Complications and Quality of Life following Gynecomastia Correction in Adolescents and Young Men.

BACKGROUND: Persistent adolescent gynecomastia negatively affects health-related quality of life. Surgery results in psychosocial improvements, but the effects of postoperative complications on health-related quality of life are unknown. The authors examined whether complications following adolescent gynecomastia surgery impact postoperative health-related quality of life. METHODS: Patients aged 12 to 21 years who underwent surgical correction of unilateral/bilateral gynecomastia between 2007 and 2019 were enrolled (n = 145). Relevant demographic and clinical data were obtained from medical records. Fifty-one patients completed the following surveys preoperatively, and at 6 months and 1, 3, 5, 7, 9, and 11 years postoperatively: 36-Item Short-Form Health Survey (Version 2), Rosenberg Self-Esteem Scale, and the 26-item Eating Attitudes Test. RESULTS: Within a median period of 8.6 months, 36 percent of breasts experienced at least one complication. The most common were residual tissue (12.6 percent), contour irregularities (9.2 percent), and hematomas (7.8 percent). Patients reported significant postoperative improvements in self-esteem and in seven health-related quality-of-life domains (Physical Functioning, Role-Physical, Bodily Pain, Vitality, Social Functioning, Role-Emotional, and Mental Health) at a median of 33.3 months. Postoperative survey scores did not vary by grade or procedure, or largely by body mass index category or complication status. However, patients aged younger than 17 years at surgery scored significantly higher than older patients in the Short-Form Health Survey Vitality and Mental Health domains postoperatively. CONCLUSIONS: Health-related quality-of-life improvements are achievable in adolescents through surgical correction of persistent gynecomastia. Postoperatively, patients largely experienced similar health-related quality-of-life gains irrespective of complication status, grade, surgical technique, or body mass index category. Minor postcorrection complications are but do not appear to limit postoperative health-related quality-of-life benefits.

Patients Decision-Making Characteristics Affects Gynecomastia Treatment Satisfaction: A Multicenter Study Using the BODY-Q Chest Module.

BACKGROUND: Patient satisfaction is the most critical outcome in gynecomastia treatment. However, patient satisfaction may be affected by the patient's decision-making trait, such as exhaustively searching for the best outcome or being content with an outcome that satisfies a preconceived requirement. OBJECTIVE: To assess whether patient's decision-making characteristic affect their satisfaction with gynecomastia treatment. METHODS: This was a cross-sectional study including patients treated for gynecomastia between January 2009 and December 2019 at two tertiary hospitals in Denmark. Alive patients were sent the BODY-Q: Chest module, the SF-36 questionnaire, and the Maximizer/Satisficer decision-making survey. Patients were classified as Maximizers if they scored more than 40 points on the Maximizer/Satisficer survey. Percentage score differences (PDs) in quality of life scales were calculated between Maximizers and Satisficers. RESULTS: In total, 192 gynecomastia patients were included in this study and classified as Maximizers (n = 152) or Satisficers (n = 40). Maximizers were younger and more had gynecomastia following abuse of anabolic steroids than Satisficers (p < 0.05). With respect to bodily satisfaction, Maximizers showed significantly worse satisfaction with nipples (PDs: - 12.98%), psychological function (PDs: - 13.68%) and social function (PDs: - 8.77%, p < 0.05). In addition, Maximizers had significantly worse emotional role functioning (- 11.03%), vitality (PDs: - 11.72%) and mental health (PDs: - 10.00%, p < 0.05). CONCLUSION: Patients exhibiting maximizing-type decision-making characteristics have worse satisfaction with gynecomastia treatment and poorer psychosocial health. This information may facilitate patient counseling and alignment of treatment expectations. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Causes and psychological impact of gynecomastia in boys and adolescents.

Not required for Clinical Vignette.

Vacuum-assisted minimally invasive surgery-An innovative method for the operative treatment of gynecomastia.

