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Toronto Notes 2019 Breast Plastic Surgery PL37 Gynecomastia
Definition
• benignenlargementofthemalebreastduetoproliferationoftheglandulartissue
Clinical Classification
• gynecomastiacanbefurtherclassifiedinto: 1. idiopathic
2. physiologic
◆ neonatal: circulating maternal estrogens via placenta
◆ pubertal: relative excess of plasma estradiol versus testosterone
◆ elderly: decreased circulating testosterone, peripheral aromatization of testosterone to estrogen
3. pathologic
◆ endocrinopathies: excess estrogen, androgen deficiency, deficient production or action of
testosterone
◆ tumours
◆ chronic disease: liver cirrhosis, renal
◆ congenital/genetic: Klinefelter’s syndrome, androgen resistance
4. pharmacologic
– drugs that may interefere with estrogen-testosterone balance including:
◆ hormones (estrogens, gonadotropins, exogenous steroids) ◆ antiandrogens
– androgen receptor antagonists (steroidal and non-steroidal) – androgen synthesis inhibitors (5α-reductase inhibitors)
– antigonadotropins (GnRH analogs, estrogens)
◆ recreational drugs (marijuana, heroin, amphetamines)
◆ antihypertensives (spironolactone) 5. massive weight gain
◆ for physical exam, investigations, and medical management (see Endocrinology, E47)
Surgical Options
• surgeryistheacceptedmanagementforgynecomastia
• surgeryaddressesthethreecomponents:breast,fat,skin
• ofteninvolvesacombinationofliposuction(toremovethefattyportion)andsurgicalexcisionthrough
a small periareolar incision (to remove the glandular component)
• patientswithsignificantskinexcessmayrequireskinexcisionaswell
Breast Reconstruction
• reconstructionofthebreastaftercancerortraumatorecreatethebreastwhichissimilartothe contralateral breast
• reconstructioncanbeperformedimmediately(atthesametimeasmastectomy),ordelayed(asa separate surgery months or years after initial surgery)
• therearealloplasticandautogenousmethodsofreconstruction,eachwithitsadvantagesand disadvantages
Table 29. Timing of Immediate Reconstruction vs. Delayed Reconstruction
Immediate Reconstruction
Delayed Reconstruction
Advantages
Generally best aesthetic outcome; may possibly preserve nipple if oncologically advisable
Does not require creation of additional skin
Tissues are not damaged from scarring
More time for patients to discuss surgical options
Best for patients unable or unwilling to have immediate reconstruction
For patients who may be getting radiotherapy and undetermined post-surgery oncologic treatment
Provides option of contralateral surgery with reconstruction, if required (i.e. contralateral cancer)
Disadvantages
Skin viability assessment can be compromised Longer surgical time
Less time for patient to consider surgical options
Loss of skin, volume, lateral border or breast, and natural landmarks, including inframammary fold
Resection of irradiated/scarred skin and associated wound healing complications, including risk of reconstructive failure
Likely requires more stages for completion