Definition
Gynecomastia or is defined as an increase of volume of the mammary gland in men. It unilateral or bilateral hyperplasia. Generally it is idiopathic, meaning there is no reason, however , in some cases it can be related to abnormal hormone production , or related to taking certain medications this is why an assessment is needed. This review will aim to assaying different known hormones, to seek a testicular or pituitary tumor. A mammogram or ultrasound may be applied to analyze the density of the gland, or eliminate breast cancer in the older man, especially in case of unilateral form. If a reason is found, it will be treated. Indeed, when etiology is found, the treatment thereof may allow more or less to a complete regression of the gynecomastia. The breast enlargement in men particularly during adolescence is often resented and can cause many psychological problems.
This physical harm in adolescents at a time where male built his image as a man, may cause a decline on himself, or even a true complex. Furthermore, this Gynecomastia can be painful.
Anatomically and pathophysiological point of view, mammary gland are in normal cases, but it is infant type reduced to a simple breast bud. In some cases, this can develop mammary gland if the hormonal environment is conducive. If no cause has been found and if the patient is embarrassed, surgery may be given, provided that the patient is in good physical and mental shape called type of intervention a” Gynecomastia.”
What Is The Gynecomastia
This is a development of the mammary gland concentrated under the areola, usually bilateral and symmetrical, firm consistency and tender to palpation. The gynecomastia is different from the pure fat accumulation in the breast which is more frequent and correspond. This fat accumulation is concentrated under the areola, consistency is soft, insensitive, bilateral, symmetrical, but the two can be combined (adipogynecomastie). Adolescent gynecomastia may appear transient, related to hormonal imbalance in favor of Estrogen, disappearing in few months.
Breast cancers have a different presentation; it is rare form, affecting men usually after 40 years. These are unilateral lesions, hard, insensitive, associated with deformations or nipple retraction or a bloody discharge.
Male Breast Surgery Principle
The goal of surgery is to restore the normal anatomy with the principles of :
• Reduce breast size by direct surgical excision (subcutaneous mastectomy) for glandular forms, or for liposuction fat forms. If mixed form, the surgeon must combine both techniques.
• Reduce the excess of skin: generally, the decrease of glandular volume will allow skin retraction. This skin retraction is aided by liposuction but it is even that in a young man the skin quality is better (skin is firm, elastic, without stretch-marks). Some post- operative procedures as massage can help skin retraction.
In some cases, where the excess skin is too large, the surgeon may need to reduce it with scars on the skin. This skin reduction can be performed right the first time or secondarily.
Before The Operation
Investigations looking for a reason for the gynecomastia was mentioned earlier.
In obese men or overweight, a diet combined with physical exercises are introduced as a weight loss may regress or even get rid of gynecomastia (the pure fat accumulation) . Depending on the anatomical context, preferences and habits of the surgeon, and the wishes of the patient, a surgical strategy has been decided. Be predetermined and the surgical technique used and the location of scars (see section "Intervention ").
Usual preoperative assessment is carried out as required. The anesthetist will be seen in consultation before the procedure. Your surgeon and anesthetist should be informed about all the medicines you take. Indeed, some of them can interfere with the anesthesia or promote bleeding.
No aspirin should be taken within 10 days preceding the surgery & 3 days after surgery.
Stop smoking is recommended at least one month before and 6 weeks after the intervention (smoking can cause a delay or bad healing & others).
Type Of Anesthesia
Liposuction can be performed, depending on the amount of areas to be treated, either under local anesthesia, local anesthesia associated with intravenous sedation or general anesthesia. In some cases, regional anesthetics, such as an epidural.
The type of anesthesia will be chosen after a discussion between yourself, your surgeon and your anesthesiologist.
Hospital Stay
The procedure may be carried out on an out-patient basis, in an ambulatory facility, the patient leaves on the same day after a few hours under observation.
However, in some cases a short hospital stay can be preferable. The patient arrives in the morning sometimes and is discharged the following morning.
Procedure
Each surgeon adopts his own technique and it adapts to each case to obtain the best results. However, it may hold common basic principles.
In the typical procedure, an incision is made at the lower edge of the areola. From this incision the surgeon can remove the mammary gland ( subcutaneous mastectomy ) and fat too . Often in addition to this, the surgeon can perform liposuction on the outskirts of excess glandular to harmonize all.
In case of gynecomastia mostly fat the treatment is liposuction alone. The scars are very short and can be located at a distance of the gynecomastia, as in the regions under the breast or underarm .
When gynecomastia and excess skin are very important, the surgeon may need to do longer and therefore more visible scars. These scars can then be peri-areolar (around the areola), horizontal and extend on either side of the areola. In extreme cases the surgeon may need to graft the areola and nipple. Other types of scars are possible (vertical tail racket ...), they depend on each particular case.
During the intervention, a drain may be implemented depending on the technique used and the habits of the surgeon. This drain is used to drain the blood and lymphatic fluid residues that may accumulate at the surgical site.
At the end of the procedure a bandage "modeling" is achieved, often with an elastic bandage.
The response time is variable depending on the surgeon and the technique used, ranging from 30 minutes in case of isolated fat to 2 hours for complex cases requiring a major reduction with liposuction.
After The Surgery
The postoperative period can sometimes be painful the first few days. Analgesic treatment adapted to the intensity of the pain will be prescribed for a few days. For individual liposuction, the patient may feel pain locally type of "strong pains. Edema (swelling), bruises (blue) and interferes with elevating arms are frequently the first period .