BACKGROUND: Gynecomastia is the most common benign enlargement of the mammary gland and adipose tissue in males. Because a feminine-looking chest contour can bring severe psychologic burden to patients, subcutaneous mastectomy has become the standard treatment for this condition. Conventional open surgery causes conspicuous scarring that may affect the appearance of the breast. We provide a novel surgical operative for the treatment of gynecomastia. METHOD: With approval from our institutional ethics committee and written informed consent, 22 patients with 33 abnormally hyperplastic breasts were enrolled at The First Affiliated Hospital with Nanjing Medical University between June 2016 and September 2018. Vacuum-assisted minimally invasive surgery was performed under general anesthesia. Patients were followed up with physical examination and ultrasonography. RESULT: Vacuum-assisted minimally invasive mastectomy was performed successfully in all cases, with no residual glands or adipose tissue observed on ultrasonography. The operation had a mean duration of 73.5 minutes per side, ranging from 40 to 102 minutes. An average of 320 specimens were excised from each side with mean blood loss of 34 mL. Of these 33 operative sides, 2 complications occurred, but satisfactory chest contour was attained eventually in all patients. All patients were satisfied with their cosmetic outcome, graded as excellent by 22 patients (100%). Redundant skin was observed in 1 patient at 1 month postoperatively, whose breast, defined as graded III, was the largest before operation. CONCLUSION: Vacuum-assisted, minimally invasive mastectomy is a feasible approach for the treatment of gynecomastia with acceptable complications.

Defining the Aesthetic Units of the Male Chest and How They Relate to Gynecomastia Based on 635 Patients.

Gynecomastia awareness and treatment have increased significantly. Treatment of gynecomastia is now one of the most popular procedures requested by men. There are many gynecomastia classification systems that have been described. The usefulness of these classifications in the diagnosis and treatment of modern gynecomastia is unknown and has fostered confusion among surgeons and patients. This article elucidates the topographic pattern consistently seen in gynecomastia patients and relates this to the diagnosis and treatment of gynecomastia. The proposed gynecomastia zone classification is a simple and objective method to clinically describe gynecomastia and direct appropriate treatment.

Evaluation of Glandular Liposculpture as a Single Treatment for Grades I and II Gynaecomastia.

BACKGROUND: Gynaecomastia is a benign enlargement of the male breast, of which the psychological burden on the patient can be considerable, with the increased risk of disorders such as depression, anxiety, and social phobia. Minimal scarring can be achieved by liposuction alone, though it is known to have a limited effect on the dense glandular and fibroconnective tissues. We know of few studies published on "liposuction alone", so we designed this study to evaluate the outcome of combining liposuction with glandular liposculpturing through two axillary incisions as a single treatment for the management of grades I and II gynaecomastia. METHODS: We made a retrospective analysis of 18 patients with grade I or II gynaecomastia who were operated on by combined liposuction and glandular liposculpturing using a fat disruptor cannula, without glandular excision, during the period 2014-2016. Patient satisfaction was assessed using the Breast Evaluation Questionnaire (BEQ), which is a 5-point Likert scale (1 = very dissatisfied; 2 = dissatisfied; 3 = neither; 4 = satisfied; 5 = very satisfied). The post-operative aesthetic appearance of the chest was evaluated by five independent observers on a scale from 1 to 5 (5 = considerable improvement). RESULTS: The patient mean (SD) overall satisfaction score was 4.7 (0.7), in which 92% of the responders were "satisfied" to "very satisfied". The mean (SD) BEQ for all questions answered increased from 2.1 (0.2) "dissatisfied" preoperatively to 4.1 (0.2) "satisfied" post-operatively. The observers' mean (SD) rate for the improvement in the shape of the front chest wall was 4.1 (0.7). No haematomas were recorded, one patient developed a wound infection, and two patients complained of remnants of tissue. The median (IQR) body mass index was 27.4 (26.7-29.4), 11 patients had gynaecomastia grade I, and 7 patients grade II. The median (IQR) volume of aspirated fat was 700 ml (650-800), operating time was 67 (65-75) minutes, 14 patients had general anaesthesia, and hospital charges were US$ 538 (481-594). CONCLUSIONS: Combined liposuction and liposculpturing using the fat disruptor cannula resulted in satisfied patients and acceptable outcomes according to the observers' ratings. It could be a useful alternative with an outcome that corresponds to that of more expensive methods. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Clinical Characteristics of Asymmetric Bilateral Gynecomastia: Suggestion of Desirable Surgical Method Based on a Single-Institution Experience.

