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
What is your treatment plan for pubertal gynecomastia?
-Observe first! +/- 12 months
-Operate if remains for extended period of time
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%)
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
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
Name three medications that can cause gynecomastia
spironolactone
ketoconazole
CCB
marijuana
-Direct excision with periareolar incision
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
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
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
Name the two classification systems for gynecomatia
Simon- qualitative assessment of skin redundancy and breast volume
Rohrich- total mass requiring excision
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
Men with gynecomastia are X% more likely to get breast cancer vs. men without
0%!
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
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
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
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
-reserpine
-enalapril
-verpamil
-diazepam
-metformin
Name 4 body systems you want to examine in the adult gynecomastia patient
-GU- testicular masses
-Thyroid
-Breast masses
-Abdominal masses/hepatomegaly
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
Describe your focused history and physical for gynecomastia
-duration of symptoms
-familial history of BCa
-+/- nipple discharge
-Eval for hepatomegaly
-Testicular exam
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
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
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
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!