The first dressing is removed after a few days. It is then replaced by a lighter dressing. Associated with garment to wear day and night for 1 month 24 hours. This helps skin retraction and promotes even healing.
The total time off work varies from 5 to 10 day. It is advisable to wait one to two months before resuming sports.
Scars
The scar is a sequel to the surgery required. The goal of the surgeon is to get a scar in the best possible quality. Scars evolve for one or two years after the intervention: they are first white and fine the first month, then turn pink or red and indurated until the fourth month. Then they gradually whiten. It is imperative to protect them from the sun during the first year.
The length and position of scars vary depending on the surgical technique (see section "Intervention"). Their quality depends on the surgical technique and patient-specific factors (age, skin type and quality ...).
The Result
The improvement is often clear and immediate. However, within two to three months is required to appreciate the final result. This is the time required for post -operative edema disappears and the excess skin retracts. Beyond this period, the tissues gradually gain greater flexibility. The decrease in breast volume provides physical comfort especially with clothing & psychological comfort too.
As regards the stability of the result, several cases are conceivable. For pure glandular forms glandular resection usually avoids recidivism. However, a significant weight gain may be accompanied by a further increase in breast volume and this is even more common for forms predominant fatty component.
Disappointing Result
Some imperfections may occur occasionally:
• Residual volume asymmetry: it may be due to a less resection on one side than the other, especially when there is already an asymmetric volume before surgery. In some cases, the asymmetry can be linked to a larger post -operative swelling of a side: in this case, the wear of garment with the massage action to correct the defect. When the asymmetry persists a year after surgery and if it is inconvenient, surgical correction may then be proposed.
• Asymmetry of height of areolas and nipples: after the surgery, even if the surgeon tried to correct it the asymmetry can persist.
In other instances, asymmetry may be related to tissue healing of the skin . Daily massages associated with proper hydration will help to correct the problem.
• An inverted areola: it can be linked to a glandular excision too focused behind the areola without peripheral harmonization. If it is bothersome, surgical remodeling could be proposed.
• An excess skin: after surgical correction of gynecomastia , excess skin is not uncommon and can take several months to retract. The skin retraction is related to the quality of the skin. Retouching may be desirable.
• Recessed areas or small nodules under the skin: they are related to liposuction which in some cases may increase the appearance of "cellulite". This is normal: daily massages associated with proper hydration will split these fibrous nodules and avoid adhesions depth (aspect of "cellulite ").
• On the question of the evolution of scars, it has been mentioned above.
The nipple sensitivity is generally not affected, or transiently during a few months. The insensitivity is exceptional. In contrast, when the surgeon is required to graft the nipple-areola complex, the latter may become permanently insensitive and may have impaired skin color (discoloration).
Complications
The treatment of gynecomastia involves the risks associated with any surgical procedure.
The postoperative period is generally simple, complications can occur, some general, like in any surgical procedure, other regional more specific.
We must distinguish the complications of anesthesia and those related to the surgery.
Regarding anesthesia during a preoperative consultation, the anesthetist will inform the patient about anesthetic risk. You should know that anesthesia in the body sometimes unpredictable and more or less easy to control reactions having recourse to a fully qualified anesthetist working in a surgical context that the risks are now statistically extremely low.
It must be borne in mind that the techniques, anesthetics and monitoring methods have made tremendous progress over the past thirty years, providing optimum safety, especially when the operation is performed outside the emergency in a healthy person.
Regarding the surgery choosing a qualified and competent plastic surgeon, trained in this type of surgery, you limit these risks, but do not remove them completely.
In practice, the majority of gynecomastia made in the rules passed without any problems. The postoperative cares are simple and patients are fully satisfied with their results. But sometimes complications can occur.
• Postoperative Bleeding and hematoma: bleeding can occur within hours after surgery. If it is important, it will result in swelling and painful tension (hematoma) and will require an act of evacuation.
• Phlebitis and pulmonary embolism: early mobilization can minimize this risk.
• Seroma (accumulation of lymph fluid) at the area of mastectomy is sometimes observed. It may require one or more aspiration by a needle to evacuate it.
• Postoperative Infection: it can occur in the following operation and results in fever, sometimes higher than 39 ° C, the surgical area is then swollen and red and painful. Antibiotic treatment may be sufficient, but often a surgical drainage is required.
• Skin Necrosis: skin needs a good vascular supply (oxygen supply) to live. If the blood supply is insufficient or of poor quality (significant traction, hematoma, infection, smoking ...), skin necrosis can occur. It will be treated with care and appropriate dressings. Healing will be obtained but with some delay.
• Pneumothorax: very rare, it will benefit from a specific treatment.
• Abnormal scar: the surgeon did his best to make beautiful sutures , but healing is a random phenomenon and sometimes scars are not invisible as necessary . In the same person depending on the region of the body, healing can be different. Hypertrophic scars or keloids require long specific local treatments.
• Resistant swelling & fibrotic tissues accumulation can be improved by sessions of Manual Lymphatic Drainage MLD by a professional physiotherapist or LPG sessions.
These are the facts which we wish to bring to your attention, to complement what you were told during the consultation.
Our advice is for you to keep this document and to read it and think it over carefully after your consultation.
Once you have done this you will perhaps have further queries, or require additional information.
We are at your disposal should you wish to ask questions during your next consultation, or by telephone, or even on the day of the operation, when we will meet in any case, before the anesthesia.
IMPORTANT NOTE:To preserve the final result of the surgery, the patient should keep his weight stable because gaining weight will appear in the other non-operated areas then with more extra weight in the same operated areas may be smaller or differently, BE CAREFUL.