BACKGROUND: Asymmetric bilateral gynecomastia (ABGM) is uncommon, and reports on its characteristics are rare. In the present study, we investigated the clinical characteristics and surgical treatment of ABGM. METHODS: We conducted a retrospective study of 1159 patients with gynecomastia who underwent subcutaneous mastectomy with liposuction at Damsoyu Hospital from January 2014 to February 2016. We then analyzed differences in the characteristics and operative results between two groups of patients: those with asymmetric and symmetric gynecomastia. Asymmetric gynecomastia was defined as gynecomastia meeting both of the following criteria: (1) upon physical examination, the size of the palpable mass below the nipple-areolar complex was twice as large as the smaller one, and (2) upon ultrasonography, the depth of the glandular tissue under the nipple-areolar complex was twice as large as the smaller one. RESULTS: Fifty-four patients were diagnosed with asymmetric gynecomastia. Among them, 51 had ABGM and three had unilateral gynecomastia. In the asymmetric group, more patients had a larger left than right breast (33 patients, 64.7%). The incidence of true-type (entirely glandular) breasts was significantly higher in the asymmetric group (84.3%) than in the symmetric group (p < 0.001). The asymmetry ratios in the asymmetric and symmetric groups were 1.87 ± 2.07 and 0.20 ± 0.16, respectively (p < 0.001). CONCLUSION: Bilateral mastectomy provided an acceptable and symmetric cosmetic outcome in patients with ABGM. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The burden of gynecomastia among men on antiretroviral therapy in Zomba, Malawi.

BACKGROUND: Many Africans who are on life-saving ART face challenges from a variety of toxicities. After the introduction of a standardized first-line efavirenz-containing ART regimen, reports of gynecomastia appeared in Malawian popular media, however data on the prevalence and risk factors of gynecomastia from Africa are lacking. METHODS: We conducted a cross-sectional study in males ≥18 years registered on ART at the HIV clinic in Zomba Central Hospital. Men who reported to have ever experienced breast or nipple enlargement received a standard questionnaire and underwent physical examination. Questions included perceptions and concerns about gynecomastia. Clinicians confirmed the presence and severity of gynecomastia. Routinely collected data on current and previous ART regimens, CD4 count, WHO clinical stage, anthropometric measurements and history of tuberculosis were extracted from the electronic database. RESULTS: We enrolled 1,027 men with median age 44 years (IQR: 38-52). The median ART duration was 57 months (IQR: 27-85); 46.7% were in WHO stage III/IV at ART initiation, 88.2% had exposure to efavirenz and 9% were overweight or obese. The prevalence of self-reported gynecomastia was 6.0% (62/1027) (95%-CI: 4.7-7.7%). Of men with gynecomastia 83.6% reported nipple enlargement and 98.4% enlarged breasts (85.5% bilateral). One-third said they had not reported gynecomastia to a health care worker. Over three-quarters mentioned that gynecomastia was an important or very important problem for them, while more than half were embarrassed by it. On examination gynecomastia was present in 90% (confirmed gynecomastia prevalence 5.5%; 95%-CI: 4.2-7.0%) and 51.8% had severity grade III or IV. History of tuberculosis treatment was independently associated with self-reported gynecomastia, adjusted OR 2.10 (95%-CI: 1.04-4.25). CONCLUSIONS: The burden of gynecomastia among men on ART in Malawi was higher than previously reported, and was associated with adverse psychological consequences, calling for increased awareness, a proactive diagnostic approach and diligent clinical management.

Surgical Masculinization of the Breast: Clinical Classification and Surgical Procedures.

Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The Characteristics and Short-Term Surgical Outcomes of Adolescent Gynecomastia.

