الفهرس 
Anatomy of the BreastOnly 14 pages are availabe for public view
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Abstract
Gynaecomastia is the most common disorder of male breast accounting nearly 65% of all male breast disorders. It also accounts for 85% of male breast masses. Just one percent of male breast enlargement is caused by malignancy. According to the American Society of Plastic Surgeons, gynecomastia is usually a transient phenomenon and is considered a normal part of male adolescence. It can occur in persons of any age. The incidence of gynecomastia has been shown to vary widely with age.
Glandular proliferation of the male breast was due to an alteration in the estrogen/testosterone (E/T) ratio. The changes frequently occur in response to an increased production and/ /or activity of estrogens and a decreased production and/or activity of testosterone.
Gynecomastia may be Idiopathic constitutes 25% of all cases; Physiological gynecomastia (Physiologic endocrine imbalance) which may be:- 1). Neonatal Gynecomastia. 60-90% 2). Pubertal GM 50-60% which appear at 13 or 14 years of age, last for 6-12 months and then spontaneously regress in 95% of the cases 3). Aging GM50-70%; Pathological gynecomastia (Endogenous endocrine imbalance) which may be due to (Congenital disorders as Klinefelter’s and hermaphroditism; acquired hormonal abnormalities as testicular trauma mumps, orchitis and leprosy; Endocrine causes as Cushing’s syndrome; Tumours as sertoli and leydig cell tumours; Metabolic as thyrotoxicosis, liver cirrhosis and starvation); Drugs (Exogenous endocrine imbalance) 25% of all new-onset cases of GM in adults as oestrogens, androgens, gonadotrophins, cimetidine, spironolactone, digitalis, progesterone, phenothiazines, reserpine, marijuana, heroin, methadone, amphetamines isoniazid, ethionamide, thiacetazone.
The aim in the management of gynecomastia is to obtain a satisfactory diagnosis and choose the proper treatment and classifying the pathology in to severity grades.
Diagnosis and evaluation needs careful history taking, physical examination and investigations; The history should include: onset, duration, history of drug intake, history of systemic diseases; General examination of the abdomen, thyroid gland and testicular examination should be done; Local examination of breasts, nipple-areola complex, skin redundancy and axillary lymph nodes; Investigations should be limited and individualized to address abnormalities identified in the history and physical examination; Certain defined finding should prompt further evaluation, these include: FNAB, mammography, breast ultrasound and hormonal assay.
There are several classifications of gynecomastia. That of Simon, is most widely known. Described by Hoffman, Simon and Kahn (Simon BE et al., 1973), classified patients into three categories based on morphology and degree of skin redundancy. It is the commonly used classification. It offers a simple guideline for diagnosis and management of gynaecomastia. The clinical grade of gynaecomastia was based on Simon’s classification.
Grade I: is minor but visible breast enlargement without skin redundancy,
Grade IIA: is moderate breast enlargement without skin redundancy,
Grade IIB: is moderate breast enlargement with minor skin redundancy,
Grade III: is gross breast enlargement with significant skin redundancy that simulates a pendulous female breast.
Other classifications depending on morphological, etiological and clinical data was described as Webster classification in 1934, Geschikter and Copeland in 1943, Letterman and Schuster in 1969, Carlson classification in 1980, The American Society of Plastic Surgeons® (ASPS®)2002, More recently Rohrich, classification 2003 and Morphological classification.
There are different modalities for treatment of gynecomastia. Treatment options vary depending on the cause, the pathophysiology, physical examination and patients’ desires.
The majority of the patients do not require treatment, but only reassurance that their condition is not malignant. Pharmacological gynecomastia will often respond to modification or elimination of the medication regimen, Metabolic gynecomastia may be treated with restoration of proper nutrition, Patients whose condition is endocrine-dependent should receive treatment for the endocrine disorder first.
