Keywords
Gynecomastia - Male - Breast - Mastectomy - Nipples
INTRODUCTION
Gynecomastia refers to the feminine breast development in men and is the most frequent
breast condition found among male patients. It can be caused by a variety of factors,
including mammary gland tissue hypertrophy, subcutaneous fat accumulation, hormone
imbalance, etc. [1].
Several treatment options are available for gynecomastia, including subcutaneous mastectomy,
ultrasound liposuction, and endoscopic mastectomy [2]. Satisfaction after gynecomastia reduction treatments depend upon the new breast
shape and size as well as the location of nipple-areola complex (NAC). While the postoperative
NAC location has been studied extensively, most of the available data had been collected
from female populations and cannot be generalized to male patients. While few studies
are available for male patients undergoing gynecomastia treatment, NAC have not been
sufficiently compared between preoperative and postoperative states.
In this study, we investigated NAC positions before and after gynecomastia treatment
in Korean patients and compared the postoperative NAC position to a control group
of Korean adults without gynecomastia.
METHODS
Participants
A retrospective case-control study was performed. The patient group consisted of 13
patients who underwent subcutaneous mastectomy and liposuction between January 2007
and September 2013. The majority of these patients had bilateral gynecomastia, with
a single patient having had unilateral gynecomastia. The control group was recruited
through a colleague, and comprised of 20 healthy Korean males with no current or past
history of gynecomastia, congenital thoracic malformations, altered thorax, or thoracic
operations. All of the operations in the case group were performed by a single surgeon.
Preoperative evaluation
Preoperative ultrasonography was performed in all patients to identify the main component
of gynecomastia. In most cases, either fat or glandular tissue accounted for the volume.
In each patient, the surgical option that best addressed the composition of gynecomastia
was offered: either subcutaneous mastectomy alone or subcutaneous mastectomy with
liposuction.
Anthropometry was obtained for breast height, weight, chest circumference, distance
from nipple center to sternal notch, distance from sternal notch to the xiphoid process,
distance from sternal notch to nipple, and distance from acromioclavicular joint to
nipple. Chest circumferences were measured at the nipple level. These measurements
were obtained twice for the patient group (before and after operation) and once for
the control group. At each of the measurement session, standard upright position photographs
were obtained. All of the measurements were obtained by a single researcher to eliminate
intra-observer variability.
Patient satisfaction levels were graded as follows: 1) high dissatisfaction; 2) low
dissatisfaction; 3) average; 4) low satisfaction; and 5) high satisfaction.
Comparisons between the groups were analyzed using SPSS ver. 6.1 (IBM, Somers, NY,
USA). Numerical values were expressed as mean±standard deviation. The sternal midline-to-nipple
distance was designated as SMN; sternal notch-to-nipple distance as SNN, and acromioclavicular
joint-to-nipple distance as ACN ([Fig. 1]). Differences were considered statistically significant for P<0.05 on regression
analysis.
Fig. 1 Anatomical landmarks
SN, sternal notch; N, nipple; ACJ, acromioclavicular joint; Sm, sternal midline.
Operation technique
Tissue contours were evaluated while patients were sitting up in a chair prior to
the operation. Excessively enlarged portions of the chest wall tissues marked along
the border, and contour lines were used to differentiate the amount of tissue to be
removed at various thoracic levels.
All patients received general anesthesia, and the breast tissue was accessed via a
semi-circular incision along the bottom half of the areolar. To minimize the risk
of NAC contracture, 1 cm thickness of breast tissue was left intact under the complex,
while dissection remained superficial under the inferior skin flap. Staircase irregularity
was avoided by using a dissection plane that extended from the skin flap to the inferior
border of the pectoralis fascia Symmetry was respected as much as possible during
the operation. In most patients, the mid-point between the lower part of the sixth
rib and the second rib was used as the reference point, and the abnormally enlarged
area to be incised was expanded or reduced. At this point, liposuction was used for
further adjustment of the breast contour to the posterior axillary line. The NAC was
secured to the underlying pectoralis fascia by one or two stitches. Drainage tubes
were placed prior to closing the skin layers.
Mild compressive dressing was applied across the chest wall to reduce the risk of
hematoma. Pressure to the area surrounding nipple and areola was minimized to prevent
necrosis of the complex and skin flap. Skin tapes were applied to the inframammary
folds for 2 weeks. Suction drainage was maintained until the daily output had decreased
below 10 mL. The stitches were removed 12 days after surgery.
RESULTS
In the patient group, 11 patients underwent subcutaneous mastectomy only, and the
remaining 2 patients underwent subcutaneous mastectomy and liposuction. The average
weight of excised breast tissue was 246 g. No postoperative complications (hematoma,
nipple necrosis, sensory deficit, asymmetry, under- or overcorrection) were noted.
Follow-up periods ranged from 6 to 19 months (mean, 9 months).
