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Overview ("What is it?")
- Gynecomastia is a benign (not cancer) enlargement of the male breast because of overgrowth of breast tissue.
- Gynecomastia may or may not cause symptoms. During some stages of childhood, it is fairly normal finding and will go away on its own. Gynecomastia is caused by many reasons including an imbalance of hormones such as estrogen, testosterone and thyroid hormone. Several medications may cause gynecomastia including some antibiotics, anti-ulcer medications, heart medicines and psychoactive medications. It has also been associated with the use of alcohol and drugs such as marijuana and amphetamines. Sometimes the cause is not clear. When gynecomastia fails to go away on its own after 1-2 years and no obvious cause is found, surgical treatment is often considered.
Signs and Symptoms ("What symptoms will my child have?")
- Gynecomastia usually occurs in both breasts but may occur on only one side. True gynecomastia is a firm, disc-like mass beneath the nipple that may be tender. While breast cancers can occur in males, cancer is rare and unusual in the children and teenagers. Very often gynecomastia will go away on its own or after stopping any associated medications. If it persists, it tends to become more firm over time. There may be some pain, but some may not be painful. Some children have problems with body image and may find it difficult to participate in activities such as swimming where they have to remove their shirts.
Diagnosis (“What tests are done to find out what my child has?”)
- The doctor will conduct history and good physical examination including testicular exam must be done. It is important to give a list of all medications that the child is taking.
- Blood tests are conducted to see if there is a cause of the gynecomastia including tests for liver, kidney and thyroid function and hormone levels (testosterone, estradiol, prolactin, luteinizing hormone, and human chorionic gonadotropin). If all these tests are normal, then idiopathic gynecomastia is diagnosed (which means we do not know the cause).
- Conditions that mimic this problem: “Pseudogynecomastia” (false gynecomastia) which is caused by increased fat rather than breast tissue enlargement. Boys and men with pseudogynecomastia are reassured that nothing serious is happening and if treatment is requested, weight loss and possibly liposuction are recommended.
Treatment ("What will be done to make my child better?”)
- Usually pubertal gynecomastia goes away by itself within 1-2 years.
- Medical Therapy: If the child is taking medicines that potentially cause breast enlargement, they should be withdrawn or changed if possible. Over-the counter-medications such as acetaminophen (Tylenol®) and ibuprofen (Motrin®, Advil®) can be used for occasional pain.
- Surgery: Surgery may be needed if gynecomastia persists after one to two years, for pain, or if there are psychologic problems. Surgery for persistent gynecomastia involves removal of the breast tissue. This is done through a small incision either through the areola or just beneath it at the junction between the dark and lighter skin. All of the breast tissue is removed. Complete surgical removal of the breast tissue cures the condition. Because removal of the breast tissue leaves a large empty space beneath the skin, many surgeons will leave a drain in place to collect fluid after the surgery.
- Preoperative preparation: The child should shower or bathe the day before or the morning of surgery. He should not eat anything solid for eight hours prior to surgery
- Postoperative care: Depending on how extensive the operation is, the child may need to stay overnight. If a drain is placed, its care would be taught before discharge. You will need to record the volume of what is coming out of the drain. The drain will be removed in clinic when there is not much drainage left. Pain medication will be provided. Some surgeons may wrap the chest with an elastic wrap to help prevent a collection of fluid forming in this space (called a seroma) and activity in the arm on the side of the operation may be limited for a period of time after surgery.
- Benefits: The procedure will remove the breast tissue, which will make the chest flat.
- Risks: The main risks of the surgery are seroma formation and hematoma (blood clot) caused by any postoperative bleeding. This is not common. The surgeon has to leave a small amount of breast tissue beneath the nipple to prevent nipple inversion after surgery. Another possible risk is wound infection. Cosmetically, the chest may be asymmetric.
Home Care ("What do I need to do once my child goes home?”)
- Diet: Most children will be able to eat normally after the anesthesia has worn off. There are no dietary restrictions to follow.
- Activity: Excessive activity in the arm on the side of the operation may be limited by your surgeon for a period of weeks to help decrease the risk of seroma formation. If a drain was placed, you will need to learn how to empty it and record the amount of drainage. Usually this amount is small. Children can go to school with the drain in place and pin it to the inside of the shirt. If a drain is in place, the area should remain dry. If no drain is placed, the patient can shower in three days but may want to wait 5-7 days after surgery before soaking the wound.
- Medicines: Medication for pain such as acetaminophen (Tylenol®) or ibuprofen (Motrin® or Advil®) or something stronger like a narcotic may be needed to help with pain for a few days after surgery. Stool softeners and laxatives are needed to help regular stooling after surgery, especially if narcotics are still needed for pain.
- What to call the doctor for: After discharge from surgery, problems that may indicate infection such as fevers, wound redness and discharge should be addressed. If the area of surgery is swelling, bloody fluid is coming out of wound, or worsening pain occurs, call the surgeon.
- Follow-up care: The patient should be seen by a surgeon to remove the drain if one is present and to check the surgical wound.
Long-Term Outcome ("Are there future conditions to worry about?”)
Surgery is curative of this condition with excellent long term cosmetic results, resolution of pain and the ability to become more comfortable with one’s body image.
Author: John H.T. Waldhausen, MD
Editors: Patricia Lange, MD; Marjorie J. Arca, MD