In a cases of acute gynecomastia that fail to resolve spontaneously and are symptomatic Tamoxifen (estrogen antagonist) (10-20 mg) twice a day for 2–4 months; should be considered as a first line treatment. Testosterone derivative treatment with Danazol also used for the same purpose it inhibits pituitary secretion of LH and follicle-stimulating hormone (FSH), which decreases estrogen synthesis from the testicles, The dose used for gynecomastia is (200 mg) twice a day.
Surgical treatment remains the treatment of choice for many patients.
Many surgical techniques have been described through the decades for surgical correction of gynaecomastia. All should have the same goals. Over the last 30 years, more attention has been paid to aesthetically acceptable, minimally invasive approaches and more conservative treatment options where suitable, in the surgical management of breast diseases as liposuction, endoscopically-assisted techniques and ultrasound-guided mammatome excision. Also open excisional techniques have been associated with high complication rates.
Surgical Treatment is indicated in patients given the limited efficacy of medical therapy, Gynecomastia with clinically noticeable large lumps or asymmetry, For cases of Simon’s grade II b and III or IV, long-standing gynecomastia without pathological etiology is best treated with surgery.
The objectives of surgical treatment
Total resection of the abnormal breast tissue;
Flattening of the thoracic region;
Elimination of the inframammary fold;
Correct positioning of the nipple-areola complex;
Removal of redundant skin;
Symmetrisation between the two hemithoraxes and the two areolas;
Containment of scars.
Excisional surgery in gynecomastia aimed at removal of glandular tissue and reduction of excess skin keeping the viability of nipple areola complex but with high rate of complications as Bleeding an, hematoma, Nipple-areola or skin necrosis, deforming scars especially with skin reduction techniques and Contour irregularities (spectrum) as depressed nipple-areola, large contour deformities and Nipple inversion
Liposuction can be used as an additional technique for optimizing the esthetic result following the excision of the glandular tissue. It makes glandular tissue excision easier, there is better hemostasis due to a hypercoagulable state that is induced by lipoplasty, and it allows for contouring of the periphery and stimulates skin contraction. I also provide shorter operating times, a lower complication rate and minimal scars. The incision used to access the breast tissue can be nicely disguised in the axilla, the inframammary line, or the periareolar edge. Liposuction techniques can be further categorized by the amount of fluid injection, liposuction could be done as dry, wet, superwet or tumescent and by the mechanism (The techniques of liposuction) in which the cannula works.
There are many techniques of liposuction as: Suction-assisted liposuction (SAL), Ultrasound-assisted liposuction (UAL) and Power-assisted liposuction (PAL).
More recently, laser assisted liposuction techniques have also been introduced, The development of laser lipolytic devices has been a major advance in ease of use, reducing downtime, increasing skin contraction, and lowering the frequency of adverse effects in fat removal.
Radiofrequency-assisted liposuction (RFAL) is the most recent technique of liposuction with fewer complication rate.
There are many minimal invasive techniques which are used for removal of glandular tissue of gynecomastia as the microdebrider (powered shaving rotary device), The use of a vacuum- assisted biopsy device (VABD, mammotome intervention) and The Pull-Through Technique for Removal of Fibroglandular Breast Tissue.
In a recent report the use of a power-assisted arthroscopic-endoscopic cartilage shaver has been described for the treatment of fibrous gynaecomastia. It is a new choice to treat gynecomastia. This technique has improved the final outcome with less scarring, short operative time, minimal complications, safe technique and good esthetic results and is suited for higher grade gynecomastia. The satisfactory rate for operative effect was 100%. No revisions were necessary. There were no long-term complications. In all cases there were only small scars on the lateral chest wall and axilla, which became unobvious 3 months later, and no operation scar could be seen on the anterior chest surface.
The Factors that affect the final outcome of gynecomastia surgery:
The elasticity of the skin and the thickness of subcutaneous tissue.
The patient age - the younger is the patient, the more elastic the skin.
The amount of excess skin.
The breast shape which can be saggy or tubular depending on the amount of excess skin and the breast shape.
The size of the areola is also a factor.
Adipose tissue.
Type of surgery.