Mean ages were 19.8 years (range, 12 to 33 years) for the patient group and 25 years
(range, 20 to 28 years) for the control group. The mean height and weight were 172.1
cm and 73.3 kg for the patient group and 175.7 cm and 68.1 kg for the control group.
In the patient group, the mean SMN were 125.9 mm and 110.3 mm for before and after
operation measurements. The mean SNN were 214.7 mm and 188.2 mm, respectively. The
mean ACN were 209.0 mm and 187.8 mm. In the control group, the same mean distances
were 107.0 mm (SMN), 185.7 mm (SNN), and 214.0 mm (ACN) ([Tables 1], [2]). There was a statistical difference in the nipple location between the control
group and the patient group (P<0.05). The comparisons are summarized in [Tables 3] and [4].
Table 1.
Patient and control group data
|
Values
|
Patients
|
Controls
|
P-value
|
|
Age (yr)
|
19.8 ± 6.7
|
22.3 ± 1.2
|
0.254
|
|
Height (cm)
|
172.1 ± 4.9
|
175.7 ± 6.2
|
0.037
|
|
Weight (kg)
|
73.3 ± 16.0
|
68.1 ± 9.7
|
0.018
|
|
Body mass index (kg/m2)
|
24.8
|
22.0
|
0.002
|
Table 2.
Mean anatomic parameters of patient and control groups
|
Parameter
|
Preoperative
|
Postoperative
|
Controls
|
|
Values are presented as mean±standard deviation.
|
|
Age (yr)
|
19.8 ± 6.7
|
19.8 ± 6.7
|
22.3 ± 1.2
|
|
Height (cm)
|
172.1 ± 4.9
|
172.1 ± 4.9
|
175.7 ± 6.2
|
|
Weight (kg)
|
73.3 ± 16.0
|
73.3 ± 16.0
|
68.1 ± 9.7
|
|
Diameter of nipple (cm)
|
0.78 ± 0.2
|
0.7 ± 0.2
|
0.67 ± 0.2
|
|
Sternal midline to nipple (cm)
|
13.5 ± 2.1
|
12.1 ± 1.4
|
10.7 ± 1.2
|
|
Sternal notch to nipple (cm)
|
21.3 ± 3.4
|
16.8 ± 1.7
|
18.5 ± 1.4
|
|
Sternal notch to xyphoid process (cm)
|
20.9 ± 3.4
|
18.7 ± 4.4
|
22.4 ± 2.1
|
|
Acromioclavicular joint to nipple (cm)
|
21.6 ± 3.6
|
21 ± 3.8
|
19.4 ± 2.2
|
|
Circumference of thorax (cm)
|
105 ± 8.8
|
95.9 ± 7.8
|
88.4 ± 5.5
|
Table 3.
Correlation between various parameters
|
Parameter
|
Correlated parameter
|
P-value
|
|
Distance between nipples
|
Chest circumference
|
0.001
|
|
Sternal notch to nipple
|
Height
|
0.001
|
|
Sternal midline to nipple
|
Chest circumference
|
0.001
|
|
Distance between nipples
|
Sternal notch to nipple
|
0.001
|
Table 4.
Correlation between preoperative, postoperative and control groups
|
Parameter
|
Correlated Parameter
|
P-value
|
|
Distance between nipples
|
Chest circumference
|
0.001
|
|
Sternal notch to nipple
|
Height
|
0.001
|
|
Sternal midline to nipple
|
Chest circumference
|
0.001
|
|
Distance between nipples
|
Sternal notch to nipple
|
0.001
|
A regression analysis was performed. Linear regression was defined as y=a+bx; y is
a dependent variable representing the distance from the sternal notch to the nipple
and the distance between the middle line of the sternum and the nipple; x is an independent
variable representing height and chest circumference; a is the intercept; and b is
the slope or regression coefficient.
The correlation between the height and the distance from the sternal notch to the
nipple
A scatter diagram and line of correlation between height and distance from the sternal
notch to the nipple are presented graphically in [Fig. 2]. Here, h indicates height, and b, the distance from the sternal notch to the nipple.
Fig. 2 Correlation between SN-N, height
Correlation between the distance of the sternal notch to the nipples (b) (cm) and
height (cm): preoperative (Pre op), postoperative (Post op), and control groups. SN,
sternal notch; N, nipple.
Preoperative patient group: b=0.406h-48.675 (P=0.079)
Postoperative patient group: b=0.175h-13.40 (P=0.129)
Control group: b=0.122h-2.921 (P=0.011)
The correlation between chest circumference and the distance from the sternal midline
to the nipple
A scatter diagram and line of correlation between chest circumference and distance
from the sternal midline to the nipple are presented graphically in [Fig. 3]. Here, s indicates the average chest size, and a, the distance between the sternal
midline and the nipple.
