1 ptosis of the right breast, and no ptosis of the left side. His skin elasticity was poor influenced by his age.Preoperative photos. Frontal and lateral view: Minimal-moderate gynecomastia. Asymmetrical breasts with grade 1 ptosis of the right breast, and no ptosis of the left breast.

Figure 1 | Preoperative photos. Frontal and lateral view: Minimal-moderate gynecomastia. Asymmetrical breasts with grade 1 ptosis of the right breast, and no ptosis of the left breast.

Presentation

• The patient presented minimal-moderate gynecomastia and poor skin elasticity
• A minimal-scarring technique was preferred (semicircular incision) and allowing skin-retraction over the next 6-9 months.
• The patient agreed on a second-stage procedure, if residual skin was present on follow-up

Procedure

• The patient underwent general anesthesia due to own preference
• Per-operative antibiotics were administered
• Kleins Solution was injected to reduce bleeding
• Semicircular incision was done in the lower half of the NAC
• The glandular extraction was done with Kocher clamps and Metzenbaum scissor by Webster’s technique (for details, read the chapter “Gynecomastia”)

Post-operative care

• A compression west was worn for 4 weeks continuously followed by 4 weeks at nighttime only.
• Heavy lifting was prohibited for 4-6 weeks
• The patient started walking as soon as possible to lower chances of blood clotting
• Pain medication was prescribed (paracetamol and tramadole). Aspirin was avoided.

Follow-up

Frontal and lateral view 3 months post-operative: Acceptable retraction of the skin and minimal skin-redundancy at 3 months postoperative. Further retraction of the skin is expected during the following 6 months. A minimal discrepancy at the upper breast border was noted. The patient was satisfied with the result, and had no interest in a second-stage procedure with skin resection methods.

Figure 2 | 3 months follow-up.