Gynecomastia

Gynecomastia in the Adolescent and Young Adult: When Is Surgery Indicated?

Gynecomastia (palpable breast enlargement in adolescent boys) is extremely common, and may be found in up to 30-60% of boys. Enlargement typically begins about 1 year after onset of puberty. It is frequently bilateral, but may be asymmetric and develop sequentially. It commonly causes pain and tenderness and may cause nipple discharge. Most cases are idiopathic and do not require an extensive workup. It typically resolves gradually over a period of 6-12 months and does not require surgery.

When is surgery indicated? There appears to be some confusion, among physicians and other health care providers (including health insurance company representatives), regarding the answer to this question. Therefore, we have attempted to summarize current available peer-reviewed literature (published textbooks and journals) regarding this issue. We believe that this summarizes what most knowledgeable physicians would consider to be the “standard of care” treatment.

Textbooks:

1. “The indications for therapy are severe pain, tenderness, or embarrassment sufficient to interfere with the patient’s normal daily activities. Subcutaneous mastectomy through a periareolar incision is definitive treatment.” Don K. Nakayama, MD (a pediatric surgeon) wrote this in 2005 in Chapter 75 (“Breast Diseases in Children”) in Pediatric Surgery, 4th edition by Ashcraft, Holcomb, and Murphy.
2. “In the adolescent male with minimal or moderate gynecomastia it is appropriate in most cases to observe the condition for perhaps 1 year to monitor for spontaneous regression. Patients who express psychosocial difficulties should be treated. Treatment is removal of the breast tissue.” Wood and Bostwick (plastic surgeons) wrote this in 1998 in Chapter 32 (“Congenital Breast Deformities”) in Pediatric Plastic Surgery by Bentz.
3. “For adolescent gynecomastia, a trial of nonoperative treatment is the rule because nearly all cases resolve within 2 years.” Miranda and Mathes (plastic surgeons) wrote this in 2006 in Chapter 128 (“Congential Defects of the Skin, Connective Tissues, Muscles, Tendons, and Hands”) in Pediatric Surgery, 6th edition by Grosfeld, O’Neill, Coran, and Fonkalsrud.
4. “Breast diameter greater than 4 cm rarely undergoes spontaneous regression… In these cases a simple mastectomy is performed with all the breast tissue excised down to the pectoralis fascia, including the axillary tail. We perform the operation through a circumareolar incision that extends for 180 degrees around the lower areolar margin.” Kuhn and Besner (pediatric surgeons) wrote this in 2003 in Chapter 122 (“Breast Disorders”) in Surgical Directives: Pediatric Surgery by Mattei.

Journals:

1. Surgical removal is recommended: if a trial of medical therapy is unsuccessful, if no regression is present after 1 year observation; if the condition worsens; if psychosocial problems rise due to gynecomastia and in patients after completing pubertal period.” Abaci and Buyukgebiz (endocrinologists) wrote this in September 2007 in a review article in Pediatric Endocrinology Reviews (Volume 5, pages 489-499).
2. As mentioned, irreversible hyalinization and fibrosis may occur, and although the length of time is unclear, it is generally accepted that after 1 year pharmacological therapy is of little benefit. Plastic surgical removal is still the most effective overall therapy in treating gynecomastia. The usual method involves removal of the glandular tissue through a peri-areolar incision, with adjunctive liposuction if significant adiposity is present.” Mathur and Braunstein (endocrinologists) wrote this in 1997 in Hormone Research (Volume 48, pages 95-102).
3. After approximately a year of gynecomastia, the tissue becomes more quiescent, with increased fibrosis and hyalinization and loss of periductal inflammatory reaction... Nonsurgical treatment of gynecomastia that has entered the fibrotic stage is unlikely to be beneficial… The most uniformly effective therapy at any stage is surgical removal of the glandular tissue through a periareolar incision.” Braunstein (an internist) wrote this in 1993 in Hospital Practice (pages 37-46).

In summary, although there may be minor disagreements concerning exact numbers, it appears that the generally-accepted standard treatment for adolescents with idiopathic gynecomastia is a period of observation for roughly 1 year. If the disease persists for greater than 1 year (especially if it is greater than 4 cm in diameter), treatment of choice is surgery, with removal of the affected tissue.