Fig. 3 Corretlation between Sm-N, chest circumference
Correlation between the distance of the sternal midline to the nipples (a) (cm) and
chest circumference (cm): preoperative (Pre op), postoperative (Post op), and control
groups. Sm, sternal midline; N, nipple.
Preoperative patient group: a=0.213s-8.884 (P=0.001)
Postoperative patient group: a=0.125s+0.075 (P=0.026)
Control group: a=0.177s-5.021 (P=0.001).
The post incisional scars were minimal; most patients did not complain about the scar
itself. No contour irregularity was observed in postoperative chest wall. All of the
patients evaluated the shape and location of NAC to be satisfactory. The mean satisfaction
score was 4.3 ([Fig. 4]).
Fig. 4 A case of gynecomastia
A 14-year-old male with bilateral gynecomastia. (A) Preoperative photograph. (B) Appearance
at 17 months after conventional subcutaneous mastectomy.
DISCUSSION
Gynecomastia can occur due to hypertrophy of the mammary gland (gynecomastia), fat
accumulation (false gynecomastia), or complex proliferation. The condition should
be treated upon clear understanding of the underlying cause [3]. Subcutaneous mastectomy is the primary method of breast excision. Liposuction is
helpful for false gynecomastia, but is more helpful as a supplementary method of controlling
contour to subcutaneous mastectomy.
Cordova and Moschella [4] proposed a morphological classification of gynecomastia (grade I-IV) and established
a scale for choosing suitable operative techniques. Lanitis et al. [5] demonstated that any grade of gynecomastia can be corrected through circumaroelar
incision, which gives better cosmetic results than other methods. Kasielska and Antoszewski
[6] reported that subcutaneous mastectomy using a circumareolar incision without additional
liposuction provides a good aesthetic outcome in patients with mild gynecomastia.
All of our patients belong to a mild gynecomastia group (morphologic grades I and
II), and subcutaneous mastectomy was sufficient for obtaining good aesthetic results.
In most cases, factors that affect the outcomes of gynecomastia surgery include reduction
in breast protrusion, leveling of the nipple and areola, and new location for the
nipple. Beckenstein et al. [7] had calculated the mean distances between sternal notch and nipple, between the
middle line of sternum and nipple, and between the left and right nipples, and claimed
that these values were correlated with height. However, we did not find that height
correlated with any of the anthropometric data. Beer et al. [8] calculated a formula for the distance between middle line of sternum and nipple
to extrapolate the optimal location for the NAC. Shulman et al. [9] verified the statistical relation between patient height, chest circumference, the
height of nipples, and distance from sternal notch to each nipple. They observed a
statistical correlation between chest circumference and distance between the nipples.
This study also used the method as described by Beer et al. [8] and Shulman et al. [9], but given that the chest circumference of Koreans is smaller than that of westerners,
some variables had to be adjusted accordingly.
In female patients with breast hypertrophy, simply fixing the NAC to the surrounding
skin was not adequate. Over a long-term, the nipple was shown to descend unless fixed
to the underlying subcutaneous tissue, which highlights the need for an objective
evaluation of post-surgical nipple location in male patients. Among the 13 patients
in our study, the post-surgical nipple location was assessed using the same anatomical
reference points used for preoperative assessment. We found that the best-fit equation
between patient height and SNN distance to be b=0.406h-48.675 (P=0.079) before surgery
and b=0.175h-3.40 (P=0.129) after surgery. This compares to b=0.122h-2.921 (P=0.011)
in the control group. For the correlation between the chest circumference and the
distance between the mid-line of the sternum and the nipple, the best-fit equation
was a=0.213s-8.884 (P=0.001) before surgery and a=0.125s+0.075 (P=0.026) after surgery.
For the control group, the equation was a=0.177s-5.021 (P=0.001). Comparing the difference
in the location of the center of nipple, the slopes for the height-distance from the
sternal notch to the nipple and chest circumference-distance between the mid-line
of the sternum and the nipple were 0.406 and 0.213 preoperatively and 0.175 and 0.125
postoperatively, respectively. The slopes of the control group were 0.122 and 0.177,
respectively, showing that when the slope was compared in cases of conventional surgery,
the postoperative slope and the slope in the control group were statistically significantly
different. These findings indicate that preoperative nipple locations were more inferolateral
in gynecomastia patients when compared to controls, and the operations were associated
with bringing the nipple closer to normal values. However, the sample size of the
patient group was not large enough to estimate the degree of sagging relative to the
amount of breast tissue.
Nipple locations were compared between gynecomastia patients undergoing subcutaneous
mastectomy and control subjects. Nipple positions were considerably lower in patients
with gynecomastia than in control subjects. Subcutaneous mastectomy was associated
with mild elevations, but postoperative locations were still lower compared to controls.
Further efforts are needed to improve the location of postoperative NAC in patients
with gynecomastia.
