Gynecomastia & Inverted Nipples Flashcards
What is gynecosmastia
Development of breast tissue in men secondary to elevated estrogen:testosterone
3 peaks of occurence: neonatal (trasnplacental), pubertal (ratio), elderly (aromatase conversion testos->estro)
What are two cancers assocaited with gynecosmastia
- non melanoma skin cancer
- testicular cancer
- NOT breast cancer compared to controls Patients with Klinefelter have 60x risk of breast ca
What are causes of gynecosmastia - Acquired
Think of “MEN”
METABOLIC
- Organ failure (renal, liver)
- Alcoholism
- Starvation
ENDOCRINE
- Hypogonadism
- Thyroitoxicosis
- Pituary failure
NEOPLASTIC
- Adrenal
- Testicular, HCG-producing
- Bronchogenic Ca
- Pituitary
DRUGS
Some Men Can Develop A Rather Excessive Thoracic Diameter
Spironolactone
Marijuana
Cimetidine
Diazepam
Alcohol
Reserpine
Estrogen
Theophylline
Digoxin
What are causes of gynecosmastia - Congenital
PHYSIOLOGIC
- Neonatal
- Pubertal
- Senile
PATHOLOGIC
- Hypogonadal
- Androgen resistance
- defect in testosterone synthesis
- Klinefelter syndrome (47 XXY)
- Congenital anorchism
- Hyper-estrogenic
- Congenital Adrenal Hyperplasia
- hermaphrodism
How do you classify gynecosmastia
- By etiology
- congenital (physiologic, pathologic)
- acquired (metabolic, endocrine, neoplastic, miscellanous, drugs)
- By deformity (Simon)
- excess skin or and gland
- small, no excess skin
- moderate, no excess skin
- modertate, excess skin
- large, skin excess
- excess skin or and gland
What is the histology and natural progression of gynecomastia
- Florid - hypercellularity. Will regress or last 4mth
- Intermediate - florid + fibrous
- Fibrous - dense stromal fibrosis, absence of adipose tissue
What are principles of management of patient with gynecomastia
- r/o pathologic, malignant causes and find out reversible causes
- characterize the cosmetic deformity
What do you want to know on history and physical
HISTORY
- duration, pain, bleeding
- systemic disease
- medications
PHYSICAL
- body habitus
- excess skin/gland, unilat, bilat
- testicular exam
What investigations in the work up of gynecomastia
- U/S of breast/ testes for unusual mass
- karyotyping
- endocrine
- biopsy
Potential referral to urologist, geneticist, endocrinologist
What are your treatment options for gynecosmastia and algorithm for treatment
Non-operative
- Reverse etiology (if <1yr)
- Watch waiting (adolescents, neonates)
- Diet (removal of soy products)
- Phamacologic (testosterone, tamoxifen, danzanol)
Operative
- SAL
- UAL
- PAL
- subcut mastectomy
- mastectomy
Algorithm by type
Liposuction -> type 1-3
Direct excision (gland+/- skin)-> 2B-3
What are indications for operative intervention
- non-physiologic gynecosmastia >12m
- increased risk of breast cancer (klinefelters, BRCA)
- symptomatic
- failed medical management
Describe the operative technique
- Subcutnaeous mastectomy +/- lipo
- Mx with skin excision
- circumareolar or wise pattern with inferior pedicle
- inferior hemiareolar, transareolar
What are the complications of oepratie tx for gynecomastia
- Early: hematom, seroma, infection, loss of NAC
- Late: nipple retraction/inversion, contour deformity, poor scar
What are issues with inverted nipples and goals of management
- Functional - breast feeding
- Hygiene
- Aesthetics
Goals
- restore projection
- maintain lactiferous ducts and sensation
How do you classify inverted nipples
- Reducible and maintains projection
- Reducible but cannot maintain projection
- Irreducible