BACKGROUND: Most adolescent gynecomastia is resolved spontaneously in 3 years. But, persistent gynecomastia could have a negative influence on psychoemotional development on adolescence. The purpose of this study is to report the characteristics of adolescent gynecomastia patients who received the surgeries, and discuss the short-term surgical outcomes. METHODS: Of the 1454 patients who underwent gynecomastia surgery at Damsoyu hospital from January 2014 to May 2016, 71 were adolescents. Subcutaneous mastectomy with liposuction was performed for adolescent patients who had gynecomastia for more than 3 years and showed psychosocial distress. Demographic and outcome variables were retrospectively analyzed. RESULTS: The mean age was 17.5 ± 0.77 years old. All gynecomastia cases were bilateral. Simon's grade IIa (35 patients, 49.3%) was the most common, and grade III was not observed. Fifty-one patients (71.8%) were classified as having a glandular-type breast component. Fourteen patients (19.7%) had complications, but only 3 cases (4.2%) required revision. Most of the patients (70 patients, 98.6%) were satisfied with the esthetic results, and the average 5-point Likert score was 4.85 ± 0.40. Recurrence was not observed. As the Simon's grade increased from I to IIA, a higher BMI, larger amounts of breast tissue, and longer operation times were observed. CONCLUSIONS: Gynecomastia that did not regress spontaneously was mostly the glandular type, so not only liposuction but also surgical removal of glandular tissue is necessary. Surgical treatment, selectively performed in patients who have had gynecomastia for 3 years, and have experienced psychosocial distress, could be an acceptable treatment for adolescent gynecomastia. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the table of contents or the online instructions to authors www.springer.com/00266 .

Gynecomastia Surgery-Impact on Life Quality: A Prospective Case-Control Study.

OBJECTIVE: To evaluate the results of surgical treatment of gynecomastia in the context of quality of life and satisfaction after the surgery. METHODS: Fifty male patients (mean age, 25.1 years [SD = 8 years]) who underwent surgery for gynecomastia and completed both (preoperative and postoperative) stages of the study were included in the analysis. The quality-of-life evaluation instrument was The Short Form-36 Health Survey Questionnaire. Additionally, we used a short questionnaire including 2 questions about patient satisfaction with gynecomastia surgery. RESULTS: The overall change in life satisfaction after gynecomastia surgery was 1 point on Likert scale (sign test, P < 0.0001). Participants after gynecomastia surgery scored significantly higher than before the procedure in all Short Form-36 Health Survey Questionnaire domains as well as in 2 main scales Psychical and Physical Health. The changes were especially visible for the domain social functioning and a scale Psychical Health (P < 0.0001). CONCLUSIONS: Gynecomastia surgery significantly improved men's life quality in all aspects and especially in the social aspect and psychical health. This indicates that adult men with gynecomastia are a specific group of patients, in which surgery may result in life quality improvement even over the average scores.

The effect of gynecomastia on body image perception and gender roles in adolescents.

The aim of our study was to evaluate the effect of gynecomastia on body image perception and gender roles in adolescents. Forty-seven adolescents with gynecomastia and 63 healthy adolescents were enrolled in the study. The Body Image Perception Scale (BIPS) and the Bem Gender Role Inventory (BGRI) were administered to the study group after the first evaluation and also one month later. The percentage of adolescents with a BIPS score lower than the median was higher in the study group than in the control group, although there was no significant difference. Additionally, considering the single item "my breasts," it was observed that body image perception disturbance existed mostly, if not entirely, in relation to this body part. After detailed information regarding gynecomastia was given during the first clinical session, the BIPS score improved at the one-month follow-up, emphasizing the importance of informing and educating patients regarding this condition. BGRI results showed that gender roles of patients with gynecomastia are not influenced in the feminine direction.

Gynecomastia and psychological functioning: A review of the literature.

Gynecomastia is defined as excess glandular growth of breast tissue in males. It is a noticeable physical difference that commonly affects males in adolescence and old age. While often transient in nature, gynecomastia persists indefinitely in 10% of cases. Much of the literature on gynecomastia has focused on etiology and management. Little research has been done regarding the impact of gynecomastia on one's mental health and quality of life; however, some studies have suggested various psychosocial and psychological consequences related to gynecomastia. These consequences include but are not limited to depression, anxiety, disordered eating, body dissatisfaction, and reduced self-esteem. The aims of this paper are to review the current gynecomastia literature, bring awareness to an understudied but troubled population, and discuss directions for future work, including offering extant models of body image to guide researchers.

