The blood supply to the cutaneous tissue in the anterior chest area, including the NAC (nipple-areola complex), is from the anterior perforators arising from the internal thoracic artery, and the musculocutaneous perforators arising from pectoral branch of thoracoacromial axis. The cutaneous tissue located laterally, to lateral cephalic of the NAC, is supplied by the superficial thoracic artery. Lateral cephalic from the superficial thoracic artery cutaneous supply, the cutaneous tissue located on the ventral portion of the axilla continuing to the medial, proximal portion of the biceps brachii, is supplied by the anterior circumflex humeral artery. Located inferiorly to the clavicle, on the lateral portion of the upper pectoralis area, the cutaneous tissue is supplied from the direct cutaneous branch arising from the thoracoacromial axis.
Figure 1. Anterior aspect of the anatomical territories of cutaneous blood vessels on the anterior trunk. (Adapted from) (1)
The fascia relevant to gynecomastia surgery are the superficial fascia, and the deep fascia. The superficial fascia, consist of adipose tissue loosely attached to the skin. Small blood vessels and nerves perforate the superficial fascia to supply the skin. (2) The gynecomastia fibroglandular tissue is found within the superficial fascia, as is true with the female breast. The deep fascia is a tough and fibrous membrane that allows some movement of the structures over one another. (2) The deep fascia investing the pectoralis major muscle is relatively thin, but polar, stronger and more distinct in the upper pole of the muscle. (2)
Figure 2. Anatomical diagram of the left anterior chest. (3)
The male NAC, like females, is susceptible to hypertrophic scarring as a result of the high tensile forces present. (2) The NAC is more susceptible to hypo and hyperpigmentation, onset by surgical wound, than the thin hirsute skin that covers most of the body. This is due to the greater degree of melanization in the NAC. (4) Physical examination is performed to evaluate the breast for any dominant masses, nipple discharge, or lymphadenopathy. (2) Patients with gynecomastia were found to have an increased incidence of testicular tumors (5), warranting examination of the testacies. Factors influencing which operative procedure a patient will require are, skin redundancy, the amount of adipose tissue present, the amount of glandular tissue present, and the diameter of the NAC. Mild cases of gynecomastia can be corrected by intraareolar incisions (infraareolar, cresentareolar), circumareolar, endoscopic approaches, and transaxillary approaches. (6) Moderate cases of gynecomastia can be addressed with the donut mastopexy. (2,7,8) Extreme cases of gynecomastia can be corrected with a vertical scar mastopexy, wise pattern mastopexy, or IMF approach (9,10). Gynecomastia operations need to be designed specifically to address the amount of skin excess, glandular breast tissue, fatty tissue, degree of breast ptosis, and the size of the NAC. (2) Each component should be considered separately to optimize the outcome.(2) An example of a single component to consider when planning a surgical approach is the NAC size. The diameter of the NAC will decrease after the removal of the glandular tissue, as a result of contraction, in absence of pressure from underlying tissue volume. Excessively large NACs sometimes require a circumareolar excision, to achieve a reduction in nipple diameter. This method comes at the expense of aesthetics, as there is a greater potential for more apparent scarring. An extensive knowledge and understanding of the anatomy relevant to gynecomastia facilitates better aesthetics in procedural outcomes.
Figure 3. A lateral, inferior infraareolar incision of the NAC. The view is parallel to the coronal plane.
Figure 4. Diagram of the NAC innervation. An infraareolar incision is labeled in black. This incision is most often appropriate for grades I and IIa, IIb (grades defined by Simon et al.). (5)
References
1. Cormack, GC and Lamberty, BGH. The Arterial Anatomy of Skin Flaps. 2nd Edition. Edinburgh : Churchill Livingstone, 1994.
2. Bahman, Guyuron, Eriksson, Elof and Persing, John A. PLASTIC SURGERY INDICATIONS AND PRACTICE. [ed.] Kevin C Chung, et al. s.l. : Elsevier Inc., 2009. Vol. I and II.
3. Gray, Henry. Gray’s Anatomy. 15th Edition. New York : Barns & Novle Books, 1901, 1995.
4. Standring, Susan. Gray’s Anatomy The Anatomical Basis of Clinical Practice. 40. s.l. : Churchill Livingstone ELSEVIER, 2008. p. xxiii. 978-0-443-06684-9.
