Pre-op
Treatment- Young Adult
Etiology and Bonus
Work-up
Inservice!
100

What are the three peaks of hormonal changes in cismen that cause physiologic gynecomastia

Neonatal- transplacental estrogen

Puberty

Older men- hypogonadism and pharmaceutical drug use

100

What is your treatment plan for pubertal gynecomastia?

-Observe first! +/- 12 months

-Operate if remains for extended period of time

100

Describe 3 general categories for the etiology of gynecomastia (ex- 1 is physiologic)

*Bonus 100 points- what is the most common?

-pathologic

-pharmacologic

-idiopathic* most common (25%)

100

Name three labs in the prepubertal female and male that you might order to work-up gynecomastia

-serum estradiol

-HCG

-LH/FSH

-Bone age

*think premature puberty

100

An otherwise healthy 13-year-old boy is brought to the plastic surgeon’s office because of a 6-month history of bilateral breast enlargement. The patient takes no medications. There is no family history of breast cancer. Examination shows bilateral, 3-cm, firm, rubbery, subareolar masses without nipple discharge. No testicular masses are noted. Workup shows no other abnormalities. The patient reports that he is afraid of being teased. Which of the following is the most appropriate management?

Observation!- Usually regresses after 6 months

200

Name three medications that can cause gynecomastia

spironolactone

ketoconazole

CCB

marijuana

200
What is your treatment plan for isolated subareolar bud development?

-Direct excision with periareolar incision

200

Name 3 pathologic causes for gynecomastia

-alcoholic cirrhosis

-refeeding after a starvation state

-feminizing adrenal tumors

-hyperthyroidism

-adrenal cortical hypherplasia

-acquired hypogonadism- renal failure, alcoholism

200

Name three labs you might order in the pubertal cismale with normal external genitalia

-LH/FSH

-Testosterone

-Estradiol

-HCG

*consider physiologic, klinefelter, drug use, cancer

200

A 35-year-old transgender man (assigned female at birth) comes to the office to discuss top surgery for a masculine chest appearance. On examination, the patient has D-cup breasts and Grade III ptosis. Which of the following is the most appropriate surgical option for this patient?

Double incision mastectomy with free nipple graft

300

Name the two classification systems for gynecomatia

Simon- qualitative assessment of skin redundancy and breast volume

Rohrich- total mass requiring excision

300

What is your treatment plan for bud development with stromal hypertrophy?

-breast bud associated with fibrofatty accumulation in periphery of breast

-liposuction to remove fatty component in periphery of breast

-direct excision under breast bud

300

Men with gynecomastia are X% more likely to get breast cancer vs. men without

0%!

300

Name three labs you might order in the adult cismale with gynecomastia

-LH/FSH

-Testosterone

-Estradiol

-HCG

*Think chronic liver disease, thyrotoxicosis, drug use, ectopic gonadotropin production, testicular failure

300

An 18-year-old transgender man (assigned female at birth) presents for an initial consultation to plastic surgery to discuss top surgery. He has been taking testosterone shots for the past year. The patient wants to know the preoperative requirements for gender affirmation surgery. Which of the following best describes the 7th Edition World Professional Association for Transgender Health (WPATH) criteria for top surgery?

The patient must have persistent, well-documented gender dysphoria

400

Describe the Simon Classification

Grade I- small enlargement, no excess skin

Grade IIa- Mod enlargement, no excess skin

Grade IIb- Mod enlargement, excess skin present

Grade III- Marked enlargement with excess skin

400

What is your treatment plan for excess skin and enlarged areolar?

-majority of cases managed with periareolar skin resection alone +volume reduction (staged)

1. volume reduction (lipo)

2. Skin resection

-inner areolar diameter marked (25-35mm)

-outer diameter made to position nipple at IMF

-de-ep between and GoreTex purse-string

400
Which med does not cause gynecomastia?

-reserpine

-enalapril

-verpamil

-diazepam

-metformin

400

Name 4 body systems you want to examine in the adult gynecomastia patient

-GU- testicular masses

-Thyroid

-Breast masses

-Abdominal masses/hepatomegaly

400

An otherwise healthy, 25-year-old transgender man (assigned female at birth) meets World Professional Association for Transgender Health guidelines for gender-affirming genital surgery. He chooses to undergo phalloplasty to achieve the ability to urinate while standing and also maintain a chance of penetrative intercourse. However, he would like to avoid a stigmatizing scar along the forearm. Therefore, he undergoes combination flap phalloplasty using anterolateral thigh tissue for penile shaft reconstruction and groin tissue for urethral reconstruction. A photograph is shown. Which of the following is the most likely vascular pedicle that will be dissected for harvesting the groin flap?

D) Superficial circumflex iliac vessels

500

Describe your focused history and physical for gynecomastia 

-duration of symptoms

-familial history of BCa

-+/- nipple discharge

-Eval for hepatomegaly

-Testicular exam

500

1. What is your treatment plan for a young cisman with excess skin? (Incision patterns)

2. What is a saucer deformity?

-Peri-areolar with extended vertical

-Wise pattern


2. Excess removal of tissue beneath NAC

500

Bonus! Name 2 characteristics (think- qualitative and quantitative) of the cismale chest

-NAC 2-4cm in diameter (average 2.8cm)

-NAC over 4th intercostal space

-SN to N- 20 cm average

500

Name three factors that would make gynecomastia mastectomy "medically necessary" under the MassHealth guidelines and two circumstances that would make MassHealth insurance reject the claim

-excess breast tissue that is glandular and NOT fatty

-persistent pain and discomfort of the breast

-at least 2 years with no signs of resolution despite conservative tx


*pseudogynecomastia

*cosmetic purposes 

500

A 35-year-old transgender man (assigned female at birth) meets World Professional Association for Transgender Health guidelines for gender-affirming genital surgery. He chooses to undergo radial forearm flap phalloplasty. During flap harvest, the plastic surgeon identifies the cutaneous nerve near the cephalic vein; the nerve is later coapted to the ilioinguinal and dorsal clitoral nerves for sensory reconstruction. This cutaneous nerve originated from which of the following more proximal nerves?

musculocutaneous!

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