A systematic review of literature on psychosocial aspects of gynecomastia in adolescents and young men.

Gynecomastia represents a serious psychosocial challenge for many adolescent and young adult males, but short of surgery, little attention has been given to this concern. The purpose of this paper is to report findings from a systematic review of the literature about psychosocial correlates, psychosocial interventions, and quality of research evidence about young males with gynecomastia. From an initial 233 published papers, 10 studies were identified and reviewed. Five were descriptive case studies and included no statistical analyses. The other studies were all conducted with small samples. Despite the limited evidence, findings suggest that many young men suffer emotional distress concerning gynecomastia, but this distress has received few interventions beyond surgical removal of the breast tissue. Future studies are needed to address this problem more fully so that more aggressive measures such as frequent assessments of the physical and psychosocial aspects of the condition can be done by healthcare professionals.

Gynecomastia: A systematic review.

BACKGROUND: Gynecomastia is a common medical problem presenting in nearly a third of the male population. Treatment for gynecomastia can be either pharmacological or surgical. Patients with gynecomastia often experience affected quality-of-life. The aim of this systematic review was to analyze the quality of evidence of the current literature in relation to different treatment modalities and Quality-of-Life in patients with gynecomastia. METHODS: A systematic search of the literature was performed in PubMed, Medline, Scopus, The Cochrane Library, and SveMed+ in accordance with the PRISMA statement. All searches were undertaken between September-November 2014. The PICOS (patients, intervention, comparator, outcomes, and study design) approach was used to specify inclusion criteria. Methodological quality was graded according to MINORS. Quality of evidence was rated according to GRADE. Data from the included studies were extracted based on study characteristics, participants specifics, type of intervention/treatment, and type of outcome measures into data extraction forms. RESULTS: A total of 134 abstracts were identified in the literature search. Seventeen studies met inclusion criteria, 14 concerning treatment and three concerning Quality-of-Life. All studies were non-randomised with a high risk of bias and very low quality of evidence according to GRADE. CONCLUSIONS: Several different surgical methods have been described with good results, minimal scars, and various levels of complications. Traditional surgical excision of glandular tissue combined with liposuction provides most consistent results and a low rate of complications. Pubertal gynecomastia may safely be managed by pharmacological anti-oestrogen treatment.

Fluoxymesterone-induced gynaecomastia in a patient with childhood aplastic anaemia.

Gynaecomastia is a benign condition characterised by enlargement of the male breast. Drug-induced gynaecomastia merits deep consideration as it may account for as many as 25% of all cases of gynaecomastia in adults. Although the mechanism is not fully clear, some mechanisms include oestrogen-like activities, stimulation of testicular production of oestrogens, inhibition of testosterone synthesis or blockade of androgen action. Anabolic steroids, in particular when used during the pubertal stage, may cause significant irreversible gynaecomastia. We report a case of 28-year-old Filipino man with persistent gynaecomastia from fluoxymesterone used for aplastic anaemia during his prepubertal stage. Hormonal work ups for gynaecomastia all turned out normal, thus isolating the drug as the cause. The patient was unable to undergo breast reconstruction surgery due to haematological contraindications, but eventually referred to psychiatry for counselling. This case will highlight the paradoxical effect of androgenic steroid used during childhood on male breast proliferation during puberty.

Boomerang pattern correction of gynecomastia.

