Pediatric and Adolescent Gynecomastia

Diagnosis of gynecomastia is made by clinical assessment, which will involve a series of questions about the different aspects of development, especially around the time of puberty. It will include a physical examination of your chest and other areas of the body that may give information about the cause of the condition. Depending on your age and assessment findings, further investigations and assessment by a Pediatric Endocrinologist, may be recommended.

Age

One important consideration is the age at which the gynecomastia started. This, together with how long it has been present and whether it is continuing to develop over time will help to determine whether it is a feature of the patient’s normal development, which will resolve without medical intervention, whether it was a part of the patient’s normal development but that it hasn’t resolved as it should have, whether it is caused by a drug that can be stopped, or whether it is caused by a disease or hormonal imbalance that will need to be treated.

Tissue Type

Another feature that can divide gynecomastia into different types is the type of tissue that has developed in the breast. Under the skin, as well as the blood vessels, nerves, ducts and connective tissue, holding everything in shape, the breast consists of two main types of tissue: dense glandular tissue, which is responsible for producing milk after childbirth, and fat. In gynecomastia, all of these tissues develop but the extent of development of each type varies. The breast can be mainly glandular, mainly fat or a mixture of the two. It is fairly common to see mainly fat on the outside of the developed breast and mainly glandular tissue close to the nipple, but the type of tissue involved is important for planning treatment.

Severity

It is also important to consider the severity of the gynecomastia. In moderate to severe gynecomastia, there is not only development of excess breast tissue, but together with that, there is often an expansion of the overlying skin, and it may be necessary to remove some of this skin at the time of surgery. In the most severe cases, it is sometimes necessary to perform an extensive skin reduction, similar to a female breast reduction.

The condition can affect children in different ways. Common complaints are embarrassment about his chest that he doesn’t like to wear tight clothes or to undress in front of his peers, and especially that he doesn’t like to go swimming. Occasionally the breast tissue can be painful or can cause discharge from the nipples, which can worsen the embarrassment. Teasing is a common worry and psychosocial concerns can make it difficult for young men with gynecomastia to enjoy sports and to form relationships.

People of both sexes have some breast tissue and whether this develops into visible breasts depends on various factors, most importantly the action of hormones. Gynecomastia is the development of this breast tissue in males and is common. It is often seen in new born babies due to the mother’s hormones acting on the baby’s breast tissue but usually disappears in the first few weeks after birth. 

The next age at which it is seen frequently is during puberty. In fact, it affects up to two thirds of all boys during this time but, again, most gynecomastia during puberty disappears without any treatment within two years. In between 5% and 10% of boys who have gone through puberty, the breast development during puberty does not fully disappear and they will be left with visible breast tissue. 

• Hyperthyroidism – gland that regulates the metabolism can alter hormones
• Hypogonadism – any condition that increases testosterone (like pituitary insufficiency or Klinefelter's syndrome)
• Hormonal imbalance
• Liver or kidney failure – hormonal changes in response to medicines and dialysis
• Malnutrition or starvation – poor nutrition causes testosterone to drop, but estrogen remains constant
• Medications – steroids, antibiotics, chemotherapy or heart medications
• Mother’s estrogen levels – boy’s breast tissue will decrease typically within two to three weeks after birth
• Puberty – rapid hormone changes alter several body functions
• Street drugs and alcohol use – such as marijuana, heroin and amphetamines
• Tumors – on the testes, adrenal glands or pituitary glands

Despite all of these known causes, in about a quarter of all cases the reason for developing gynecomastia is unknown.

Treatment for gynecomastia involves establishing and treating any underlying cause, if appropriate, and then planning surgery to improve any ongoing problems with the contour of the chest.

Mild to moderate cases

For mild to moderate gynecomastia, surgery consists of liposuction together with Ultrasound Assisted Liposuction and Open Excision as necessary.

Liposuction is the removal of tissue, most commonly fat, by passing a suction probe backwards and forwards under the skin. In general, the area is injected with fluid to reduce the amount of blood loss and to reduce injury to the tissues that will be left behind. One or more small cuts are made and the suction probe is inserted into the layer of fat to be removed. The suction, combined with the motion of the probe, removes fat cells. This is very effective for gynecomastia that is mainly fat but the dense, glandular tissue is not typically removed by liposuction alone. In mixed gynecomastia, often liposuction is used at the start of the operation to remove the fat part, and so the breast tissue left behind is smaller and easier to remove.

Ultrasound Assisted Liposuction is a combination of liposuction as above connected to an ultrasound machine. Ultrasound is the use of sound waves that are higher than we can hear. When they are used together with the suction probe, they tend to break down certain types of cells and tissues, so they can often remove both the fat part and the glandular part.

Occasionally, the glandular part of the breast is so thick that even Ultrasound Assisted Liposuction cannot remove it. Then it can be removed by making a semi-circular cut under nipple areolar complex, the nipple and darker colored skin around the nipple. Using this cut, the thick glandular tissue can be removed and the chest can be reshaped.

Severe cases

In the more severe cases, there is extra skin as a result of the breast development and that will need to be removed. This can often be removed as a ring around the nipple areolar complex or, in the most severe cases, techniques that are usually used for female breast reduction can be used.

Surgical outcomes and risks

Most young men who choose to have surgery for gynecomastia have good outcomes, but there is the always the risk of complications. Infection and bleeding can occur after any surgery, and a collection of fluid under the skin may require further surgery to resolve.

There is the possibility of:

• Undercorrection, in which too much of the gynecomastia is left behind, creating a difference between the two sides
• Overcorrection, where there can be hollowing behind the nipple or the nipple can scar down to the ‘pec’ muscle and move unnaturally.
• More severe complications, such as loss of the nipple or blood clots in the legs or chest are possible but rare.

Aftercare

Aftercare is important as gynecomastia can occasionally re-grow and further treatment is sometimes required. The chest, is an area that changes dramatically during adolescence and early adulthood, and it is important that any treatment is planned to give the best long-term result.