5. Testicular tumours presenting as gynaecomastia. Daniels, IR and Layer, GT. 29, 2003, Eur J Surg Oncol, pp. 437-439.
6. A transaxillary incision for gynecomastia. Balch, CR. 61, 1978, Plast Reconstruct Surg, Vol. 1, pp. 13-16.
7. Concentric circle operation for massive gynecomastia to excise the redundant skin. Davidson, BA. 63, 1979, Plast Reconstruct Surg , Vol. 3, pp. 350-354.
8. Eccentric skin resection and purse-string closure for skin reduction with mastectomy for gynecomastia. Smoot, EC 3rd. 41, 1998, Ann Plast Surg, Vol. 4, pp. 378-383.
9. Correction of gynecomastia with an inframammary incision and subsequent scar. Beraka, GJ. 96, 1995, Plast Reconstruct Surg, Vol. 7, pp. 1753-1754.
10. Correction of extreme gynaecomastia. Wray, RC Jr, Hoopes, JE and Davis, GM. 27, 1974, Brit J Plast Surg, Vol. 1, pp. 39-41.
11. Classification and surgical correction of gynecomastia. Simon, BE, Hoffman, S and Kahn, S. 1973, Plast Reconstr Surg, Vol. 51, pp. 48-52.
Figure 5. Bilateral fibro-sclerotic glandular tissue excised through an infraareolar incision. Glands were released by sharp dissection. Visual inspection elucidates a small percent of adipose tissue present. Lipoplasty was not applied for the purpose of evening the contour of the chest periareolar-NAC area, due to the patients low percent body fat.(11)
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Gynecomastia Surgery: A Closer Look
Gynecomastia is an unacceptable condition when it comes to bodybuilders. Gynecomastia can develop in bodybuilders for many reasons. Some hormones affecting growth and differentiation of breast tissue are growth hormone, estrogen, androgens, and progesterone. A myriad of other peptides both endogenous and exogenously introduced can contribute to developing this condition. Whatever the cause, the development is analogous to female breast development and the results are devastating. It is unacceptable for a bodybuilder who invests the most time, energy, and money per day of life than any other sport or form of human competition to be hindered by breast tissue development.
Drug based therapy is not a viable solution for gynecomastia in the bodybuilder. Surgery is the only effective means of treating this condition. It is important to note that of the general public gynecomastia patients, 50% are not satisfied with the post-operative outcome, as their aesthetic expectations have not been meet. That being said, what the bodybuilder considers aesthetically acceptable is drastically more demanding than a general patient. One can deduce from this, bodybuilders who do not extensively research for an exceptional, experienced surgeon will likely be disappointed with the results.
Gynecomastia is unacceptable to athletes, recreational bodybuilders, and especially competitive bodybuilders. The staple poses of the competitor are the: quarter turn, front double bicep, front lat spread, abs and thigh, side chest, side tricep, rear double bicep, rear lat spread, and of course most muscular. Competitors suffering from even a mild case of gynecomastia will be most vulnerable in posing the: quarter turn, side chest, and side tricep.
Most Vulnerable Poses
Quarter Turn
Side Chest
Side Tricep
Apex of Aesthetic Points
Contour
A surgery thats primary intention is to remove mammillary glandular tissue will often result in failure. There are several features that demand more attention in catering a corrective surgical protocol to bodybuilders. Bodybuilders obtain an extremely low percent body fat for a duration of time. Percent body fat is inversely proportional to the aesthetic appearance of the gynecomastia present. This is another reason why correcting the condition is required. The musculature of the chest is a focal point in posing and more generally an accented feature on bodybuilders. Breast tissue proceeds to develop as follows: growth and division of ducts, formation of club-shaped terminal end buds, then forming alveolar buds, clusters of buds make up a lobule, lobules differentiate into ductules. This is significant because of the protrusion caused behind the nipple often made more pronounced by adipose tissue behind the gland. The amount of tissue removed will be unique to the severity of each bodybuilder’s condition and physique. Not removing enough tissue results in the failure to meet aesthetic requirements and enables the possibility of further breast development. Removing excess tissue may result in depressions that cannot be acceptably fixed. Achieving a natural contour is key to a successful surgery. Achieving a natural contour will require a plastic surgeon with specialized experience, perfected technique, and skill.
Scars
Scars are unwanted by a general patient and as such are absolutely unacceptable for bodybuilders. Avoiding scars requires delicate cosmetic surgical techniques. A periareolar incision does not rule out the possibility of scaring. A specialized surgeon with experience is key.
Example of Successful Surgical Treatment of Gynecomastia
Post-Operative Photos: 1 Year
Before photo: Bodybuilder with Bilateral symmetric gynecomastia. Post Op Photo: No scarring.