BACKGROUND: After excess skin and fat are removed, a body-lift suture advances skin and suspends ptotic breasts, the mons pubis, and buttocks. For women, the lift includes sculpturing adiposity. While some excess fat may need removal, muscular men should receive a deliberate effort to achieve generalized tight skin closure to reveal superficial muscular bulk. For skin to be tightly bound to muscle, the excess needs to be removed both horizontally and vertically. To aesthetically accomplish that goal, a series of oblique elliptical excisions have been designed. METHODS: Twenty-four consecutive patients received boomerang pattern correction of gynecomastia. In the last 12 patients, a J torsoplasty extension replaced the transverse upper body lift. Indirect undermining and the opposing force of a simultaneous abdominoplasty obliterate the inframammary fold. To complete effacement of the entire torso in 11 patients, an abdominoplasty was extended by oblique excisions over bulging flanks. RESULTS: Satisfactory improvement was observed in all 24 boomerang cases. A disgruntled patient was displeased with distorted nipples after revision surgery. Scar maturation in the chest is lengthy, with scars taking years to flatten and fade. Complications were limited and no major revisions were needed. CONCLUSIONS: In selected patients, comprehensive body contouring surgery consists of a boomerang correction of gynecomastia. J torsoplasty with an abdominoplasty and oblique excisions of the flanks has proven to be a practical means to achieve aesthetic goals. Gender-specific body lift surgery that goes far beyond the treatment of gynecomastia best serves the muscular male patient after massive weight loss. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Psychosocial impact of adolescent gynecomastia: a prospective case-control study.

BACKGROUND: The purpose of this study was to determine the physical and psychosocial impact of gynecomastia and its severity on adolescents seeking treatment as compared with healthy adolescent males. METHODS: The following surveys were administered to adolescents with gynecomastia and healthy male controls, aged 12 to 21 years: Short Form-36 Version 2, the Rosenberg Self-Esteem Scale, and the Eating Attitudes Test-26. Demographic variables were compared between the two groups, and controls were administered a short chest symptoms survey. Linear regression models, unadjusted and adjusted for body mass index category, were fit to determine the effect of case status and graded severity of gynecomastia on survey score. RESULTS: Forty-seven patients with gynecomastia and 92 male control subjects participated in this study. There was no difference in mean age between the groups, although patients with gynecomastia had a significantly higher body mass index. Gynecomastia subjects had three lower Short Form-36 domain and Rosenberg Self-Esteem Scale scores independent of body mass index category as compared with controls, although there was no difference in Eating Attitudes Test-26 scores between the groups. Graded gynecomastia severity had no effect on survey scores, all independent of body mass index category. CONCLUSIONS: Gynecomastia has a significant negative impact on primarily the psychosocial well-being of affected adolescent patients, specifically in regard to social functioning, mental health, and self-esteem. Psychosocial impact was not affected by graded severity of disease. Health care providers and patients should be aware of the psychosocial impairments associated with gynecomastia and consider early treatment for adolescents suffering from this condition, regardless of severity.

The psychological burden of idiopathic adolescent gynecomastia.

BACKGROUND: For a population of adolescents, gynecomastia is a persistent problem. Occurring during a critical period in the formation of self-image and gender identity, this gender-incongruent process may disrupt normal psychological development. This study was designed to identify the prevalence of psychological disturbances in young male patients presenting with symptomatic gynecomastia to determine whether psychological examination should be included as a routine portion of this patient population's treatment. METHODS: From 2002 to 2009, patients aged between 10 and 18 presenting to our institution for idiopathic adolescent gynecomastia were recruited to participate in a retrospective cohort study. All patients underwent psychological interviews conducted by the same clinical psychologist (C.W.) and were examined using the following metrics: the Children's Depression Inventory, the Multidimensional Anxiety Scale for Children, and the Child Behavior Checklist. All patient scores were compared against population norms. RESULTS: Twenty-four patients between the ages of 12 and 18 were observed. Compared with the general population, measures of anxiety, depression, and social phobia were significantly elevated in patients with gynecomastia; 100 percent of patients with gynecomastia received a Diagnostic and Statistical Manual of Mental Disorders-IV diagnosis. CONCLUSIONS: Idiopathic adolescent gynecomastia is a psychological threat to normal self-esteem and sexual identity. Patients presenting with this condition likely suffer an adjustment disorder subsequent to this anatomic stressor. Surgeons should strongly consider referring their patients with gynecomastia for psychological evaluation and treatment as an adjunct to successful surgical management of this condition. Future studies examining the postoperative effects on psychological health both with and without psychological treatment will be of great interest to treating physicians. CLINICAL QUESTION/LEVEL OF EVIDENCE: : Risk, IV.