Before photo: 3/4 Turn showing protrusion feminizing chest. Post-Operative Photo: Tight, natural contour with no scarring or depressions.
Gynecomastia Corrective Surgery performed by Dr. Mordcai Blau
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What is Gynecomastia?
Gynecomastia is enlargement of the male breast. It is important to distinguish the enlargement present in gynecomastia from the adaptive response induced by resistance training (hypertrophy) of the pectoralis muscles. Gynecomastia is firm subareolar tissue and or diffuse fibroglandular tissue aggregating behind the nipple.
Facts about Gynecomastia?
Gynecomastia is present in 30% to 50% of healthy adult men. There are three times that males are most susceptible to developing gynecomastia. The neonatal period (infant), during puberty, and the age of fifty onward are the most vulnerable to developing the condition. Obesity greatly increases the chances of developing gynecomastia. Other factors that can increase the chances of developing gynecomastia are: genetic predisposition, smoking, drinking, prolonged high stress levels, physical inactivity, and drug use. The potential to develop gynecomastia with any combination of the aforementioned factors is directly proportional to age.
Ultimate cause of Gynecomastia
Males normally possess the equipment (glands + tissue) but lack the means (hormonal profile) to develop breasts. Most cases of gynecomastia result from an imbalance between estrogenic and androgenic effects on breast tissue. Estrogens stimulate breast tissue growth while androgens inhibit it. While there are many mechanisms caused by factors previously mentioned, most of their potential to induce gynecomastia is from ability to disrupt the estrogen / androgen balance present in healthy males.
Significance!
Gynecomastia though not an immediately life threatening condition, can have negative effects on the quality of life of a patent. A male with gynecomastia can experience behavioral health changes serious enough to effects his social, mental, physical and thus overall health. A few examples of this are feelings of anxiety, psychosocial discomfort, and a chronic fear of breast cancer.
Will Gynecomastia naturally go away?
Gynecomastia during the neonatal period normally regresses spontaneously requiring no treatment. Gynecomastia in puberty commonly is asymptomatic and regresses spontaneously. Gynecomastia that has not spontaneously regressed from puberty will likely not do so. The only effective treatment is for this case is surgery. Gynecomastia onset in adulthood from: stress, drugs, refeeding following starvation (prolonged catabolic states), and obesity will likely not regress. Adult onset gynecomastia requires surgery for effective treatment.
Do I have gynecomastia? I have puffy looking nipples…..
It is common that overweight men may feel they have gynecomastia because of the protruding appearance of their nipples and chest area. It is possible that many of these cases are pseudogynecomastia. Pseudogynecomastia results from having excessive body fat. The fatty breasts behind the areola and chest area are swollen adipocytes (fat cells) and are a result of sustained energy input (diet), exceeding output (metabolic demands). Body fat is not site specific and its storage distribution throughout the body varies genetically. Pseudogynecomastia can be treated effectively with exercises and diet. It is important to emphasize that carrying excessive amounts of body fat increases the risk of developing real gynecomastia that is only effectively treated by surgery.
Both Nipples? One Nipple?
Gynecomastia is commonly bilateral and symmetric (both glandular mammilary tissue deposits are of equal size). Gynecomastia can also be unilateral (asymmetric tissue deposits).
Treatment
Surgery is the only effective treatment for gynecomastia that has not spontaneously regresses during puberty or that is adult onset. The surgical method is to remove the glandular tissue through a periareolar incision. A lipectomy may or may not be necessary as determined by the surgeon. The surgical procedure requires skill and experience by the surgeon. Finding the right surgeon will determine the success of the treatment and meeting your personal expectations.
Example # 1 - Mild Case of Gynecomastia
Patient with bilateral symmetric gynecomastia
Surgeon: Dr. Mordcai Blau
Post-Operative Photo: 1 year
Cosmetically: There are no visible scars present from the incisions. The size of both nipples was reduced as a result not being stretched over the breast tissue. The natural contour of the nipples resting on the chest has been restored. There are no protrusions or depressions present in the surgically corrected area.
Example #2 - Severe Case of Gynecomastia
Patient with bilateral symmetric gynecomastia
Surgeon: Dr. Mordcai Blau
Post-Operative Photo: 1 year
Cosmetically: Patient was concerned that scar tissue would be a serious issue with his dark skin complexion. There is no visible scar and his severe case of gynecomastia was corrected, achieving a natural smooth contour of the chest.
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